Global Tuberculosis Control WHO REPORT 2010

The World Health Organization monitors

the global tuberculosis epidemic in support
of national TB control programmes.

For further information about tuberculosis contact: Global

Tuberculosis
Information Resource Centre HTM/STB
World Health Organization
20 Avenue Appia, 1211–Geneva–27, Switzerland
Email: tbdocs@who.int
Web site: www.who.int/tb Control
2010
ISBN 978 92 4 156406 9
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ACSM advocacy, communication and social mobilization

AFR WHO African Region
AIDS acquired immunodeficiency syndrome
AMR WHO Region of the Americas
ARI annual risk of infection
ART antiretroviral therapy
CDR case detection rate
CPT co-trimoxazole preventive therapy
CBC community-based TB care
DOT directly observed treatment
DOTS the basic package that underpins the Stop TB Strategy
DRS drug resistance surveillance or survey
DST drug susceptibility testing
ECDC European Centre for Disease Prevention and Control
EMR WHO Eastern Mediterranean Region
EU European Union
EUR WHO European Region
FIND Foundation for Innovative New Diagnostics
GDF Global TB Drug Facility
GLC Green Light Committee
GLI Global Laboratory Initiative
Global Fund The Global Fund to fight AIDS, Tuberculosis and Malaria
Global Plan Global Plan to Stop TB, 2011–2015
GNI gross national income
HBC high-burden country of which there are 22 that account for approximately 80% of all new TB cases
arising each year
HIV human immunodeficiency virus
HRD Human resource development
ICD-10 International Classification of Diseases (tenth revision)
IPT isoniazid preventive therapy
IRR incidence rate ratio
ISTC International Standards for Tuberculosis Care
LED Light-emitting diode
LPA Line-probe assay
MDG Millennium Development Goal
MDR-TB multidrug-resistant tuberculosis (resistance to, at least, isoniazid and rifampicin)
NGO nongovernmental organization
NTP national tuberculosis control programme or equivalent
PAL Practical Approach to Lung Health
PPM Public–Private Mix
SEAR WHO South-East Asia Region
TB tuberculosis
UNAIDS Joint United Nations Programme on HIV/AIDS
UNITAID international facility for the purchase of diagnostics and drugs for diagnosis and treatment of HIV/
AIDS, malaria and TB
USAID United States Agency for International Development
VR Vital registration
WHA World Health Assembly
WHO World Health Organization
WPR WHO Western Pacific Region
XDR-TB Extensively drug-resistant TB
ZN Ziehl-Neelsen
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8 his report on global tuberculosis control was produced by a core team of 12 people: Léopold Blanc, Dennis Falzon,
Christopher Fitzpatrick, Katherine Floyd, Inés Garcia, Christopher Gilpin, Philippe Glaziou, Tom Hiatt, Delphine
Sculier, Charalambos Sismanidis, Hazim Timimi and Mukund Uplekar. The team was led by Katherine Floyd and
Léopold Blanc. Overall guidance was provided by the Director of the Stop TB Department, 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 sup-
port from Tom Hiatt. Christopher Fitzpatrick and Inés Garcia conducted all review and follow-up of financial data.
Annemieke Brands, Dennis Falzon, Christopher Gilpin, Malgosia Grzemska, Christian Gunneberg, Tom Hiatt, Eva
Nathanson, Salah Ottmani, Delphine Sculier, Hazim Timimi, Wayne Van Gemert, Fraser Wares, Matteo Zignol and
four colleagues from the Global Fund – Nino Mdivani, Sai Pothapregada, John Puvimanasinghe and Lal Sadasivan
Sreemathy – conducted the review and follow-up of data related to epidemiology and the implementation of the
Stop TB Strategy. Data for the European Region were collected and validated jointly by the WHO Regional Office 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
figures and tables on these topics, with assistance from Tom Hiatt. Delphine Sculier and Tom Hiatt analysed TB/
HIV data and prepared the associated figures and tables. Dennis Falzon analysed data and prepared the figures and
tables related to MDR-TB. Mukund Uplekar contributed a summary of recent progress in engaging all care providers
through public-private and public-public mix (PPM) approaches, Christopher Gilpin and Karin Weyer provided an
update on the Global Laboratory Initiative and Karin Bergstrom analysed data related to human resource develop-
ment. Christopher Fitzpatrick and Inés Garcia analysed financial data, and prepared the associated figures and tables.
Tom Hiatt checked and finalized all figures 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 main part of the report was written by Katherine Floyd. Annex 1, which explains methods used to produce
estimates of disease burden, was written by Philippe Glaziou, Katherine Floyd, Charalambos Sismanidis and Hazim
Timimi. Karen Ciceri edited the report.
Annex 2, which contains a wealth of global, regional and country-specific data from the global TB database, was
prepared by Tom Hiatt and Hazim Timimi.
We 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 financial support for WHO’s 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.
Data collection, validation and analysis 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 benefited from the input of many staff
at the World Health Organization (WHO) and the Joint United Nations Programme on HIV/AIDS (UNAIDS), particu-
larly for data collection, validation and review. Among those listed below, we thank in particular Amal Bassili, Andrei
Dadu, Khurshid Alam Hyder, Daniel Kibuga, Rafael López Olarte, Angélica Salomão, Nobuyuki Nishikiori and Daniel
Sagebiel for their major contribution to data collection, validation and review.

8)0
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Pamela Baillie, Victoria Birungi, Daniel Chemtob, Haileyesus Getahun, Eleanor Gouws, Wieslaw Jakubowiak, Ernesto
Jaramillo, Tracy Mawer, Paul Nunn, Alasdair Reid and Diana Weil.

8)0
"GSJDBO
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Diriba Agegnehu, Shalala Ahmadova, Ayodele Awe, Gani Alabi, Dorothée Ntakirutimana, Joseph Imoko, Kalpesh
Rahevar, Joel Kangangi, Hilary Kipruto, Bah Keita, Daniel Kibuga, Mwendaweli Maboshe, Vainess Mfungwe, André
Ndongosieme, Nicolas Nkiere, Ishmael Nyasulu, Wilfred Nkhoma, Roberta Pastore, Angélica Salomão, Kefas Samson,
Neema Simkoko and Henriette Wembanyama.
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Jarbas Barbosa, Mirtha del Granado, Jacobo Finkelman, Rafael López Olarte, Yamil Silva, Rodolfo Rodríguez, Alfon-
so Tenorio and Adriana Bacelar Gomes.

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&BTUFSO
.FEJUFSSBOFBO
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Samiha Baghdadi, Salem Barghout, Amal Bassili, Philip Ejikon, Sevil Huseynova, Ridha Jebeniani, Wasiq Khan, Peter
Metzger, Aayid Munim, Syed Karam Shah, Akihiro Seita, Ireneaus Sindani, Bashir Suleiman, Khaled Sultan, Rahim
Taghizadeh and Martin van den Boom.

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Pierpaolo de Colombani, Evgeny Belilovskiy, Andrei Dadu, Jamshid Gadoev, Bahtygul Karriyeva, Hans Kluge, Peter
Knudsen, Sayohat Hasanova, David Mercer, Valentin Rusovich, Roman Spataru, Javahir Suleymanova, Gombogaram
Tsogt and Richard Zaleskis.

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"TJB
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Mohammed Akhtar, Erwin Cooreman, Puneet Dewan, Khurshid Alam Hyder, Partha P. Mandal, Ye Myint, Nani Nair,
Chadrakant Revankar, Kim Son Il, Sombat Thanprasertuk and Supriya Warusavithana.

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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, Marithel Tesoro, Kitty van
Weezenbeek, Rajendra 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,
based on data collected in the 2010 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 collection system to
report data to WHO in 2010 are listed below, and we thank them all for their invaluable contribution and collabora-
tion.

8)0
"GSJDBO
3FHJPO
Oumar Abdelhadi, Abdou-Salam Abderemane, Juan Acuresila, Francis Adatu, Nkou Bikoe Adolphe, Shalala Ahma-
dova, Sofiane Alihalassa, Inacio de Carvalho Alvarenga, Omoniyi Amos, Géneviève Angue, Ghislaine Nkone Asseko,
Younoussa Assoumani, Fantché Awokou, Jorge Barreto, Adama Bangoura, Mohammed Berthe, Frank Bonsu, Ballé
Boubakar, Marafa Boubacar, Maria da Conceição Palma Caldas, Miguel Camará, Edelmiro Castaño Bizantino, Joco-
niah Chirenda, Ernest Cholopray, Nkem Chukwueme, Fodé Cisse, Catherine Cooper, Claudina Cruz, Foday Dafae,
Isaiah Dambe, Mathurin Sary Dembélé, Aicha Diakité, Awa Diop, Themba Dlamini, Ismael Edris, Saidi Egwaga, Justin
Freminot, Evariste Gasana, Michel Gasana, Francis Gausi, Martin Gninafon, Andre Gotingar, Thabo Hlophe, Adama
Jallow, Mansur Kabir, Nathan Kapata, Javan Kayobotsi, Aristide Komangoya-Nzonzo, André Kouabosso, Jacquemin
Kouakou, Egidio Langa, Mame Bocar Lo, Llang Maama, Marie-Léopoldine Mawagali, Angelo Makpenon, Omphemet-
se Mokgatlhe, Azmera Molla, Momar Talla Mbodji, Farai Mavhunga, Médard Mvé, Clifford Munyandi, Lindiwe Mvusi,
Diallo Naco, Fulgence Ndayikengurukiye, Thadée Ndikumana, Adolphe Nkou, Gérard Ntahizaniye, Jean Paul Okiata
Kenkana Mayala, Augé Wilson Ondon, Jucael Hermann Ongouo, Mohamed Ould Sidatt, Aleixo Rodrigues de Sousa
Pires, Martin Rakotonjanahary, Thato Raleting, Gabriel Marie Ranjalahy, Bakoliarisoa Ranivomahefa, F Rujeedawa,
Charles Sandy, Mineab Sebhatu, Joseph Sitienei, Nicholas Siziba, Tandaogo Saouadogo, Celestino Teixeira, Desta
Tiruneh, Dawit Tsegaye, Mohamed Vadel, Abbas Zezai and Assefash Zehaie.

8)0
3FHJPO
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Christian Acosta, Shalauddin Ahmed, Xochil Alemán de Cruz, Mirian Álvarez, Raúl Álvarez, Alister Antoine, Wied-
jaiprekash Balesar, Stefano Barbosa Codenotti Draurio Barreira, María del Carmen Bermúdez, Jaime Bravo, Mar-
ta Isabel Calona de Abrego, Martín Castellanos Joya, Kenneth Castro, Gemma Chery, Roger Duncan, Mercedes F.
España Cedeño, Ed Ellis, Victor Gallant, Julio Garay Ramos, Christian García Calavaro, Jennifer George, Margarita
Godoy, Alexis Guilarte, Rosalinda Hernández Munoz, Jorge Iñiguez, Alina Jaime, Ronala Jamanca Shuan, Héctor
Oswaldo Jave Castillo, Carla Jeffries, Eva Lewis Fuller, Cecilia Lyons De Arango, María Josefa Llanes Cordero, Andrea
Yvette Maldonado Saavedra, Francisco Maldonado, Marvin Maldonado, Raúl Marcelo Manjón Tellería, R.A. Manohar
Singh, Belkys Marcelino, Ada Martínez Cruz, Celia Martínez de Cuellar, Zeidy Azofeifa Mata, Pearl Mc Millan, Mery
Mercedes, Leilawati Mohammed, Jeetendra Mohanlall, Evelyn Morales, Yndira Morales, Ernesto Moreno Naranjo,
 8)0
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Francis Morey, Mercianna Moxey, Miriam Nogales Rodríguez, Persaud Nordia, Pablo Pacheco, E. Areli Paredes García,
Tomasa Portillo, Bob Pratt, Dottin Ramoutar, Anna Esther Reyes Godoy, Leonarda Reyes, Paul Ricketts, Adalberto
Rodríguez, María Rodríguez, Jorge Rodríguez-De Marco, David Rodríguez Pérez, Nilda Romero, Orlando Sequeira,
Clarita Torres, Zulema Torres Gaete, Christopher Ulisses Trujillo García, William Turner, Melissa Valdez, Reina Vale-
rio, Daniel Vázquez, Michael Williams, Oritta Zachariah, Nydia Zelaya and Elsa Zerbini.

8)0
&BTUFSO
.FEJUFSSBOFBO
3FHJPO
Mohammad Salama Abouzeid, Naila Abuljadayel, Khaled Abu Rumman, Nadia Abu Sabrah, Khadiga Adam, Shahnaz
Ahmadi, Amin Noman Alabsi, Samia Alagab, Hala Alkjhayer, Abdelbari Al-Hammadi, Abdul Latif Al-Khal, Ali
Mohammed Hussain Al-Lawati, Rashid Al-Owaish, Issa Ali Al-Rahbi, Saeed Alsaffar, Kifah Saleh Alshaqeldi, Noor
Ahmad Baloch, Kenza Bennani, Salah Ben Mansour, Kinaz Chiekh, Walid Daoud, Mohamed Elfurjani, Essam Elmog-
hazy, Awatef El Shamry, Hashim Suleiman El Wagie, Ameera Fabella, Razia Fatima, Rachid Fourati, Mohamad Gaafar,
Amal Galal, Dhikrayet Gamara, Said Abdallah Guelleh, Dhafer Hashim, Kalthoom Hassan, Kefah, Kinaz, Laasri Lah-
sen, Joseph Lasu, Stephen Macharia, Sayed Daoud Mahmoodi, Assia Haissama Mohammed, Mahshid Nasehi, Ejaz
Qadeer, Mtanios Saade, Mohmmad Khalid Seddiq, Bashir Suleiman and Mohemmed Tbena.

8)0
&VSPQFBO
3FHJPO
Elmira Abdrakhmanova, Tleukhan Abildaev, Ibrahim Abubakar, Natavan Alikhanova, Aftandil Alisherov, Ekkehardt
Altpeter, Peter Anderson, Delphine Antoine, Andrei Astrovko, António Antunes, Thorsteinn Blondal, Stefanos Bon-
vas, Bonita Brodhun, Norbert Charle, Ana Ciobanu, Radmila Curcic, Edita Davidavičiené, Gurbanmammet Elyasov,
Connie Erkens, Damijan Erzen, Noa Cedar, Svetlana Cherenko, Margarida Coll Armangué, Olivera Bojovic, Hamza
Bozkurt, Jennifer Fernández Garcia, Maria Grazia Pompa, Ulgen Gullu, Gennady Gurevich, Efrat Haddad, Hasan
Hafizi, Peter Helbling, Elmira Ibraim, Abdukarim Jalolovich, Jerker Jonsson, Iagor Kalandadze, Jean-Paul Klein,
Maria Korzeniewska-Kosela, Kai Kliiman, Gábor Kovács, Olga Krivoanos, Wanlin Maryse, Rukije Mehmeti, Donika
Mema, Narine Mezhliumyan, Vladimir Milanov, Zohar Mor, Ucha Nanava, Joan O’Donnell, Elena Pavlenko, Bozi-
darka Rakocevic, Vija Riekstina, Elena Rodríguez-Valín, Karin Ronning, Petri Ruutu, Dmitri Sain, Firuza Sharipova,
Aleksander Simunovic, Elena Skachkova, Ivan Solovic, Antonella Sorcinelli, Soteroulla Soteriou, Gianfranco Spiteri,
Ileana Stoicescu, Stefan Talevski, Aigul Tursynbaeva, Gulnoz Uzakova, Piret Viiklepp, Jiri Wallenfels, Maja Zakoska
and Hasan Zutic.

