p1 · 10 million IncidentcasesofTB(2017).3 million TBdeaths(HIV-negative;2017) 1 MethodsusedbyWHOtotranslatesurveillanceandsurvey

10millionIncident cases of TB (2017)

.3millionTB deaths (HIV-negative; 2017)1

Methods used by WHO to translate surveillance and surveydata into estimates of TB incidence and mortality need to beperiodically reviewed. The latest methods are documented inWHO’s Global Tuberculosis Report (2018).

4: METHODS TO ESTIMATE DISEASE BURDEN

The first milestones of the End TB Strategy, set for 2020, are a35% reduction in the absolute number of TB deaths and a 20%reduction in the TB incidence rate, compared with levels in 2015.To reach these milestones, the TB incidence rate needs to befalling by 4–5% per year globally by 2020 and the proportionof people with TB who die from the disease (the case fatalityratio or CFR) needs to be reduced to 10% globally by 2020.

Globally, the absolute number of TB deaths (excluding TB deathsamong HIV-positive people) and the TB incidence rate have fallensince 2000. The number of HIV-negative TB deaths fell from1.8 million in 2000 to 1.3 million in 2017. However, the globalrate of decline in the TB incidence rate from 2016-2017 was only2% per year, and the case fatality ratio in 2017 was 16%.

The Global Project on Anti-TB Drug Resistance Surveillancewas launched in 1994. Its aims are to estimate the magnitudeof drug resistance among TB patients and determine trendsover time. Approaches to surveillance are described andexplained in the Guidelines for surveillance of drug resistancein tuberculosis (5th ed: 2015).

In 2017, 7 countries completed a drug resistance survey(DRS). Eritrea, Indonesia and Lao People's Democratic Republic,completed their first nationwide survey, and Eswatini, Sri Lanka,Togo and the United Republic of Tanzania completed a repeatsurvey.

By April 2019, data from continuous national surveillancesystems based on routine drug susceptibility testing of TBpatients were available from 91 countries, and 77 countrieshad implemented at least one nationally representative (orsubnational) survey since 1994. In April 2019, 19 countrieswere implementing a survey (map).

B. SURVEYS OF ANTI-TB DRUG RESISTANCE

A handbook has been developed to support countries toconduct nationally representative surveys of costs faced by TBpatients and their households, and to assess whether these costsare catastrophic. By early 2019, 13 countries had completed asurvey (China, Fiji, Ghana, Kenya, Myanmar, Mongolia,Nigeria, Philippines, Republic of Moldova, Timor-Leste, Uganda,Viet Nam and Zimbabwe), 5 other countries had started, and14 were planning to implement a survey in 2019 (map). Thesurveys inform policy discussions on how to improve TB servicesand their financing, and how to advance universal healthcoverage and enhance social protection, with the overall aim ofachieving the target that no TB patients and their householdsface catastrophic costs due to TB.

D. PATIENT & HOUSEHOLD COST SURVEYS

C. MORTALITY SURVEYSMortality surveys can be used to provide a directmeasurement of TB deaths in countries without national vitalregistration systems of sufficient quality and coverage. Theycan also be used to validate the quality of data compiled innational vital registration systems.

5: ANALYSIS AND USE OF DATA AT COUNTRY LEVEL3: PRIORITY STUDIES TO MEASURE TB DISEASE BURDEN 3: PRIORITY STUDIES TO MEASURE TB DISEASE BURDEN TUBERCULOSISPATIENTCOSTSURVEYS:AHANDBOOK

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TheWorldHealthOrganization’s newEnd TB Strategyaims to end the global TB epidemic as part ofthe UN Sustainable Development Goals.

IT’S ABOUTSAVING LIVES, TACKLING POVERTY AND INEQUITY

Investing in ending TB is great value for money –For every US$ 1 invested, US$ 30 is gained in return

WHAT IS THE END TB STRATEGY?

©W

HO

2015

Understanding and using tuberculosis data is a handbookthat provides practical advice on analysis of TB-relevant data,especially surveillance data from national notification andvital registration systems, and data from periodic surveys.

A comprehensive country package is nowavailable to support the transition from paperto electronic TB surveillance and theroutine analysis and use of data for action.The package includes DHIS2 TB modules foraggregated TB data and case-based TB dataand a curriculum with accompanying exerciseson data interpretation, based on the standardanalytical dashboards that are part of theDHIS2 modules.

The TB country package is being developedalongside packages for other programmese.g. HIV, malaria, immunization underthe umbrella of the Health Data Collaborative.

Five countries have installed the DHIS2 TBmodule for aggregated data and a further25 have expressed interest. The case-basedmodule for TB is in the final stages ofdevelopment. More than 50 countries havestored historic national and subnational datain a DHIS2 platform developed by WHO.

A guide on TB modelling at country levelwas published in 2018. It was developedunder the leadership of the TB Modellingand Analysis Consortium (TB MAC), inclose collaboration with WHO.

Between 2007 and 2018, national surveys of the prevalenceof TB disease were implemented in 27 countries (map),following guidance in the Tuberculosis prevalence surveyshandbook (2nd ed: the “lime book”) developed by the TaskForce. Myanmar (repeat survey), Namibia and Viet Nam (repeatsurvey) completed field operations in 2018. Results are expectedby mid-2019. Eswatini, Mozambique, Nepal and South Africaplan to finish their surveys in 2019. India is planning to start asurvey in 2019.

Numerous country missions and workshops have been used tofacilitate inter-country collaboration and boost capacity to designand implement high-quality surveys and to analyse and report resultsaccording to best-practice standards.

