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WHO REPORT 2011 | GLOBAL TUBERCULOSIS CONTROL
Acknowledgements
This report on global tuberculosis control was produced by a core team of 14 people: Annabel Baddeley, Hannah
Monica Dias, Dennis Falzon, Christopher Fitzpatrick, Katherine Floyd, Christopher Gilpin, Philippe Glaziou, Tom
Hiatt, Andrea Pantoja, Delphine Sculier, Charalambos Sismanidis, Hazim Timimi, Mukund Uplekar and Wayne van
Gemert. The team was led by Katherine Floyd. Overall guidance was provided by the Director of the Stop TB Depart-
ment, Mario Raviglione.
The data collection forms (long and short versions) were developed by Philippe Glaziou, with input from staff
throughout the Stop TB Department. Hazim Timimi led and organized all aspects of data management, with support
from Tom Hiatt. Christopher Fitzpatrick, Inộs Garcia and Andrea Pantoja conducted all review and follow-up of nan-
cial data. The review and follow-up of all other data was done by a team of reviewers that included Annemieke Brands,
Hannah Monica Dias, Dennis Falzon, Christopher Gilpin, Christian Gunneberg, Tom Hiatt, Jean de Dieu Iragena,
Fuad Mirzayev, Delphine Sculier, Hazim Timimi, Wayne van Gemert, Fraser Wares and Matteo Zignol in WHO head-
quarters, and Suman Jain, Nino Mdivani, Sai Pothapregada, Lal Sadasivan Sreemathy, Alka Singh and Saman Zamani
from the Global Fund. Data for the European Region were collected and validated jointly by the WHO Regional Of ce
for Europe and the European Centre for Disease Prevention and Control (ECDC), an agency of the European Union
based in Stockholm, Sweden.
Philippe Glaziou and Charalambos Sismanidis analysed surveillance and epidemiological data and prepared the
gures and tables on these topics, with assistance from Tom Hiatt. Tom Hiatt and Delphine Sculier analysed TB/
HIV data and prepared the associated gures and tables, with support from Annabel Baddeley. Dennis Falzon anal-
ysed data and prepared the gures and tables related to multidrug-resistant TB. Christopher Fitzpatrick and Andrea
Pantoja analysed nancial data, and prepared the associated gures and tables. Tom Hiatt prepared gures and tables
on laboratory strengthening and the roll-out of new diagnostics, with support from Wayne van Gemert. Tom Hiatt
checked and nalized all gures and tables in an appropriate format, ensuring that they were ready for layout and
design according to schedule, and was the focal point for communications with the graphic designer.
The writing of the main part of the report was led by Katherine Floyd, with input from the following people: Philippe
Glaziou, Charalambos Sismanidis and Sai Pothapregada (Chapter 2); Dennis Falzon, Mukund Uplekar and Hannah
Monica Dias (Chapter 3); Christopher Fitzpatrick and Andrea Pantoja (Chapter 4); and Haileyesus Getahun and
Annabel Baddeley (Chapter 6). Chapter 5, on new diagnostics and laboratory strengthening, was prepared by Wayne
van Gemert, Christopher Gilpin, Karin Weyer and Fuad Mirzayev. Chapter 7, on research and development, was writ-
ten by Christian Lienhardt and Katherine Floyd. The contribution to Chapter 3 of a case study about the engagement
of the full range of care providers in TB care and control in Nigeria by Joshua Obasanya, manager of the National TB
Programme in Nigeria, deserves special mention. Karen Ciceri edited the entire report.
Annex 1, which explains methods used to produce estimates of the burden of disease caused by TB, was written by
Philippe Glaziou, Katherine Floyd and Charalambos Sismanidis. The country pro les that appear in Annex 2 were
prepared by Hazim Timimi and Tom Hiatt. Annex 3, which contains a wealth of global, regional and country-speci c
data from the global TB database, was prepared by Tom Hiatt and Hazim Timimi.
We thank Elizabeth Corbett and Jeremiah Chakaya for serving as external reviewers of the report.
We also thank Sue Hobbs for her excellent work on the design and layout of this report; her contribution, as in
previous years, is greatly appreciated.
The principal source of nancial support for WHOs work on monitoring and evaluation of TB control is the United
States Agency for International Development (USAID), without which it would be impossible to produce this report
on global TB control. Data collection, validation, analysis, printing and dissemination were also supported by funding
from the government of Japan and the Global Fund. We acknowledge with gratitude their support.
In addition to the core report team and those mentioned above, the report bene ted from the input of many staff
at the World Health Organization (WHO), particularly for data collection, validation and review. Among those listed
below, we thank in particular Amal Bassili, Andrei Dadu, Khurshid Alam Hyder, Daniel Kibuga, Rafael Lúpez Olarte,
Nobuyuki Nishikiori, Angộlica Salomóo, Marithel Tesoro and Daniel Sagebiel for their major contribution to data col-
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WHO REPORT 2011 | GLOBAL TUBERCULOSIS CONTROL
lection, validation and review.
WHO headquarters Geneva
Pamela Baillie, Victoria Birungi, Reuben Granich, John Kirkwood, Tracy Mawer, Paul Nunn, Yves Souteyrand, Jean-
Michel Tassie and Diana Weil.
WHO African Region
Diriba Agegnehu, Shalala Ahmadova, Ayodele Awe, Gani Alabi, Joseph Imoko, Kalpesh Rahevar, Joel Kangangi, Hilary
Kipruto, Bah Keita, Daniel Kibuga, Mwendaweli Maboshe, Andrộ Ndongosieme, Nicolas Nkiere, Ishmael Nyasulu,
Wilfred Nkhoma, Philips Patrobas, Angộlica Salomóo, Kefas Samson and Neema Simkoko.