8)0
4PVUI&BTU
"TJB
3FHJPO
Sunil de Alwis, Ratna Bhattarai, Lakbir Singh Chauhan, Emdadul Haque, Jang Yong Hui, Kim Jong Guk, Kim Tong
Hyok, Nazrul Islam, Usha Jayasuriya, Kashi Kanta Jha, Suksont Jittimanee, Badri Nath Jnawali, Yuttichai Kaset-
jaren, Constantino Lopes, Thandar Lwin, Partha Pratim Mandal, Dyah Mustika, Fathmath Reeza, Chewang Rinzin
and Asik Surya.

8)0
8FTUFSO
1BDJ¾D
3FHJPO
Farzana Adam, Paul Aia, Cecilia Arciaga, Susan Barker, Iobi Batio, Lokman Hakim Bin Sulaiman, Pengiran Khalifah
bin Pg Ismail, Kennar Briand, Richard Brostrom, Risa Bukbuk, Nou Chanly, Phonenaly Chittamany, Suzana Binte
Mohd Hashim, Chou Kuok Hei, Nese Ituaso Conway, Du Xin, Dinh Ngoc Sy, Khandaasuren Dovdon, Jane Dowa-
bobo, Mayleen Jack Ekiek, Marites Fabul, Rangiau Fariu, Louise Fonua, Anna-Marie Garfin, Hlaing Myo Tun,
David Hunsberger, Xaysangkhom Insisiengmay, Noel Itogo, Andrew Kamarepa, Khin Mar Kyi Win, Liza Lopez,
Henri-Pierre Mallet, Tomomi Mizuno, Laurent Morisse, Serafi Moa Mulumulu, Johana Ngiruchelbad, Nguyen Binh
Hoa, Connie Olikong, Fandy Osman, Faimanifo Peseta, Jean-Paul Pescheux, Nukutau Pokura, Waimanu Pulu, Bereka
Reiher, Bernard Rouchon, Oksana Segur, Temilo Seono, Cheng Shiming, Tieng Sivanna, Grant Storey, Phannasinh
Sylavanh, Kenneth Tabutoa, Markleen Tagaro, Tam Cheuk Ming, Susan Schorr, Faafetai Teo-Yandall, Tserenbaljid
Tseveen, Rosalind Vianzon, Wang Lixia, Wang Yee Tang and Byunghee Yoo.
 
7YQQEV]
8 he World Health Organization (WHO) has published
an annual report on global control of tuberculosis
(TB) every year since 1997. 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, regional and country levels.
Progress towards global targets set for 2015 is given par-
ticular attention. The target included in the Millennium
Development Goals (MDGs) is that TB incidence should
be falling by 2015. The Stop TB Partnership has set two
additional targets, which are to halve rates of prevalence
and mortality by 2015 compared with their levels in
1990. Collectively, the WHO’s Stop TB Strategy and the
Stop TB Partnership’s Global Plan to Stop TB have set
out how the 2015 targets can be achieved.
This fifteenth annual report1 contains more up-to-
date information than any previous report in the series,
following earlier data collection and the completion of
the production cycle within a calendar year.
The estimates of the global burden of disease caused
by TB in 2009 are as follows: 9.4 million incident cases
(range, 8.9 million–9.9 million), 14 million prevalent
cases (range, 12 million–16 million), 1.3 million deaths
among HIV-negative people (range, 1.2 million–1.5 mil-
lion) and 0.38 million deaths among HIV-positive people
(range, 0.32 million–0.45 million). Most cases were in
the South-East Asia, African and Western Pacific regions
(35%, 30% and 20%, respectively). An estimated 11–13%
of incident cases were HIV-positive; the African Region
accounted for approximately 80% of these cases.
There were 5.8 million notified cases of TB in 2009,
equivalent to a case detection rate (CDR, defined as the
proportion of incident cases that were notified) of 63%
(range, 60–67%), up from 61% in 2008. Of the 2.6 mil-
lion patients with sputum smear-positive pulmonary TB
in the 2008 cohort, 86% were successfully treated.
New and compelling data from 15 countries show that
efforts by national TB programmes (NTPs) to engage all
care providers in TB control (termed public-private mix,
or PPM) can be a particularly effective way to increase
the CDR. In areas where PPM was implemented, non-
NTP providers accounted for around one-fifth to one-
third of total notifications in 2009.
In 2009, 26% of TB patients knew their HIV status
(up from 22% in 2008), including 53% of patients in
the African Region. A total of 300 000 HIV-positive TB
patients were enrolled on co-trimoxazole preventive
therapy, and almost 140 000 were enrolled on antiret-
roviral therapy (75% and 37% respectively of those who
1
Two reports were published in 2009. The -2863(9'8-32 and
1)8,3(7 sections of this report explain why this was necessary.
tested HIV-positive). To prevent TB, almost 80 000 peo-
ple living with HIV were provided with isoniazid preven-
tive therapy. This is an increase from previous years, but
still represents less than 1% of the estimated number of
people living with HIV worldwide.
Among TB patients notified in 2009, an estimated
250 000 (range, 230 000–270 000) had multidrug-
resistant TB (MDR-TB). Of these, slightly more than
30 000 (12%) were diagnosed with MDR-TB and notified.
Diagnosis and treatment of MDR-TB need to be rapidly
expanded.
Funding for TB control continues to increase and will
reach almost US$ 5 billion in 2011. There is considerable
variation in what countries spend on a per patient basis
(<US$ 100 to >US$ 1000), and the extent to which coun-
tries rely on domestic or external sources of funds. Com-
pared with the funding requirements estimated in the
Global Plan, the funding gap is approximately US$ 1 bil-
lion in 2011. Given the scale-up of interventions set out
in the plan, this could increase to US$ 3 billion by 2015
without intensified efforts to mobilize more resources.
Incidence rates are falling globally and in five of
WHO’s six regions (the exception is the South-East Asia
Region, where the incidence rate is stable). If these trends
are sustained, the MDG target will be achieved. Mortal-
ity rates at global level fell by around 35% between 1990
and 2009, and the target of a 50% reduction by 2015
could be achieved if the current rate of decline is sus-
tained. At the regional level, the mortality target could
be achieved in five of WHO’s six regions; the exception
is the African Region (although rates of mortality are
falling). Prevalence is falling globally and in all six WHO
regions. The target of halving the 1990 prevalence rate
by 2015 appears out of reach at global level, but could be
achieved in three of six regions: the Region of the Ameri-
cas, the Eastern Mediterranean Region and the Western
Pacific Region.
Reductions in the burden of disease achieved to date
follow 15 years of intensive efforts to improve TB care
and control. Between 1995 and 2009, a total of 41 mil-
lion TB patients were successfully treated in DOTS pro-
grammes, and up to 6 million lives were saved including
2 million among women and children. Looking forwards,
the Stop TB Partnership launched an updated version of
the Global Plan to Stop TB in October 2010, for the years
2011–2015. In the five years that remain until the tar-
get year of 2015, intensified efforts are needed to plan,
finance and implement the Stop TB Strategy, according
to the updated targets included in this plan. This could
save at least one million lives per year.
  
-RXVSHYGXMSR
8 he World Health Organization (WHO) has published
an annual report on global control of tuberculosis
(TB) every year since 1997. 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, regional and country levels.
This fifteenth annual report1 contains more up-to-date
information than any previous report in the series, fol-
lowing earlier data collection and the completion of the
#09


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JSVIEGLSJXLILMKLFYV
HIRGSYRXVMIW,&'W
XVIRHWMRVEXIWSJ8&MRGMHIRGI
N Methods. This section explains how the data used to ERHQSVXEPMX]WMRGIGSQFMRIH[MXLTVSNIGXMSRWSJ
produce the report are collected, reviewed and ana- [LIXLIVXLIXEVKIXSJLEPZMRKXLIQSVXEPMX]VEXI
lysed.
 IWXMQEXIW SJ XLI PMZIW
N The global burden of disease caused by TB in
2009. This section presents estimates of incidence,
prevalence and mortality (absolute numbers and
F]  [MPP FI EGLMIZIH MM
WEZIHF]8&GSRXVSPFIX[IIRERHERHTVS
NIGXMSRWSJXLIEHHMXMSREPPMZIWXLEXGSYPHFIWEZIHYT
XSMRGPYHMRKWITEVEXIIWXMQEXIWJSV[SQIRERH
rates) at global, regional and country levels in 2009.
EWWIWWQIRXSJTVSKVIWWMRMQTPIQIRXMRK
N Global targets, the WHO Stop TB Strategy and
the Global Plan to Stop TB. This section defines
GLMPHVIRMMM
ERH´RERGMRK8&GEVIERHGSRXVSPEKEMRWXXLIXEVKIXW
MRGPYHIHMRENYWXVIPIEWIHERHYTHEXIHZIVWMSRSJXLI
ERI[ERHGSQTIPPMRK
the global targets for TB control that have been set
for 2015, as part of the Millennium Development
+PSFEP4PERXS7XST8&ERHMZ
GSQTMPEXMSRSJHEXEWLS[MRKXLIGSRXVMFYXMSRXLEX441
GERQEOIXSGEWIHIXIGXMSR*SYVXLGSYRXV]TVS´PIW
Goals (MDGs) and by the Stop TB Partnership. It then
describes the main components of the Stop TB Strat-
ERHGERFIHS[RPSEHIHSRPMRIEX[[[[LSMRX
egy and the Stop TB Partnership’s Global Plan to Stop
TB, which in combination have set out how the global
targets can be achieved.
N Progress in implementing the Stop TB Strat-
egy and the Global Plan to Stop TB. This section
includes analysis of case notifications, treatment out-
comes, case detection rates (for all forms of TB), the
contribution of public–private mix (PPM) initiatives
to case notifications, implementation of collabora-
tive TB/HIV activities and the management of drug-
resistant TB. It also features the topic of human
resource development and provides an update about
the work of the Global Laboratory Initiative, whose
goal is to strengthen laboratories worldwide.
N Financing for TB control. Recent trends in fund-
ing for TB control, including comparisons with the
funding requirements estimated in the Global Plan,
are presented and discussed. Recent successes in
strengthening planning and budgeting for TB control
using the WHO TB planning and budgeting tool are
showcased.
N Progress towards the 2015 targets. This section
analyses trends in rates of TB incidence, prevalence
and mortality from 1990 to 2009, and assesses wheth-
er the 2015 targets can be achieved at global, regional
and country levels.
EVIEZEMPEFPIJSVEPPGSYRXVMIWVEXLIVXLERXLI,&'W
SRP]
XFHEXEEP[E]WHVE[MRKSRXLIPEXIWXHEXEEZEMPEFPIMR
;,3«WKPSFEP8&HEXEFEWI
N Improving measurement of the burden of disease
caused by TB. This section summarizes progress at
country level in strengthening surveillance (of cases
and deaths) and implementing surveys of the preva-
lence of TB disease, in the context of the policies and
recommendations of the WHO Global Task Force on
TB Impact Measurement.
N Conclusions. This final section draws together the
main findings and recommendations in the report.
%22)< explains the methods that were used to produce
estimates of disease burden. %22)< contains summary
tables that provide global, regional and country-specific
data for the main indicators of interest. '39286=
463*-0)7 for all countries are available online at www.
who.int/tb/data; their content is advertised in %22)<.
1
Two reports were published in 2009. The first report (March) includ-
ed key indicators up to and including 2007 (for example, estimates
of disease burden and case notifications). The second report (pub-
lished on the web in December) included key indicators up to and
including 2008. Two reports were produced in one year in anticipa-
tion of a different production cycle in which reports would always
contain data up to and including the previous calendar year.
 
 1IXLSHW
* or the 2010 round of data collection, WHO updated
the forms that were used in 2009. The main change
was that questions on surveillance of MDR-TB, which
had previously been asked through a separate data col-
lection effort, were integrated into the global TB data
collection form. As in 2009, two versions of the form
were developed (a long form and a short form). The short
form was adapted for use in high-income countries (that
is, countries with a gross national income per capita of
≥US$ 12 196 in 2009, as defined by the World Bank) and/
or low-incidence countries (defined as countries with an
incidence rate of <20 cases per 100 000 population or
<10 cases in total). In consultation with WHO regional
offices, a few countries that met the criteria for receiving
the short form were instead requested to complete the
long form. This included countries that had in previous
years provided the more detailed financial data request-
ed on the long form.
Both forms requested data on the following topics:
case notifications 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 development (HRD); TB
control in vulnerable populations and high-risk groups;
TB infection control; the Practical Approach to Lung
Health (PAL); PPM; advocacy, communication and social
mobilization (ACSM); the budgets of national TB control
programmes (NTPs) in 2010 and 2011; utilization of gen-
eral health services (hospitalization and outpatient visits)
during treatment; and NTP expenditures in 2009.
A web-based online system (www.stoptb.org/tme)
was used to report and validate data in all regions except
the European Region (&3< ).1 In 2010, data collection
was launched in mid-March, about four months earlier
than in any previous year, with a deadline of 16 May for
all regions except the Region of the Americas (31 May)
and the European Region (30 September). Following the
deadlines for reporting of data, all reports were carefully
reviewed using a system of built-in validation checks (also
available to country-based staff reporting data). Follow-
up queries were returned to respondents online. By 16
June (the deadline for responding to queries), 147 coun-
tries (excluding the European Region) had reported data
(for further details, see &3<).2 In the European Region,
21 out of 53 countries reported data by 16 June. Most of
the countries that had not reported data by 16 June were
high-income countries in western Europe. Taken togeth-
er, the 168 countries that reported data by the dead-
line of 16 June account for 99% of the world’s TB cases.
All data collected online in 2010 were added to a mas-
ter dataset that holds the TB-related data that have been
compiled by WHO since 1995. Data from the two online
systems used in the European Region3 were also upload-
ed to the master dataset. All data in the global and Euro-
pean online systems as of the morning of 17 June 2010
were then used, together with historical data reported
in previous years, to produce the tables and figures that
appear in the main part of the report. Country respond-
ents continue to have the option of updating or adding
data to the online system.
The master dataset was updated for a second time on
31 August 2010, using all data in the global and Euro-
pean online systems at this time. This updated dataset
was used to create the detailed tables that are included
in %22)< , ensuring that data published for all coun-
tries were as up-to-date as possible at the time that the
report went to press.
Four additional points should be highlighted:
N NTPs sometimes provide WHO with updated infor-
mation for previous years, for incorporation in the
global TB database. As a result, the data presented in
this report may differ from those published in previ-
ous reports.
N Assessments of progress made in implementing PPM
initiatives and of global efforts to strengthen labora-
tory services and impact measurement draw on infor-
mation obtained from key informants as well as data
received via the online WHO TB data collection form.
N Financial data are presented in real terms, after
adjustment for inflation. This allows fair comparison
of funding amounts across years, without distortions
caused by changes in prices.
N The annual data collection form and database system
used by WHO are designed for collecting aggregated
national data. They are not recommended for collec-
tion of data within countries.4
1
The European Region has its own system for online reporting of
data, which is managed jointly by the European Centre for Disease
Control and Prevention (ECDC) and the WHO Regional Office for
Europe.
2
The four countries for which data were not reported by 16 June were
Canada, Haiti, Brunei Darussalam and Japan. Data were reported
for all except Haiti by 31 August 2010 and as a result data for these
countries are included in %22)<.
3
One system for countries of the European Union, managed by the
ECDC; the other for all European countries, managed by the WHO
Regional Office for the European Region. Two data collection tools
are used. Data from the ECDC system are uploaded to the WHO
system.
4
WHO recommendations for recording and reporting within coun-
tries are described at: http://www.who.int/tb/dots/r_and_r_forms/
en/index.html
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%22)<  provides details about the methods used to
produce estimates of the disease burden caused by TB
(measured as incidence, prevalence and mortality).
In line with the methods explained in this annex, the
results provided in the main text of the report and in
%22)< are presented as best, low and high estimates.
When the term “range” is used after a best estimate in
the main text of the report, the lower and higher num-
bers correspond to the 2.5th and 97.5th centiles of the
outcome distributions produced by simulations. These
are distinct from 95% confidence intervals, which are
estimated directly from observed, empirical data.
 