In 2016, the Task Force recommended the following criteria forimplementing a national TB prevalence survey: a country had alreadyconducted a survey between 2007 and 2015; or an estimatedincidence of ≥150 per 100,000 population per year, no nationwide

3: PRIORITY STUDIES TO MEASURE TB DISEASE BURDEN

A. NATIONAL TB PREVALENCE SURVEYS

For tuberculosisprogramme managers

WORKING DOCUMENT SEPTEMBER 2018

Up to 2016

2016—2018

Ongoing/Planned

Completed in 2012—2015

Completed in 2016—2018

Planned within the next year

The 2020 milestones of the End TB strategy are a35% reduction in TB deaths and a 20% reductionin the TB incidence rate compared with levels in2015, and that no TB patients and their householdsface catastrophic costs as a result of TB disease.

1 & 2: STRENGTHENING NATIONALNOTIFICATION & VITAL REGISTRATION SYSTEMS

Health

NATIONAL TB CONTROL PROGRAMMES OF MANY COUNTRIES

WEBSITE:www.who.int/tb/data

EMAIL:[email protected]

95%90%

90%80%

0%0%

TARGETS†

*

Reduction in thenumber of TB deathscompared with 2015 (%)

Reduction inTB incidence ratecompared with 2015 (%)

TB-affected householdsfacing catastrophiccosts due to TB (%)

20352030END TBSTRATEGY

THE

The initial aim of the Task Force was to ensure thatWHO’s assessment of whether 2015 global TBtargets were achieved was as rigorous, robustand consensus-based as possible. Followingpublication of this assessment in the 2015 GlobalTB Report and in the context of The End TB Strategy(2016-2035) and the Sustainable DevelopmentGoals (2016-2030), the Task Force reviewed andupdated its mandate and strategic areas of workfor the post-2015 era in April 2016.

FIVE STRATEGIC AREASOF WORK, 2016-20201. Strengthening national notification systems fordirect measurement of TB cases, includingdrug-resistant TB and HIV-associated TB specifically.

2. Strengthening national vital registration systemsfor direct measurement of TB deaths.

3. Priority studies to periodically measure TBdisease burden. These include (but are notlimited to):• National TB prevalence surveys• Drug resistance surveys• Mortality surveys• Surveys of costs faced by TB patients and their households

4. Periodic review of methods used by WHO toestimate the burden of TB disease and latent TBinfection.

5. Analysis and use of TB data at country level.This includes:• Disaggregated analyses (e.g. age, sex, location) to assessinequalities and equity• Projections of disease burden and intervention impact• Guidance, tools and capacity building

In the context of The End TB Strategy and theSustainable Development Goals (SDGs), theTask Force’s mandate (2016-2020) is:

1. To ensure that assessments of progress towardsEnd TB Strategy and SDG targets and milestonesat global, regional and country levels are asrigorous, robust and consensus-based as possible.

2. To guide, promote and support the analysisand use of TB data for policy, planning, andprogrammatic action.

In June 2006, the Global TB Programme (GTB) inthe World Health Organization (WHO) establisheda Global Task Force on TB Impact Measurement,with the TB monitoring and evaluation (TME) unitin GTB acting as the secretariat.

The Task Force includes a wide range of expertsin TB epidemiology, statistics and modelling,representatives from major technical and financialpartners and representatives from countries with ahigh burden of TB. There have been seven full TaskForce meetings since its inception and many othermeetings on specific topics.

WHAT IS OURMANDATE?

* Milestones have been defined for 2020 and 2025† Targets linked to the Sustainable Development Goals

1 & 2: STRENGTHENING NATIONALNOTIFICATION & VITAL REGISTRATION SYSTEMS

Between January 2013 and April 2019, 75 countriescompleted the TB surveillance checklist and a TBepidemiological review (map).

Priority areas of work identified by the Task Force are:

Strengthening national notification systems fordirect measurement of TB cases1. TB epidemiological reviews, including the use of the WHOTB surveillance checklist.

2. Regional analysis workshops.3. Transitioning from paper to electronic case-basedsurveillance.

4. TB inventory studies to measure under-reporting ofdetected TB cases.

Strengthening national vital registration (VR)systems for direct measurement of TB deaths1. Promote use of VR data for measurement of TB deaths.2. Create and sustain links with relevant stakeholders.3. Mortality studies to validate VR data.

Estimates of TB incidence rely on the systematic analysis of casenotification and programmatic data combined with assessmentof the number of cases not reported and not diagnosed. TheAssessing tuberculosis under-reporting through inventory studiesguide, published in 2012, describes and explains how to design,implement and analyse inventory studies to measure theunder-reporting of detected TB cases.

Inventory studies are now being promoted in selected countries,linked to recommendations following TB epidemiological reviewsand use of the TB surveillance checklist. They are of particularrelevance in countries with large private sectors or where largenumbers of TB patients are thought to be treated in the publicsector but not reported to national authorities.

By the end of 2018, a national inventory study had been completedin 16 countries. Inventory studies have started in China, South Africaand Tanzania and are planned in Armenia, the Philippines andUkraine (map).

INVENTORY STUDIES TO MEASURE UNDER-REPORTINGOF DETECTED TB CASES

globalTUBERCULOSIS

2018

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p1 · 10 million IncidentcasesofTB(2017).3 million TBdeaths(HIV-negative;2017) 1 MethodsusedbyWHOtotranslatesurveillanceandsurvey