TB in South-East Asia

Achievements

DOTS coverage

DOTS coverage is defined as the population living in administrative areas where DOTS services are available. This indicator serves as a proxy for people with access to DOTS. Population access to DOTS in the Region has been 100% since the end of 2006.

Case notifications

There has been a significant and steady increase in detection of TB cases in the last five years, as a result of efforts towards universal case detection. More than 1 000 000 sputum smear-positive TB patients and  2 300 000 all forms of TB have been detected and notified in 2009, representing about a 20% increase over 2005 (See figure1).

Figure 1: Number of TB cases reported by the 11 Member States of the WHO SEA Region, by type, 2005-2009 

Table 1 shows TB cases notified by type, in each Member States for the year 2009. The 11 Member States of the South-East Asia Region together notified 2 124 370 cases of tuberculosis (new and relapses, all forms), which represents a case notification rate of 119 per 100 000 population. Of those, 1 028 656 were new smear-positive pulmonary cases (62% of all new pulmonary cases). Five countries in the Region (Bangladesh, India, Indonesia, Myanmar and Thailand), are among the 22 countries with the highest burdens of TB (HBCs) globally, and notified a total of 2 190 068 cases, or 94% of all cases notified in the Region.

New smear-negative pulmonary and extra-pulmonary cases represented 27% and 14%, respectively, of all notified new cases. 

Relapse and re-treatment cases

The proportions of relapse and re-treatment cases represent 5.5% and 8.7% of all notified cases, respectively. However, the true percentages could be slightly higher, given underreporting by some countries.

Table 1: Estimated incidence and cases notified (by type) in Member States of SEA Region, 2009*

*Figures may be updated in early 2011 following revision or completion of surveillance data by Member States

**The calculation method for estimates changed in 2010, and therefore new and old estimates should not be compared.

Treatment outcomes

Table 2 shows the treatment success rates among new smear-positive cases and re-treatment cases enrolled for treatment in the Member States during 2008. For new smear-positive cases the treatment success rate is above the target of 85% in the SEA Region as a whole, and this target has been achieved or surpassed in 9 of the 11 countries.

The overall cure rate in the Region for new smear-positive cases was 84.2% and the completion rate 3.8% (overall success rate of 88%), for the 1 011 353 cases registered in 2008.

The success rate among re-treatment cases is lower, 74% for the whole Region, and ranging from 66% to 82% in the countries. Similarly, while the case fatality rate among new smear-positive cases is low, it is more than double among the re-treatment cases. Default rates are also higher among re-treatment cases, and are especially high (for all cases) in India, Sri Lanka and Timor-Leste.

Table 2: Treatment outcomes of new smear-positive cases and re-treatment cases notified in 2008 in Member States of the SEA Region (expressed as percentage of the total number of cases notified)*

*Figures may be updated in early 2011 following revision or completion of surveillance data from Member States

Key milestones achieved in 2009

As a result of the resolution at the Sixtieth Regional Committee held in Bhutan in 2007, the new Stop TB Strategy has been adopted by all 11 countries and it is the basis for national TB control plans. National TB Programme manuals have been also updated and national programme capacity for scaling up interventions under the Stop TB strategy has being built in various technical areas.

Management of drugs has been strengthened and no stock-outs of first-line anti-TB drugs have been reported at the national level in all 11 countries; 5 countries are receiving GDF grants; and 6 are transitioning/fully utilizing GDF direct procurement services

All 11 countries have nation-wide quality-assured networks for smear microscopy, and laboratories in Bangladesh, India, Indonesia, Myanmar, Nepal, Sri Lanka and Thailand have been accredited for quality assurance for culture and drug susceptibility testing (C and DST). Two supra-national reference laboratories have been set up in the Region.

National guidelines for the management of multidrug resistant TB (MDR-TB) have been developed for Bangladesh, Bhutan, India, Indonesia, Myanmar, Nepal, Sri Lanka and Timor-Leste. Sites for the management of MDR-TB under programme conditions are functional in all these countries, and enrollment of patients is ongoing in all except for Bhutan and Sri-Lanka, where enrollment will start in late 2010. in total, 3 000 MDR-TB patients are currently on treatment and the number of MDR-TB treatment sites is expanding.

Ten of the 11 countries in the Region established National Coordinating committees for TB/HIV collaborative activities. TB/HIV interventions are widely available in Thailand, which has established a “one-stop shop” approach and India, which implemented an “intensified” package of interventions available to 600 million people in 18 states: intervention are being expanded in Indonesia (in Papua and Java Bali where epidemic is concentrated), Myanmar and Nepal.

Medical colleges and private sector providers are increasingly involved in working with national TB control programmes in the Region through public-private mix (PPM) initiatives; the International standards for TB care are being promoted through professional societies in Bangladesh, India, Indonesia, Myanmar, Nepal and Sri Lanka to link with all private and public health professionals. Member States reported that over 360 medical colleges, nearly 20 000 private practitioners, 2 500 NGOs, 150 corporate institutions, 1500 large public and private hospitals and 550 prisons are collaborating in PPM initiatives.

There are several hundred community-based interventions in place in the Region, with very encouraging examples of community-based approaches. A wealth of initiatives, particularly for case finding and treatment support, are increasingly being incorporated into routine service delivery by national programmes. However, systematic approaches to social mobilization are yet to be developed and established in countries, with the possible exceptions of Bangladesh and Indonesia.

Attention to advocacy, communications and social mobilization (ASCM) in increasing across the Region. A regional framework on ASCM will be finalized by early 2011; seven countries have appointed ACSM focal points and ACSM activities have been included in all Global Fund for Aids Tuberculosis and Malaria proposals.

During 2009, external monitoring and evaluation through joint reviews of the national TB programme were undertaken in Bangladesh, Bhutan, India and Sri Lanka.