SAARC EPIDEMIOLOGICAL RESPONSE ON TUBERCULOSIS … · million total number of an estimated...

SAARC EPIDEMIOLOGICAL RESPONSE ON

TUBERCULOSIS

2018

SAARC Tuberculosis & HIV/AIDS Centre

(STAC)

[ T y p e t h e c o m p a n y a d d r e s s ]

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SAARC EPIDEMIOLOGICAL RESPONSE ON

TUBERCULOSIS

2018

SAARC Tuberculosis & HIV/AIDS Centre (STAC)

Thimi, Bhaktapur

P.O.Box No. 9517, Kathmandu, Nepal.

Tel: 6631048, 6632477, 6632601 Fax: 00977-1-6634379

E-mail: [email protected] Website: www.saarctb.org


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© SAARC TB & HIV/AIDS CENTER 2018

All rights reserved. Publications of the SAARC TB & HIV/AIDS CENTER are available on the STAC web site

(www.saarctb.org), SAARC TB & HIV/AIDS CENTER, Thimi, Bhaktapur, Nepal (tel.: +977-1- 6631048; fax:

+977-1-6634379; e-mail: [email protected]). All reasonable precautions have been taken by the SAARC TB &

HIV/AIDS CENTER to verify the information contained in this publication. However, the published material is

being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation

and use of the material lies with the reader. In no event shall the SAARC TB & HIV/AIDS CENTER be liable for

damages arising from its use.

http://www.saarctb.org/

mailto:[email protected]


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FOREWORD

Tuberculosis – a disease from early times still remains a major public health problem, in the

SAARC region. In member states of SAARC Region, there has been a considerable development

in TB care services. However, three countries in the region namely India, Pakistan and

Bangladesh are in WHO high TB and High MDR-TB countries list.

All most all SAARC Member States have achieved MDG TB related targets and stop TB targets

in 2015 compared with 1990 as base line. Taking 2015 as base line, the new WHO “End TB”

strategy targets a 95% reduction in TB deaths and 90% incidence by 2035. In SAARC Region

2017, an estimated 3.7 million cases of were reported and about 0.5 million people died of it, the

Gap between, notifications of new TB cases and the estimated no. of incident cases was 1.1

million. The missing cases were a combined result of non-detection and under-reporting of

detected cases.

This report is an excellent review of the current status and future plans for the control of TB in

the SAARC Region. It includes information on burden of tuberculosis in the SAARC region,

including incidence, mortality along with the MDR-TB, TB/HIV confection etc. It also covers

the information of the year 2017 and has been prepared on the basis of information collected

from member countries during the year 2018 and by reviewing other related documents.

This is the sixteenth Report on Tuberculosis (TB) situation of SAARC Region which is being

published by SAARC Tuberculosis and HIV/AIDS Centre (STAC) in a series that started in

2003, which includes a compilation of regional and country-specific achievements, challenges

and plans. The main purpose of the report is to provide a comprehensive and up-to-date

assessment of the TB epidemic and progress made in TB care and control at Global, SAARC

Region and Member States level.

I would like to thank the programme managers and experts within SAARC member countries,

who have generated and shared the epidemiological data that has been used in this report.

We look forward to your continued collaboration in our joint efforts to broaden the partnership

for control of tuberculosis in the SAARC region.

_____________________

Dr. Rajendra Prasad Pant

Director

SAARC Tuberculosis and HIV/AIDS Centre


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CONTENTS

ABBREVIATIONS ................................................................................................ vii

EXECUTIVE SUMMARY ..................................................................................... ix

1. INTRODUCTION ................................................................................................. 1

1.1 Introduction of SAARC ............................................................................... 1

1.2 SAARC TB and HIV/AIDS Centre (STAC) ............................................... 1

2. GLOBAL BURDEN OF TUBERCULOSIS ......................................................... 3

2.1 Basic facts about TB .................................................................................... 3

2.2 The Sustainable Development Goals ........................................................... 4

2.3 The End TB Strategy ................................................................................... 6

2.4 Global Epidemiology ................................................................................... 8

3. BURDEN OF TUBERCULOSIS IN SAARC REGION .................................... 12

3.1 SAARC Epidemiology ..............................................................................12

3.2 Notifications and Treatment Success .........................................................13

3.3 Drug Resistance TB ...................................................................................14

4. PROGRESSES ON TB CONTROL IN SAARC MEMBER STATES .............. 17

AFGHANISTAN .............................................................................................18

BANGLADESH ..............................................................................................24

BHUTAN .........................................................................................................29

INDIA ..............................................................................................................35

MALDIVES .....................................................................................................40

NEPAL .............................................................................................................45

PAKISTAN ......................................................................................................50

SRI LANKA ....................................................................................................55

5. TB/HIV CO-INFECTION ................................................................................... 60


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ABBREVIATIONS

ACF : Active Case Finding

ACSM : Advocacy, Communication and Social Mobilization

AIDS : Acquired Immuno - Deficiency Syndrome

ART : Antiretroviral Treatment

BDQ : Bedaquiline

CBDOT : Community Based Dots on Tuberculosis

CBNAAT : Cartridges Based Nucleic Acid Amplification Test

CDR : Case Detection Rate

CFR : Case Fatality Ratio

CFZ : Clofazimine

CI : Confidence Interval

CTB : Challenge TB

DOTS : Directly Observed Treatment Short course

DRS : Drug Resistance Survey

DR-TB : Drug-resistant tuberculosis

DST : Drug Susceptibility Testing

EP-TB : Extra-Pulmonary Tuberculosis

GF : Global Fund to Fight AIDS, Tuberculosis and Malaria

GOB : Government of Bangladesh

HIV : Human Immunodeficiency Virus

IDPs : Internally displaced Population

IEC : Information, Education and Communication

INH : Isoniazid

JEET : Joint Effort for Elimination of Tuberculosis

JICA : Japan International Cooperation Agency

KAP : Knowledge, attitude and practice

LPA : Line Probe Assay

LZD : Linezolid

MDG : Millennium Development Goal

MDR : Multi Drug Resistance

MoH : Ministry of Health

NACP : National AIDS Control Programme


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NFM : New Funding Model

NPTCCD : National Programme for Tuberculosis Control and Chest Diseases

NRL : National Reference Laboratories

NTP : National Tuberculosis Programme

NTRL : National TB Reference laboratory

PBC : Pulmonary Bacteriological Confirmed

PHIs : Peripheral Health Institutions

PLHIV : People Living with HIV

PMDT : Programmatic Management of Drug-Resistant Tuberculosis

PPM : Public-private Mix

PSM : Procurement and Supply Management

RCDC : Royal Centre for Disease Control

RR-TB : Rifampicin resistant tuberculosis

SAARC : South Asian Association for Regional Cooperation

SCC : Short Course Chemotherapy

SDGs : Sustainable Development Goals

SOP : Standard Operating Procedure

SORT : Structured Operational Research and Training

STAC : SAARC TB and HIV/AIDS Centre

STC : SAARC Tuberculosis Centre

TB : Tuberculosis

TRL : TB Reference Laboratory

UHC : Upazila Health Complexe

UN : United Nations

UNAIDS : The Joint United Nations Programme on HIV/AIDS

USAID : United States Agency for International Development

VCCT : Voluntary Counseling and Testing Centre

WHO : World Health Organization

XDR : Extensively Drug-Resistant Tuberculosis


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EXECUTIVE SUMMARY

This is the sixteenth Report on tuberculosis (TB) situation of SAARC Region which is being

published by SAARC Tuberculosis and HIV/AIDS Centre (STAC) in a series that started in

2003. However the name of the report has changed “SAARC Epidemiological Response on

Tuberculosis” from year 2014.The main purpose of the report is to provide a comprehensive and

up-to-date assessment of the TB epidemic and progress made in TB care and control at Global,

SAARC Region and Member States level.

The incidence has been falling globally achieving the Millennium Development Goal target. Of

estimated 10 million new cases of TB (133 per 100 000 Population), 6.7 million cases were

notified in 2017, globally there was 3.3 million gap between incident and notified cases.

Globally, an estimated 558 000 people newly eligible for MDR-TB treatment. A total of

approximately 1.3 million people died of TB in 2017 and an additional 0.3 million deaths from

TB among people who were HIV-positive.

The SAARC region, with an estimated incidence of 3.7 million TB cases, carries 37% of the

global burden of TB. Three of the eight Member Countries in the Region are among the 30 high

burden countries (Bangladesh, India and Pakistan) together notified 95% of the region. India

alone accounted to 73% of all notifications in the SAARC region. The SAARC region has 0.1

million total number of an estimated MDR/RR-TB cases among notified pulmonary TB cases in

the year 2017.

In 2017, a total 33404 TB patients with known HIV status has tested in which India accounts

highest number of TB patients with known HIV status who are HIV positive. Total 29074

patients are on ART in the region. The proportion of known HIV-positive TB patients on

antiretroviral therapy (ART) was 87% globally as well as in the SAARC Region in 2017.

All the SAARC Member States have developed their strategic plans for expansion of TB/HIV

collaborative activities and are in the expansion mode. While, all the SAARC Member States

have initiated management of MDR-TB under the National TB Control Programme, one of the

most important constraints to rapid expansion of diagnostic and treatment services for MDR-TB

identified by all the SAARC Member States, is laboratory capacity. Constraints in availability

and retention of adequately trained human resources, is one of the major concerns of all the

SAARC Member States.