WHO Region of the Americas
Marcos Espinal, Mirtha del Granado, Rafael Lúpez Olarte, Rodolfo Rodriguez, Yamil Silva and Alfonso Tenorio.
WHO Eastern Mediterranean Region
Ali Akbar, Mohamed Abdel Aziz, Samiha Baghdadi, Amal Bassili, Philip Ejikon, Sevil Huseynova, Ridha Jebeniani,
Wasiq Khan, Aayid Munim, Syed Karam Shah, Ireneaus Sindani, Bashir Suleiman, Khaled Sultan, Rahim Taghizadeh
and Martin Van Den Boom.
WHO European Region
Evgeny Belilovskiy, Pierpaolo de Colombani, Andrei Dadu, Irina Danilova, Masoud Dara, Jamshid Gadoev, Gayane
Ghukasyan, Ogtay Gozalov, Sayohat Hasanova, Gulshat Jumayeva, Bahtygul Karriyeva, Olena Kheylo, Mehmet Yavuz
Kontas, Kristin Kremer, Dmitry Pashkevich, Valentin Rusovich, Bogdana Shcherbak-Verlan, Javahir Suleymanova,
Vadim Testov, Gombogaram Tsogt and Richard Zaleskis.
WHO South-East Asia Region
Mohammed Akhtar, Erwin Cooreman, Puneet Dewan, Khurshid Alam Hyder, Partha Mandal, Ye Myint, Eva Nathan-
son, Rajesh Pandav, Sri Prihatini, Kim Son Il, Chawalit Tantinimitkul, Sombat Thanprasertuk, Supriya Warusavithana
and Namgyel Wangchuk.
WHO Western Paci c Region
Cornelia Hennig, Woo-Jin Lew, Catherine Lijinsky, Ngyuen Nhat Linh, Nobuyuki Nishikiori, Giampaolo Mezzabot-
ta, Yamuna Mundade, Katsunori Osuga, Daniel Sagebiel, Fabio Scano, Jacques Sebert, Harpal Singh, Marithel Tesoro,
Catharina van Weezenbeek, Rajendra-Prasad Yadav and Liu Yuhong.
The main purpose of this report is to provide the latest data on the TB epidemic and progress in TB care and control
of the disease, based on data collected in the 2011 round of global TB data collection and previous years. Data are
supplied primarily by national TB control programme managers and their staff. Those who used the online data col-
lection system to report data to WHO in 2011 are listed below, and we thank them all for their invaluable contribution
and collaboration.
WHO African Region
Oumar Abdelhadi, Jean Louis Abena, Juan Eyene Acuresila, Francis Adatu-Engwau, So ane Alihalassa, Inacio Alva-
renga, Omoniyi Amos Fadare, Gộneviốve Angue Nguema, Claudina Augusto da Cruz, Fantchố Awokou, Boubakar
Ballộ, Swasilanne Bandeira de Sousa, Adama Marie Bangoura, Marie Catherine Barouan, Jorge Noel Barreto, Frank
Bekolo Mba, Richard Betchem, Mame Bocar Lo, Frank Adae Bonsu, Marafa Boubacar, Mahamat Bourhanadine, Miguel
Camara, Evangelista Chisakaitwa, Nkem Chwukueme, Amadou Cisse, Catherine Cooper, Cheick Oumar Coulibaly,
Victor Manuel Da Costa Pereira, Isaias Dambe, Serge Diagbouga, Aùcha Diakite, Awa Helene Diop, Themba Dlamini,
Saidi Egwaga, Justin Freminot, Louisa Ganda, Michel Gasana, Evariste Gasana, Boingotlo Gasennelwe, Ntahizaniye
Gộrard, Sandile Ginindza, Martin Gninafon, Nii Hanson-Nortey, Adama Jallow, Abdoul Karim Kanoutộ, Nathan
Kapata, Biruck Kebede Negash, Hillary Kipruto, Aristide Komangoya-Nzonzo, Patrick Konwloh, Jacquemin Koua-
kou, Felix Kwami Afutu, Egidio Langa, Bernard Langat, Llang Maama-Maime, Angelo Makpenon, Farai Mavhunga,
Momar Talla Mbodji, Marie-Lộopoldine Mbulula, Azmera Molla Tikuye, James Mpunga, Clifford Munyandi, Lindiwe
Mvusi, Ronald Ncube, Fulgence Ndayikengurukiye, Thaddộe Ndikumana, Antoine Ngoulou, Emmanuel Nkiligi,
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WHO REPORT 2011 | GLOBAL TUBERCULOSIS CONTROL
Ghislaine Nkone Asseko, Joshua Obasanya, Jean Okiata, Davidson Olufemi Ogunade, Augộ Wilson Ondon, Hermann
Ongouo, Maria da Conceiỗóo Palma Caldas, Martin Rakotonjanahary, Thato Raleting, Bakoliarisoa Ranivomahefa,
Gabriel Marie Ranjalahy, F. Rujeedawa, Mohameden Salem, Charles Sandy, Tandaogo Saouadogo, Mineab Sebhatu,
Joseph Sitienei, Nicholas Siziba, Dawda Sowe, Celestino Francisco Teixeira, Mộdard Toung Mve, Kassim Traore, Mod-
ibo Traorộ, Dawit Abraham Tsegaye, Mohamed Vadel, Fantchố Wokou, Alie Wurie, Assefash Zehaie and Abbas Zezai.