 8LIKPSFEPFYVHIRSJ8&


*ODJEFODF tinues to increase slightly from year to year, as slow

- n 2009, there were an estimated 9.4 million incident

cases (range, 8.9 million–9.9 million)1 of TB glo-
bally (equivalent to 137 cases per 100 000 population)
(8%&0), *-+96)). The absolute number of cases con-
reductions in incidence rates per capita (see 7)'8-32)
continue to be outweighed by increases in population.
Estimates of the number of cases broken down by age
and sex have been prepared by an expert group2 as part of

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1
The range is the uncertainty interval that corresponds to the 2.5th and 97.5th centiles of the outcome distributions produced by simulations.
See also 7)'8-32 and %22)<.
2
This expert group is convened by the WHO Global Task Force on TB Impact Measurement. See also 7)'8-32 of this report.
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Estimated new TB
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100 000 population
0–24
25–49
50–99
100–299
≥300
No estimate

'*(63&

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an update to the Global Burden of Disease study.1 These
indicate that women2 account for an estimated 3.3 mil-
lion cases (range, 3.1 million–3.5 million), equivalent to
35% of all cases.
Estimates of the numbers of TB cases among women
and children need to be improved through more report-
ing and more analysis of notification data disaggregated
by age and sex.
Most of the estimated number of cases in 2009
occurred in Asia (55%) and Africa (30%);3 smaller pro-
portions of cases occurred in the Eastern Mediterranean
Region (7%), the European Region (4%) and the Region of
the Americas (3%). The 22 HBCs that have received par-
ticular attention at the global level since 2000 account
for 81% of all estimated cases worldwide (8%&0)). The
five countries with the largest number of incident cases
in 2009 were India (1.6–2.4 million), China (1.1–1.5 mil-
lion), South Africa (0.40–0.59 million), Nigeria (0.37–
0.55 million) and Indonesia (0.35–0.52 million). India
alone accounts for an estimated one fifth (21%) of all TB
cases worldwide, and China and India combined account
for 35%.
Of the 9.4 million incident cases in 2009, an estimated
1.0–1.2 million (11–13%) were HIV-positive, with a best
estimate of 1.1 million (12%) (8%&0), *-+96)). These
numbers are slightly lower than those reported in pre-
vious years, reflecting better estimates (based on more
direct measurements as documented in %22)<) as well
as reductions in HIV prevalence in the general popula-
tion. Of these HIV-positive TB cases, approximately 80%
were in the African Region.

1SFWBMFODF
There were an estimated 14 million prevalent cases
(range, 12 million–16 million) of TB in 2009 (8%&0)),
equivalent to 200 cases per 100 000 population. As
explained in %22)< , prevalence is a robust indicator
of the burden of disease caused by TB when it is directly
measured in a nationwide survey. When survey data are
not available, it is difficult to estimate its absolute level
and trend. In those countries where surveys are done
and repeated at periodic intervals (see 7)'8-32), esti-
mates of the prevalence of TB and trends in rates of TB
prevalence will improve.

.PSUBMJUZ
In 2009, an estimated 1.3 million deaths (range, 1.2 mil-
lion–1.5 million) occurred among HIV-negative cases
of TB (8%&0) ), including 0.38 million deaths (range,
0.3 million–0.5 million) among women. This is equiva-
lent to 20 deaths per 100 000 population. In addition,
there were an estimated 0.4 million deaths (range,
0.32 million–0.45 million) among incident TB cases
that were HIV-positive (data not shown); these deaths
are classified as HIV deaths in the 10th revision of the
International Classification of Diseases (ICD-10). Thus
in total, approximately 1.7 million people died of TB in
2009. The number of TB deaths per 100 000 population
among HIV-negative people plus the estimated number
of TB deaths among HIV-positive people equates to a
best estimate of 26 deaths per 100 000 population.

.%35#
BOE
9%35#
There were an estimated 440 000 cases of multi-drug
resistant TB (MDR-TB) in 2008 (range, 390 000–
510 000).4 The 27 countries (15 in the European Region)
that account for 86% of all such cases have been termed
the 27 high MDR-TB burden countries (see also 7)'8-32
). The four countries that had the largest number of
estimated cases of MDR-TB in absolute terms in 2008
were China (100 000; range, 79 000–120 000), India
(99 000; range, 79 000–120 000), the Russian Federa-
tion (38 000; range, 30 000–45 000) and South Africa
(13 000; range 10 000–16 000). By July 2010, 58 coun-
tries and territories had reported at least one case of
extensively drug-resistant TB (XDR-TB).5
1
This study is an update to Lopez AD et al. Global burden of disease
and risk factors. New York, Oxford University Press and The World
Bank, 2006.
2
Defined as females aged ≥15 years old.
3
Asia here means the WHO regions of South-East Asia and the West-
ern Pacific. Africa means the WHO African Region.
4
The latest estimates are for 2008, as published in March 2010 in:
Multidrug and extensively drug-resistant TB (M/XDR-TB): 2010 global
report on surveillance and response. Geneva, World Health Organiza-
tion, 2010 (WHO/HTM/TB/2010.3). Figures have not been updat-
ed for this report.
5
XDR-TB is defined as resistance to isoniazid and rifampicin (i.e.
MDR-TB) plus resistance to a fluoroquinolone and, at least, one
second-line injectable agent (amikacin, kanamycin and/or capreo-
mycin).
  
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+ lobal targets for reducing the burden of disease
caused by TB have been set for 2015 and 2050
(&3<). Currently, most attention is given to the tar-
gets set for 2015. The target set within the context of
the MDGs is to halt and reverse the incidence of TB by
2015. The additional targets set by the Stop TB Partner-
ship are to halve TB prevalence and death rates by 2015,
compared with their levels in 1990.

5IF
4UPQ
5#
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The Stop TB Strategy1 is the approach recommended by
WHO to reduce the burden of TB in line with global tar-
gets set for 2015. The strategy is summarized in &3<.
The six major components of the strategy are: (i) pursue
high-quality DOTS expansion and enhancement; (ii)
address TB/HIV, MDR-TB, and the needs of poor and
vulnerable populations; (iii) contribute to health-system
strengthening based on primary health care; (iv) engage
all care providers; (v) empower people with TB, and com-
munities through partnership; and (vi) enable and pro-
mote research.
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implementation of DOTS and the Stop TB Strategy, and
prospects for the further gains that could be made up to
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The Stop TB Partnership’s Global Plan to Stop TB, 2006–
2015,2 was launched in January 2006. It set out the scale
at which the interventions included in the Stop TB Strat-
egy need to be implemented to achieve the 2015 targets.
In 2010, as the mid-point of the original 10-year plan
approached, the plan was updated. This updated ver-
sion of the plan, which covers the five years from 2011
to 2015, includes an updated set of targets.3 The major
targets for 2015 in this updated plan have been defined
as follows:
N diagnosis, notification and treatment of approximate-
ly 7 million cases;
N a treatment success rate among sputum smear-
positive cases of 90%;
N HIV testing of 100% of TB patients;
N enrolment of 100% of HIV-positive TB patients on
co-trimoxazole preventive therapy (CPT) and antiret-
roviral therapy (ART);
N provision of isoniazid preventive therapy (IPT) to all
people living with HIV who are attending HIV care
services and are considered eligible for IPT;
N testing of 100% of previously treated TB patients for
considered at high risk of having MDR-TB (estimated
globally at around 20% of all new TB patients);
N enrolment of all patients with a confirmed diagnosis
of MDR-TB on treatment consistent with internation-
al guidelines;
N mobilization of US$ 7 billion per year to finance
implementation of the Stop TB Strategy, plus around
US$ 1.3 billion per year for research and development
related to new drugs, new diagnostics and new vac-
cines.
1
The Stop TB Strategy: building on and enhancing DOTS to meet the TB-
related Millennium Development Goals. Geneva, World Health Organ-
ization, 2006 (WHO/HTM/TB/2006.368).
2
The Global Plan to Stop TB, 2006–2015: actions for life towards a world
free of tuberculosis. Geneva, World Health Organization, 2006
(WHO/HTM/STB/2006.35).
3
The Global Plan to Stop TB, 2011–2015. Geneva, World Health Organ-
ization, 2010 (WHO/HTM/STB/2010.2).
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8 his section examines the latest data on implementa-
tion of the Stop TB Strategy, and compares progress
with the targets included in the Global Plan to Stop TB,
2011–2015 where applicable. The first three topics cov-
ered are case notifications, treatment success rates for
sputum smear-positive TB patients and case detection
rates for all forms of TB. These all illustrate progress in
implementing DOTS – the foundation of the Stop TB
Strategy. The fourth topic is the engagement of the full
range of care providers in TB control (component 4 of
the strategy) through PPM. Such engagement is essen-
tial to ensure high levels of case detection and treatment
success. The next two sections cover collaborative TB/
HIV activities and the diagnosis and treatment of drug-
resistant TB, both of which fall under component 2 of
the Stop TB Strategy.
Boxes are used to feature four topics – laboratory
strengthening, HRD, strengthened surveillance and
rational use of anti-TB medicines. All four topics are
closely related to health-system strengthening (compo-
nent 3 of the Stop TB Strategy) as well as DOTS and the
engagement of all care providers. ACSM, community TB
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care and research (components 5 and 6 of the strategy)
are not discussed because there are limitations in the
available data. In future, additional efforts to compile
better data on these topics will be needed. The data that
are currently available as well as data for all other topics
covered in the 2010 data collection form can be viewed
and downloaded on the WHO web site (www.who.int/tb/
data).

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In 2009, 5.8 million cases of TB (new cases and relapse
cases) were notified to NTPs, including 2.6 million new
cases of sputum smear-positive pulmonary TB, 2.0 mil-
lion new cases of sputum smear-negative pulmonary TB
(including cases for which smear status was unknown),
0.9 million new cases of extrapulmonary TB and 0.3 mil-
lion relapse cases (8%&0)).1
Among pulmonary cases, 57% of global notifications
were sputum smear-positive. Among the 22 HBCs, the
percentage of notified cases of pulmonary TB that were
sputum smear-positive was relatively low in Zimbabwe
(29%), the Russian Federation (31%), Pakistan (42%),
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1
No distinction is made between DOTS and non-DOTS programmes. This is because by 2007, virtually all (more than 99%) notified cases were
reported to WHO as treated in DOTS programmes. Since 2009, the WHO data collection form has made no distinction between notifications
in DOTS and non-DOTS programmes.
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Myanmar (45%), Kenya (46%) and Ethiopia (46%). A
comparatively high proportion of notified cases were
sputum smear-positive in Bangladesh (81%), the Demo-
cratic Republic of the Congo (85%) and Viet Nam (73%).

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Globally, the rate of treatment success for new sputum
smear-positive cases of pulmonary TB who were treated
in the 2008 cohort was 86% (8%&0) ). This is the sec-
ond successive year that the target of 85% (first set in
1991) has been exceeded globally. Of the 22 HBCs, 13
reached the 85% target. This included Kenya and the
United Republic of Tanzania, demonstrating that coun-
tries in which there is a high prevalence of HIV among
TB patients are able to achieve this target. Among WHO
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ern Mediterranean Region, the South-East Asia Region
and the Western Pacific Region. The treatment success
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The case detection rate (CDR)1 has been a much-used
indicator of national progress in TB control since the
mid-1990s. For a given country, it is calculated as the
number of notified cases of TB in one year divided by the
number of estimated incident cases of TB in the same
year, and expressed as a percentage. The considerable
attention given to the CDR was in line with the two prin-
cipal global targets (case detection and treatment suc-
cess rates) set for TB control during the period 1991 to
2005. The targets of reaching a CDR of ≥70% and a treat-
1
The CDR is actually a ratio rather than a rate, but the term “rate”
has become standard terminology in this context of this indicator.
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ment success rate of 85% among sputum smear-positive
cases of pulmonary TB by 2000 were set by the Forty-
fourth World Health Assembly in 1991, with the target
year subsequently reset to 2005.
Given uncertainty in estimates of TB incidence, this
report places less emphasis on the CDR, compared with
past reports (and this will be true of future reports on
global TB control as well). In particular, this report (for
the first time in the series of reports published since
1997) does not include estimates of the CDR for sputum
smear-positive cases of pulmonary TB (&3<).
The best estimate of the CDR of all forms of TB in 2009
was 63% (range, 60–67%) (8%&0)). The highest rates of
case detection in 2009 are estimated to be in the Euro-
pean Region (best estimate 80%; range, 74–85%) and
the Region of the Americas (best estimate 79%; range,
74–85%), followed by the Western Pacific Region (best
estimate 70%; range, 64–78%). The African Region has
the lowest estimated rate of case detection (best esti-
mate 50%; range, 48–53%). Among the HBCs, the high-
est rates of case detection in 2009 are estimated to be in
Brazil, the Russian Federation, South Africa, Kenya, the
United Republic of Tanzania and China; the lowest rate
is in Nigeria.
While estimated rates of TB incidence are falling
slowly, notification rates are increasing in the African
Region and (particularly since around the year 2000)
the Eastern Mediterranean and South-East Asia regions,
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indicating that case detection is improving (see *-+96)
 in 7)'8-32). In the Western Pacific Region, notifi-
cations increased sharply between 2002 and 2006, but
have since stabilized; here, patterns are strongly influ-
enced by China, which accounts for almost 70% of inci-
dent cases in this region (8%&0)).
Despite difficulties with estimating the case detection
rate (&3<, %22)<), efforts to increase the percentage
of TB cases that are diagnosed and treated according to
international guidelines are clearly of major importance.
This will be necessary to move towards the 7 million
notifications targeted in the Global Plan for 2015 (and
eventually, to achieve early detection of all cases).
There are three main reasons why incident cases of TB
may not be notified (see also %22)<, 8%&0)%). These
are:
N Cases are diagnosed but not reported. For people
in this category, strengthening surveillance systems,
establishing links with the full range of health-care
providers and stronger enforcement of legislation
regarding notification of cases (where this is mandat-
ed by law) will help.
N Cases seek care but are not diagnosed. For people
in this category, better diagnostic capacity is needed.
This could mean better laboratory capacity as well as
more knowledgeable and better trained staff, espe-
cially in peripheral-level health-care facilities.
N Cases do not seek care. For people in this category,
reasons could include not recognizing any symptoms
of TB and/or no access (financial and/or geographi-
cal) to health-care services. To reach cases in this
category, health systems need to be strengthened so
that basic health-care services are available to more
people, and financial barriers to diagnosis (and subse-
quently treatment) need to be mitigated or removed.
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A case study from China, which illustrates how strength-
ening surveillance can lead to increased notifications
of TB cases and an increase in the CDR, is provided in
&3<. Engagement of all care providers is discussed
in the next section. Strengthening of laboratory capac-
ity and human resource development are discussed in
&3< and &3<, respectively.