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1. INTRODUCTION

-----------------------------------------------------------------------------------------------------------------

1.1 Introduction of SAARC

SAARC is an organization of eight countries located in the South Asia and it stands for the South

Asian Association for Regional Corporation (SAARC). This is an economic and geopolitical

organization, established to promote socio-economic development, stability, welfare economics,

and collective self-reliance within the Region. The first summit was held in Dhaka, Bangladesh

on 7–8 December 1985 and was attended by the Government Representatives and Presidents

from Bangladesh, Maldives, Pakistan and Sri Lanka, the Kings of Bhutan and Nepal, and the

Prime Minister of India. The dignitaries signed the SAARC Charter on 8 December 1985,

thereby establishing the regional association and to carry out different important activities

required for the development of the Region. The summit also agreed to establish a SAARC

secretariat in Kathmandu, Nepal and adopted an official SAARC emblem. Due to rapid

expansion within the region, Afghanistan received full-member status and some countries are

considered as observers. SAARC respects the principles of sovereign equality, territorial

integrity, and national independence as it strives to attain sustainable economic growth.

1.2 SAARC TB and HIV/AIDS Centre (STAC)

The Centre was established in 1992 as SAARC Tuberculosis Centre (STC) and started

functioning from 1994. The Centre had been supporting the National Tuberculosis Control

Programmes of the SAARC Member States. The Thirty–first session of Standing Committee of

SAARC held in Dhaka on November 09th – 10th 2005, appreciating the efforts of the centre on

TB/HIV co-infection and other works related to HIV/AIDS discipline and approved the

renaming of the Centre as SAARC Tuberculosis and HIV/AIDS Centre (STAC) with additional

mandate to support SAARC Member States for prevention of HIV/AIDS. Since then with its

efforts and effective networking in the Member States the Centre is contributing significantly for

control of both TB and HIV/AIDS.



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Vision, Mission, Goal and Objective of STAC

The vision of the Centre is to be the leading institute to support and guide SAARC Member

States to make the region free of TB and HIV/AIDS and the mission is to support the efforts of

National TB and HIV/AIDS Control Programmes through evidence based policy guidance,

coordination and technical support.

The goal of the Centre is to minimize the mortality and morbidity due to TB and HIV/AIDS in

the Region and to minimize the transmission of both infections until TB and HIV/AIDS cease to

be major public health problems in the SAARC Region and the objective of the Centre is to work

for prevention and control of TB HIV/AIDS in the Region by coordinating the efforts of the

National TB Programmes and National HIV/AIDS Programmes of the SAARC Member

Countries.

Role of STAC

To act as a Regional Co-ordination Centre for NTPs and NACPs in the Region.

To promote and coordinate action for the prevention of TB/HIV co-infection in the Region.

To collect, collate, analyze and disseminate all relevant information regarding the latest

development and findings in the field of TB and HIV/AIDS in the Region and elsewhere.

To establish a networking arrangement among the NTPs and NACPs of Member States and

to conduct surveys, researches etc.

To initiate, undertake and coordinate the Research and Training in Technical Bio-medical,

operational and other aspects related to control of Tuberculosis and prevention of HIV/AIDS

in the Region.

To monitor epidemiological trends of TB, HIV/AIDS and MDR-TB in the Region.

To assist Member States for harmonization of policies and strategies on TB, HIV/AIDS and

TB/HIV co-infection.

To assist National TB Reference Laboratories in the Region in quality assurance of sputum

microscopy and standardization of culture and drug sensitivity testing and implementation of

bio-safety measures.

To carry-out other important works identified by the Programming Committees/Governing

Board.



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2. GLOBAL BURDEN OF TUBERCULOSIS

---------------------------------------------------------------------------------------------------------------------

2.1 Basic facts about TB

TB is an infectious disease caused by the bacillus Mycobacterium tuberculosis. It typically

affects the lungs (pulmonary TB) but can also affect other sites (extra pulmonary TB). The

disease is spread when people who are sick with pulmonary TB expel bacteria into the air, for

example by coughing. Overall, a relatively small proportion (5–10%) of the estimated 1.7 billion

people infected with M. tuberculosis will develop TB disease during their lifetime. However, the

probability of developing TB disease is much higher among people infected with HIV, and also

higher among people affected by risk factors such as under-nutrition, diabetes, smoking and

alcohol consumption. Overall, about 90% of cases occur among adults, with more cases among

men than women. The male: female ratio among adults is approximately 2:1.



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2.2 The Sustainable Development Goals

In 2016, the MDGs were succeeded by a new set of goals, known as the Sustainable

Development Goals (SDGs). Adopted by the UN in September 2015 following 3 years of

consultations, the SDG framework of goals, targets and indicators is for the period 2016–2030.1

The End TB Strategy was unanimously endorsed by all WHO Member States at the 2014 World

Health Assembly, and is for the period 2016–2035.2

The consolidated goal on health is SDG 3. It is defined as “Ensure healthy lives and promote

well-being for all at all ages”, and 13 targets have been set for this goal (Box 2.1). One of these

targets, Target 3.3, explicitly mentions TB: “By 2030, end the epidemics of AIDS, tuberculosis,

malaria and neglected tropical diseases and combat hepatitis, waterborne diseases and other

communicable diseases”. The language of “ending epidemics” is also now a prominent element

of global health strategies developed by WHO and the Joint United Nations Programme on

HIV/AIDS (UNAIDS) for the post- 2015 era,3 including the End TB Strategy. SDG 3 also

includes a target (Target 3.8) related to universal health coverage (UHC) in which TB is

explicitly mentioned.

1 United Nations. Sustainable Development Goals (https://sustainabledevelopment.un.org/topics/sustainabledevelopmentgoals,

accessed 2 August 2017). 2 Uplekar M, Weil D, Lonnroth K, Jaramillo E, Lienhardt C, Dias HM, et al. WHO’s new End TB Strategy. Lancet. 2015;385(9979):1799–

1801 (http:// www.sciencedirect.com/science/article/pii/ S0140673615605700?via%3Dihub, accessed 2 August 2017). 3 World Health Organization. Accelerating progress on HIV, tuberculosis, malaria, hepatitis and neglected tropical diseases: a new agenda for

2016–2030. Geneva: WHO; 2015 (http://www.who.int/about/structure/ organigram/htm/progress-hiv-tb-malaria-ntd/en/, accessed 21 June 2018).

http://www.sciencedirect.com/science/article/pii/

http://www.who.int/about/structure/



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Box No. 2.1

Sustainable Development Goal 3 and its 13 targets

SDG3: Ensure healthy lives and promote well-being for all at all ages

Targets

3.1 By 2030, reduce the global maternal mortality ratio to less than 70 per 100 000 live births

3.2 By 2030, end preventable deaths of newborns and children under 5 years of age, with all

countries aiming to reduce neonatal mortality to at least as low as 12 per 1000 live births and

under-5 mortality to at least as low as 25 per 1000 live births

3.3 By 2030, end the epidemics of AIDS, tuberculosis, malaria and neglected tropical diseases and

combat hepatitis, water-borne diseases and other communicable diseases

3.4 By 2030, reduce by one third premature mortality from non-communicable diseases through

prevention and treatment and promote mental health and well-being

3.5 Strengthen the prevention and treatment of substance abuse, including narcotic drug abuse and

harmful use of alcohol

3.6 By 2020, halve the number of global deaths and injuries from road traffic accidents

3.7 By 2030, ensure universal access to sexual and reproductive health-care services, including for

family planning, information and education, and the integration of reproductive health into national

strategies and programmes

3.8 Achieve universal health coverage, including financial risk protection, access to quality essential

health-care services and access to safe, effective, quality and affordable essential medicines and

vaccines for all

3.9 By 2030, substantially reduce the number of deaths and illnesses from hazardous chemicals and air,

water and soil pollution and contamination

3.a Strengthen the implementation of the World Health Organization Framework Convention on

Tobacco Control in all countries, as appropriate

3.b Support the research and development of vaccines and medicines for the communicable and non

communicable diseases that primarily affect developing countries, provide access to affordable

essential medicines and vaccines, in accordance with the Doha Declaration on the TRIPS Agreement

and Public Health, which affirms the right of developing countries to use to the full the provisions in

the Agreement on Trade-Related Aspects of Intellectual Property Rights regarding flexibilities to

protect public health, and, in particular, provide access to medicines for all

3.c Substantially increase health financing and the recruitment, development, training and retention of

the health workforce in developing countries, especially in least developed countries and small island

developing States

3.d Strengthen the capacity of all countries, in particular developing countries, for early warning, risk

reduction and management of national and global health risks



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2.3 The End TB Strategy

The overall goal is to “End the global TB epidemic”, and there are three high-level, overarching

indicators and related targets (for 2030, linked to the SDGs, and for 2035) and milestones (for

2020 and 2025). The three indicators are:

The number of TB deaths per year;

The TB incidence rate per year; and

The percentage of TB-affected households that experience catastrophic costs as a result

of TB disease.

The 2035 targets are a 95% reduction in TB deaths and a 90% reduction in the TB incidence rate,

compared with levels in 2015. The 2030 targets are a 90% reduction in TB deaths and an 80%

reduction in the TB incidence rate, compared with levels in 2015. The most immediate

milestones set for 2020, are a 35% reduction in TB deaths and a 20% reduction in the TB

incidence rate, compared with levels in 2015. The trajectories of TB incidence and TB deaths

that are required to reach these milestones and targets are shown in Figure 01.

