Tuberculosis: International Efforts and Issues for Congress

Tuberculosis: International Efforts
and Issues for Congress
Updated May 1, 2008
Tiaji Salaam-Blyther
Specialist in Global Health
Foreign Affairs, Defense, and Trade Division

Tuberculosis: International Efforts and Issues
for Congress
Summary
Infectious diseases are estimated to cause more than 25% of all deaths around
the world. A number of infectious disease outbreaks over the past decade, such as
H5N1 avian influenza and severe acute respiratory syndrome (SARS), have
heightened concerns about how infectious diseases might threaten global security.
International air travel and trade have complicated efforts to detect and contain
infectious diseases. People could cross borders carrying a highly contagious disease
before an infectious agent causes symptoms.
Non-health officials are becoming increasingly aware of the threat that
infectious diseases pose. An event that illuminated the issue occurred in May 2007,
when a man known to be carrying a drug-resistant form of tuberculosis (TB) crossed
a number of international borders unabated. The World Health Organization (WHO)
estimates that someone contracts TB every second and that about one-third of all
people in the world carry TB; most of these cases, however, are latent. In 2006, an
estimated 14.4 million people were living with TB globally, including 9.2 million
who contracted the disease that year. About 1.7 million people carrying TB died in
2006, including 200,000 people co-infected with HIV/AIDS. About 80% of all
estimated new TB cases arising in the world each year occur in 22 high-burden
countries (HBCs).
WHO indicates that the global incidence of TB per capita peaked around 2003
and since then, incidence per 100,000 population stabilized in Europe and declined
in all five WHO regions, although the absolute number of new cases increased
between 2005 and 2006 in Africa, the Middle East, Europe, and Southeast Asia. In
sub-Saharan Africa, weak health systems, minimal access to health facilities,
insufficient staffing and little human resource development, ill-equipped and
substandard laboratories, and human immunodeficiency virus/acquired
immunodeficiency syndrome (HIV/AIDS) co-infection have limited countries’ ability
to contain TB.
In FY2008, Congress funded U.S. global TB operations at unprecedented levels.
Through FY2008 Consolidated Appropriations, Congress provided $162.2 million
to international TB programs and an additional $840.3 million for a U.S. contribution
to the Global Fund to Fight HIV/AIDS, TB, and Malaria (Global Fund). The House
passed and the Senate Foreign Relations Committees reported out companion TB
bills, Stop TB Now Act (H.R. 1567 and S. 968) to support global TB efforts and
authorize $330 million in FY2008 and $450 million in FY2009. They also authorized
$70 million and $100 million for anti-TB programs at the U.S. Centers for Disease
Control and Prevention (CDC) in FY2008 and FY2009, respectively. Although
Congress voted to increase support for global TB efforts, some Members expressed
concern that the additional funds might be provided at the expense of other global
health programs. The Administration requested $97.1 million for FY2009 global TB
efforts, some $55 million less than appropriated in FY2008. This report, which will
be updated periodically, discusses some key issues Congress might consider as
debate ensues about the proper level and use of global TB funds.

Contents
The Global Threat of Infectious Diseases ...............................1
Tuberculosis .................................................1
Global TB Statistics........................................2
HIV/AIDS and TB.........................................3
Drug Resistance to TB Treatments....................................4
Multi-Drug Resistant TB (MDR-TB) ..............................4
Extensive Drug Resistant (XDR)-TB..............................6
U.S. Global TB Efforts.............................................8
U.S. Agency for International Development.........................8
U.S. Centers for Disease Control and Prevention (CDC)...............8
Department of State............................................9
International TB Efforts.............................................9
World Health Organization and Implementing Partners...............10
DOTS-Plus ..............................................11
Green Light Committee....................................11
Stop TB Partnership.......................................11
Global Drug Facility (GDF).................................12
The Global Fund to Fight AIDS, Tuberculosis, and Malaria............12
Bill and Melinda Gates Foundation...............................13
Issues for Congress...............................................13
Strengthen Health Systems.....................................14
Address Health Worker and Health Center Shortages.................15
Integrate HIV/AIDS and TB Programs ............................16
Provide Additional Funds for Research ...........................17
Treatments ..............................................17
Vacci nes ................................................17
Diagnostic Tools.........................................17
Consider Involuntary Detention..................................18
Address Poverty..............................................19
Appendix. Tables and Figures.......................................20
List of Tables
Table 1. Tuberculosis Cases in the 22 High-Burden Countries, 2006.........21
Table 2. Global Tuberculosis Cases (Regional), 2006.....................22
Table 3. MDR-TB Cases in 27 Global Priority Countries, 2006.............23
Table 4. MDR-TB Cases Among All TB Cases (Regional), 2006...........24
Table 5. U.S. International Tuberculosis Spending: FY2004-FY2009........25
Table 6. Global TB Financing Needs and Outcomes: 2006-2015............25
Table 7. Laboratory Capacity in High-Burden Countries, 2006.............26
Table 8. Health Workers in High-Burden Countries and the United States....27