WHO Region of the Americas
Marta Isabel de Abrego, Christian Acosta, Sarita Aguirre, Shalauddin Ahmed, Xochil Alemỏn de Cruz, Raỳl Alvarez,
Mirian Alvarez, Alister Antoine, Cecilia de Arango, Fabiola Arias, Wiedjaiprekash Balesar, Stefano Barbosa, Draurio
Barreira, Maria del Carmen Bermỳdez, Jaime Bravo, Lynrod Brooks, Violet Brown, Marta Isabel Calona de Abre-
go, John Cann, Maria Lourdes Carrasco Flores, Martớn Castellanos Joya, Kenneth Castro, Roxana Cộspedes Robles,
Gemma Chery, Jesse Chun, Sonia Copeland, Clara Cruz, Celia de Cuellar, Ofelia Cuevas, Dy-Juan De Roza, Richard
DMeza, Roger Duncan, Rachel Eersel, Mercedes Espaủa Cedeủo, Clara Freile, Victor Gallant, Julio Garay Ramos,
Christian Garcớa Calavaro, Jennifer George, Izzy Gerstenbluth, Margarita Godoy, Franz Gonzalez, Yaskara Halabi,
Yaskara Halabi, Dorothea Hazel, M. Henry, Alina Jaime, Ronal Jamanca Shuan, Hector Jave Castillo, Carla Jeffries,
Sharline Koolman-Wever, Ashok Kumar, Athelene Linton, Marớa Josefa Llanes Cordero, Marvin Maldonado, Fran-
cisco Maldonado Benavente, Andrea Y. Maldonado Saavedra, Raỳl Manjún Tellerớa, Belkys Marcelino, Ada Martinez
Cruz, Maria de Lourdes Martớnez Olivares, Zeidy Mata Azofeifa, Timothy McLaughlin-Munroe, Mery Mercedes,
Leilawati Mohammed, Jeetendra Mohanlall, Ernesto Moreno, Francis Morey, Alice Neymour, Persaud Nordai, Gisele
de Oliveira, M. Perry Gomez, Tomasa Portillo, Irad Potter, Bob Pratt, Edwin Quiủonez Villatoro, Dottin Ramoutar,
Leonarda Reyes, Anna Esther Reyes Godoy, Paul Ricketts, Adalberto Rodriguez, Maria Rodriguez, David Rodrớguez,
Jorge Rodriguez De Marco, Myrian Roman, Katia Romero, Nilda de Romero, Joan Simon, R.A. Manohar Singh, Jack-
urlyn Sutton, Clarita Torres, Zulema Torres Gaete, Maribelle Tromp, Christopher Trujillo Garcia, William Turner,
Melissa Valdez, Reina Valerio, Daniel Vazquez, Eva de Weever, Michael Williams, Thomas Wong, Oritta Zachariah,
Nydia Zelaya and Elsa Zerbini.
WHO Eastern Mediterranean Region
Khaled Abu Rumman, Nadia Abu Sabra, Naila Abuljadayel, Khadiga Adam, Shahnaz Ahmadi, Mohamed Redha
Al Lawati, Fatma Al Saidi, Amin Al-Absi, Abdelbari Al-Hammadi, Samia Ali Alagab, Issa Ali Al-Rahbi, Abdul Latif
Al-Khal, Rashed Al-Owaish, Saeed Alsaffar, Kenza Benani, Abrar Chugati, Ahmad Chughtai, Walid Daoud, Sayed
Doud Mahmoodi, Suleiman El Bashir, Rachid Fourati, Mohamed Furjani, Mohamed Gaafar, Amal Galal, Dhikrayet
Gamara, Said Guelleh, Kifah Ibrahim Mustafa, Assia Haissama, Dhafer Hashim, Kalthoom Hassan, Ali Mohammed
Hussain, Heba Kamal, Joseph Lasu, Stephen Macharia, Alaa Mokhtar, Mulham Saleh Mustafa, Mahshid Nasehi,
Onwar Otien, Ejaz Qadeer, Mtanios Saade, Mohammad Salama Abouzeid, Khaled Sediq, Mohammed Sghiar, Kinaz
Sheikh, Mohamed Tabena and Hyam Yacoub.