Figure 01: Projected incidence and mortality curves that are required to reach End TB

Strategy targets and milestones, 2015–2035

Source: WHO Global Tuberculosis Report-2018



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The End TB Strategy at a glance (2016–2035) VISION A WORLD FREE OF TB

- zero deaths, disease and suffering due to TB

GOAL END THE GLOBAL TB EPIDEMIC

INDICATORS MILESTONES TARGETS

2020 2025 SDG 2030a End TB 2035

Reduction in number of TB deaths compared

with 2015 (%) 35% 75% 90%

95%

Reduction in TB incidence rate compared with

2015 (%)

20%

(<85/100

000)

50%

(<55/100

000)

80%

(<20/100

000)

90%

(<10/100

000)

TB-affected families facing catastrophic costs

due to TB (%) 0 0 0 0

PRINCIPLES

1. Government stewardship and accountability, with monitoring and evaluation

2. Strong coalition with civil society organizations and communities

3. Protection and promotion of human rights, ethics and equity

4. Adaptation of the strategy and targets at country level, with global collaboration

PILLARS AND COMPONENTS

1. INTEGRATED, PATIENT-CENTRED CARE AND PREVENTION

A. Early diagnosis of TB including universal drug-susceptibility testing, and systematic screening of contacts and

high-risk groups

B. Treatment of all people with TB including drug-resistant TB, and patient support

C. Collaborative TB/HIV activities, and management of co-morbidities

D. Preventive treatment of persons at high risk, and vaccination against TB

2. BOLD POLICIES AND SUPPORTIVE SYSTEMS

A. Political commitment with adequate resources for TB care and prevention

B. Engagement of communities, civil society organizations, and public and private care providers

C. Universal health coverage policy, and regulatory frameworks for case notification, vital registration, quality and

rational use of medicines, and infection control

D. Social protection, poverty alleviation and actions on other determinants of TB

3. INTENSIFIED RESEARCH AND INNOVATION

A. Discovery, development and rapid uptake of new tools, interventions and strategies

B. Research to optimize implementation and impact, and promote innovations

a Targets linked to the Sustainable Development Goals (SDGs)



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With 2015 marking the end of the MDGs and a new era of SDGs, as well as the last year of the

Stop TB Strategy before its replacement with the End TB Strategy, it was an ideal time to revisit

these three HBC lists. Following a wide consultation process, in 2015 WHO defined three HBC

lists for the period 2016–2020: one for TB, one for MDR-TB and one for TB/HIV. Three (viz.

Bangladesh, India and Pakistan) of eight Member States in the SAARC Region are belongings to

high TB and MDR-TB burden countries among 30 high burden countries. However, In SAARC

Region, only India belongs to TB, MDR-TB and TB/HIV Co-infection among 30 high burden

countries, which is shown in Figure 02.

Figure 02: Countries in the three high-burden country lists for TB, TB/HIV and MDR-TB

being used by WHO during the period 2016–2020, and their areas of overlap


2.4 Global Epidemiology

Worldwide, tuberculosis (TB) is one of the top 10 causes of death, and the leading cause from a

single infectious agent above HIV/AIDS); millions of people continue to fall sick with the

disease each year.

In 2017, TB caused an estimated 1.3 million deaths (range, 1.2–1.4 million) among HIV-



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negative people, and there were an additional 300 000 deaths from TB (range, 266 000–335 000)

among HIV-positive people. There were an estimated 10.0 million new cases of TB (range, 9.0–

11.1 million), equivalent to 133 cases (range, 120–148) per 100 000 population.

Globally in 2017, there were an estimated 558 000 new cases (range, 483 000–639 000) of

rifampicin resistant TB (RR-TB), of which almost half were in three countries: India (24%),

China (13%) and the Russian Federation (10%). Among RR-TB cases, an estimated 82% had

multidrug-resistant TB (MDR-TB).

Globally, 3.5% of new TB cases and 18% of previously treated cases had MDR/RR-TB, with the

highest proportions (>50% in previously treated cases) in countries of the former Soviet Union.

In 2017, the best estimate of the proportion of people with TB who died from the disease (the

case fatality ratio, CFR) was 16%, down from 23% in 2000. The CFR needs to fall to 10% by

2020 to reach the first milestones of the End TB Strategy.

.

Table 01: Global Epidemiological Burden of TB (2017)

TB Control Indicators Global

Estimated Population 7.5 billion

Estimated Incidence 10.0 million

(133 cases/100 000)

Estimated Deaths Due to TB 1.3 million

(17 cases/100 000)

Total cases notified 6.7 million

New and relapse notified cases 6.4 million

Treatment Success Rate (2015 cohort) 82%

Estimated MDR/RR- TB cases among notified pulmonary TB cases 0.33 million

Patients with Known HIV Status who are HIV Positive 0.46 million

Patients with Known HIV Status who are HIV Positive on ART 0.37 Million (84%)




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2.4.1 Estimates of TB incidence

Globally in 2017 there were an estimated 10 million incident cases of TB (range, 9 million to

11.1 million), equivalent to 133 cases per 100 000 population. Most of the estimated number of

cases in 2016 occurred in the WHO South-East Asia Region (44%). The 30 high TB burden

countries accounted for 87% of all estimated incident cases worldwide and eight of these

countries accounted for two thirds of the global total: India (27%), China (9%), Indonesia (8%),

the Philippines (6%), Pakistan (5%), Nigeria (4%), Bangladesh (4%) and South Africa (3%)

2.4.2 TB Mortality

Globally, the absolute number of deaths from TB among HIV-negative people has been

estimated to have fallen by 29% since 2000, from 1.8 million in 2000 to 1.3 million in 2017, and

by 5% since 2015 (the baseline year for targets set in the End TB Strategy). The number of TB

deaths among HIV-positive people has fallen by 44% since 2000, from 534 000 in 2000 to

300000 in 2017, and by 20% since 2015. The TB mortality rate (TB deaths among HIV-negative

people per 100 000 population per year) is falling at about 3% per year, and the best estimate for

the overall reduction during 2000–2017 is 42%.

Figure 03: Global trends in estimated TB incidence and mortality rates, 2000–2016. Shaded

areas represent uncertainty intervals.


2.4.3 Trend of Treatment Success Rate

The latest treatment outcome data show treatment success rates of 82% for TB (2016 cohort),

77% for HIV-associated TB (2016 cohort), 55% for MDR/RR-TB (2015 cohort) and 34% for

extensively drug-resistant TB (XDR-TB) (2015 cohort).



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Figure 04: Trend of Treatment success rate for New Smear Positive Cases (1995 - 2016)

Source: Global Tuberculosis Report, WHO-2018

2.4.4 Drug-resistant TB

Globally, 160 684 cases of multidrug-resistant TB and rifampicin-resistant TB (MDR/RR-TB)

were notified in 2017 (up from 153 119 in 2016), and 139 114 cases were enrolled in treatment

(up from 129 689 in 2016).

There are also large gaps in detection and treatment of MDR/RR-TB and HIV-associated TB. In

2017, the number of MDR/RR-TB cases started on treatment was only 25% of the estimated

incidence of 558 000 cases, while the number of notified HIV-positive TB cases was only 51%

of the estimated 920 000 new cases of TB among people living with HIV.



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3. BURDEN OF TUBERCULOSIS IN SAARC REGION ---------------------------------------------------------------------------------------------------------------------

3.1 SAARC Epidemiology

The SAARC region, with an estimated annual incidence of 3.7 million TB cases equivalent to

212 cases per 100 000, carries 37% of the global burden of TB incidence (Table 02). Estimated

incidence by age and sex has shown in table 03.Three of eight Member States in the SAARC

Region are high TB and MDR-TB burden countries among 30 high burden countries. India

accounting for 27% of the world’s TB Cases. An estimated 0.5 million (31 cases per 100 000)

TB deaths in the region, however, India accounted 32 % of Global TB deaths.

Table 02: Estimates of the burden of diseases caused by TB in the SAARC Region 2017

Country

Population

('000)*

Incidence**

Mortality (Excluding

HIV)**

Number ('000) Rate***

Number

('000) Rate ***

Afghanistan 36000 67 189 10 29 (17-43)

Bangladesh 165000 360 221 66 40 (23-52)

Bhutan 779 0.8 178 0.03 20 (13-28)

India 1339000 2790 211 420 32 (28-33)

Maldives 402 0.13 39 0.016 3.7 (3.4-4.1)

Nepal 29000 45 152 6.6 23 (16-30)

Pakistan 197000 518 268 54 27 (21-34)

Sri Lanka 21000 13 65 1.2 6 (4.3-8.0)

Total 1788181 3794 212 558 31 Source: *Global Tuberculosis Report 2018, ** data taken from report sent by member states and Global tuberculosis report

2018, *** Rates are per 100 000 population

Table 03: Estimated TB incidence by age and sex (thousands) *, 2017

Country

Females

Total

Males

Total 0-14 years >14 years

0-14

years >14 years

Afghanistan 3.5 31.0 34.5 3.9 29.0 32.9

Bangladesh 17.0 118.0 135.0 18.0 212.0 230.0

Bhutan 0.05 0.35 0.40 0.06 0.63 0.69

India 107.0 847.0 954.00 117.0 1670.0 1787.0

Maldives 0.0 0.1 0.1 0.0 0.1 0.1

Nepal 2.3 14.0 16.3 2.5 26.0 28.5

Pakistan 27.0 207.0 234.0 30.0 261.0 291.0

Sri Lanka 0.7 4.1 4.8 0.8 7.9 8.7

Total (in

million) 0.2 1.2 1.4 0.2 2.2 2.4 *ranges represents uncertainty intervals

Source: *Global Tuberculosis Report 2018



Page 13

3.2 Notifications and Treatment Success

A total 2.6 million TB cases were notified in 2017 in the SAARC region (Table 04). An

increasing trend of total case notification has shown in figure 05. The treatment success rate for

new smear positive cases were 75% (2016 cohort) in the SAARC Region (Figure 06).