Tuberculosis: International Efforts and
Issues for Congress
The Global Threat of Infectious Diseases
In January 2000, the National Intelligence Council (NIC) released a report
asserting that, “[n]ew and reemerging infectious diseases will pose a rising threat to
U.S. and global security over the next 20 years. These diseases will endanger U.S.
citizens at home and abroad, threaten U.S. armed forces deployed overseas, and
exacerbate social and political instability in key countries and regions in which the
United States has significant interests.”¹ NIC cited a number of factors that heighten
the infectious diseases threat, including increasing drug resistance, slow development
of new antibiotics, urban sprawl, environmental degradation, and the growing ease
and frequency of cross-border movements.
Over the past decade, there has been considerable debate about countries’
abilities to contain and prevent infectious disease outbreaks. In 2002, the
international community struggled to identify an unknown infectious disease that
rapidly spread across 31 countries, infected more than 8,400 people, and killed 813
of those who contracted it. In 2003, when the disease was ultimately contained,
scientists called the agent severe acute respiratory syndrome (SARS).² That same
year, Influenza A/H5N1 (bird flu) reemerged and spread to more than 50 countries.
As of April 17, 2008, 381 people have contracted H5N1, 240 of whom died.³ About

63% of those who contracted the disease have died.

Tuberculosis
TB is one of the most widespread infectious diseases in the world. The World
Health Organization (WHO) estimates that someone contracts TB every second and
that about one-third of all people in the world are currently infected with TB; most

¹ National Intelligence Council, The Global Infectious Disease Threat and Its Implications
for the United States. January 2000, at [http://www.dni.gov/nic/PDF_GIF_otherprod/
infectiousdisease/infectiousdiseases.pdf], visited on January 29, 2008.
² For more information on SARS, see CRS Report RL32072, Severe Acute Respiratory
Syndrome (SARS): The International Response, by Rhoda Margesson and Tiaji Salaam-
Blyther.
³ For most recent data on human H5N1 cases and deaths, see WHO website on avian flu at
[http://www.who.int/csr/disease/avian_influenza/en/]. Also see, CRS Report RL33219, U.S.
and International Responses to the Global Spread of Avian Flu: Issues for Congress, by
Tiaji Salaam-Blyther and CRS Report RL33871, Foreign Countries’ Response to the Avian
Influenza (H5N1) Virus: Current Status, by Emma Chanlett-Avery et al.

of these cases, however, are latent.⁴ TB is a highly contagious disease that spreads
through the air when infectious people cough, sneeze, talk or spit. People with TB
are only infectious when the bacteria is active. Those with active TB who do not
receive treatment and are not properly quarantined infect, on average, between 10 and
15 people every year.⁵ TB can lie dormant in an infected person for years and may not
cause any symptoms or illness. The TB bacteria most often becomes active and
causes sickness when one’s immune system is weakened, such as with human
immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS).
Global TB Statistics.⁶ Although TB is curable, WHO estimates that in 2006
(the year for which the most current data are available), there were 14.4 million
prevalent cases of TB, including some 9.2 million people who contracted the disease⁷
that year. About 80% of annual TB cases occur in 22 high-burden countries (see
Figure 1 in the Appendix).⁸ All but two of those high-burden countries were in
Africa or Asia.⁹ More than 50% of all new TB cases occurred in five countries (in
descending order of TB cases): India, China, Indonesia, South Africa, and Nigeria.
The disease killed an estimated 1.7 million people in 2006, including 230,857 who
were also infected with HIV/AIDS (see Table 1 in the Appendix).
Although southeast Asia had the highest number of new TB cases, incidence and
mortality per capita rates were considerably higher in sub-Saharan Africa. Among the
15 countries with the highest estimated TB incidence rates, 13 were in Africa, due
in part to relatively high rates of HIV co-infection (see Table 2 in the Appendix).¹⁰
In 2006, about 3.10 million people in Southeast Asia were newly infected with TB
(109 per 100,000 people) and about 2.81 million in sub-Saharan Africa (363 per
100,000). The actual number of TB-related deaths and the mortality per capita rates
were higher in sub-Saharan Africa than in Southeast Asia. About 514,699 people