WHO European Region
Elmira Djusupbekovna Abdrahmanova, Tleukhan Shildebayevich Abildaev, Ra g Abuzarov, Aynura Ashyrbekovna
Aesenalieva, Natavan Alikhanova, Avtandil Shermamatovich Alisherov, Ekkehardt Altpeter, Nury Kakaevich Aman-
nepesov, Peter Henrik Andersen, Delphine Antoine, Margarida Coll Armangue, Analita Pace Asciak, Gordana Rados-
avljevic Asic, Rusudan Aspindzelashvili, Andrei Petrovich Astrovko, Ewa Augustynowicz-Kopec, Elizabeta Bachiyska,
Ana Ivanovna Barbova, Venera Lazarevna Bismilda, Thorsteinn Blondal, Oktam Ikramovich Bobohodjaev, Olivera
Bojovic, Stefanos Bonovas, Eric Bửttger, Hamza Bozukurt, Bonita Brodhun, Noa Cedar, Ismail Ceyhan, Ana Ciobanu,
Nicoleta Cioran, Radmila Curcic, Edita Valerija Davidaviciene, Liliana Domente, Manca Zolnir Dovc, Mladen Duron-
jic, Connie Erkens, Jos Even, Jennifer Fernandez, Akhmedov Tura Gafurovich, Viktor Gasimov, Catherine Guichard,
Larus Jon Guomundsson, Ghenadiy Lvovich Gurevich, Weber Guy, Walter Haas, Efrat Haddad, Hasan Ha zi, Armen
Hayrapetyan, Peter Helbling, Sven Hoffner, Daniela Homorodean, Elmira Ibraim, Djahonhir Dkurahovich Ismailov,
Vincent Jarlier, Maglajlic Jasminka, Marớa Soledad Jimộnez Pajares, Jerker Jonsson, Iagor Kalandadze, Kai Kliiman,
Maria Korzeniewska-Kosea, Mitja Kosnik, Gabor Kovacs, Olga Vladimerovna Krivonos, Tiina Kummik, Aliya Kur-
banova, Arutiun Kushkean, Jean Lorenzi, Turid Mannsồker, Merja Marjamọki, Fauville-Dufaux Maryse, Wanlin
Maryse, Rujike Mehmeti, Narine Mejlumean, Donika Mema, Vladimir Milanov, Vladimir Milanov, A Mirziyat, Zohar
Mor, Nicolae Moraru, Gjyle Mulliqi-Osmani, Anne Negre, Joan ODonnell, Vibeke ỉstergaard Thomsen, Dimitrijevic
Pava, Elena Pavlenko, Branka Perovic, Edita Pimkina, Monika Polanova, Bozidarka Rakocevic, Vija Riekstina, Elena
Rodrớguez-Valớn, Tom Rogers, Karin Rứnning, Kazimierz Roszkowski, Sabine Rỹsch-Gerdes, Petri Ruutu, Eugeniy
Romanovich Sagalchik, Branislava Savic, Aynabat Amansahatovna Seitmedova, Hasia Kaidar Shwartz, Aleksandar
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Simunovic, Elena Igorievna Skachkova, Girts Skenders, Ivan Solovic, Dick van Soolingen, Petra Svetina Sorli, Olga
Mihailovna Stemlah, Janos Strausz, Silva Tafaj, Stefan Talevski, Odorina Tello Anchuela, Turaev Laziz Temurovich,
Medina Nazirdjanovna Tuichibaeva, Uzakova Gulnoz Tulkunovna, Aigul Sultanovna Tursynbayeva, Piret Viiklepp,
Ludmila Viksna, Cveta Vragoterova, Gerard de Vries, Maryse Wanlin, Guy Weber, Aysegul Yildrim, Maja Zakoska and
Hasan Zutic.
WHO South-East Asia Region
Sunil de Alwis, Si Thu Aung, Arjin Cholapand, Kim Jong Guk, Ashok Kumar Gupta, Emdadul Hoque, Jang Yong
Hui, Ashaque Husain, Kim Ting Hyok, Kashi Kant Jha, Suksont Jittimanee, Badri Nath Jnawali, Neeraj Kulshrestha,
Thandar Lwin, Dyah Erti Mustikawati, Fathmath Reeza, Chewang Rinzin, Aminath Shenalin, Paramita Sudharto and
Asik Surya,
WHO Western Paci c Region
Paul Aia, Cecilia Teresa Arciaga, Susan Barker, Christina Barry, Iobi Batio, Connie Bien Olikong, Nguyen Binh Hoa,
Kennar Briand, Richard Brostrom, Risa Bukbuk, Nou Chanly, Phonnaly Chittamany, Cho En Hi, Kuok Hei Chou, Jilo-
ris Dony, Jane Dowabobo, Marites Fabul, Rangiau Fariu, Louise Fonua, Anna Marie Celina Gar n, Shakti Gounder,
David Hunsberger, Xaysangkhom Insisiengmay, Noel Itogo, Tomoo Ito, Nese Ituaso Conway, Narantuya Jadambaa,
Mayleen Jack Ekiek, Seiya Kato, Pengiran Khalifah bin Pg Ismail, Khin Mar Kyi Win, Leo Lim, Wang Lixia, Liza
Lopez, Henri-Pierre Mallet, Faimanifo Peseta, Sera Moa, Suzana Binte Mohd Hashim, Dinh Ngoc Sy, Fandy Osman,
Nukutau Pokura, Waimanu Pulu, Nasanjargal Purev, Yanjindulam Purevsuren, Marcelina Rabauliman, Bereka Rei-
her, Bernard Rouchon, Oksana Segur, Temilo Seono, Cheng Shiming, Tieng Sivanna, Ong Sok King, Grant Sto-
rey, Phannasinh Sylavanh, Kenneth Tabutoa, Markleen Tagaro, Cheuk-ming Tam, Mao Tan Eang, Ulisese Tapuvae,
Faafetai Teo-Yandall, Kazuhiro Uchimura, Rosalind Vianzon, Du Xin, Wang Yee Tang and Byunghee Yoo.
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WHO REPORT 2011 | GLOBAL TUBERCULOSIS CONTROL
Executive summary
This is the sixteenth global report on tuberculosis (TB)
published by WHO in a series that started in 1997. It pro-
vides a comprehensive and up-to-date assessment of the
TB epidemic and progress in implementing and nanc-
ing TB prevention, care and control at global, regional
and country levels using data reported by 198 countries
that account for over 99% of the worlds TB cases.
The introductory chapter (
Chapter 1) provides general
background on TB as well as an explanation of global
targets for TB control, the WHOs Stop TB Strategy
and the Stop TB Partnerships Global Plan to Stop TB
20112015. The main ndings and messages about the
six major themes covered in the rest of the report are pro-
vided below.
The burden of disease caused by TB
(Chapter 2)
In 2010, there were 8.8 million (range, 8.59.2 million)
incident cases of TB, 1.1 million (range, 0.91.2 mil-
lion) deaths from TB among HIV-negative people and an
additional 0.35 million (range, 0.320.39 million) deaths
from HIV-associated TB.