Table 04: TB Case notifications (2017) and Treatment Success Rate (2016 Cohort) in

SAARC Region

Country Population ('000)

Total Case

notified

Total (New and

relapse cases)

Treatment

Success (%)

Afghanistan 36000 47406 46640 93

Bangladesh 165000 244201 242639 95

Bhutan 779 881 865 95

India 1339000 1908371 1786681 69

Maldives 402 136 136 83

Nepal 29000 31764 31064 91

Pakistan 197000 368897 359224 92

Sri Lanka 21000 8511 8314 86

Total 1788181 2610167 2475563 75 Source: Data taken from report sent by member states and WHO Global tuberculosis report 2018

Figure 05: Trend of total case notified in the SAARC Region (2010-2017)

Source: SAARC Epidemiological reports & Global tuberculosis report 2018



Page 14

Figure 06: Trend of Treatment success rate for new smear positive and relapse cases

(2000-2016)

Source: WHO Global TB Report-2018, SAARC Epidemiological Response on Tuberculosis-2017

3.3 Drug Resistance TB

In the year 2017, the SAARC region has 101198 total number of an estimated MDR/RR-TB

cases among notified pulmonary TB cases. In the Region, laboratory confirmed cases in the same

year were 43691 MDR/RR-TB cases and 2802 XDR-TB cases. However, 40661 MDR/RR-TB

and 2933 XDR-TB patients started on treatment (Table 05).

Table 05: Estimates of Drug-resistant TB care in the SAARC Region, 2017

Country

Estimated

MDR/RR-TB

cases among

notified

pulmonary TB

cases (Total

Number)***

% of TB cases with

MDR-TB Laboratory confirmed

cases

Patients started on

treatment****

New Previously

Treated

MDR/RR-

TB

XDR-

TB

MDR/RR-

TB

XDR-

TB

Afghanistan 1700 3.7 21 279 5 198 5

Bangladesh 3000 1.6 29 944 6 920 6

Bhutan 50 11 18 60 0 60 0

India 84000 2.8 12 39009 2650 35950 2838

Maldives 2 1.7 18 1 0 1 0

Nepal 900 2.2 15 533 13 429 19

Pakistan 11499 3.7 16 2840 128 3081 65

Sri Lanka 47 0.54 3.1 25 0 22 0

Regional 101198 43691 2802 40661 2933 *** Includes cases with unknown previous TB Treatment history

****Includes patients diagnosed before 2016 and patients who were not laboratory- confirmed

Source: Data taken from report sent by member states and WHO Global tuberculosis report 2018



Page 15

3.4 TB/HIV Co-infection

In 2017, the region has 33404 TB Patients with known HIV status, among them 29074 (87%)

were on Antiretroviral Therapy. India accounts 32932 TB patients with known HIV status, 87%

patients were on ART, however, only Bhutan had provided 100% ART to TB patients with

Known HIV status in the region. In the SAARC region 10% Children (age <5) house hold contacts

of bacteriologically-confirmed TB cases on Isoniazid treatment (Table 06)

Table 06: Estimates of TB/HIV case in new and relapse TB patients, 2017

Country

Patients with known HIV

status who are HIV positive patients on

Antiretroviral Therapy

(ART)

Children (age <5) house

hold contacts of

bacteriologically-

confirmed TB cases on

preventive treatment

Number % Number % %

Afghanistan 7 <1 3 43 >100

Bangladesh 89 2 84 94 21

Bhutan 5 <1 5 100 NA

India 32932 3 28651 87 11

Maldives NA NA NA NA NA

Nepal 221 1 206 93 1.1

Pakistan 121 <1 97 80 NA

Sri Lanka 29 <1 28 97 43

Regional 33404 29074 87 - Source: Data taken from report sent by member states and WHO Global tuberculosis report 2018

The estimated Population of SAARC region in year 2017 was 1.78 billion which 24% of global

Population. Table 07 shows the comparison between global and SAARC Region on TB indicator

for the year 2017.



Page 16

Table 07: Global vs. SAARC Region on TB Indicators, 2017

TB Control Indicators Global SAARC

% of

Global

Estimated Population 7.5 billion 1.78 billion 24

Estimated Incidence 10.0 million 3.7 million

37

(133 cases/100

000)

(212 cases/100

000)

Estimated Deaths Due to TB 1.3 million 0.5 million

43 (17 cases/100 000) (31 cases/100 000)

Total cases notified 6.7 million 2.6 million 39

New and relapse notified cases 6.4 million 2.4 million 38

Treatment Success Rate (2015

cohort) 82% 75% -

Estimated MDR/RR- TB cases

among notified pulmonary TB cases 0.33 million 0.1 million 30

Patients with Known HIV Status

who are HIV Positive 0.46 million 0.03 million 6.5

Patients with Known HIV Status

who are HIV Positive on ART 0.37 Million (84%) 0.029 Million (87%) 8 Source: Data taken from report sent by member states and Global tuberculosis report 2018



Page 17

4. PROGRESSES ON TB CONTROL IN SAARC MEMBER STATES

------------------------------------------------------------------------------------------------------------

AFGHANISTAN MALDIVES

BANGLADESH NEPAL

BHUTAN PAKISTAN

INDIA SRI LANKA



Page 18

Islamic Republic of Afghanistan is one of the eight countries of the SAARC Region.

Afghanistan officially the Islamic Republic of Afghanistan, is a landlocked country located

within South Asia and Central Asia. It has Population of approximately 36 million (WHO Global

Tuberculosis Report-2018). It is bordered by Pakistan in the south and east; Iran in the west;

Turkmenistan, Uzbekistan, and Tajikistan in the north; and China in the far northeast.

TB Epidemiology

Tuberculosis is a major health problem in Afghanistan. Despite many challenges, the National

Tuberculosis Programme (NTP) has chosen to address the problem with interventions that are

proving successful. Earlier Afghanistan was in WHO 22 high TB burden countries list. But in

2015 WHO has removed Afghanistan from their high burden TB countries list.

In Afghanistan, an estimated annual incidence 67000 (CI: 43000-96000) TB cases equivalent to

189 cases per 100,000 populations and 10000 TB mortality equivalents to 29 cases per 100,000

populations in 2017. The TB case notifications in the year 2017 were 47406 and 93% treatment

success were registered in the year (2016 cohort). In year 2017, an estimated MDR/RR- TB

cases among notified pulmonary TB cases were 1700 (CI: 1000-2300) and the laboratory

confirmed cases on MDR/RR-TB and XDR-TB were 279 and 5 cases respectively. There were 7

TB patients with known HIV status who are HIV positive among them 3 patients (43%) were on

ART.

Major Achievements

NTP Afghanistan with the support of SAARC (STAC) assessed the effectiveness of

extending the active screening approaches at doorsteps through the operational research

“Additional Yield of Active TB Case Finding through Household Survey in Kabul City”

Strategic plan developed for 2017 – 2021

AFGHANISTAN



Page 19

Political commitment to DOTS:

Donors supports ensured (GF, JICA for anti-TB medicine and CTB/USAID for

improved TB control procedures beside government contribution to TB control in

the form of co-financing)

National TB guidelines/SOPs revised according to latest WHO recommendations and

disseminated nationally

Widest coverage of DOTS ensured and community based DOTS was initiated

MDR-TB management commenced and successful implementation ensured with

expansion to major provinces

CDR increased annually and sustained accordingly:71% (2017)

Challenges

Programmatic:

Low TB case notification (29% missing cases)

In sufficient diagnostic and treatment facilities for MDR-TB across the country

Within health system

Unreal integrated TB care services

Lower commitment from the health staff

Missed opportunities within health system

Within the community

Lower knowledge about TB in the community

Stigma against the disease

Outside of the system

Security Problem

Geographical limitations



Page 20

New Initiatives:

Introducing of Gene Xpert for diagnosis of MDR – TB

TB Screening among IDPs and prisoners by digital mobile x-ray

Future Plans:

Expand MDR TB Management

Promote New Technology in line with WHO recommendation (Gene X-pert)

Promote and sustain TB case findings (active and passive)

Addressing latent TB ( contact investigation and INH preventive therapy )



Page 21

Graphical presentations, Afghanistan

Source: Global Tuberculosis Report-2014 & 2015

Trend of incidence and Mortality (2005-2017)

20

05

20

10

20

13

20

14

20

15

20

16

20

17

Mortality Rate 45 39 42 44 37 33 29

Incidance Rate 189 189 189 189 189 189 189

020406080100120140160180200

05

101520253035404550

Incid

en

ce R

ate

/10

0 0

00

po

pn

Mo

rta

lity

Ra

te

Trend of Treatment success rate for new & relapse cases

(2000 - 2016)

Trend of TB case notifications (new and relapse)

2000 - 2017

Estimated TB incidence by age and sex, 2017

Source: WHO Global Tuberculosis Report-2018, SAARC

Epidemiological Response on Tuberculosis -2017

Source: WHO Global Tuberculosis Report- 2018







Page 22

TB Epidemiology 2017, Afghanistan

Population (2017) 36 million

Estimates of TB burden * 2017

Number

(thousands)

Rate (per 100 000

population)

Mortality (excludes HIV+TB) 10 (6-15) 29 (17-43)

Mortality (HIV+TB only) 0.064 (<0.01-0.17) 0.18 (0.03-0.47)

Incidence (includes HIV+TB) 67 (43-96) 189 (122-270)

Incidence (HIV+TB only) 0.21 (0.14-0.3) 0.6 (0.39-0.86)

Incidence (MDR/RR-TB)** 3.2 (1.5-5.5) 9 (4.3-15)

Estimated TB incidence by age and sex (thousands)*, 2017

0-14 years >14 years Total

Females 3.5 (3.2-3.9) 31 (23-39) 34 (25-44)

Males 3.9 (3.5-4.3) 29 (22-36) 33 (24-42)

Total 7.4 (6.5-8.4) 60 (38-82) 67 (43-96)

TB case notifications, 2017

Total cases notified 47406

Total new and relapse 46640

-% tested with rapid diagnostics at time of diagnosis

-% with known HIV status 48%

- % pulmonary 73%

- % bacteriologically confirmed among pulmonary 61%

Universal Health Coverage and Social protection

TB treatment coverage (notified/estimated incidence), 2017 70% (49-110)