⁴ People who have latent TB infection do not feel sick, do not have any symptoms, and
cannot spread TB to others. Latent TB becomes active when the host becomes infectious and
begins to feel ill.
⁵ Information in this paragraph was summarized from WHO’s fact sheet on tuberculosis, at
[http://www.who.int/mediacentre/factsheets/fs104/en/], visited on March 5, 2008.
⁶ Data in this section was compiled by CRS from WHO, 2008 Global Tuberculosis Control
Report, at [http://www.who.int/tb/publications/global_report/2008/pdf/fullreport.pdf].
⁷ The incidence of a disease is the number of new cases arising within a given time period,
such as a year. The prevalence is the total number of cases that exist within a given time
period. Prevalence is sometimes referred to as burden. Prevalence and burden are used
interchangeably in this report.
⁸ The 22 high-burden countries, in descending order of absolute TB case numbers, were
India, China, Indonesia, South Africa, Nigeria, Bangladesh, Ethiopia, Pakistan, Philippines,
Democratic Republic of Congo, Russia, Vietnam, Kenya, Tanzania, Uganda, Brazil,
Mozambique, Thailand, Burma, Zimbabwe, Cambodia, and Afghanistan.
⁹ Of the high burden-countries, Brazil and Russia are not in Africa or Asia.
¹⁰ The 15 countries with the highest TB incidence per capita rates (in order from highest to
lowest rates) were Swaziland, South Africa, Djibouti, Namibia, Lesotho, Zimbabwe, East
Timor, Zambia, Botswana, Sierra Leone, Cambodia, Mozambique, Cote d’Ivoire, Congo,
and Rwanda.

died of TB in southeast Asia (30 per 100,000 infected), while some 639,089 people
died of TB in sub-Saharan Africa (83 per 100,000 infected). WHO asserts that a
number of factors contribute to Africa’s relatively high per capita rate. Key factors
include weak health systems, low quality health care, poor access to health facilities,
insufficient staffing and other human resource constraints, ill-equipped and
substandard laboratory services, and little collaboration between TB and HIV
programs.
HIV/AIDS and TB. In areas with significant HIV/AIDS prevalence, the virus
is contributing to rising TB prevalence.¹¹ People living with HIV/AIDS are at greater
risk of contracting TB because of their weakened immunity. Each disease accelerates
the advancement of the other. TB considerably shortens the survival of people with
HIV/AIDS and quickens the progression of HIV into AIDS. Meanwhile, HIV/AIDS
is the most potent risk factor for converting latent TB into active TB. Many people
infected with HIV/AIDS in developing countries develop TB as the first
manifestation of AIDS. The two diseases represent a deadly combination, since they
are more destructive together than either disease alone. Other key facts about
HIV/AIDS-TB co-infection include:
^!In HIV-positive people, TB is harder to diagnose, progresses faster,
is almost always fatal if undiagnosed or left untreated, and kills up
to half of all AIDS patients worldwide;
^!People with HIV/AIDS are up to 50 times more likely to develop TB
in a given year than HIV-negative people; and
^!About 90% of people living with HIV/AIDS die within four to
twelve months of contracting TB if they are not treated for TB.
In sub-Saharan Africa, HIV/AIDS and TB co-infection is becoming a growing
problem. In 2006, about 85% of all HIV-positive people with TB were found in
Africa.¹² That year, an estimated 709,000 people were co-infected with HIV/AIDS
and TB, some 606,000 of whom were African. About 205,000 of the 231,000 co-
infected patients who died from TB were African, representing 89% of those deaths.
In countries with high HIV/AIDS prevalence, HIV/TB co-infection poses a
significant health challenge. In Swaziland, for example, 75% of TB patients were¹³
HIV-positive. South Africa, with 0.7% of the world’s population and the most
number of people living with HIV/AIDS, had 28% of all HIV/TB co-infection cases
and 33% of HIV-positive cases in sub-Saharan Africa.
In many high-burden countries, particularly in sub-Saharan Africa, TB patients
are not yet routinely tested for HIV, and HIV patients are not yet routinely tested for

¹¹ Information in this paragraph was compiled by CRS from WHO, Frequently asked
questions about TB and HIV/AIDS. [http://www.who.int/tb/hiv/faq/en/].
¹² Unless otherwise noted, information in this paragraph was compiled by CRS from WHO,

2008 Global Tuberculosis Control Report, at [http://www.who.int/tb/publications/

gl obal_report/2008/pdf/fullreport.pdf].
¹³ WHO, 2007 Global Tuberculosis Control: Surveillance, Planning, Financing, at
[http://www.who.int/tb/ publications/global_report/en/index.html ].