Important new ndings at the global level are:
The absolute number of TB cases has been falling
since 2006 (rather than rising slowly as indicated in
previous global reports);
TB incidence rates have been falling since 2002 (two
years earlier than previously suggested);
Estimates of the number of deaths from TB each year
have been revised downwards;
In 2009 there were almost 10 million children who were
orphans as a result of parental deaths caused by TB.
Updates to estimates of disease burden follow the comple-
tion of a series of consultations with 96 countries between
2009 and 2011, including China, India and 17 African
countries in the past year, and much greater availability
and use of direct measurements of TB mortality. Ongo-
ing efforts to further improve measurement of TB cases
and deaths under the umbrella of the WHO Global Task
Force on TB Impact Measurement, including impressive
progress on TB prevalence surveys and innovative work
to strengthen surveillance, are summarized.
At country level, dramatic reductions in TB cases and
deaths have been achieved in China. Between 1990 and
2010, prevalence rates were halved, mortality rates fell
by almost 80% and TB incidence rates fell by 3.4% per
year. Methods used to measure trends in disease burden
in China nationwide prevalence surveys, a sample vital
registration system and a web-based case noti cation
system provide a model for many other countries.
Other results reinforce the ndings of previous global
reports:
The world and all of WHOs six regions are on track to
achieve the Millennium Development Goal target that
TB incidence rates should be falling by 2015;
TB mortality rates have fallen by just over a third since
1990, and the world as well as ve of six WHO regions
(the exception being the African Region) are on track
to achieve the Stop TB Partnership target of halving
1990 mortality rates by 2015;
The Stop TB Partnership target of halving TB preva-
lence rates by 2015 compared with 1990 is unlikely to
be achieved globally, although the target has already
been reached in the Region of the Americas and the
Western Paci c Region is very close to reaching the
target;
There were 3.2 million (range, 3.03.5 million) inci-
dent cases of TB and 0.32 million (range, 0.2044 mil-
lion) deaths from TB among women in 2010;
About 13% of TB cases occur among people living
with HIV.
Case noti cations and treatment outcomes
(Chapter 3)
In 2010, there were 5.7 million noti cations of new and
recurrent cases of TB, equivalent to 65% (range 6368%)
of the estimated number of incident cases in 2010. India
and China accounted for 40% of the worlds noti ed
cases of TB in 2010, Africa for a further 24% and the 22
high-TB burden countries (HBCs) for 82%. At global lev-
el, the treatment success rate among new cases of smear-
positive pulmonary TB was 87% in 2009.
Between 1995 and 2010, 55 million TB patients were
treated in programmes that had adopted the DOTS/Stop
TB Strategy, and 46 million were successfully treated.
These treatments saved almost 7 million lives.
Alongside these achievements, diagnosis and appro-
priate treatment of multidrug-resistant TB (MDR-TB)
remain major challenges. Less than 5% of new and pre-
viously treated TB patients were tested for MDR-TB in
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WHO REPORT 2011 | GLOBAL TUBERCULOSIS CONTROL
most countries in 2010. The reported number of patients
enrolled on treatment has increased, reaching 46 000 in
2010. However, this was equivalent to only 16% of the
290 000 cases of MDR-TB estimated to exist among noti-
ed TB patients in 2010.
Financing TB care and control (Chapter 4)
In 97 countries with 92% of the worlds TB cases for
which trends can be assessed, funding from domestic
and donor sources is expected to amount to US$ 4.4 bil-
lion in 2012, up from US$ 3.5 billion in 2006. Most
of this funding is being used to support diagnosis and
treatment of drug-susceptible TB, although funding for
MDR-TB is growing and expected to reach US$ 0.6 bil-
lion in 2012. Countries report funding gaps amounting
to almost US$ 1 billion in 2012.
Overall, domestic funding accounts for 86% of total
funding, with the Global Fund accounting for 12%
(82% of all international funding) and grants from other
agencies for 2%, but striking contrasts between BRICS
(Brazil, the Russian Federation, India, China and South
Africa) and other countries are highlighted:
BRICS invested US$ 2.1 billion in TB control in 2010,
95% of which was from domestic sources;
In the other 17 HBCs, total expenditures were much
lower (US$ 0.6 billion) and only 51% of funding was
from domestic sources.
Most of the funding needed to scale up the treatment of
MDR-TB towards the goal of universal access is needed
in BRICS and other middle-income countries (MICs).
If BRICS and other MICs fully nance the scale-up of
treatment for MDR-TB from domestic sources, current
levels of donor nancing for MDR-TB would be almost
suf cient to fund the scale-up of MDR-TB treatment in
low-income countries.
Donor funding for TB is expected to reach US$ 0.6 bil-
lion in 2012, a 50% increase compared with US$ 0.4 bil-
lion in 2006, but far short of donor funding for malaria
(US$ 1.8 billion in 2010) and HIV (US$ 6.9 billion in
2010).
New diagnostics and laboratory
strengthening (Chapter 5)
The rst data on the roll-out of Xpert MTB/RIF, a new
rapid molecular test that has the potential to substantial-
ly improve and accelerate the diagnosis of TB and drug-
resistant TB, are presented. By 30 June 2011, six months
after the endorsement of Xpert MTB/RIF by WHO in
December 2010, 26 of the 145 countries eligible to pur-
chase GeneXpert instruments and Xpert MTB/RIF car-
tridges at concessional prices had done so. This shows
that the transfer of technology to developing countries
can be fast.
The continued inadequacy of conventional laboratory
capacity is also illustrated:
In 2010, 8 of the 22 HBCs did not meet the benchmark
of 1 microscopy centre per 100 000 population;
Among the 36 countries in the combined list of 22
HBCs and 27 high MDR-TB burden countries, 20 had
less than the benchmark of 1 laboratory capable of
performing culture and drug susceptibility testing per
5 million population.