TB cases fatality ratio (estimated mortality/estimated incidence), 2017 0.16 (0.08-0.26)

TB/HIV Care in new and relapse TB

patients, 2017 Number %

Patients with known HIV status who are HIV positive 7 <1%

- On antiretroviral therapy 3 43%

Drug- resistant TB care, 2017 New cases

Previously treated

cases Total Number***

Estimated MDR/RR-TB cases among

notified pulmonary TB cases 1700 (1000-2300)

Estimated % of TB cases with

MDR/RR-TB 3.7% (2-5.9) 21% (15-27)

% notified tested for rifampicin

resistance 6% 95% 5251

MDR/RR-TB cases tested for

resistance to second line drugs 279

Laboratory confirmed cases MDR/RR-TB: 279 XDR-TB:5

Patients started on treatment**** MDR/RR-TB: 198 XDR-TB:5

Treatment success rate and cohort size Success Cohort

New and relapse cases registered in 2016 93% 40287

Previously treated cases, excluding relapse, registered in

2016 90% 568

HIV-positive TB cases, all types, registered in 2016 0% 1



Page 23

MDR/RR-TB cases started on second line treatment in

2015 64% 83

XDR-TB cases started on second-line treatment in 2015 0

TB Preventive treatment, 2017

% of HIV+ people (newly enrolled in care) on preventive treatment 4%

% of Children ( aged <5) household contacts of bacteriologically- confirmed TB

cases on preventive treatment >100%

* Ranges represent uncertainty intervals

** MDR is TB resistant to rifampicin and isoniazid; RR is TB resistant to

rifampicin

*** Includes cases with unknown previous TB Treatment history

****Includes patients diagnosed before 2017 and patients who were not laboratory- confirmed Source: WHO Global Tuberculosis Report-2018



Page 24

People's Republic of Bangladesh is a country in South Asia. It is bordered by India to its west,

north and east; Myanmar (Burma) to its southeast; and is separated from Nepal and Bhutan by

the Chicken's Neck corridor. To its south, it faces the Bay of Bengal. The total area of the

country is 147,570 km2.

Population of Bangladesh is 165 million (WHO Global Tuberculosis

Report-2018) and it is one of the most densely populated countries in the world.

TB Epidemiology

Bangladesh is among countries with the high burden of TB and MDR-TB. The estimated

mortality and incidence rates of all forms of tuberculosis were 40 (CI: 23-52) and 221 (CI: 161-

291) per 100 000 population respectively in 2017.WHO has estimated 360000 (CI: 265000-

479000) incident cases in 2017.

Total 244201 notified new and relapse cases were detected in 2017, among them total new and

relapse cases were 242639.

The treatment success rate among new and relapse cases is above 90% since 2007, and it was

95% in 2016 cohort. However, in 2016 cohort, the treatment success rate among HIV positive

TB cases was only 49% and MDR/RR cases started on second line treatment in 2015 showed a

78% treatment success rate.

Achievements

Research of “Comparative evaluation of treatment for MDR TB with and without co-

morbidity a retrospective analysis in Bangladesh” has jointly completed by NTP

Bangladesh and SAARC TB and HIV/AIDS Centre, Nepal.

Xpert MTB/RIF was first introduced in Bangladesh in March 2012 with the support of

the TB CARE II project. Till December 2016, a total of 56 Xpert MTB/ RIF machines

were functioning at different settings in the country, including six machines in Dhaka

city.

Implementation of New Drugs; bedaquiline & delamide

Increased case detection

Treatment success rate 95% for DS TB and MDR TB treatment success rate 76% for long

BANGLADESH



Page 25

regimen and 83 % for short regimen.

Countrywide implementation of Short Regimen of MDR treatment

Expansion of Gene Expert Sites (51 Sites by 2017, 193 sites till date )

Major Challenges:

• Slow decline of Annual Incidence

• Recent cross border migration Population in Coxbazar

• Management of Child TB and MDR –TB

• Unchanged annual incidence since 1990

• Identification of 33% missing TB cases

• Identification of 80% missing MDR/RR TB cases

• Identification of missing child TB cases ( currently 4.32% of notified TB cases)

• Urban TB

• Insufficient number of latest diagnostics (e.g. Xpert, LPA)

• Infection Control

• Human resource

• Less involvement of Private Sector

• Mandatory notification

• Engagement of Private Sectors in TB Program Management and Reporting

Future Plan

Further expansion of Gene Expert Sites.

Implement mandatory notification

Increase case detection

Expand PMDT sites, shorter regimen and new drugs

Updating guidelines

Specially designed program for urban area

Scale up PPM activity

Capacity building with special attention to DR-TB, Child TB, PSM

Ensure the long-term availability of required funding;

o Increase GOB contribution

Strengthening Supervision and monitoring



Page 26

Graphical presentations, Bangladesh


Case detection rate and Treatment success rate for new

smear positive cases (2000 - 2016)

Trend of TB case notification (new and relapse)

2000 – 2017






Epidemiological Response on Tuberculosis -2017 Source: WHO Global Tuberculosis Report-2018, SAARC




Page 27

TB Epidemiology 2017, Bangladesh



Number

(thousands)

Rate (per 100 000

population)

Mortality (excludes HIV+TB)a 66 (38-85) 40 (23-52)

Mortality (HIV+TB only) 0.17 (0.085-0.29) 0.11 (0.05-0.18)

Incidence (includes HIV+TB)a 360 (265-479) 221 (161-291)


Incidence (MDR/RR-TB)** 8.4 (3.8-15) 5.1 (2.3-9)



Females 17 (16-18) 118 (98-137) 134 (110-158)

Males 18 (17-19) 212 (164-259) 230 (176-284)

Total 35 (32-38) 329 (237-421) 364 (265-479)




-% tested with rapid diagnostics at time of diagnosis <1%


- % pulmonary 81%





TB/HIV Care in new and relapse TB patients, 2017 Number %

Patients with known HIV status who are HIV positive 89 2%



Previously

treated cases Total Number***

Estimated MDR/RR-TB cases

among notified pulmonary TB

cases 5800 (3800-7800)


MDR/RR-TB 1.6% (0.74-2.8) 29% (24-35)



MDR/RR-TB cases tested for resistance to second line drugs 362




New and relapse cases registered in 2016a 95% 222252


2016 86% 1669


MDR/RR-TB cases started on second line treatment in 2015 78% 880



Page 28



% of HIV+ people (newly enrolled in care) on preventive

treatment

% of Children ( aged <5) household contacts of

bacteriologically- confirmed TB cases on preventive

treatment 21% (19-23)



rifampicin


****Includes patients diagnosed before 2017 and patients who were not

laboratory- confirmed

Source: WHO Global Tuberculosis Report-2018, a: Data sent by NTP Bangladesh



Page 29

Bhutan officially the Kingdom of Bhutan, is a landlocked country in South Asia at the eastern

end of the Himalayas. It is bordered to the north by China and to the south, east and west

by India. To the west, it is separated from Nepal by the Indian state of Sikkim, while farther

south it is separated from Bangladesh by the Indian states of Assam and West Bengal. Bhutan's

capital and largest city is Thimphu. It has a land area of 38,394 square kilometers and the altitude

varying from 180m to 7,550 m above sea level. The total Population of Bhutan was estimated to

be 779666 (Data sent by Bhutan NTP-2018) in the year 2017.

TB Epidemiology

National Tuberculosis Control Program under the Department of Public Health started in the

year 1986. NTCP is responsible for programming, planning, resource mobilization, monitoring

and evaluation. National Referral/ Regional Referral and District hospitals diagnose and start the

treatment for TB. The health workers in the basic health units report cases, follow up and refer

TB suspects to the district hospitals for confirmation. In 1991, a tuberculin survey measured the

annual risk of tuberculosis infection to be 1.5%. Bhutan piloted Short Course Chemotherapy

(SCC) in three districts in 1994 and was implemented nationwide in the same year. In 1997 the

Directly Observed Treatment Short Course (DOTS) strategy was adopted nationwide.

The estimated mortality and incidence rates of all forms of tuberculosis were 20 (CI: 13-28) and

178 (CI: 137-226) per 100 000 population respectively in 2017.WHO has estimated 864 (CI:

830-1400) incidence cases in 2017. Total 881 notified new and relapse cases were detected in

2017, among them the notified new and relapse cases were 865.

The treatment success rate among new and relapse cases is above 91% since 2005, and it was 95

% in 2016 cohort. MDR/RR-TB cases started on second line treatment in 2015 showed a 91%

treatment success rate.

BHUTAN



Page 30

Achievements

Committed and motivated health staff at central- and peripheral-level care and

prevention delivery points

General awareness from clinicians and providers at health facilities about and

concerning epidemiologic trends (increased extra-pulmonary (EPTB) and multidrug

resistant TB (MDR TB)

Excellent recording and reporting system through TB-ISS, reduced recording burden

and paperwork

Continued support from Royal Government of Bhutan to sustain health financing –

including the procurement of vital anti-tuberculosis drugs.

Study to determine causality of EPTB in Bhutan funded by SAARC TB and

HIV/AIDS Centre

Challenges:

The Kingdom of Bhutan has a relatively small population living in remote areas

Substandard implementation and quality for directly observed therapy (DOT) service

delivery

Infection control practices are poor, inadequate, and poses a sustained and dangerous

threat to transmission in the community and to Bhutan’s health care delivery workforce

Prolonged delays diagnosis (shipment of sputum samples from peripheral microscopy

centers to National Tuberculosis Reference Laboratory (NTRL); affecting the quality of

culture and drug susceptibility testing (DST)

Unstable internet connectivity to optimize the utilization of TB-ISS

Future Plan

Improving Tuberculosis case finding

Improving Quality of tuberculosis diagnosis

Improving Anti-tuberculosis medicine and supply management streamline

Improving Human resource capacity and development

Improving Clinical and programmatic management of tuberculosis cases (non-drug

resistant)

Improving Clinical and programmatic management of drug-resistant cases

Improving Surveillance: recording and reporting

Improving Tuberculosis and HIV programme integration

Improving Pediatric tuberculosis

Improving Extra pulmonary tuberculosis

Community engagement and ACSM



Page 31

Operational research and development

National TB Prevalence Survey

New initiatives/ Best practices:

Follow up of TB patients through mobile phone has been initiated through the support of

TB NFM grant.