TB.¹⁴ HIV testing for TB patients has increased, however, between 2002 and 2006.
In 2002, nine countries reported testing 21,806 TB cases for HIV, representing less
than 1% of notified TB cases. By 2006, 112 countries had reported testing 687,174
patients for HIV, equivalent to about 12% of notified TB cases. In Africa, 287,945
patients were tested for HIV — some 22% of all notified TB cases. In Africa, HIV
testing of TB patients increased from 7.5% to 35% from 2004 to 2006. The testing
increase was driven primarily by Kenya and South Africa. In spite of improvements
in HIV testing in Africa, the region still lagged behind other countries. On average,

56% of TB patients were tested for HIV outside of Africa.

Drug Resistance to TB Treatments
Multi-Drug Resistant TB (MDR-TB)
MDR-TB are TB organisms that do not respond to at least two first-line drugs.¹⁵
Drug resistance mostly arises from poor treatment adherence or incorrect drug usage.
Adherence means taking accurately prescribed drugs in the right amounts at the
correct time. If the wrong drugs or the wrong combinations of drugs are prescribed,
providers fail to ensure that they are taken correctly on schedule, or patients do not
take their medicine for the full term, TB may become resistant to the drugs.
The development of MDR-TB is particularly troubling to scientists, because
MDR-TB carriers can transmit resistant forms of TB to others. MDR-TB is
transmissible, even among those who have never had TB. Research has indicated
that patients are less likely to complete regimens for treatment-resistant forms of TB,
in part, because resistant forms take longer to cure. Non-resistant forms of TB take
between six and nine months to cure, while MDR-TB takes about two years to cure.
MDR-TB treatments are also more toxic, more expensive, often of limited
availability in resource-limited settings, and generally less effective, especially
among HIV-positive people. If patients adhere to treatment regimens, cure rates for
non-resistant TB range between 80% and 95%; cure rates for MDR-TB range
between 50% and 60%.
WHO advises that health care providers treat MDR-TB patients in separate
facilities than those with HIV/AIDS. Separating MDR-TB patients from HIV/AIDS

¹⁴ Information in this paragraph was compiled by CRS from WHO, 2008 Global
Tuberculosis Control Report, p. 48, at [http://www.who.int/tb/publications/global_report/

2008/pdf/fullreport.pdf].

¹⁵ Unless otherwise specified, data on MDR-TB was compiled by CRS from WHO,
Tuberculosis Infection Control in the Era of Expanding HIV/AIDS Care and Treatment,

2007, at [http://whqlibdoc.who.int/hq/1999/WHO_TB_99.269_ADD_eng.pdf] and WHO,

Anti-Tuberculosis in the World, 2008, at [http://www.who.int/entity/tb/publications/
2008/drs_report4_26feb08.pdf]. General TB statistics included throughout this report were
mostly taken from WHO’s 2007 Global Tuberculosis Control Report. Data in this
paragraph may vary slightly from those, as they were taken from WHO’s 2008 report, Anti-
Tuberculosis in the World, which included more recent statistics on drug resistance but did
not provide analysis on TB generally.