Overall, laboratory strengthening needs to be acceler-
ated, as is currently happening in 27 countries through
the EXPAND-TB project supported by UNITAID.
Addressing the co-epidemics of TB and HIV
(Chapter 6)
Progress in scaling up interventions to address the co-
epidemics of TB and HIV has continued:
In 2010, HIV testing among TB patients reached 34%
globally, 59% in the African Region and *75% in 68
countries;
Almost 80% of TB patients known to be living with
HIV were started on cotrimoxozole preventive therapy
(CPT) and 46% were on antiretroviral therapy (ART)
in 2010;
A large increase in screening for TB among people
living with HIV and provision of isoniazid preventive
therapy to those without active TB disease occurred in
2010, especially in South Africa.
Impressive improvements in recent years notwithstand-
ing, much more needs to be done to reach the Global
Plan targets that all TB patients should be tested for HIV
and that all TB patients living with HIV should be pro-
vided with CPT and ART.
Research and development (Chapter 7)
The topic of research and development is discussed for
the rst time in the global report. There has been consid-
erable progress in diagnostics in recent years, including
the endorsement of Xpert MTB/RIF at the end of 2010;
other tests including point-of-care tests are in the pipe-
line. There are 10 new or repurposed TB drugs in clini-
cal trials that have the potential to shorten the treatment
of drug-susceptible TB and improve the treatment of
MDR-TB. Results from three Phase III trials of 4-month
regimens for the treatment of drug-susceptible TB are
expected between 2012 and 2013, and results from two
Phase II trials of new drugs for the treatment of MDR-TB
are expected in 2012. There are 9 vaccine candidates
in Phase I or Phase II trials. It is hoped that one or both
of the candidates currently in a Phase II trial will enter a
Phase III trial in the next 23 years, with the possibility
of licensing at least one new vaccine by 2020.
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WHO REPORT 2011 | GLOBAL TUBERCULOSIS CONTROL
CHAPTER 1
Introduction
Tuberculosis (TB) is an infectious disease caused by
the bacillus Mycobacterium tuberculosis. It typically affects
the lungs (pulmonary TB) but can affect other sites as
well (extrapulmonary TB). The disease is spread in the
air when people who are sick with pulmonary TB expel
bacteria, for example by coughing. In general, a relatively
small proportion of people infected with Mycobacterium
tuberculosis will go on to develop TB disease; however,
the probability of developing TB is much higher among
people infected with the human immunode ciency virus
(HIV). TB is also more common among men than wom-
en, and affects mostly adults in the economically produc-
tive age groups; around two-thirds of cases are estimated
to occur among people aged 1559 years.
The most common method for diagnosing TB world-
wide is sputum smear microscopy (developed more than
100 years ago), in which bacteria are observed in sputum
samples examined under a microscope. In countries with
more developed laboratory capacity, cases of TB may also
be diagnosed via culture methods (the current gold stan-
dard) or, increasingly, using rapid molecular tests.
Without treatment, mortality rates are high. In stud-
ies of the natural history of the disease among sputum
smear-positive and HIV-negative cases of pulmonary TB,
around 70% died within 10 years; among culture-positive
(but smear-negative) cases, 20% died within 10 years.
1
Treatment using combinations of anti-TB drugs devel-
oped in the 1940s and 1950s can dramatically reduce
mortality rates. In clinical trials, cure rates of above
90% have been documented; the treatment success rate
among smear-positive cases of pulmonary TB reported
to WHO reached 87% at the global level in 2009.
Despite the availability of highly ef cacious treatment
for decades, TB remains a major global health problem.
In 1993, the World Health Organization (WHO) declared
TB a global public health emergency, at a time when an
estimated 78 million cases and 1.31.6 million deaths
occurred each year. In 2010, there were an estimated
8.59.2 million cases and 1.21.5 million deaths (includ-
ing deaths from TB among HIV-positive people).
2
TB
is the second leading cause of death from an infectious
disease worldwide (after HIV, which caused an estimated
1.8 million deaths in 2008).
3
WHO has published a global report on TB every year
since 1997 (
Figure 1.1). The main aim of the report is to
provide a comprehensive and up-to-date assessment of
BOX 1.1
Goals, targets and indicators
for TB control
Millennium Development Goals set for 2015
Goal 6: Combat HIV/AIDS, malaria
and other diseases
Target 6c: Halt and begin to reverse the incidence of
malaria and other major diseases
Indicator 6.9: Incidence, prevalence and death rates
associated with TB
Indicator 6.10: Proportion of TB cases detected and
cured under DOTS
Stop TB Partnership targets set for
2015 and 2050
By 2015: Reduce prevalence and death rates by 50%,
compared with their levels in 1990
By 2050: Reduce the global incidence of active TB cases
to <1 case per 1 million population per year
the TB epidemic and progress made in prevention, care
and control of the disease at global, regional and coun-
try levels, in the context of global targets set for 2015
and WHOs recommended strategy for achieving these
targets.
The 2015 global targets for reductions in disease
burden (
Box 1.1) are that TB incidence should be fall-
ing (MDG Target 6.c) and that prevalence and death
rates should be halved compared with their levels in
1990. WHOs recommended strategy for achieving
these targets is the Stop TB Strategy
4
(Box 1.2), which
was launched in 2006 as an enhancement of the DOTS
1
Tiemersma EW et al. Natural history of tuberculosis: dura-
tion and fatality of untreated pulmonary tuberculosis in HIV-
negative patients: A systematic review. PLoS ONE 2011 6(4):
e17601.