Line Probe Assay established in Royal Centre for Disease Control (RCDC)

Expansion of rapid diagnostic tool to other sites

Plan to establish SL DST in RCDC

Adopt any newer diagnostic tools as per WHO recommendations



Page 32

Graphical presentations, Bhutan


Treatment success rate for new smear positive cases

(2000 - 2016)


2000 - 2017





Source: Data sent by NTP Bhutan-2018, SAARC Epidemiological

Response on Tuberculosis -2017 Source: WHO Global Tuberculosis Report-2018, SAARC




Page 33

TB Epidemiology 2016, Bhutan

Population (2017)a 779666

Estimates of TB burden * 2017 Number (thousands)

Rate (per 100 000

population)

Mortality (excludes HIV+TB)a 0.03 20 (CI:13-28)

Mortality (HIV+TB only) <0.01 (<0.01-<0.01) 0.16 (0.11-0.22)

Incidence (includes HIV+TB)a 0.8 (CI: 0.8-1.4) 178 (CI:137-226)

Incidence (HIV+TB only) <0.01 (<0.01-0.01) 0.77 (0.5-1.1)

Incidence (MDR/RR-TB)** 0.18 (0.12-0.25) 22 (15-31)



Females 0.05 (0.047-0.053) 0.35 (0.32-0.4) 0.4 (0.34-0.46)

Males 0.056 (0.053-0.059) 0.63 (0.51-0.75) 0.68 (0.55-0.82)

Total 0.11 (0.098-0.11) 0.98 (0.74-1.2) 1.1 (0.83-1.4)


Total cases notifieda 881


-% tested with rapid diagnostics at time of diagnosis 51%


- % pulmonary 59%





TB/HIV Care in new and relapse TB patients,

2017 Number %

Patients with known HIV status who are HIV

positive 5 <1%


Drug- resistant TB care,

2017 New cases

Previously treated


Estimated MDR/RR-TB cases among notified pulmonary TB cases 81 (57-110)

Estimated % of TB cases

with MDR/RR-TB 13% (10-17) 33% (7.5-70) -

% notified tested for

rifampicin resistance 55% 70% 493






Previously treated cases, excluding relapse,

registered in 2016 100% 6


MDR/RR-TB cases started on second line treatment

in 2015 91% 47

XDR-TB cases started on second-line treatment in

2015 0




Page 34

% of HIV+ people (newly enrolled in care) on

preventive treatment -



treatment -



rifampicin


****Includes patients diagnosed before 2017 and patients who were not

laboratory- confirmed

Source: WHO Global Tuberculosis Report-2018, a: data sent by NTP Bhutan-2018



Page 35

India, officially the Republic of India is a country in South Asia. It is the seventh-largest country

by area, the second-most populous country with 1339 million people (WHO Global Tuberculosis

Report-2018), and the most populous democracy in the world. The land area is 3,287,263 square

kilometers. Bounded by the Indian Ocean on the south, the Arabian Sea on the south-west, and

the Bay of Bengal on the south-east, it shares land borders with Pakistan to the

west; China, Nepal, and Bhutan to the north-east; and Myanmar and Bangladesh to the east. In

the Indian Ocean, India is in the vicinity of Sri Lanka and the Maldives; in addition,

India's Andaman and Nicobar Islands share a maritime border with Thailand and Indonesia.

TB Epidemiology

In 2017, an estimated 2.79 (CI: 1.8-3.7) million cases occurred and 0.42 (CI: 0.38-0.44) million

people died due to TB. The estimates of TB for India has been revised upwards based on the

newer evidences gained. This apparent increase in the disease burden reflects the incorporation

of more accurate data. With backward calculations, both tuberculosis incidence and mortality

rates are decreasing from 2000 to 2017.

The incidence of TB has reduced from 289 per lakh per year in 2000 to 211 per lakh per year in

2017 and the mortality due to TB has reduced from 56 per lakh per year in 2000 to 32 per lakh

per year in 2017. Moreover, these revisions are interim in nature, with further changes likely

when India conducts its first national tuberculosis prevalence survey in 2017–18.

Achievements

Annual TB notification rate of TB patients in India has increased to 144 cases / lakh

population in 2017 as compared to 135 in 2016

3,90,154 TB patients were notified from private sector in 2017 as compared to 3,31,909

in 2016

Active case finding Targeted to reach 8 crore vulnerable population mapped in 378

districts in 2017

TrueNat – an indigenous rapid molecular test was tested for feasibility of implementation

in the country

Daily Regimen for treatment of drug sensitive TB patients has been scaled up across the

INDIA



Page 36

country

Bedaquiline has been rolled out at 21 DR-TB Centres under programmatic settings

National Strategic Plan for 2017-25 has been prepared

Mobile TB Diagnostic vans were provided in tribal area for case detection enhancement

TB Diabetes and TB Tobacco collaborative framework was launched

Guidelines on TB Nutrition was initiated.

New Initiatives:

Active case finding among vulnerable and marginalized population to increase the case

detection

TrueNat – an indigenous rapid molecular test has been used for testing feasibility at

peripheral laboratory to replace microscopy

Challenges:

Sub-optimal involvement of private sector

Treatment outcome of Drug Resistant TB

Reaching the unreached – Slums, Tribal, vulnerable

Co-morbidities – HIV, Diabetes

Issues of poverty, nutrition, overcrowding

Lack of awareness and poor health seeking behaviour lead to delay in diagnosis

Wide geographical variation in the epidemic

Future Plans:

Nutritional support for all TB patients through provision of 500 INR monthly direct

benefit transfer

Joint Effort for Elimination of Tuberculosis (JEET) Project launched on 15th May 2018

for intensified efforts and linkage of free diagnostic and treatment services in private

sector in 45 large cities and 348 districts

Engagement with IMA for sensitization activities in 1000 district level branches

Expansion of CBNAAT laboratories to 1135 from 651 in 2017

Operationalization of Universal drug susceptibility implementation in entire country

Expansion of newer drug regimen including Bedaquiline and Delamanid and shorter

regimen across the country



Page 37

Graphical presentations, India



(2000 - 2016)


2000 - 2017


Source: WHO Global Tuberculosis Report-2018 & SAARC

Epidemiological Response on Tuberculosis-2017


Source: Data sent by NTP India-2018, SAARC Epidemiological

Response on Tuberculosis -2017 Source: WHO Global Tuberculosis Report-2018 & SAARC




Page 38

TB Epidemiology 2017, India


Estimates of TB burden * 2017 Number (thousands)

Rate (per 100 000

population)

Mortality (excludes HIV+TB)a 420 (CI: 380-440) 32 (CI: 28-33)

Mortality (HIV+TB only) 11 (6.5-16) 0.79 (0.48-1.2)

Incidence (includes HIV+TB)a 2790 (CI: 1870-3770) 211 (CI: 140-281)

Incidence (HIV+TB only) 86 (57-120) 6.4 (4.3-9.0)

Incidence (MDR/RR-TB)** 135 (78-208) 10 (5.6-16)



Females 107 (100-114) 847 (684-1010) 954 (759-1150)

Males 117 (109-126) 1670 (1220-2120) 1780 (1290-2280)

Total 224 (202-247) 2510 (1680-3350) 2740 (1870-3770)






- % pulmonary 85%








Drug- resistant TB care, 2017 New cases Previously treated cases Total Number***




MDR/RR-TB 2.8 % (2-3.5) 12 % (10-13)



MDR/RR-TB cases tested for resistance to second line

drugs 26832






2016 70% 172282



2015 46% 26966

XDR-TB cases started on second-line treatment in 2015 28% 2130



treatment 10%



Page 39



treatment 11 % (10-12)


** MDR is TB resistant to rifampicin and isoniazid; RR is TB resistant to rifampicin


****Includes patients diagnosed before 2017 and patients who were not laboratory-

confirmed

Source: WHO Global Tuberculosis Report-2018, a: data sent by NTP India-2018



Page 40

Republic of Maldives is an island country formed by a number of natural atolls and a few islands

in the Indian Ocean consisting of a double chain of twenty-six atolls, The islands are located

southwest of the Indian subcontinent stretching 860 km north to south and 80 – 129 km east to

west. The population of Maldives in year 2017 was 402071 (Data sent by Maldives, NTP-2018).

The economy of the Maldives depends mainly on tourism, fishing trade, shipping and

construction. Resort islands and modern hotels in Male are the main attractions for the increasing

numbers of tourists.

TB Epidemiology

With increased case notification and treatment coverage, there is high political commitment

towards ending TB in the country. Diagnosis and treatment guidelines adopted by the NTP are in

line with WHO recommended standards. New and more convenient paediatric formulation for

childhood TB cases introduced. Gene Xpert testing services initiated. Quality assured anti-TB

drugs are procured using domestic funding. All TB services are provided free of charge. Case

detection among risk groups (prisons, home for people with special needs, migrants)

strengthened through collaboration between related agencies.

The estimated mortality and incidence rates of all forms of tuberculosis were 3.7 (CI: 3.4-4.1)

and 39 (CI: 30-49) per 100 000 population respectively in 2017.WHO has estimated 136 (CI:

130-220) incidence cases in 2017. Total 136 notified new and relapse cases were detected in

2017.