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11.


number of countries. New and compelling data compiled

JOJUJBUJWFT
In many countries, one of the best ways to increase case
detection is for NTPs to establish collaboration with the
full range of health-care providers. This is component 4
of the Stop TB Strategy (&3<), and its two subcompo-
nents are:
N involvement of all public, voluntary, corporate and
private providers through Public-Private Mix (PPM)
approaches; and
N promotion of the International Standards for Tuber-
culosis Care through PPM initiatives.
Efforts to engage all care providers through PPM initia-
tives, beyond those which fall under the direct respon-
sibility of the NTP (termed “non-NTP providers” in this
report), are being introduced and scaled up in many
countries. Unfortunately, demonstrating this progress
is not always possible. First, it requires that systematic
GSPPEFSVEXMSR FIX[IIR LSWTMXEPW ERH 8& HMWTIRWEVMIW
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recording and reporting of the source of referral and
place of TB treatment is being done. Second, it requires
that data reported at the local level are aggregated, ana-
lysed and reported at the national level.1 Often, one or
both conditions are not yet met.
Despite this recording and reporting challenge, sub-
stantial progress in engaging non-NTP care provid-
ers through PPM can be documented for an increasing
from 15 countries (including nine HBCs) in 2010, which
demonstrate the major contribution that PPM can make
to case notifications, are summarized in 8%&0) . In
these 15 countries, the contribution of PPM initiatives
typically ranges from between about one fifth to one
third of total notifications, in the geographical areas in
which PPM has been implemented. This has been accom-
panied by maintenance of high rates of treatment suc-
cess (data not shown).
As also illustrated in 8%&0), NTPs have used a vari-
ety of approaches to engage non-NTP care providers,
according to the local context. These include incentive-
based schemes for individual and institutional providers
in India and Myanmar; a web-based system for man-
datory reporting of TB cases by all providers in China
1
WHO recommends that the source of referral and the place of treat-
ment should be routinely recorded and reported.
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(&3<); and reimbursement for TB care delivered by pri-
vate providers through health insurance, when care con-
forms with agreed-upon standards, in the Philippines. It
is also noticeable that countries have prioritized differ-
ent types of care providers. This includes pharmacies in
Cambodia, private hospitals in Nigeria, public hospitals
in China and Indonesia, social security organizations in
Mexico and prison services in Kazakhstan.
In general, only a small proportion of targeted care
providers collaborate actively with NTPs and contribute
to TB case notifications in most countries. For this rea-
son, it is not surprising that NTPs often give first priority
to engaging institutional providers with whom estab-
lishing collaborative links may be less demanding and,
for a given amount of effort, will yield a higher number
of notifications. At the same time, involving front-line
health workers such as community-based informal pro-
viders, private practitioners and pharmacies – who are
often the first point of contact for people with symp-
toms of TB – can help to reduce diagnostic delays and
the out-of-pocket expenditures of TB patients. For these
reasons, scaling up PPM, in phases if not at once, should
aim to systematically map and engage all relevant care
providers in TB care and control.

$PMMBCPSBUJWF
5#)*7
BDUJWJUJFT
Collaborative TB/HIV activities are essential to ensure
that HIV-positive TB patients are identified and treated
appropriately, and to prevent TB in HIV-positive people.1
These activities include establishing mechanisms for col-
QMPPMSRTSTYPEXMSR
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laboration between TB and HIV programmes; infection
control in health-care and congregate settings; HIV test-
ing of TB patients and – for those TB patients infected
with HIV – CPT and ART; and intensified TB case-finding
among people living with HIV followed by IPT for those
without active TB. Testing TB patients for HIV and pro-
viding CPT for HIV-positive TB patients are typically the
responsibility of NTPs; national HIV programmes are
usually responsible for initiating intensified case-finding
among HIV-positive people and provision of IPT to those
without active TB. Provision of ART to HIV-positive TB
patients is often the responsibility of national HIV pro-
grammes, but may also be done by NTPs. When NTPs do
not provide ART directly, they are responsible for refer-
ring HIV-positive TB patients to ART services.
Further progress in implementing collaborative TB/
HIV activities was made in 2009, which consolidated the
achievements documented in previous reports. Just over
1.6 million TB patients knew their HIV status in 2009
(26% of notified cases), up from 1.4 million in 2008 (*-+
96) ). The highest rates of HIV testing were reported
in the European Region, the African Region and the
Region of the Americas, where 86%, 53% and 41% of TB
patients knew their HIV status, respectively (8%&0)).
In 55 countries, at least 75% of TB patients knew their
HIV status, including 16 African countries (*-+96)
), up from 50 countries in total and 11 in the African
1
Interim policy on collaborative TB/HIV activities. Geneva, World
Health Organization, 2004 (WHO/HTM/TB/2004.330; WHO/
HTM/HIV/2004.1).
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5
Cases (millions)

2 26%
20% 22%
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1 12%  8LIRYQFIVWYRHIVIEGL]IEVWLS[XLI
8.5%
4.2% 3.2% RYQFIVSJGSYRXVMIWVITSVXMRKHEXESR,-:
0 XIWXMRKJSPPS[IHF]XLITIVGIRXEKISJXSXEP
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92 84 131 146 169 167 143
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TB cases with known
HIV status
0–14
15–49
50–74
≥75
No data
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'*(63&
 Region in 2008. The number of HIV-positive TB patients

$PUSJNPYB[PMF
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enrolled on CPT and ART has been increasing in recent
UIFSBQZ
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° years, especially since 2005 (*-+96)). By 2009, almost
500 300 000 HIV-positive TB patients were started on CPT
Tested HIV-positive and almost 140 000 were enrolled on ART. Almost 80%
Number of TB patients (thousands)

400
of TB patients who were known to be HIV-positive were
started on CPT and almost 40% were enrolled on ART
300 CPT
(*-+96) , *-+96) ). Further efforts are needed to
200
reach the Global Plan target of starting 100% of HIV-
ART positive TB patients on both CPT and ART by 2015.
100 Screening for TB among HIV-positive people and
providing IPT to those without active TB have steadily
0
increased, particularly since 2007 (*-+96), *-+96)).
2003 2004 2005 2006 2007 2008 2009
In 2009, 1.7 million HIV-positive people were screened
for TB and close to 80 000 of those without active TB
'*(63&
 were enrolled on IPT. The numbers screened are equiva-
$PUSJNPYB[PMF
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lent to about one third of the people living with HIV who
5#
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°B are on ART, about 10% of the people living with HIV who
100
are estimated to be in need of ART and about 5% of the
estimated total number of HIV-positive people world-
Percentage of HIV-positive TB patients

80 wide. The numbers started on IPT are less than 1% of the

CPT
estimated number of people living with HIV. Intensified
60 efforts are needed to approach the Global Plan target of
providing IPT to all those attending HIV care services
40
who are eligible for it by 2015.
20

.BOBHFNFOU
PG
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5#
0 Globally, just over 30 000 cases of MDR-TB were noti-
2003 2004 2005 2006 2007 2008 2009
27 (30%) 24 (29%) 39 (53%) 55 (64%) 73 (92%) 86 (93%) 63 (75%)
fied to WHO in 2009, mostly by European countries and
South Africa (*-+96), 8%&0)). This represents 12%
E
 2YQFIVWYRHIV]IEVWWLS[XLIRYQFIVSJGSYRXVMIWVITSVXMRKHEXE
JSPPS[IHF]XLITIVGIRXEKISJXSXEPIWXMQEXIH,-:TSWMXMZI8&GEWIW of the estimated number of cases of MDR-TB among all
EGGSYRXIHJSVF]VITSVXMRKGSYRXVMIW notified cases of pulmonary TB in 2009 (8%&0)). Coun-
try plans suggest that, overall, the numbers of patients
diagnosed with MDR-TB and started on treatment will
'*(63&

almost double in 2010 and 2011, compared with 2009
"OUJSFUSPWJSBM
UIFSBQZ
GPS
)*7QPTJUJWF
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(*-+96) ). Substantial increases in the numbers of
°B
patients diagnosed with MDR-TB and started on treat-
100
ment are expected in the three countries where the esti-
Percentage of HIV-positive TB patients

mated number of cases is highest: China, India and the

80
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60 There has been an impressive increase in the share
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ART
40 programmes approved by the Green Light Committee
(GLC), in which patients are known to be receiving treat-
20
ment according to international guidelines. The number
0
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2003 2004 2005 2006 2007 2008 2009 to over 30 000 in 2011 (approximately 60% of all noti-
47 (9%) 24 (25%) 47 (55%) 69 (64%) 93 (85%) 109 (96%) 89 (80%)
fications of MDR-TB that are projected by countries in
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 2YQFIVWYRHIV]IEVWWLS[XLIRYQFIVSJGSYRXVMIWVITSVXMRKHEXE that year). This remains a small fraction of the estimated
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umn from right, 8%&0)). Much more rapid expansion
of diagnosis and treatment – within and outside projects
and programmes approved by the GLC – is needed to
approach the targets for MDR-TB that are included in
the Global Plan (*-+96)).
National data on treatment outcomes among cohorts
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of at least 200 patients are currently limited to nine '*(63&


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100
variable, ranging from below 40% to almost 80%. High
90
rates of default are a common problem (with a median 80
value of 17%). 70

Percentage of cohort
One of the most important constraints to rapid expan- 60
sion of diagnostic and treatment services for MDR-TB is 50

laboratory capacity. Without greater capacity to diagnose 40

30
MDR-TB, the number of cases diagnosed and treated will
20
remain low. Diagnostic testing for drug susceptibility, or
10
DST, among new cases of TB remains almost entirely 0
Kazakhstan Turkey Philippines Perub Uzbekistan Republic Brazil South Romania
confined to the European Region and the Region of the (1609) (240) (296) (670) (330) of Moldova (406) Africa (707)
(254) (3815)
Americas (*-+96) ). Even in these regions, however,
Successfully treated Died Failed Defaulted Not evaluated
the percentage of previously treated patients who were
E
tested for drug resistance was less than 40%, far below  3RP]GSYRXVMIWVITSVXMRKSYXGSQIWJSV"GEWIWSJ1(68&[MXL  
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20
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susceptible TB) also requires that proper measures for 10
infection control are in place. These measures include
personal protection (for example, masks), administra- 0
AFR AMR EMR EURb SEAR WPR Total
tive controls (for example, in waiting areas for people (15) (16) (11) (42) (3) (11) (98)

attending outpatient services) and environmental meas-

40
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% of re-treatment cases tested

assess the quality of infection control is the ratio of the 30

notification rate of TB among health-care workers to
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ratio should be approximately 1. The data required to

10
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collection form, but to date the availability of reliable 0
AFR AMR EMR EURb SEAR WPR Total
data is limited. Collection and reporting of data on this (22) (15) (10) (40) (6) (11) (104)
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Among 80 countries that provided data, 55 (69%) report-
ed having a focal point for infection control related to TB
in at least one of their tertiary hospitals. Of 75 countries
that provided data, 36 (48%) had performed an assess-
ment of the status of infection control for TB in at least
part of their network of tertiary hospitals in 2009.
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Bangladesh
Myanmar
Viet Nam
Haiti Senegal Indonesia
Djibouti
Ethiopia
Côte d’Ivoire Uganda
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Peru
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has increased year-on-year since 2002, with the
exception of a small dip in 2009, and is expected to reach
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accounted for by funding in the Russian Federation and 1.5 1.6 PPM/PAL/
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1.0
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Loans
2.0
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1.5 1.6 general health-
year. In 2011, funding gaps are anticipated for all com- 1.5 care services
(excluding loans)
ponents of the Stop TB Strategy, including for DOTS (the 1.0 Government,
NTP budget
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include Kenya, Indonesia and Mozambique, where fund-
ing has fallen since 2008 (*-+96)). Funding has been
closest to keeping pace with increases in NTP budgets
in Brazil, China, India, the Philippines and the Russian
Federation. In contrast, funding gaps have persisted in
most African countries as well as Cambodia, Myanmar
and Pakistan. In 2011, the Russian Federation, Thailand,
Brazil, South Africa, China, the Philippines and Viet Nam
will rely primarily on domestic funding (including loans
from development banks). In other HBCs, there is much
greater reliance on donor funding, ranging from around
1
The first round was completed in 2003. Round 9 was completed
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funding) in 2009.
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3.0 411
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22 HBCs Afghanistan Bangladesh Brazil Cambodia
63
2819 21 45 64 38
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China DR Congo Ethiopia India Indonesia

394 64 39 147 94
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Kenya Mozambique Myanmar Nigeria Pakistan

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31
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14 37
54

8 28 35
12 8

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Philippines Russian Federation South Africa Thailand Uganda

43 43 1258
1286 413 52 23
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14 704 258 47 2

2002 2005 2008 2011 2002 2005 2008 2011

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34 20 21

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21
13 E
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Russian Federation Internal sources
Thailand Government, NTP budget
Brazil (excluding loans)
South Africa Government, general
China health-care services
(excluding loans)
Philippines
Loans
Viet Nam
India External sources
Indonesia
Grants (excluding
Kenya Global Fund)
Pakistan Global Fund
Mozambique
Nigeria
Ethiopia
Afghanistan
UR Tanzania
Cambodia
Uganda
Myanmar
Zimbabwe
Bangladesh
DR Congo

0 10 20 30 40 50 60 70 80 90 100

% of total available funding

40% of available funding in India to more than 90% of 
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available funding in the Democratic Republic of the Con-
go (*-+96)).
There is also considerable variation in the estimated
cost per patient treated according to the DOTS strat-
egy (*-+96) ). This ranges from under US$ 100 (in
Bangladesh, India, Myanmar, Pakistan and Zimbabwe)
to around US$ 750 in Thailand, US$ 1000–1500 in Bra-
zil and South Africa and more than US$ 7 500 in the
Russian Federation. In most HBCs, the cost per patient
treated under DOTS is around US$ 150–400. As shown
in *-+96), variation in the cost per patient treated
is clearly related to income levels (for example, Brazil
and South Africa are upper-middle income countries,
where prices for inputs such as NTP staff and hospi-
tal care are higher than in low-income countries). The
major reason why the Russian Federation is an outlier
is the model of care used: high costs are associated with
a policy of lengthy hospitalization of TB patients with-
in an extensive network of TB hospitals and sanatoria.
A further explanation for variation in costs appears to
be the scale at which treatment is provided. The coun-
tries with relatively low costs for their income level (for
example, Bangladesh, China, India, Indonesia and the
Philippines) are also the countries where the total num-
bers of patients treated are highest (as shown by the size
of the circles in *-+96)). A similar pattern exists for
the cost per patient successfully treated, which combines
information about both costs and effectiveness (*-+96)
).
Besides the 22 HBCs, 81 other countries have reported
financial data to WHO since 2006 that allow assessment
of trends in funding for TB control. Combined, these 103
countries account for 96% of the world’s notified cases
of TB. Funding for TB control has grown from US$ 3.9
billion in 2006 to a projected US$ 4.7 billion in 2011
(*-+96) , *-+96) ). As in HBCs, the largest share
of funding is for DOTS implementation; an increasing
amount is for MDR-TB. National governments account
for 86% of the funding expected in 2011, followed by
the Global Fund (US$ 513 million, or 11% of total fund-
ing) and then by grants from donors besides the Global
Fund (US$ 101 million, or 2%). Loans from development
banks account for the remaining 1% of total funding. The
funding gaps reported by these 103 countries amount to
US$ 0.6 billion in 2010 and US$ 0.3 billion in 2011 (*-+
96)).
A comparison of the funding available in the coun-
tries that reported financial data with the funding
requirements set out in the Global Plan is provided, by
region and for the period 2011–2015, in *-+96).1
Overall, funding falls short of the requirements of the
Global Plan. The gap is approximately US$ 1 billion in
2011. Given the scale-up of interventions set out in the
plan, this could increase to US$ 3 billion by 2015 with-
out intensified efforts to mobilize more resources.
1
This analysis is for the 22 HBCs and a subset of 85 other countries
that are among the 149 countries considered in the Global Plan. The
total funding available in the group of 107 countries for which data
were available was adjusted upwards according to the fraction of
cases for which they accounted, to allow direct comparison with the
group of 149 countries considered in the Global Plan. The Global
Plan excludes high-income countries.
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Cost per DOTS patient treated (logarithmic scale)