2
These deaths are classi ed as HIV deaths in the International
statistical classi cation of diseases and related health problems, 10th
revision (ICD-10), 2nd ed. Geneva, World Health Organization,
2007.
3
http://apps.who.int/ghodata. These HIV deaths include 0.4
million deaths from TB.
4
The Stop TB Strategy: building on and enhancing DOTS to meet the
TB-related Millennium Development Goals. Geneva, World Health
Organization, 2006 (WHO/HTM/TB/2006.368).
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WHO REPORT 2011 | GLOBAL TUBERCULOSIS CONTROL
BOX 1.2
The Stop TB Strategy at a glance
THE STOP TB STRATEGY
VISION A TB-free world
GOAL
To dramatically reduce the global burden of TB by 2015 in line with the Millennium Development Goals
(MDGs) and the Stop TB Partnership targets
OBJECTIVES
Achieve universal access to high-quality care for all people with TB
Reduce the human suffering and socioeconomic burden associated with TB
Protect vulnerable populations from TB, TB/HIV and drug-resistant TB
Support development of new tools and enable their timely and effective use
Protect and promote human rights in TB prevention, care and control
TARGETS
MDG 6, Target 6.c: Halt and begin to reverse the incidence of TB by 2015
Targets linked to the MDGs and endorsed by the Stop TB Partnership:
2015: reduce prevalence of and deaths due to TB by 50% compared with a baseline of 1990
2050: eliminate TB as a public health problem
COMPONENTS
1. Pursue high-quality DOTS expansion and enhancement
a. Secure political commitment, with adequate and sustained nancing
b. Ensure early case detection, and diagnosis through quality-assured bacteriology
c. Provide standardized treatment with supervision, and patient support
d. Ensure effective drug supply and management
e. Monitor and evaluate performance and impact
2. Address TB/HIV, MDR-TB, and the needs of poor and vulnerable populations
a. Scale-up collaborative TB/HIV activities
b. Scale-up prevention and management of multidrug-resistant TB (MDR-TB)
c. Address the needs of TB contacts, and of poor and vulnerable populations
3. Contribute to health system strengthening based on primary health care
a. Help improve health policies, human resource development, nancing, supplies, service delivery and information
b. Strengthen infection control in health services, other congregate settings and households
c. Upgrade laboratory networks, and implement the Practical Approach to Lung Health
d. Adapt successful approaches from other elds and sectors, and foster action on the social determinants of health
4. Engage all care providers
a. Involve all public, voluntary, corporate and private providers through publicprivate mix approaches
b. Promote use of the International Standards for Tuberculosis Care
5. Empower people with TB, and communities through partnership
a. Pursue advocacy, communication and social mobilization
b. Foster community participation in TB care, prevention and health promotion
c. Promote use of the Patients Charter for Tuberculosis Care
6. Enable and promote research
a. Conduct programme-based operational research
b. Advocate for and participate in research to develop new diagnostics, drugs and vaccines
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WHO REPORT 2011 | GLOBAL TUBERCULOSIS CONTROL
strategy. DOTS was a ve-point package that remains the
rst component and foundation of the Stop TB Strategy.
The other components of the Stop TB Strategy highlight
the need to address the challenge of drug-resistant TB
and the co-epidemics of TB and HIV, the importance of
engaging all care providers in TB care and control and
of contributing to strengthening health systems, the role
of communities and people with TB, and the fundamen-
tal role of research and development for new diagnostics,
new drugs and new vaccines. The Stop TB Partnerships
Global Plan to Stop TB for 20112015 has set out the
scale at which interventions included in the Stop TB
Strategy need to be implemented to achieve the 2015 tar-
gets for reductions in disease burden.
1
The plan comes
with a price tag of US$ 47 billion and the main indicators
and associated baselines and targets are summarized in
Table 1.1.
This 2011 edition of WHOs annual global TB report
the 16th in the series continues the tradition of pre-
vious reports. It is based primarily on data compiled in
annual rounds of global TB data collection in which
countries are requested to report a standard set of data
to WHO.
2
In 2011, data were requested on the follow-
ing topics: case noti cations and treatment outcomes,
including breakdowns by age, sex and HIV status; an
overview of services for the diagnosis and treatment of
TB; laboratory diagnostic services; drug management;
monitoring and evaluation; surveillance and surveys of
drug-resistant TB; management of drug-resistant TB;
collaborative TB/HIV activities; human resource devel-
opment; TB control in vulnerable populations and high-
risk groups; TB infection control; the Practical Approach
to Lung Health;
3
engagement of all care providers in TB
control; advocacy, communication and social mobiliza-
tion; the budgets of national TB control programmes
(NTPs) in 2011 and 2012; utilization of general health
services (hospitalization and outpatient visits) during
treatment; and NTP expenditures in 2010. A shortened
version of the online questionnaire was used for high-
income countries (that is, countries with a gross national
income per capita of *US$ 12 276 in 2010, as de ned
by the World Bank)
4
and/or low-incidence countries
(de ned as countries with an incidence rate of <20 cases
per 100 000 population or <10 cases in total).
Since 2009, data have been reported using an online
web-based system.
5
In 2011, the online system was
opened for reporting on 15 March, with a deadline of
17 May for all WHO regions except the Region of the
Americas (31 May) and the European Region (15 June).