Achievements

The Government of Maldives is committed to support the program.

Most activities for the program including drug purchase are undertaken through state

funding with limited external support through WHO

Availability of quality assured anti-TB drugs from Global Drug Facility is being

maintained

MALDIVES

http://en.wikipedia.org/wiki/Maldives

http://en.wikipedia.org/wiki/Atolls_of_the_Maldives

http://en.wikipedia.org/wiki/Indian_Ocean

http://en.wikipedia.org/wiki/Archipelago

http://en.wikipedia.org/wiki/Atolls_of_the_Maldives

http://en.wikipedia.org/wiki/Atoll



Page 41

Continuous allocation of funds by the government for the procurement of anti-TB drugs

Direct Observation of the treatment for full course of treatment is in place due to the well

functional DOT centers at all health facilities.

For the last decade, number of notified case has been steadily decreasing.

Screening of all HIV positives cases for active TB is in place in collaboration with the

HIV program since 2003.

National Strategic plan to end TB in Maldives 2018-2022 been launched

Challenges

Still lacks human and financial capacity to implement, fully control and coordinate all TB

related activities in the country.

No capacity is available in country for DST: no adequate system of sputum transport has

been established with external TB laboratory for DST for diagnoses as well as for follow

up for X/MDR patients.

Inadequate levels of collaboration between all care-providers and the National TB

program.

There are no specific treatment facilities for patients with a high default risk.

Lack of human resources and funds

Future Plans

Implementation of WHO Biennium 2018/2019 activities.

Working towards implementing strategies planned to END TB in Maldives by 2022.

Formation National Steering Committee and Technical Working group is also in

progress.

New Initiatives/Best Practices

Practical Approach to lung Health guideline has been developed and has to be endorsed.

Developed and finalized a contact screening protocol and is being implemented.

Develop and finalized MDRTB case management guideline.

Develop and finalized TB case management Guideline.

Maldives has successfully adopted WHO DS TB and DR TB guide line. Technical

discussion is planned to incorporate new available drugs.

Developed and launched a national strategic plan to end TB in Maldives 2018-2022.



Page 42

Graphical presentations, Maldives



(2000 - 2017)


2000 - 2017






Epidemiological Response on Tuberculosis-2017 Source: WHO Global Tuberculosis Report-2018 & SAARC




Page 43

TB Epidemiology 2017, Maldives

Population (2017) 402071


Number

(thousands)

Rate (per 100

000 population)

Mortality (excludes HIV+TB) 0.016 (0.015-0.018) 3.7 (3.4-4.1)

Mortality (HIV+TB only) 0 0

Incidence (includes HIV+TB) 0.17 (0.13-0.22) 39 (30-49)

Incidence (HIV+TB only) 0 0

Incidence (MDR/RR-TB)** <0.01 (0-0.012) 0.91 (0.08-2.7)



Females <0.01 (<0.01-<0.01) 0.055 (0.047-0.062)

0.063 (0.053-

0.072)

Males <0.01 (<0.01-<0.01) 0.099 (0.08-0.12) 0.11 (0.086-0.13)

Total 0.017 (0.015-0.018) 0.15 (0.12-0.19) 0.17 (0.13-0.22)






- % pulmonary 72%









Previously treated

cases

Total

Number***




MDR/RR-TB 1.7 (0.04-9.1) 18% (11-26)


resistance 56% 75




Treatment success rate Success Cohort


Previously treated cases, excluding relapse, registered in 2016


MDR/RR-TB cases started on second line treatment in 2015 0% 1




Page 44


% of HIV+ people (newly enrolled in care) on preventive treatment 0%

% of Children ( aged <5) household contacts of bacteriologically-

confirmed TB cases on preventive treatment 0%








Page 45

Nepal is a landlocked country and is located in the Himalayas and bordered to the north by the

China and to the south, east, and west by the India. Nepal is divided into 7 states and 77 districts.

It has an area of 147,181 square kilometers and Population of approximately 29 million (WHO

Global Tuberculosis Report-2018). The urban Population is largely concentrated in the

Kathmandu valley.

TB Epidemiology

Tuberculosis (TB) is still a major public health problem in Nepal. In 2017 WHO has estimated

45000 (CI: 39000-50000) incident cases with the rate of 152 (CI: 134-172) per 100,000

population)). At the same year mortality was 6600 (CI: 4700-8900) with the rate of 23 (CI: 16-30

per 100,000 population). In 2017, total of 31764 new and relapse cases of TB were registered.

Among them, 77% were pulmonary bacteriological confirmed (PBC).

Key Constraint & Challenges

The Nepal NTP has regularly been facing several challenges and constraints, which influence

inability to expand and sustain the vision of the programme. Following are the key challenges

and constraints faced by the NTP in order to reach intended goals and targets of the programme

in last fiscal year.

Challenges:

Insufficient income generation program for patient and their family members.

Inadequate TB management training to medical doctors

Minimum interventions for strengthening PPM component

Lack of operational research regarding increasing retreatment cases

Lack of patient friendly TB treatment service

Existing currier system for slide- not adequate

Inadequate TB IEC materials

Difficult to coordinate with regional and provincial hospitals.

NEPAL

http://en.wikipedia.org/wiki/Himalayas

http://en.wikipedia.org/wiki/People%27s_Republic_of_China

http://en.wikipedia.org/wiki/India



Page 46

Action to be taken:

Expansion of CBDOT programme in the country

Strengthen Public Private Mix approach

Strengthen the Community Support System programme

Plan for operational research on TB

Develop and distribute patients centered TB IEC materials

Pilot patient friendly treatment centers in the country



Page 47

Graphical presentations, Nepal



(2000 - 2017)


2000 - 2017











Page 48

TB Epidemiology 2017, Nepal



Number

(thousands)

Rate (per 100 000

population)

Mortality (excludes HIV+TB) 6.6 (4.7-8.9) 23 (16-30)



Incidence (HIV+TB only) 0.88 (0.49-1.4) 3 (1.7-4.8)

Incidence (MDR/RR-TB)** 1.5 (0.84-2.4) 5.2 (2.9-8.1)



Females 2.3 (2.2-2.3) 14 (13-14) 16 (15-17)

Males 2.5 (2.4-2.5) 26 (24-29) 29 (26-32)

Total 4.7 (4.5-4.9) 40 (35-45) 45 (39-50)




-% tested with rapid diagnostics at time of diagnosis


- % pulmonary 71%



TB treatment coverage (notified/estimated incidence), 2017 70 % (62-79)







Previously treated




Estimated % of TB cases with MDR/RR-

TB 2.2 % (1.1-3.6) 15 % (9.6-22)



MDR/RR-TB cases tested for resistance to second line

drugs 535






2016 88% 1261




Page 49


2015 70% 333

XDR-TB cases started on second-line treatment in 2015



treatment

% of Children ( aged <5) household

contacts of bacteriologically- confirmed

TB cases on preventive treatment 1.1 (1-1.2)



rifampicin






Page 50

Islamic Republic of Pakistan is the second largest country in the South Asia. It is bordered by

India to the east, China in the far northeast, Afghanistan to the west and north, Iran to the

southwest and Arabian Sea in the south. The land area of the country is 796,095 square

kilometers. Population of Pakistan was approximately 197 million (WHO Global Tuberculosis

Report-2018) at the end of 2017.

TB Epidemiology

Pakistan is among countries with the high burden of TB and MDR-TB. The estimated mortality

and incidence rates of all forms of tuberculosis were 27 (CI: 21-34) and 268 (CI: 189-357) per

100,000 population respectively in 2017.WHO has estimated 518000 (CI: 373000-704000)

incidence cases and 54000 (CI: 42000-67000) deaths in 2017.

Total 368987 notified cases detected, among them 359224 total new and relapse cases has noted

in year 2017. Out of this notified number 80% were pulmonary TB cases. Among Pulmonary

cases 48% were bacteriologically confirmed.

Achievements

NRL- Xpert scale up to 106 sites & 94 Xpert sites connected with GxAlert,

Implementation of rapid DST (LPA first and second line), Introduction of Xpert Ultra,

Comprehensive DST coverage 80% of RR/MDR enrolled cases and introduction of

Bedaquiline phenotypic DST

Successfully implemented three cohorts of National SORT-IT courses from 2016 based

on The UNION International standards

Published 40 research papers in international open access peer reviewed journals

Establishment of IRB ethics committee

Challenges

Limited domestic financing for TB

Insufficient Multi sectoral collaboration

Adjustment to revised role & responsibilities after devolution

PAKISTAN



Page 51

Implementation of mandatory case notification law

No control over the counter sale of anti TB drugs

160,000 DS TB not notified- 1.5% decline in TB incidence/year

24,000 DRTB cases not notified

Static TB case notification in public sector

Referral mechanism between primary –secondary- tertiary care levels

NRL- Specimen transportation

Limited Funding: more finances are needed to continue SORT beyond 2020 and to

support publication cost and to conduct research on provincial priorities

Future Plan

NRL- Scale up of Xpert to more than 350 facilities & 100% coverage of GxAlert,

Scale up of Xpert Ultra, Scale up of LPA to 12 facilities

Successful completion of third SORT-IT course in Pakistan 2018.

Implementation of fourth and fifth SORT-IT course in 2019-20

IRB ethics committee proceedings/meetings

International Publications 2018-20 i.e. MDR Trial, articles of GIS based intervention ,

KAP on infection control measures among MDR-TB patients, and household contact

tracing among MDR-TB patients etc.