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756

6 VIET NAM
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139 140
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US$ billions (constant 2010 US$)b

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US$ billions (constant 2010 US$)b

5 5 4.6
4.6 care services:
Global Fund
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4.0 4.0 Grants (excluding
4 General health- 4
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vincing plans and well-justified budgets. The WHO TB

CVEHFUJOH
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The quality of financial data reported to WHO has stead- assist with the development of comprehensive plans and
ily improved since data were first collected in 2002. At budgets for all relevant components of TB control. When
the same time, reported budgets and expenditures are completed, one advantage of the tool is that it automati-
not always consistent from one year to the next; assess- cally summarizes NTP budgets and sources of funding
ments of the funding required – particularly for newer in the format requested on the annual WHO TB data col-
components of TB control (such as management of lection form. Successes in using the tool to help with the
drug-resistant TB) – can appear too low (or, less often, development and budgeting of strategic plans in Bang-
too high); and persistent funding gaps indicate a need to ladesh, Cambodia and Mongolia between mid-2009 and
strengthen resource mobilization efforts based on con- mid-2010 are highlighted in &3<.
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4 rogress made towards achieving the impact targets
set for 2015 – to halt and reverse the incidence of TB
by 2015 (MDG Target 6.c), and to halve prevalence and
mortality rates compared with a baseline of 1990 (the
targets set by the Stop TB Partnership) – is illustrated
at the global level in *-+96) and at the regional level
in *-+96) , *-+96)  and *-+96) .1 Progress in
achieving reductions in incidence and mortality is shown
for each of the 22 HBCs in *-+96) and *-+96).
Globally, rates of incidence, prevalence and mortality
are all declining (*-+96)). Incidence rates are falling
slowly, at around 1% per year, following a peak at just
over 140 cases per 100 000 population in 2004. If cur-
rent trends are sustained, then MDG Target 6.c will be
achieved. Mortality rates have fallen by one third since
1990, and prevalence rates are also in decline. Projec-
tions suggest that the target of halving mortality by
2015 compared with 1990 could be achieved at global
level. The target of halving the prevalence rate appears
out of reach. It should be noted, however, that there is
more uncertainty about trends in prevalence, compared
with trends in mortality (see also %22)<).
Regionally, incidence rates are declining in five of
WHO’s six regions (*-+96)). The exception is the
South-East Asia Region (where the incidence rate is sta-
ble), largely explained by apparent stability in the TB
incidence rate in India. Further evaluation of trends
in the disease burden in India is needed, and has been
'*(63&

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planned for early 2011. Among the five regions where
incidence rates are falling, the rate of decline varies from
less than 1% per year in the Eastern Mediterranean and
European regions to around 2% per year in the African
Region (since 2004) and 4% per year in the Region of
the Americas. As also illustrated in *-+96), notifica-
tions are closest to estimated incidence in the Region of
the Americas and the European Region, indicating that
the highest rates of case detection are achieved in these
regions (see also 7)'8-32 ). As incidence falls slowly,
notifications are increasing in the African Region and
(particularly since 2000) in the Eastern Mediterranean
and South-East Asia regions, indicating improving rates
of case detection. In the Western Pacific Region, notifi-
cations increased sharply between 2002 and 2006, but
have since stabilized; here, patterns are strongly influ-
enced by China, which accounts for almost 70% of inci-
dent cases in this region (8%&0)).
The latest assessment for the 22 HBCs suggests that
incidence rates are falling or stable in all countries
except South Africa (*-+96)). Trends in incidence
rates are assumed to be stable in Afghanistan, Bangla-
desh, India, Indonesia, Myanmar and Pakistan, in the
absence of convincing evidence to the contrary (%22)<
). The stability in TB incidence rates in India (which
accounts for 61% of cases in this region) as well as Bang-
ladesh, Indonesia and Myanmar explains the flat trend
in estimated incidence in the South-East Asia Region.
MRGEWIRSXM´GEXMSRVEXIRI[ERHVIPETWIGEWIWEPPJSVQW
FPEGO
IWXMQEXIHMRGMHIRGIVEXIMRGPYHMRK,-:TSWMXMZI8&
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7LEHIHEVIEWVITVIWIRXYRGIVXEMRX]FERHW1SVXEPMX]I\GPYHIW8&HIEXLWEQSRK,-:TSWMXMZITISTPI
Incidence and notifications Mortality Prevalence
35
140 300

30
120
Rate per 100 000 population

250
25
100
200
20
80
150
60 15

100
40 10

20 5 50

0 0 0

1990 1995 2000 2005 1990 1995 2000 2005 2010 2015 1990 1995 2000 2005 2010 2015

1
See &3< in 7)'8-32 of this report for definitions of the global
targets for TB control.
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RI[ERHVIPETWIGEWIWEPPJSVQW FPEGO IWXMQEXIHMRGMHIRGIVEXIMRGPYHMRK,-:TSWMXMZI8&FPYI ERHIWXMQEXIH
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Africa The Americas Eastern Mediterranean

60 140

300 120
50
100
40
200 80
30
60
20
100 40
Rate per 100 000 population

10 20

0 0 0

Europe South-East Asia Western Pacific

60
150
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50

40 150
100

30
100

20 50
50
10

0 0 0

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VIHYGXMSRMRXLITVIZEPIRGIVEXIF]GSQTEVIH[MXL8LISXLIVHEWLIHPMRIWWLS[TVSNIGXMSRWYTXS
Africa The Americas Eastern Mediterranean

400
600 120

500 100
300
400 80

300 60 200

200 40
100
Rate per 100 000 population

100 20

0 0 0

Europe South-East Asia Western Pacific

120 400
500

100
400 300
80
300
60 200

200
40
100
20 100

0 0 0

1990 1995 2000 2005 2010 2015 1990 1995 2000 2005 2010 2015 1990 1995 2000 2005 2010 2015
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Africa The Americas Eastern Mediterranean

10
60 40

50 8
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30 20
4
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2
Rate per 100 000 population

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15 40
60

50
30
10
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10
10

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1990 1995 2000 2005 2010 2015 1990 1995 2000 2005 2010 2015 1990 1995 2000 2005 2010 2015

E
 8LI[MHXLSJYRGIVXEMRX]FERHWREVVS[WEWXLITVSTSVXMSRSJVIKMSREPQSVXEPMX]IWXMQEXIHYWMRKZMXEPVIKMWXVEXMSRVIGSVHWMRGVIEWIW

In most of the HBCs, notifications have been getting
closer to estimated incidence in recent years, notably in
Afghanistan, Bangladesh, Cambodia, China, Indonesia,
Pakistan, South Africa and the United Republic of Tan-
zania (*-+96)).
Prevalence rates are falling in all six WHO regions (*-+
96)). The most impressive progress is in the Region
of the Americas, where the Stop TB Partnership’s target
of halving the 1990 prevalence rate has been achieved.
Projections suggest that the Western Pacific and Eastern
Mediterranean regions are on track to achieve the target
by 2015, and the European Region could get close. On
current projections, the African and South-East Asian
regions will not achieve the target.
Mortality rates (excluding TB deaths among HIV-
positive people) are falling in all six WHO regions. The
best progress towards the 2015 target of halving the
1990 mortality rate is in the Region of the Americas and
the Western Pacific Region, both of which appear to have
achieved the target already. The Eastern Mediterranean,
European and South-East Asia regions are close to reach-
ing the target, and could do so before 2015. In the Afri-
can Region, achieving the target appears out-of-reach,
following a major increase in TB incidence and mortality
rates associated with the HIV epidemic throughout the
1990s and up to around 2004.
Among the 22 HBCs, mortality rates appear to be
falling with the possible exception of Afghanistan and
Uganda (*-+96) ). Even allowing for uncertainty in
these estimates, four countries reached the target of
halving the 1990 mortality rate by 2009 (Brazil, Cam-
bodia, China and the United Republic of Tanzania), and
six additional countries (India, Indonesia, Kenya, Myan-
mar, Pakistan and the Russian Federation) have a good
chance of doing so by 2015. In the other HBCs, current
forecasts suggest that the target may not be achieved.
The reductions in mortality associated with progress
to date in implementing the DOTS strategy (1995–2006)
and its successor, the Stop TB Strategy (launched in
2006) have saved millions of lives since 1995, and con-
tinued implementation could save millions more in the
years up to 2015 (*-+96) ).1 From 1995 to 2009, 49
1
These results are based on the following manuscript: Glaziou P et
al. Lives saved by tuberculosis control and prospects for achiev-
ing the 2015 global target for reductions in tuberculosis mortality
(submitted for publication in May 2010).
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Afghanistan Bangladesh Brazil Cambodia China
120
250 300 150
100
200 250 600
200 80 100
150 60 400
150
100 40
100 200 50
50 50 20
0 0 0 0 0
DR Congo Ethiopia India Indonesia Kenya
500 500
250
400 400 200
200 400
300 300 150 300
150
200 200 100 100 200
100 100 50 50 100
0 0 0 0 0
Rate per 100 000 population

Mozambique Myanmar Nigeria Pakistan Philippines

500 500 300 500
400 300 250 400
400
300 200
300 200 300
150
200 200 200
100 100
100 100 50 100
0 0 0 0 0
Russian Federation South Africa Thailand Uganda UR Tanzania
150 250
1000 400
150 200
100 800 300
600 100 150
200 100
50 400
50 100
200 50
0 0 0 0 0
Viet Nam Zimbabwe 1990 1995 2000 2005 1990 1995 2000 2005 1990 1995 2000 2005
1000
250
800
200
600
150
100 400

50 200 E
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1990 1995 2000 2005 1990 1995 2000 2005

million patients were treated, of whom 41 million were

successfully treated in DOTS programmes, saving up to 6
million lives. This includes approximately 2 million lives
saved among women and children. From 2010 to 2015,
a further 5 million lives could be saved if current efforts
and levels of achievement in TB control are sustained,
including around 2 million women and children. With
expansion of treatment for MDR-TB and interventions
such as ART for HIV-positive TB patients in the period
2011–2015, as set out in the Global Plan, even more lives
could be saved.
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0 0 0 0 0
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120 100 70 60
60 80
100 80 50
80 50 60 40
60 40
60 40 30
40 30
40 20 20
20 20 20
10 10
0 0 0 0 0
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Mozambique Myanmar Nigeria Pakistan Philippines

200 120
80 100 60
100
150 80 50
60 80
60 40
100 60 30
40
40 40
50 20
20 20 20 10
0 0 0 0 0
Russian Federation South Africa Thailand Uganda UR Tanzania
60 40 150
80 40
50
30
40 60 100 30
30 20 20
40
20 50
20 10 10
10
0 0 0 0 0
Viet Nam Zimbabwe 1990 1995 2000 2005 2010 2015 1990 1995 2000 2005 2010 2015 1990 1995 2000 2005 2010 2015

70 120
60
100
50
80
40
30 60
20 40
10 20
0 0
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 -QTVSZMRKQIEWYVIQIRXSJXLI
KPSFEPFYVHIRSJ8&
) stimates of TB incidence, prevalence and mortality
and their trend (presented in 8%&0)  and in *-+
96)7 ¦) are based on the best available data and
analytical methods. Methods were updated in 2009 fol-
lowing 18 months of work by an expert group convened
under the umbrella of the WHO Global Task Force on
TB Impact Measurement.1 Improvements to methods
(full details are provided in %22)<) include systematic
documentation of expert opinion and how this has been
used in estimates of the burden of disease caused by TB,
simplification of models,2 updates to parameter values
based on the results of systematic reviews, much greater
use of mortality data from vital registration systems (89
countries for the analyses presented in this report, up
from three in the years up to 2008) and systematic docu-
mentation of uncertainty.
Despite this progress, estimates of the disease burden
need to be further improved in the period up to 2015
(and beyond) using better surveillance systems, more
extensive and in-depth analysis of available surveil-
lance and programmatic data, and additional survey
data. For example, with the exception of Eritrea in 2005,
the last nationwide and population-based surveys of
the prevalence of TB disease in the African Region were
undertaken between 1957 and 1961; only around 10%
of TB-attributable deaths (in HIV-negative people) are
recorded in vital registration systems and reported to
WHO; and most notification systems are recording only
around 50–70% of estimated cases.
Besides its work on reviewing and updating the meth-
ods that are used to produce estimates of the burden of
disease caused by TB, the WHO Global Task Force on TB
Impact Measurement is thus making concerted efforts
to support countries to pursue two other major strategic
tracks of work (full details are available in a recent WHO
Policy Paper3). These are:
N Surveys of the prevalence of TB disease, with particu-
lar attention to 21 “global focus” countries (*-+96)
). These surveys should be carried out according to
WHO guidelines and related Task Force recommenda-
tions;
N Strengthening surveillance of cases and deaths
through notification and vital registration systems.
The ultimate goal is for TB incidence and mortality
to be measured directly from these systems. The Task
Force has defined a conceptual framework for this
work (*-+96)) and related tools to help countries
to implement it in practice.
As of mid-2010, all of the countries in the South-East
Asia and Western Pacific regions where prevalence sur-
veys are recommended (Bangladesh, Cambodia, China,
Indonesia, Myanmar, the Philippines, Thailand and Viet
Nam) were on track with survey implementation. Bangla-
desh (2008), the Philippines (2007) and Viet Nam (2007)
recently completed surveys, and subsequent surveys are
planned close to 2015. The most notable successes in
2009/2010 among Asian countries were the completion
of nationwide surveys in Myanmar (in April 2010; see
&3< ) and China (in July 2010). The results of these
surveys will be of major importance for gaining a better
understanding of the burden of disease (both countries)
and the impact of TB control in the past two decades (in
China, following previous surveys in 1990 and 2000).
Looking forwards, a survey will be implemented in
Cambodia in 2011, following a previous survey in 2002.
This will allow assessment of the impact of TB control
since 2002 i.e. the years since DOTS was implemented. A
survey is in the advanced stages of preparation in Thai-
land, and in Indonesia a follow-up to the 2004 survey is
planned for 2013 or 2014.
In the Eastern Mediterranean Region, Pakistan
secured full funding for a survey in 2008, but security
concerns and other factors that affect field operations
may preclude implementation.
The greatest challenge in terms of implementation of
prevalence surveys is in the African Region. Nonetheless,
considerable progress was made during 2009 and 2010.
As of July 2010, five countries were in a strong position to
start surveys in late 2010 or early 2011 (Ethiopia, Ghana,
Nigeria, Rwanda and the United Republic of Tanzania).
Preparations were relatively advanced in Kenya, Malawi,
Uganda, Zambia and South Africa, although funding
gaps remained a major bottleneck in Kenya (dependent
on the approval of funding from a Round 9 grant from
the Global Fund), Uganda (where reprogramming of Glo-
bal Fund grants is needed) and Zambia (where full fund-
ing had been secured but the subsequent suspension of
a Global Fund grant now impedes progress). Intensive
efforts are needed to ensure that countries planning sur-
veys in 2010 and 2011 are able to do so successfully.
In 2009 and 2010, there was substantial progress in
1
For further details, see the Task Force web site at: http://www.
who.int/tb/advisory_bodies/impact_measurement_taskforce/en/
index.html. The review is also the basis for the TB component of
the forthcoming update to the Global Burden of Disease, due for
publication in 2010.
2
For example, some parameter values are now estimated only at glo-
bal level or for regions, rather than for each country individually.
3
TB impact measurement: policy and recommendations for how to assess
the epidemiological burden of TB and the impact of TB control. Gene-
va, World Health Organization, 2009 (Stop TB policy paper no. 2;
WHO/HTM/TB/2009.416).
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analysing surveillance and programmatic data, with
analyses used to develop recommendations for how
surveillance systems need to be strengthened and to
produce updated estimates of disease burden. Regional
workshops to apply the Task Force framework (*-+96)
) for systematic assessment of surveillance data were
held in the Eastern Mediterranean, European, South-
East Asia and Western Pacific regions and the Region
of the Americas. Country missions in which the frame-
work was applied were undertaken in the Philippines,
the United Republic of Tanzania and Viet Nam. By July
2010, these workshops and country missions had cov-
ered a total of 70 countries (*-+96) ). A workshop
for 17 countries in the African Region is scheduled for
December 2010.
An important conclusion from workshops and country
missions was that there is an urgent need to strengthen
vital registration systems, to allow better measurement
of mortality (&3< ). There is also an urgent need to
introduce electronic recording and reporting systems,
without which it is difficult or impossible to adequately
assess many aspects of data quality. Examples of aspects
of data quality that are difficult or impossible to assess
without case-based and electronic reporting systems
include the extent to which misclassifications and dupli-
cations exist. In addition, the availability of electronic
data, stored in well-managed relational databases (not
Excel spreadsheets), greatly facilitates data analysis.
More widespread adoption of updated recommendations
on recording and reporting is also required (for example,
to ensure availability of data disaggregated by HIV sta-
tus and source of referral).
An example of experience with implementing a case-
based and electronic recording and reporting system
(from China) in provided in&3<.
Besides improving estimates of the disease burden
caused by TB, better data from surveys and surveillance
combined with better analysis of these data should be of
great value in identifying where and why cases are not
being detected. In turn, findings should help to identify
which components of the Stop TB Strategy need to be
introduced or scaled-up to improve TB control. Examples
from Cambodia, Myanmar and Viet Nam are highlighted
in the second edition of WHO’s guidelines on surveys of
the prevalence of TB disease.1