A total of 198 countries and territories accounting for
over 99% of the worlds estimated cases of TB reported
data by the deadlines, including all or almost all coun-
tries in ve of WHOs six regions (
Table 1.2). Data were
reviewed, and followed up with countries where appro-
priate, by a team of reviewers from WHO (headquarters
and regional of ces) and the Global Fund. Validation of
data by respondents was also encouraged via a series of
inbuilt and real-time checks of submitted data as well as
a summary report of apparent inconsistencies or inaccu-
racies that can be generated at any time within the online
system. The data contained in the global TB database on
21 June 2011 were used for the main part of this report.
The detailed data in
Annex 2 and Annex 3 re ect the data
available on 2 September, the nal deadline for receipt
FIGURE 1.1
Fifteen annual WHO reports on TB in 14 years, 19972010
1997: First report:
epidemiology and
surveillance
2002: Added nancing and
strategy for 22 high-burden
countries (HBCs)
July 2009: Online data collection introduced
December 2009: Short update to 2009 report in transition
to earlier reporting of data and report publication
2003: Financing
and strategy
(all countries)
1
The Global Plan to Stop TB, 20112015. Geneva, World Health
Organization, 2010 (WHO/HTM/STB/2010.2).
2
The annual data collection form is designed for collecting
aggregated national data. It is not recommended for collection
of data within countries. WHO recommendations for record-
ing and reporting within countries are described at: www.
who.int/tb/dots/r_and_r_forms/en/index.html
3
The Practical Approach to Lung Health (PAL) is a patient-
centred approach to improving the quality of diagnosis
and treatment for common respiratory illnesses in primary
health-care facilities.
4
http://data.worldbank.org/about/country-classi cations
5
www.stoptb.org/tme. Countries in the European Union
submit noti cation data to a system managed by the Europe-
an Centre for Disease Prevention and Control (ECDC). Data
from the ECDC system were uploaded into WHOs online
system.
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WHO REPORT 2011 | GLOBAL TUBERCULOSIS CONTROL
of data from countries in the European Union.
1
Besides
the data reported through the standard TB question-
naire, the report uses data about screening for TB among
people living with HIV and provision of isoniazid preven-
tive therapy to those without active TB that are collected
annually by the HIV department in WHO, as well as data
and information that are available to WHO through sep-
arate mechanisms.
The report is structured in six major chapters. Each
chapter is intended to stand alone, but links to other
chapters are highlighted where appropriate. The six
chapters are:
Chapter 2: The burden of disease caused by TB.
This chapter presents estimates of the numbers of TB
cases and deaths caused by TB in 2010, estimates of
trends in cases and deaths since 1990, and an assess-
ment of whether the 2015 targets for reductions in
cases and deaths will be achieved. This is done for
the world as a whole, for WHOs six regions and for
TABLE 1.1
Summary of main indicators, baselines and targets set in the Global Plan to Stop TB 20112015
PLAN COMPONENT AND INDICATORS
BASELINE
(2009)
TARGET
(2015)
DOTS/laboratory strengthening
Number of cases diagnosed, noti ed and treated according to the DOTS approach (per year) 5.8 million 6.9 million
Treatment success rate (in annual cohort) 86% 90%
Number of countries with 1 laboratory with sputum-smear microscopy services per 100 000 population 75 149
Drug-resistant TB/laboratory strengthening
Percentage of previously treated TB patients tested for MDR-TB 7% 100%
Percentage of new bacteriologically-positive patients tested for MDR-TB 7% 20%
Number of countries among the 22 HBCs and 27 high MDR-TB burden countries with 1 culture laboratory per
5 million population
1821 36
Percentage of con rmed cases of MDR-TB enrolled on treatment according to international guidelines 36% 100%
Number of con rmed cases of MDR-TB enrolled on treatment according to international guidelines 11 000
~
270 000
Treatment success rate among con rmed cases of MDR-TB 60% 75%
TB/HIV/laboratory strengthening
Percentage of AFB smear-negative, newly noti ed TB cases screened using culture and/or molecular-based test <1% 50%
Percentage of TB patients tested for HIV 26% 100%
Percentage of HIV-positive TB patients treated with CPT 75% 100%
Percentage of HIV-positive TB patients treated with ART 37% 100%
Percentage of people living with HIV attending HIV care services who were screened for TB at their last visit
~
25% 100%
Percentage of people living with HIV attending HIV care services who were enrolled on IPT; among those eligible <1% 100%
Laboratory strengthening (additional to those above)
Percentage of national reference laboratories implementing a quality management system (QMS) according to
international standards
<5% 50%
AFB, acid-fast bacilli; ART, antiretroviral therapy; CPT, co-trimoxazole preventive therapy; HBC, high TB burden country; HIV, human immunode ciency virus; IPT, isoniazid
preventive therapy; MDR-TB, multidrug-resistant tuberculosis.
TABLE 1.2
Reporting of data in the 2011 round of global
TB data collection
WHO REGION OR SET OF COUNTRIES NUMBER OF
COUNTRIES AND
TERRITORIES
NUMBER OF COUNTRIES
AND TERRITORIES
REPORTING DATA
a
African Region 46 45
Eastern Mediterranean Region 22 21
European Region 55 42
Region of the Americas 46 46
South-East Asia Region 11 10
Western Paci c Region 36 34
High-burden countries 22 22
WORLD 216 198
a
Countries that did not report data included Comoros (African Region), Libyan
Arab Jamahiriya (Eastern Mediterranean Region), Timor-Leste (South-East
Asia Region), Japan and Wallis and Futuna Islands (Western Paci c Region).
Countries that did not report in the European Region were mostly in Western
Europe.
1
Countries can edit their data at any time. After the global
report is published, the most up-to-date data can be down-
loaded from WHOs global TB database (
www.who.int/tb/
data
). For most countries, there are few updates after the
global report is published.
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