Collaboration with national / international research and academic institutions / health

programs

New initiatives/ Best practices:

NRL- Surveillance for emerging Bedaquiline resistance

Introduction of DST to BDQ, CFZ, LZD for Routine clinical services

Establishment of IRB ethic committee at CMU

Child Inventory Study was first of its kind in world to assess underreporting of child TB

cases in developing country in Pakistan



Page 52

Graphical presentations, Pakistan


200

5

201

0

201

3

201

4

201

5

201

6

201

7

Mortality Rate 64 33 27 26 23 23 27

Incidance Rate 276 276 275 270 270 268 268

264

266

268

270

272

274

276

278

0

10

20

30

40

50

60

70

Inci

den

ce R

ate

/10

0 0

00

po

pn

Mo

rta

lity

Ra

te


(2000 - 2016)


2000 – 2017

11050

142017

264235 264934 267475288910

308417323856

356390368897

0

50000

100000

150000

200000

250000

300000

350000

400000

2000 2005 2010 2011 2012 2013 2014 2015 2016 2017

Year











Page 53

TB Epidemiology 2017, Pakistan



Number

(thousands)

Rate (per 100 000

population)

Mortality (excludes HIV+TB) 54 (42-67) 27 (21-34)



Incidence (HIV+TB only) 7.3 (3.6-12) 3.7 (1.8-6.2)

Incidence (MDR/RR-TB)** 27 (17-39) 14 (8.8-20)



Females 27 (25-29) 207 (166-248) 235 (185-284)

Males 30 (28-32) 261 (203-319) 291 (223-359)

Total 57 (51-63) 468 (329-607) 525 (373-704)






- % pulmonary 80%



TB treatment coverage (notified/estimated incidence), 2017 68 %(58-96)







Previously treated





MDR/RR-TB 4.2 % (3.2-5.3) 16% (15-17)



MDR/RR-TB cases tested for resistance

to second line drugs 2887






2016 78% 9671

HIV-positive TB cases, all types, registered in 2016 -



Page 54


2015 64% 2544

XDR-TB cases started on second-line treatment in 2015 29% 77



treatment -


contacts of bacteriologically- confirmed

TB cases on preventive treatment -







Page 55

The Democratic Socialist Republic of Sri Lanka is an island in the Indian Ocean with an area of

65,610 square kilometers. Sri Lanka has maritime borders with India to the northwest and

the Maldives to the southwest. Population in Sri-Lanka was 21 millions in 2017 (WHO Global

Tuberculosis Report-2018).

TB Epidemiology

A middle-burden country, around 25% of total TB cases are from Colombo District,

predominantly affecting males in the productive age group (15–54 years). Multidrug resistant TB

is not a major problem and TB/HIV co-infection remains low. Treatment success rate above 85%

since 2005. Incidence remains stable but case notification among new and relapse cases

decreased since 2013. Loss to follow-up is low (<5%). The National Strategic Plan 2015–2020

finalized following Joint Monitoring Mission in 2014. National TB Reference Laboratory

(NTRL) upgraded to Biosafety level III in 2015. Gene Xpert services being expanded, a 16-

module machine to be placed at NTRL and 4-module machines at four more sites.

The estimated mortality and incidence rates of all forms of tuberculosis were 6 (CI: 4.3-8) and 65

(CI: 48-84) per 100 000 population respectively in 2017.WHO has estimated 13000 (CI: 9900-

17000) incidence cases in 2017. Total 8511 notified cases were detected, among them 8328

notified new and relapse cases has noted in 2017.

Achievements

reaching and sustaining the global targets:

Treatment success rate for all forms for TB was improved and it was 84.6 in 2016.

NPTCCD has managed to sustain lost to follow rate below 5% since 2011and it was 3.9

% in 2016

Expansion of rapid diagnostic facilities (Xpert MTB/RIF) in all provinces.

o Further strengthening of active case detection among high-risk categories such as

prisoners.

o ‒ Strengthening of activities aimed at private public partnership and involvement

of them in TB care

SRI LANKA



Page 56

Improvements in capacity building.

Preparation of training modules for nurses & PHIs of chest clinics & facilitator guide

Further improvement in TB infection control activities in chest clinics;

Sustaining the control of MDR-TB and TB/HIV co-infection; and

Undertaking operational research on TB-related deaths.

Challenges

Maintaining adequate number of trained man power in the face of high turnover of staff

Reduction of deaths among TB patients

Addressing TB control among migratory working population from high burden countries;

Combating stigma related to TB



Page 57

Graphical presentations, Sri-Lanka


2005

2010

2013

2014

2015

2016

2017

Mortality Rate 7.2 5.9 6.2 6.1 5.6 6 6

Incidance Rate 66 66 66 65 65 65 65

64.464.664.86565.265.465.665.86666.2

0

1

2

3

4

5

6

7

8

Incid

en

ce R

ate

/100

000 P

op

n

Mo

rta

lity

Ra

te


(2000 - 2016)


2000 - 2017


0

2

4

6

8

10

12

14

0-14 > 14Esti

mate

d

TB

in

cid

en

ce

by

ag

e &

Sex (

'00

0)

Age Group

Female Male

Source: Data sent by NTP-Sir Lanka 2018, & SAARC



Source: Data sent by NTP-Sir Lanka 2018 & SAARC


Source: Data sent by NTP-Sir Lanka 2018, SAARC Epidemiological

Response on Tuberculosis -2017



Page 58

TB Epidemiology 2017, Sri Lanka



Number

(thousands)

Rate (per 100 000

population)

Mortality (excludes HIV+TB)a 1.2 6 (4.3-8)


Incidence (includes HIV+TB)a 13 65 (48-84)


Incidence (MDR/RR-TB)** 0.088 (0.034-0.17) 0.42 (0.16-0.8)



Females

0.68 (0.63-

0.72) 4.1 (3.4-4.7) 4.8 (4-5.6)

Males 0.75 (0.7-0.8) 7.9 (6.2-9.6) 8.7 (6.7-11)

Total 1.4 (1.3-1.6) 12 (8.6-15) 13 (9.9-17)


Total cases notifieda 8511

Total new and relapsea 8314



- % pulmonary 73%



TB treatment coverage (notified/estimated incidence), 2017 62 % (48-84)







Previously treated





MDR/RR-TB 0.5%(0.2-1) 4.1% (1.1-10)



MDR/RR-TB cases tested for

resistance to second line drugs 22




New and relapse cases registered in 2016a 86% 8660


2016 66% 222




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2015 77% 13

XDR-TB cases started on second-line treatment in 2015 - 0



treatment 20%


contacts of bacteriologically-

confirmed TB cases on preventive

treatment 43% (40-48)



rifampicin





Page 60

5. TB/HIV CO-INFECTION

---------------------------------------------------------------------------------------------------------------------

TB HIV Co-infection poses a critical challenge for the health-sector and for people living with

HIV and TB. Starting in the 1980s, the HIV epidemic led to a major upsurge in TB cases and TB

mortality in many countries.

In 2017, there were an estimated 1.3 million TB deaths among HIV-negative people (down from

1.7 million in 2000) and there were an additional 300 000 deaths from TB among HIV-positive

People.

Globally, the absolute number of deaths from TB among HIV-negative people has been

estimated to have fallen by 29% since 2000, from 1.8 million in 2000 to 1.3 million in 2017, and

by 5% since 2015 (the baseline year for targets set in the End TB Strategy). The number of TB

deaths among HIV-positive people has fallen by 44% since 2000, from 534 000 in 2000 to

300 000 in 2017, and by 20% since 2015.

There were 464 633 reported cases of TB among people living with HIV in 2017 (51% of the

estimated 920 000 new cases in the same year), of whom 84% were on antiretroviral therapy.

The number of people living with HIV reported to have been started on preventive treatment was

958 559 in 2017.

Improvements in the coverage and quality of data for this indicator are necessary to track the

impact of HIV care, especially antiretroviral therapy (ART), on the burden of TB in people

living with HIV.

Preventing TB deaths among HIV-positive people requires intensified scale-up of TB prevention,

diagnosis and treatment interventions, including earlier initiation of ART among people living

with HIV and those with HIV-associated TB. Increased efforts in joint TB and HIV

programming could facilitate further scale-up and consolidation of collaborative TB/HIV

activities.

Joint activities between national TB and HIV/AIDS programmes are crucial to prevent, diagnose

and treat TB among people living with HIV and HIV among people with TB. These include



Page 61

establishing mechanisms for collaboration, such as coordinating bodies, joint planning,

surveillance and monitoring and evaluation; decreasing the burden of HIV among people with

TB (with HIV testing and counseling for individuals and couples, co-trimoxazole preventive

therapy, antiretroviral therapy and HIV prevention, care and support); and decreasing the burden

of TB among people living with HIV (with the three I’s for HIV and TB: intensified case-

finding; TB prevention with isoniazid preventive therapy and early access to antiretroviral

therapy; and infection control for TB). Integrating HIV and TB services, when feasible, may be

an important approach to improve access to services for people living with HIV, their families

and the community.

Table 08: Estimates of TB/HIV care in new and relapse TB patients, 2017

Country

Patients with known HIV status who are

HIV positive patients on Antiretroviral Therapy

(ART)

Number % Number %

Afghanistan 7 <1 3 43

Bangladesh 89 2 84 94

Bhutan 5 <1 5 100

India 32932 3 28651 87

Maldives NA NA NA NA

Nepal 221 1 206 93

Pakistan 121 <1 97 80

Sri Lanka 29 <1 28 97

Regional 33404 29074 87 Source: WHO Global TB Report, 2018

In 2017, a total 33404 TB patients with known HIV status has tested in which India accounts

highest number of TB patients with known HIV status who are HIV positive. Total 29074

patients are on ART in the region which is around 87 % of total TB patients with known HIV

status who are HIV positive in SAARC region.

A total of 464 633 TB cases among HIV-positive people were reported; of these, 84% were on

antiretroviral therapy (ART) globally, and 87% in India. However Bhutan has 100 % patients on

Antiretroviral Therapy (ART) in 2017.

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