1
The second edition of these guidelines (following publication of
the first edition in 2007) has been produced as a major collabora-
tive effort among technical and financial partners and lead survey
investigators from Asian and African countries. The guidelines
were in the late stages of preparation at the time this report went
to press, with publication expected before the end of 2010.
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8 his section summarizes the main conclusions that can
be drawn from the findings included in this report.
It also draws together the main recommendations that
appear in the report, in the form of a Box (&3<).
The global burden of TB is falling slowly. Incidence
rates have been declining since 2004 at the global lev-
el, and if this trend is sustained, MDG Target 6.c will
be achieved worldwide. Five of WHO’s six regions are
also on track to achieve this target (the exception is
the South-East Asia Region, where the incidence rate
is stable). Mortality rates at global level fell by around
35% between 1990 and 2009, and the target of a 50%
reduction by 2015 could be achieved if the current rate
of decline is sustained. At the regional level, the mortal-
ity target could be achieved in five of WHO’s six regions;
the exception is the African Region (although rates of
mortality are falling in this region). Prevalence is fall-
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ing globally and in all six WHO regions. However, the
target of halving 1990 prevalence rates by 2015 may
not be reached at global level. Three regions are on track
to achieve this target: the Region of the Americas, the
Eastern Mediterranean Region and the Western Pacific
Region.
Reductions in the disease burden achieved to date fol-
low 15 years of intensive efforts at country level to imple-
ment the DOTS strategy (1995–2005) and its successor,
the Stop TB Strategy (launched in 2006). Between 1995
and 2009, a cumulative total of 41 million TB patients
were successfully treated in DOTS programmes, and up
to 6 million lives were saved. The treatment success rate
achieved in DOTS cohorts worldwide has now exceeded
the global target of 85% for two successive years.
Although increasing numbers of TB cases have access
to high-quality treatment for TB as well as access to
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related interventions such as ART, much more remains
to be done. More than one-third of incident TB cases are
not reported as treated in DOTS programmes, around
90% of patients with MDR-TB are not being diagnosed
and treated according to international guidelines, many
HIV-positive TB cases do not know their HIV status and
most of the HIV-positive TB patients who do know their
HIV status are not yet being provided with ART. Fund-
ing gaps remain large at more than US$ 1 billion per
year, despite increases in funding over the past decade
and substantial financing from the Global Fund in many
countries.
Looking forwards, the Stop TB Partnership launched
an updated version of the Global Plan to Stop TB in
October 2010, for the years 2011–2015. In the five
years that remain until the target year of 2015, intensi-
fied efforts to plan, finance and implement the Stop TB
Strategy, according to the updated targets included in
the Global Plan, are needed. This could save a cumulative
total of 5 million lives, including 2 million women and
children.
 "//&9


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8 his annex explains the methods that were used to
produce estimates of the global burden of disease
caused by TB (measured in terms of incidence, preva-
lence and mortality). It has eight major sections:
N General approach. This section provides some back-
ground information about the methods used to pro-
duce estimates of disease burden.
N Definitions. This section defines TB incidence, prev-
alence and mortality and the case fatality rate. It also
explains the regions for which estimates of disease
burden are produced and sources of information on
population estimates.
N Estimates of TB incidence, 1990–2009. This section
explains the five main methods used to estimate TB
incidence, and the countries for which they have been
applied. It also discusses estimates of the incidence of
sputum smear-positive cases of pulmonary TB, and
explains why such estimates (and related estimates of
the case detection rate for sputum smear-positive cases
of pulmonary TB) are not included in this report.
N Estimates of HIV prevalence among incident TB
cases, 1990–2009. This section explains the meth-
ods used to estimate the prevalence of HIV among
incident cases of TB.
N Estimates of TB prevalence, 1990–2009. This sec-
tion explains the two main methods used to estimate
TB prevalence. These are national surveys of the prev-
alence of TB disease and indirect estimates based on
combining estimates of incidence with estimates of
the duration of TB disease.
N Estimates of TB mortality, 1990–2009. This sec-
tion explains the two methods used to estimate TB
mortality. These are direct measurements from vital
registration (VR) data and indirect estimates based
on combining estimates of TB incidence with esti-
mates of the case fatality rate. The countries for which
these methods have been used are explained. Meth-
ods for estimating mortality by age and sex are also
described.
N Projections of TB incidence, prevalence and
mortality. This section explains how projections up
to 2015 were produced.
N Uncertainty framework. This section explains the
general approach to including uncertainty in all esti-
mates.

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Estimates of the burden of disease caused by TB (meas-
ured in terms of incidence, prevalence and mortality) are
produced annually by WHO using information gathered
through surveillance systems (case notifications and
death registrations), special studies (including surveys
of the prevalence of disease and in-depth analyses of
surveillance data), expert opinion and consultations
with countries. Two recent publications provide up-to-
date guidance about how TB incidence, prevalence and
mortality should be measured,1,2 based on the work of
the WHO Global Task Force on TB Impact Measure-
ment.3 The methods used to estimate the burden of dis-
ease were updated in 2009 following 18 months of work
by an expert group convened under the umbrella of the
Task Force. Improvements to methods include system-
atic documentation of expert opinion and how this has
been used to produce estimates of disease burden, sim-
plification of models,4 updates to parameter values based
on the results of systematic reviews, much greater use of
mortality data from VR systems (89 countries instead of
the three from which estimates were derived up to 2008)
and systematic documentation of uncertainty (hence
the uncertainty intervals shown on all of the estimates
of disease burden in this report).

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 XLIGEWIJEXEPMX]VEXI
Incidence is defined as the number of new and relapse
cases of TB (all forms) occurring in a given year. Relapse
cases are defined as people who have been previously
treated for TB and for whom there was bacteriological
confirmation of cure and/or documentation that treat-
ment was completed. Relapse cases may be true relapses
or a subsequent episode of TB caused by reinfection.
Prevalence is defined as the number of cases of TB dis-
ease (all forms) at a given point in time (the middle of
the year).
Mortality is defined as the number of deaths caused by
TB, excluding deaths occurring in HIV-positive TB cases,
according to the definitions used in the 10th revision of
the International Classification of Diseases (ICD-10).
Estimates of deaths caused by TB in HIV-positive cases
are presented separately.
The case fatality rate is defined as the risk of death
from TB among people with active TB disease.
 6IKMSRW
Regional analyses are generally undertaken for the six
WHO regions (that is, the African Region, the Region
of the Americas, the Eastern Mediterranean Region,
the European Region, the South-East Asia Region and
1
Dye C et al. Measuring tuberculosis burden, trends and the impact
of control programmes. Lancet Infectious Diseases (published online
16 January 2008; http://infection.thelancet.com).
2
TB impact ,measurement: policy and recommendations for how
to assess the epidemiological burden of TB and the impact of TB
control. Geneva, World Health Organization, 2009 (Stop TB policy
paper no. 2; WHO/HTM/TB/2009.416). The policy paper is avail-
able on the Task Force’s website http://www.who.int/tb/advisory_
bodies/impact_measurement_taskforce/en/index.html.
3
For further details, see the Task Force web site at: http://www.who.
int/tb/advisory_bodies/impact_measurement_taskforce/en/index.
html. The review is also the basis for the TB component of the update
to the Global Burden of Disease, due for publication in 2010.
4
For example, some parameter values are now estimated only at glo-
bal level or for regions, rather than for each country individually.
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the Western Pacific Region). For some analyses, Eastern
Europe (countries of the former Soviet states plus Bul-
garia and Romania) as well as the group of high-income
countries1 are distinguished.
 4STYPEXMSRIWXMQEXIW
Where population sizes are needed to calculate TB indi-
cators, the 2008 revision of estimates provided by the
United Nations Population Division (UNPD) was used.2
The UNPD estimates sometimes differ from those made
by countries.

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° administrative levels) and programmatic data reflecting
No country has ever undertaken a nationwide survey of
TB incidence because of the large sample sizes required
and associated major logistic and financial challenges.
As a result, there are no direct measurements of the
incidence of TB. Theoretically, data from TB surveillance
systems that are linked to health systems of high cov-
erage and performance may capture all (or almost all)
incident cases of TB. However, as yet no standard and
widely-endorsed criteria and benchmarks for classifying
TB surveillance systems are available. The WHO Global
Task Force on TB Impact Measurement is working on
the development of such standards, and initial ideas are
available in a background paper.
In the absence of direct measurements, estimates of
TB incidence rely on one or more of the five methods
described in 7)'8-327¦.
It should be noted that, with very few exceptions,
incidence estimates are no longer derived from surveys
of the prevalence of tuberculous infection as measured
in tuberculin surveys. The WHO Global Task Force on TB
Impact Measurement has agreed that methods for deriv-
ing incidence from the prevalence of infection are unre-
liable. The Task Force has also stated that it is doubtful
whether repeat tuberculin surveys provide a reliable
estimate of the trend in TB incidence.4
 )WXMQEXMRK8&MRGMHIRGIJVSQIWXMQEXIWSJXLI
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Notification data for new and relapse cases have been
analysed in combination with evidence about the cover-
age of the TB surveillance system5 and expert opinion in
five regional workshops and three country missions held
2008–2010, according to a framework developed by the
WHO Global Task Force on TB Impact Measurement (see
7)'8-32 of the main part of this report). By mid-2010,
these workshops and country missions had covered 71
countries in the Region of the Americas, the Eastern
Mediterranean Region, the European Region, the South-
East Asia Region and the Western Pacific Region. The
African region was the only region where such work-
shops had not been held by mid-2010; at the time this
report went to press, the first workshop in this region,
for 17 of the 46 countries in the region, was scheduled
for December 2010.
For countries participating in these regional work-
shops, incidence was estimated according to the follow-
ing equation:
case notifications
incidence =
proportion of cases detected
The proportion of all TB cases6 detected (the case detec-
tion rate, or CDR) was estimated, with plausible ranges,
for three years (1997, 2003 and 2008 or 2009), follow-
ing in-depth analysis of national and sub-national data.
Expert opinion was elicited after in-depth analysis of
notification data (including data from sub-national
efforts in TB control (for example, data on infrastruc-
ture, staffing, the performance of services and funding).
In addition, data on access to health care from Demo-
graphic and Health Surveys and the overall performance
of health systems (using indicators such as the infant
mortality rate) were used to substantiate opinion on
the proportion of cases with no or very limited access to
health care (8%&0)%).
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1
As defined by the World Bank. High-income countries are those
with a per capita gross national income (GNI) of US$ 12 196 or
more in 2009.
2
http://esa.un.org/unpp/; accessed on 7 June 2010.
3
See the second background paper prepared for the fourth meeting
of the Global Task Force on TB Impact Measurement, held 17–18
March 2010. The paper is available on the Task Force’s web site
http://www.who.int/tb/advisory_bodies/impact_measurement_
taskforce/en/index.html.
4
TB Impact Measurement: Policy and recommendations for how
to assess the epidemiological burden of TB and the impact of TB
control. Geneva, World Health Organization, 2009 (Stop TB policy
paper; no. 2 (WHO/HTM/TB/2009.416). The recommendation on
tuberculin surveys is provided on page 12. The policy paper is avail-
able on the Task Force’s website http://www.who.int/tb/advisory_
bodies/impact_measurement_taskforce/en/index.html.
5
For example, measurements from “inventory” studies or estima-
tion from capture-recapture modelling in which at least three
sources of information were used – thus allowing adjustment for
between-source dependencies. A useful reference on capture-recap-
ture methods is: Chao A et al. The applications of capture-recap-
ture models to epidemiological data. Statistics in Medicine, 2001,
20(20):3123–3157.
6
Defined as cases of all forms of TB, including sputum smear-pos-
itive pulmonary cases, sputum smear-negative pulmonary cases,
and extrapulmonary cases.
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Data were assessed using a three-step process. This
started with a systematic assessment of data quality,
including an assessment of the over-dispersion of count
data over time and across regions/districts (or similar
geographical areas). This was followed by exploration of
potential factors driving time-changes in case notifica-
tions (such as improvements in diagnostic capacity and
the HIV epidemic), and then by assessment of the likely
number of TB cases that are not notified. To facilitate
the documentation of expert opinion, an “onion” frame-
work1 was used. In this framework, different “layers”
of the onion represent distinct populations of TB cases
that are not captured by national TB information sys-
tems (for example, cases with no access to health care
and cases with access to private health-care services but
not reported to NTPs – see 8%&0)%).
These methods are documented in a workbook avail-
able on the web site of the WHO Global Task Force on TB
Impact Measurement.2
Distributions of CDRs for the three years for which
they were estimated were assumed to follow a Beta dis-
tribution (8%&0) %). Reasons for using Beta distribu-
tions include the following:
N They are continuous and defined on the interval (0,
1). Since the variance of CDR distributions tend to be
large as a result of high uncertainty, random draws
of numbers from a normal distribution would yield
numbers outside the interval (0, 1). The use of trun-
cated normal distributions may result in excess den-
sity towards one of the bounds.
N They are not necessarily symmetrical.
N They are defined with two parameters that can be
estimated from available data using the method of
moments.
The two shape parameters necessary to define the
Beta distribution were computed using the method of
moments, as follows:
1
TB impact measurement: policy and recommendations for how to assess
the epidemiological burden of TB and the impact of TB control. Geneva,
World Health Organization, 2009 (Stop TB policy paper no 2; WHO/
HTM/TB/2009.416. The onion framework is described on pages
19–24). The policy paper is available on the Task Force’s website
http://www.who.int/tb/advisory_bodies/impact_measurement_
taskforce/en/index.html.
2
http://www.who.int/tb/advisory_bodies/impact_measurement_
taskforce/en/index.html.
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First, the variance for the distribution was taken as:
V = ((u – l)/4)2
where l and u are the lower and upper bounds of the plau-
sible range for the CDR.
Shape 1 (noted α) and shape 2 (noted β) follow from:
s = E(l – E) – l
V
α = sE
β = s(l – E)
where E is the expected value of the distribution.
Time series for the period 1990–2009 were built accord-
ing to the characteristics of the three CDRs that were
estimated. A cubic spline extrapolation of V and E, with
knots set at the three reference years, was used. Inci-
dence trajectories were derived from the series of noti-
fied TB cases using Monte Carlo simulations from which
expected values, 2.5th and 97.5th centiles were extract-
ed. All computations were conducted in the R statistical
environment.1
If there were insufficient data to determine the factors
leading to time-changes in case notifications, incidence
was assumed to follow a horizontal trend going through
the most recent estimate of incidence.
 )WXMQEXMRK8&MRGMHIRGIJVSQHEXESR
 GEWIRSXM´GEXMSRWERHI\TIVXSTMRMSRJSV
 LMKLMRGSQIGSYRXVMIW
For high-income countries, the level of TB incidence was
assumed to be distributed between the notification rate
for new and relapse cases combined (lower uncertainty
bound, noted l) and 1.3 times the notification rate (upper
uncertainty bound, noted u), as informed by expert opin-
ion. The distribution of incidence was assumed to follow
a Beta distribution with shape parameters computed
using the method of moments, as described above.
In the absence of country-specific data on the quality
and coverage of TB surveillance systems, it was assumed
that TB surveillance systems from countries in the high-
income group performed similarly well, although the
model does allow for stochastic fluctuations.
 )WXMQEXMRK8&MRGMHIRGIJVSQIQTMVMGEP
 QIEWYVIQIRXWSJHMWIEWITVIZEPIRGI
Incidence can be estimated using measurements from
national surveys of the prevalence of TB disease com-
bined with estimates of the duration of disease. Inci-
dence is estimated as the prevalence of TB divided by the
average duration of disease.
The duration of disease cannot be directly measured.
For example, measurements of the duration of symptoms
in prevalent TB cases that are detected during a preva-
1
R Development Core Team. R: a language and environment for statis-
tical computing. Vienna, R Foundation for Statistical Computing, ,
2009 (ISBN 3-900051-07-0; http://www.R-project.org).
lence survey are systematically biased towards lower
values, since active case-finding truncates the natural
history of undiagnosed disease. Measurements of the
duration of disease in notified cases ignore the duration
of disease among non-notified and untreated cases.
Literature reviews commissioned by the WHO Global
Task Force on TB Impact Measurement have provided
estimates of the duration of disease in untreated TB
cases from the pre-chemotherapy era (before the 1950s).
The best estimate of the mean duration of disease (for
smear-positive cases and smear-negative cases com-
bined) in HIV-negative individuals is about three years.
There are few data on the duration of disease in HIV-
positive individuals.
When measurements from two prevalence surveys
were available, trends in TB incidence were derived by
fitting a log-linear model to indirect estimates of TB
incidence. When three or more prevalence measure-
ments were available, the prevalence trajectory was built
using cubic spline interpolation. If only one prevalence
survey measurement was available, time-trends were
assessed using in-depth analysis of surveillance data, as
described above.
In this report, the prevalence to incidence method
was used for only one country (Viet Nam), following a
meeting in early 2009 in which consensus was reached
among national experts and experts from WHO and the
KNCV Tuberculosis Foundation.
 )WXMQEXMRK8&MRGMHIRGIJVSQQIEWYVIQIRXWSJ
 QSVXEPMX]ERHIWXMQEXIWSJXLIGEWIJEXEPMX]VEXI
In three countries (Brazil, Mexico and South Africa),
incidence was estimated from 1990 up to 2008 from TB
mortality data, using the following equation:
deaths
incidence =
proportion of incident cases that die
Previously published time-series of incidence for those
three countries were then extended to 2009, using meth-
ods described in 7)'8-32.
 )WXMQEXMRK8&MRGMHIRGIJVSQTVIZMSYWP]
 TYFPMWLIHXMQIWIVMIWSJMRGMHIRGI
In all remaining countries, previously published time-
series of TB incidence were extended by fitting a log-lin-
ear model to the estimates for 2006–2008, to predict a
value for 2009.
 )WXMQEXMRKXLIMRGMHIRGISJWTYXYQ
 WQIEVTSWMXMZI8&ERHXLIGEWIHIXIGXMSR
 VEXIJSVWTYXYQWQIEVTSWMXMZI8&
All the annual reports on global TB control published by
WHO from 1997 to 2009 included estimates of the inci-
dence of sputum smear-positive TB and the related CDR
for such cases. The CDR for sputum smear-positive pulmo-
nary TB is the number of new and relapse cases of sputum
smear-positive pulmonary TB notified to NTPs divided by
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the estimated number of incident cases that occurred in
the same year.
Estimates of the incidence of sputum smear-positive
pulmonary TB and the related CDR for these cases are
not published in this report. There are several reasons
for this, which are summarized in the main part of the
report (&3< ). Among the reasons noted in this box
are the findings and associated recommendations from
the 18-month expert review of methods used to esti-
mate disease burden described in 7)'8-32 above, and
associated updates to methods used to estimate disease
burden that have been applied in a series of regional

°
workshops and country missions (7)'8-32). A fuller
explanation is provided here.
In regional workshops and country missions, the
starting point for estimates of the incidence of TB was
an estimate of the CDR for all forms of TB. This was
because, for many countries, estimates of the incidence
of all forms of TB are used to produce indirect estimates
of TB mortality and TB prevalence (these do not require
estimates of the CDR for smear-positive TB).
The incidence of sputum smear-positive pulmonary
TB can theoretically be estimated by multiplying the
incidence of all forms of TB by the estimated proportion
of all incident cases of TB that have sputum smear-posi-
tive pulmonary TB. The CDR for sputum smear-positive
pulmonary TB would then be estimated by dividing
reported notifications of sputum smear-positive cases
of pulmonary TB by the estimated incidence of sputum
smear-positive pulmonary TB. This approach was used
in global reports published up to December 2009. Sub-
sequently, the findings of one of the systematic reviews
conducted by the expert group have cast doubts on this
approach. A systematic review of the evidence about the
proportion of TB cases that have sputum smear-positive
pulmonary TB found considerable uncertainty around
the best estimate of this proportion.1
It may appear that an alternative method is to assume
that, for any given country, the proportion of all inci-
dent cases with sputum smear-positive pulmonary TB
is equal to the proportion of all notified cases that had
smear-positive pulmonary TB in the region of reference
(this could be an epidemiologically-defined region or a
WHO region, for example). However, use of this method
will mean that, for many countries, changes in the esti-
mated CDR for sputum smear-positive pulmonary TB
will occur from one year to the next simply because of
a change in the share of regional notifications that are
smear-positive, without any real change in the level of
case detection in the country itself (since a change in the
regional proportion will cause the estimated incidence
of smear-positive TB in a given country, the denomina-
tor of the CDR, to go up and down even when the coun-
try’s notifications are stable). This is wrong and likely to
cause confusion.
Another alternative is to assume that, in any given
country, the proportion of sputum smear-positive cases
of pulmonary TB among all notified cases reflects the
true proportion of sputum smear-positive TB among
incident cases of TB in the country. In this case, the esti-
mated CDR for all forms of TB and the estimated CDR
for sputum smear-positive cases are the same.
If needed for reporting purposes, it is suggested that
the CDR for smear-positive TB is assumed to be similar
to the CDR for all forms of TB.

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The prevalence of HIV among incident cases of TB was
directly estimated from country-specific and empirical
data wherever possible. For the estimates published in
this report, suitable data (as defined in 8%&0)%) were
available for a total of 440 country-year data points, up
from 288 country-year data points in the previous year
(for details of the source of data used for each country,
please see the %44)2(-<).
For the 3785 country-year data points for which surveil-
lance data were either not available or for which the per-
centage of TB patients tested for HIV was below 50%,
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the prevalence of HIV was estimated indirectly accord-
ing to the following equation:
hρ
t=
l + h(ρ – l)
In this equation, t is HIV prevalence among incident TB
cases, h is HIV prevalence among the general population
(from the latest time-series provided by UNAIDS) and ρ
is the incidence rate ratio (IRR) (defined as the incidence
rate of TB in HIV-positive people divided by the inci-
dence rate of TB in HIV-negative people).2 To estimate
ρ from empirical data (that is, from countries that have
an empirical estimate of both t and h), the equation was
rearranged as follows:
t(l – h)
ρ=
h(l – t)
We then let logit(t) be log(t/(1-t)) and logit(h) be log(h/
(1-h)). Using data from countries where HIV prevalence
1
Research Institute of Tuberculosis, Tokyo 2010 (data not shown).
2
Data on HIV prevalence in the general population are unpublished
data provided to WHO by UNAIDS.
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has been estimated by UNAIDS as an independent varia-

°
ble, a linear model of logit-transformed t was fitted using
logit-transformed h according to the following equation,
written in matrix notation:
T̂ = Xβ
where T̂ is a vector of predicted logit(t), X is an n \ 2
matrix in which the first column holds 1s, and the sec-
ond column holds logit(h). The vector β holds estimated
model parameters.
Models were run using Monte Carlo simulations in
which h was drawn randomly from a Beta distribution
with shape parameters computed as described in 7)'
8-32, (low and high uncertainty bounds are provid-
ed by UNAIDS – also see 8%&0)%). The model was run
50 000 times using country-specific distributions for H
and T (noted in capital letters to denote vectors or matri-
ces) based on their uncertainty intervals (*-+96) %).
The uncertainty bounds for β were chosen as the 2.5th
and 97.5th centiles.
The source of data used for each country is listed in
the %44)2(-<.
'*(63&
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The best way to measure the prevalence of TB is through
national population-based surveys of TB disease.1,2 Data
from such surveys are available for an increasing number
of countries. It should be noted, however, that measure-
ments of prevalence are typically confined to the adult
population. Furthermore, prevalence surveys exclude
extrapulmonary cases and do not allow the diagnosis of
cases of culture-negative pulmonary TB.
When there is no direct measurement from a national
survey of the prevalence of TB disease, prevalence is the
most uncertain of the three TB indicators used to meas-
ure disease burden. This is because prevalence is the
product of two uncertain quantities: (i) incidence and
(ii) disease duration. The duration of disease is very dif-
ficult to quantify because measurements from surveys
of the prevalence of TB disease are not reliable (surveys
truncate the natural history of disease). Duration can be
assessed in self-presenting patients, but there is no prac-
tical way to measure the duration of disease in patients
who are not notified to NTPs.
Indirect estimates of prevalence were calculated
according to the following equation:
P = ∑ I i,j d i,j ,i∈{1,2},j∈{1,2}
where the index variable i denotes HIV+ and HIV–, the
index variable j denotes notified and non-notified cases,
d denotes the duration of disease and I is total incidence.
In the absence of measurements, we did not allow dura-
tion in notified cases to vary among countries. Given
their underlying uncertainty, prevalence estimates
should be used with great caution in the absence of direct
measurements from a prevalence survey. Assumptions
of the duration of disease are shown in the last four rows
of 8%&0)%.

&TUJNBUFT
PG
5#
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The best sources of data about deaths from TB (exclud-
ing those among HIV-positive people) are VR systems
in which causes of death are coded according to ICD-10
(although the older ICD-9 and ICD-8 classification are
still in use in several countries). Deaths from TB in HIV-
positive people are coded under HIV-associated codes.
Estimates of TB mortality were produced directly
from VR data, or indirectly from estimates of TB inci-
dence and case-fatality rates (CFRs). The source of data
used in each country is listed in the %44)2(-<.
 )WXMQEXMRK8&QSVXEPMX]JVSQHMVIGX
 QIEWYVIQIRXWSJZMXEPVIKMWXVEXMSRHEXE
Data from VR systems are reported to WHO by Mem-
ber States and territories every year. In countries with
1
Glaziou P et al. Tuberculosis prevalence surveys: rationale and
cost. International Journal of Tuberculosis and Lung Disease, 2008,
12(9):1003–1008.
2
Assessing tuberculosis prevalence through population-based sur-
veys. Manila, World Health Organization, 2007.
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functioning VR systems in which causes of death are
coded according to the two latest revisions of the Inter-
national Classification of Diseases (underlying cause
of death: ICD-10 A15-A19, equivalent to ICD-9: 010-
018), VR data are the best source of information about
deaths from TB among people not infected with HIV.
When people with AIDS die from TB, HIV is registered
as the underlying cause of death and TB is recorded as
a contributory cause. Since one third of countries with
VR systems report to WHO only the underlying causes
of death and not contributory causes, VR data usually
cannot be used to estimate the number of TB deaths in
HIV-positive people.
In 2009, 90 countries had well-functioning VR systems
according to the following definition: (i) coverage of at
least 70% of the population, and (ii) ill-defined causes of
death (ICD-9 code B46, ICD-10 codes R00-R99) of <20%
of all registered deaths.1 These countries included four of
the 22 HBCs (Brazil, the Philippines, the Russian Fed-
eration and South Africa). However, we could not use the
VR data on TB deaths from South Africa because large
numbers of HIV deaths were miscoded as TB deaths.
Among the remaining 89 countries, there was an aver-
age of 6.2 years (interquartile range, 4–8) of VR data on
TB mortality between 1991 and 2009 that met the above
criteria, equivalent to 602 country-years. We assumed
that the proportion of TB deaths among deaths not
recorded by the VR system was the same as the propor-
tion of TB deaths in VR-recorded deaths. For VR-record-
ed deaths with ill-defined causes, we assumed that the
proportion of deaths attributable to TB was half of the
observed proportion in recorded deaths, since ill-defined
causes are typically observed in higher proportions in
rural areas with a low population density where the risk
of TB is lower. We assumed errors in measurement (due
to misclassifications) and assumptions (redistributions)
to be log-normally distributed with a standard deviation
on a log scale given by σ = 0.05μ / (ν – s/2), where μ is the
VR recorded TB mortality rate, v the coverage of the VR
system and s the rate of ill-defined causes. Incomplete
coverage and ill-defined causes introduce uncertainty
in measurements μ. The standard deviation of μ was
based on the assumption that uncertainty intervals of μ
spanned at least ±10% of the measurement μ, increasing
with decreasing VR coverage and with increasing rates of
ill-defined causes of death.
 )WXMQEXMRK8&QSVXEPMX]JVSQMRHMVIGXIWXMQEXIW
 SJGEWIJEXEPMX]VEXIWERH8&MRGMHIRGI
For the years in which VR data of sufficient quality and
coverage were not available for the 89 countries defined
above plus the 124 countries without any VR data, mor-
tality was estimated as the product of TB incidence and
1
Mathers CD et al. Counting the dead and what they died from: an
assessment of the global status of cause of death data. Bulletin of the
World Health Organization, 2005, 83:171–177.
the CFR. CFRs were estimated separately for TB cases
notified to NTPs and non-notified cases and, within these
two groups, separate estimates were made for HIV-posi-
tive TB cases and HIV-negative TB cases (8%&0)%).
For consistency with VR-based mortality estimates,
CFRs were estimated such that they gave the best fit to
the VR-recorded TB death rates (within their uncertainty
ranges) across the 602 country-years of data from the 89
countries with functioning VR systems, in conjunction
with WHO estimates of distributions of TB incidence
in those countries. This statistical fitting used Bayesian
linear models and was done separately for three groups
of countries (high-income, eastern Europe, and all oth-
er countries), to account for differences in the ratio of
reported TB mortality to TB notification rates among
these three groups (data not shown).
The models used normal errors and Gibbs sampling:
y = (I – N)β1 + Nβ2 + ε, ε ~ N(0,σ2)
where y is TB mortality from VR, I denotes TB incidence
excluding people living with HIV, N denotes TB notifica-
tions excluding people living with HIV, and parameters
β1 and β2 denote the CFR in non-notified and notified
cases respectively. Semi-conjugate priors were set with
an uninformative inverse Gamma prior on the condi-
tional error variance:
b ~ N(b i ,B i -2),σ2 ~ IG(5.10 -4 ,5.10 -4)
Priors b and their precision B were defined based on lit-
erature reviews and the country-year CFR parameters
used by WHO for the years 1999–2008 (8%&0) %).
Convergence of Markov Chains was assessed graphically
and using two convergence diagnostic tests. Within each
case category 1990–2009, mortality estimates were com-
puted by taking the product of posterior distributions of
the CFR, assumed to be time-independent (8%&0) %),
and country-year specific distributions of estimated
incidence.
Among the 89 countries, the combination of using
VR data for some years and indirect estimates (based on
incidence and CFRs) for others sometimes led to implau-
sible differences between adjacent time-points. Where
this occurred, we assumed that VR measurements were
more reliable than the indirect estimates. We re-scaled
the indirectly estimated TB mortality values to ensure,
on average, smooth mortality trend lines. Rescaling fac-
tors were defined for each country as the ratio of the
mean of available VR-recorded TB mortality rates over
the mean of indirectly estimated mortality, among cases
excluding those infected with HIV, for the years covered
by VR measurements.
 )WXMQEXMRK8&QSVXEPMX]JVSQHMWEKKVIKEXIH
 IWXMQEXIWSJ8&HIEXLWF]EKIERHWI\
For countries with VR data, it was possible to disaggre-
gate estimated TB deaths by age (with age groups defined
as 0–4 years, 5–14 years, 15–24 years, 25–34 years,
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35–44 years, 45–54 years, 55–64 years, ≥65 years) and
sex, in line with the way in which deaths are reported.
In countries with no functional VR system, the total
number of estimated TB deaths was redistributed into
the different age and sex strata according to the disag-
gregation of the combined population of countries with
VR data (with standardization against the individual
country’s age and sex distribution). TB deaths in HIV-
positive people were not disaggregated by age and sex
due to limited data from countries with functional VR
systems.

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do countries provide appropriate data corrections. It

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UP

Projections of TB incidence, prevalence and mortality
rates up to 2015 enable assessment of whether global
targets set for 2015 are likely to be achieved at global,
regional and country levels. Projections for the years
2010–2015 were made using log-linear regression mod-
els fitted to rates from 2006–2009, with the assumption
that recent trends would continue.

&TUJNBUJPO
PG
VODFSUBJOUZ
There are many potential sources of uncertainty asso-
ciated with estimates of TB incidence, prevalence and
mortality, as well as estimates of the burden of HIV-
associated TB and MDR-TB. These include uncertainties
in input data, in parameter values, in extrapolations
used to impute missing data, and in the model used.
We used fixed population values from the UNPD. We
did not account for any uncertainty in these values.
Notification data are of uneven quality. Cases may be
underreported (missing quarterly reports from remote
administrative areas are not uncommon), misclassified
(in particular, misclassification of relapse cases in the
category of new cases is common), or over-reported as a
result of duplicated entries in TB information systems.
The latter two issues can only be addressed efficiently
in countries with case-based nationwide TB databas-
es that include patient identifiers. Sudden changes in
notifications over time are often the result of errors or
inconsistencies in reporting, but may sometimes reflect
abrupt changes in TB epidemiology (for example, result-
ing from a rapid influx of migrants from countries with
a high-burden of TB, or from rapid improvement in case-
finding efforts).
Missing national aggregates of new and relapse cases
were imputed by cubic spline interpolation. However,
notification trajectories were not automatically smoothed
over time to avoid introducing systematic errors in coun-
tries where time-changes are reflecting true changes in
the epidemiology of TB. Attempts to obtain corrections
for historical data are made every year, but only rarely
is therefore generally unclear when bumps in notifica-
tions are most likely reflecting reporting errors. Future
regional workshops will include a systematic effort to
correct for such data deficiencies using expert opinion,
for those cases where corrections appear necessary.
Mortality estimates incorporated the following sourc-
es of uncertainty: sampling uncertainty in the under-
lying measurements of TB mortality rates from data
sources, uncertainty in estimates of incidence rates and
rates of HIV prevalence among both incident and noti-
fied TB cases, and parameter uncertainty in the Bayesian
model. Time-series of TB mortality were generated for
each country through Monte Carlo simulations.
Unless otherwise specified, uncertainty bounds and
ranges were defined as the 2.5th and 97.5th centiles of
outcome distributions. Throughout this report, ranges
with upper and lower bounds defined by these centiles
are provided for all estimates established with the use of
simulations. When uncertainty was established with the
use of observed or other empirical data, 95% confidence
intervals are reported.
The model used the following sequence: (1) incidence
estimation, (2) estimation of HIV-positive TB incidence,
(3) estimation of mortality, (4) estimation of prevalence.
By design, some steps were independent from each other
(for example, step 4 may be done before or after step 3).
The general approach to uncertainty analyses was
to draw values from specified distributions for every
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parameter (except for notifications and population
values) in Monte Carlo simulations, with the number
of simulation runs set so that they were sufficient to
ensure stability in the outcome distributions. The same
random generator seed was used for every country, and
errors were assumed to be time-dependent within coun-
tries (thus generating autocorrelation in time-series).
Regional parameters were used in some instances (for
example, for CFRs). Summaries of quantities of interest
were obtained by extracting the 2.5th, 50th and 97.5th
centiles of posterior distributions. The country-specific
estimates produced using the just-described simulations
were then used as the building blocks for further simula-
tions, from which aggregated summaries at global and
regional levels for incidence, prevalence and mortality
were drawn. Two sets of simulations were run, the first
to produce aggregates at regional level and the second
to produce aggregates at global level. These summary
estimates are the result of simulations based on non-
symmetric distributions. As a result, best estimates for
regions do not necessarily sum to the best estimate for
the world.
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Estimated values are shown as best estimates followed
by lower and upper bounds. The lower and upper
bounds are defined as the 2.5th and 97.5th centiles of
outcome distributions produced in simulations.
See %22)< for further details.
Estimated numbers are shown rounded to two
significant figures. Estimated rates are shown rounded
to three significant figures unless the value is under
100, in which case rates are shown rounded to two
significant figures.
Estimates for all years are recalculated as new
information becomes available and techniques are
refined, so they may differ from those published in
previous reports in this series. Estimates published in
previous global TB control reports should no longer be
used.

(SBQIT
Graphs where displayed show data from all years within
the range stated.

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Data shown in this annex are taken from the WHO
global TB database on 31 August 2010. Data shown
in the main part of the report were taken from the
database on 17 June 2010. As a result, data in this
annex may differ slightly from those in the main part of
the report.
Data can be downloaded from www.who.int/tb/data.
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Estimated values are shown as best estimates followed
by lower and upper bounds. The lower and upper
bounds are defined as the 2.5th and 97.5th centiles of
outcome distributions produced in simulations.
See %22)< for further details.
Estimated numbers are shown rounded to two
significant figures. Estimated rates are shown rounded
to three significant figures unless the value is under
100, in which case rates are shown rounded to two
significant figures.
Estimates for all years are recalculated as new
information becomes available and techniques are
refined, so they may differ from those published in
previous reports in this series. Estimates published in
previous global TB control reports should no longer be
used.

(SBQIT
Graphs where displayed show data from all years within
the range stated.

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TPVSDF
Data shown in this annex are taken from the WHO
global TB database on 31 August 2010. Data shown
in the main part of the report were taken from the
database on 17 June 2010. As a result, data in this
annex may differ slightly from those in the main part of
the report.
Data can be downloaded from www.who.int/tb/data.
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Estimated values are shown as best estimates followed
by lower and upper bounds. The lower and upper
bounds are defined as the 2.5th and 97.5th centiles of
outcome distributions produced in simulations.
See %22)< for further details.
Estimated numbers are shown rounded to two
significant figures. Estimated rates are shown rounded
to three significant figures unless the value is under
100, in which case rates are shown rounded to two
significant figures.
Estimates for all years are recalculated as new
information becomes available and techniques are
refined, so they may differ from those published in
previous reports in this series. Estimates published in
previous global TB control reports should no longer be
used.
'EVMFFIER-WPERHW
Data from the territories of Anguilla, Bermuda,
British Virgin Islands, Cayman Islands, Montserrat,
Netherlands Antilles, Turks & Caicos Islands and US
Virgin Islands are no longer included in the tables. Data
collected in previous years from these territories can
still be downloaded from www.who.int/tb/data.
97%
In addition to the 51 reporting areas, the USA includes
territories that report separately to WHO. The data for
these territories are not included in the data reported
by the USA.
Definitions of case types and outcomes do not exactly
match those used by WHO.

(SBQIT
Graphs where displayed show data from all years within
the range stated.

%BUB
TPVSDF
Data shown in this annex are taken from the WHO
global TB database on 31 August 2010. Data shown
in the main part of the report were taken from the
database on 17 June 2010. As a result, data in this
annex may differ slightly from those in the main part of
the report.
Data can be downloaded from www.who.int/tb/data.
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Estimated values are shown as best estimates followed
by lower and upper bounds. The lower and upper
bounds are defined as the 2.5th and 97.5th centiles of
outcome distributions produced in simulations.
See %22)< for further details.
Estimated numbers are shown rounded to two
significant figures. Estimated rates are shown rounded
to three significant figures unless the value is under
100, in which case rates are shown rounded to two
significant figures.
Estimates for all years are recalculated as new
information becomes available and techniques are
refined, so they may differ from those published in
previous reports in this series. Estimates published in
previous global TB control reports should no longer be
used.

(SBQIT
Graphs where displayed show data from all years within
the range stated.

%BUB
TPVSDF
Data shown in this annex are taken from the WHO
global TB database on 31 August 2010. Data shown
in the main part of the report were taken from the
database on 17 June 2010. As a result, data in this
annex may differ slightly from those in the main part of
the report.
Data can be downloaded from www.who.int/tb/data.
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Estimated values are shown as best estimates followed
by lower and upper bounds. The lower and upper
bounds are defined as the 2.5th and 97.5th centiles of
outcome distributions produced in simulations.
See %22)< for further details.
Estimated numbers are shown rounded to two
significant figures. Estimated rates are shown rounded
to three significant figures unless the value is under
100, in which case rates are shown rounded to two
significant figures.
Estimates for all years are recalculated as new
information becomes available and techniques are
refined, so they may differ from those published in
previous reports in this series. Estimates published in
previous global TB control reports should no longer be
used.

(SBQIT
Graphs where displayed show data from all years within
the range stated.

%BUB
TPVSDF
Data shown in this annex are taken from the WHO
global TB database on 31 August 2010. Data shown
in the main part of the report were taken from the
database on 17 June 2010. As a result, data in this
annex may differ slightly from those in the main part of
the report.
Data can be downloaded from www.who.int/tb/data.

$PVOUSZ
OPUFT
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Notification data for countries that are members of the
European Union were not available on 31 August 2010.
These data will be provided on-line when available.

(IRQEVO
Data for Denmark exclude Greenland.
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Estimated values are shown as best estimates followed
by lower and upper bounds. The lower and upper
bounds are defined as the 2.5th and 97.5th centiles of
outcome distributions produced in simulations.
See %22)< for further details.
Estimated numbers are shown rounded to two
significant figures. Estimated rates are shown rounded
to three significant figures unless the value is under
100, in which case rates are shown rounded to two
significant figures.
Estimates for all years are recalculated as new
information becomes available and techniques are
refined, so they may differ from those published in
previous reports in this series. Estimates published in
previous global TB control reports should no longer be
used.
(SBQIT
Graphs where displayed show data from all years within
the range stated.
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Data shown in this annex are taken from the WHO
global TB database on 31 August 2010. Data shown
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database on 17 June 2010. As a result, data in this
annex may differ slightly from those in the main part of
the report.
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&ERKPEHIWL
8%&0)%: the population estimate used by the NTP
(148 million) is lower than that of the United Nations
Population Division (162 million). Using the smaller
population estimate gives a notification rate of 109
per 100 000 population (all forms of TB) and 74 per
100 000 population (smear-positive TB).
Bangladesh completed a survey of the prevalence of TB
disease in 2009. A reassessment of the epidemiological
burden of TB, using data from the survey combined
with an in-depth analysis of surveillance and
programmatic data, will be undertaken in 2011.
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8%&0)%: the population estimate used by the NTP
(1164 million) is lower than that of the United Nations
Population Division (1198 million). Using the smaller
population estimate gives a notification rate of new
smear-positive cases of 116 per 100 000 population. The
incidence of smear-positive TB has been estimated at 75
per 100 000 population using data from surveys of the
annual risk of infection. Using the notification rate for
smear-positive TB of 54 per 100 000 population (using
national estimates of population size) and a smear-
positive incidence rate of 75 per 100 000 population
gives an estimated case detection rate of 72%.
1]ERQEV
Myanmar completed a survey of the prevalence of TB
disease in 2010. A reassessment of the epidemiological
burden of TB will be undertaken following finalization
and dissemination of survey results.
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Estimated values are shown as best estimates followed
by lower and upper bounds. The lower and upper
bounds are defined as the 2.5th and 97.5th centiles of
outcome distributions produced in simulations.
See %22)< for further details.
Estimated numbers are shown rounded to two
significant figures. Estimated rates are shown rounded
to three significant figures unless the value is under
100, in which case rates are shown rounded to two
significant figures.
Estimates for all years are recalculated as new
information becomes available and techniques are
refined, so they may differ from those published in
previous reports in this series. Estimates published in
previous global TB control reports should no longer be
used.
'LMRE
China completed a survey of the prevalence of TB
disease in 2010. A reassessment of the epidemiological
burden of TB will be undertaken following finalization
and dissemination of survey results.
4ETYE2I[+YMRIE
Estimates of incidence, prevalence and mortality as
well as the case detection rate are provisional, pending
an in-depth and up-to-date analysis of surveillance and
programmatic data with the NTP.

(SBQIT
Graphs where displayed show data from all years within
the range stated.

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TPVSDF
Data shown in this annex are taken from the WHO
global TB database on 31 August 2010. Data shown
in the main part of the report were taken from the
database on 17 June 2010. As a result, data in this
annex may differ slightly from those in the main part of
the report.
Data can be downloaded from www.who.int/tb/data.
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 Global Tuberculosis Control WHO REPORT 2010
The World Health Organization monitors
the global tuberculosis epidemic in support
of national TB control programmes.

For further information about tuberculosis contact: Global

Tuberculosis
Information Resource Centre HTM/STB
World Health Organization
20 Avenue Appia, 1211–Geneva–27, Switzerland
Email: tbdocs@who.int
Web site: www.who.int/tb Control
2010
ISBN 978 92 4 156406 9