patients can be particularly challenging in resource-limited settings, where hospitals
are frequently overcrowded, ill-equipped, and unable to house individuals for the
entire treatment term. In areas with high HIV-prevalence, efforts to care for MDR-
TB patients separately from HIV/AIDS patients are often complicated by the high
proportion of hospital beds filled with HIV/AIDS patients.
In February 2008, WHO released a report on TB drug resistance that
summarized findings from surveys conducted between 2002 and 2006 in 81
countries.¹⁶ Based on those surveys, WHO estimates that almost 490,000 MDR-TB
cases emerged in 2006, representing about 5% of all new TB cases — though MDR-
TB rates varied widely from 0% in some western European countries to over 35% in
some former Soviet states. Among the 490,000 MDR-TB cases, 285,718 were new
cases and 203,230 had been previously treated.
WHO estimated that, of the countries for which adequate data exist, China,
India, and Russia are estimated to have the highest number of MDR-TB cases. China
and India hold about 50% of all MDR-TB cases and Russia comprises another 7%.
Russia has the greatest proportion of MDR-TB cases among new ones, however.
About 13% of all new TB cases were MDR-TB, 19% of all TB cases were MDR-TB,
and almost 50% of previously treated TB cases were identified as MDR-TB.¹⁷
Although no other HBC reported equally high MDR-TB rates, a number of Eastern
European countries are estimated to have greater proportion of MDRT-TB prevalent
rates. WHO has identified 27 countries, which together account for about 86% of all
global MDR-TB cases; 15 of them are in Eastern Europe (see Figure 1 and Table 3
in the Appendix).
Although WHO’s report provided greater insight into the prevalence of drug
resistant forms of TB, little is known about resistance in Africa. The findings
included in the report were estimated to have measured about one-half of all drug-
resistant TB cases, because the surveys were conducted only in those countries with
the capacity to conduct drug resistance surveys. Such capacity remains limited in
Africa. Findings from six countries in sub-Saharan Africa were included in the
analysis (Cote d’Ivoire, Ethiopia, Madagascar, Rwanda, Senegal, and Tanzania).
Data from South Africa were included in the illustrations and tables throughout the
report, but not in the analysis, because WHO used a different methodology to analyze
data previously collected from South Africa.
Based on available data, WHO estimates that in 2006, some 2% of all TB cases
were MDR-TB in Africa, 7% in the Western Pacific Region, and 19% in Eastern
Europe (see Table 4 in the Appendix). WHO asserts that although it can use
available data to approximate the global burden of MDR-TB, it cannot detect global
changes in MDR-TB prevalence, because data in many high-burden countries are
unavailable, incomplete, and/or have only recently begun to be compiled. The
organization can, however, extrapolate trends in key areas. WHO found that MDR-
TB cases declined in China and the United States; were stable in Thailand, some

¹⁶ Unless otherwise indicated, data included in this section was taken from WHO, Anti-
Tuberculosis in the World, 2008, pp. 73 and 82.
¹⁷ WHO, 2008 Global Tuberculosis Control Report, p.51.

parts of Vietnam, and three Baltic countries; and increased in the Republic of Korea
and Peru. In Peru, a decline in TB notification rates suggests weaknesses in TB
control. In Korea, the TB burden is shifting to the elderly and the number of MDR-
TB cases among new TB cases is increasing. Two regions in the Russian Federation
are showing increases in the proportion of MDR-TB among new cases at a very rapid
rate, while the TB notification rate in those regions is falling slowly.
WHO has indicated that similar outbreaks of drug resistance with associated
high mortality are likely occurring in other African countries but are going undetected
because of insufficient laboratory capacity.¹⁸ MDR-TB patients are not yet routinely
checked for HIV/AIDS in Africa, though they are extremely susceptible to the
disease. Botswana, Mozambique, and South Africa are reportedly the only countries
in sub-Saharan Africa that routinely test drug-resistant TB cases for HIV.¹⁹
According to the latest available data, in 2006, almost 90% of new MDR-TB cases
that occurred in the three countries were found in high HIV-prevalent settings.
Extensive Drug Resistant (XDR)-TB
MDR-TB is considered XDR-TB when it becomes resistant to three or more of
the six classes of second-line drugs. In high-quality health facilities, XDR-TB
treatment is successful in 30% of the cases. In low-resource settings, XDR-TB is
almost always fatal. WHO is uncertain about the extent of XDR-TB prevalence, in
large part because drug resistance testing to second-line drugs is not available in most
high-burden countries.²⁰ The majority of countries that reported XDR-TB cases to
WHO were low-burden countries and do not reflect the global magnitude of the
phenomenon. WHO estimates that XDR-TB is widespread, with 45 countries having
reported at least one case.
A survey conducted by WHO and the Centers for Disease Control and
Prevention (CDC) on data from 2000-2004 found that XDR-TB occurs in all regions
of the world, but most frequently in the countries of the former Soviet Union and
Asia.²¹ In the United States, 4% of MDR-TB cases met the criteria for XDR-TB. In
Latvia, a country with one of the highest rates of MDR-TB, 19% of MDR-TB cases
met the XDR-TB criteria.

¹⁸ Unless otherwise noted, information in this paragraph was compiled by CRS from WHO,
Anti-Tuberculosis Drug Resistance in the World, 2008, p. 91, at [http://www.who.int/tb/
publications/2008/drs_report4_26feb08.pdf], and Sello Motseta, “Botswana Confirms Cases
of Resistant TB.” Associated Press, January 16, 2008.
¹⁹ Information in this paragraph was compiled by CRS from WHO, Anti-Tuberculosis in the
World, 2008, at [http://www.who.int/tb/publications/2008/drs_report4_26feb08.pdf], visited
on March 5, 2008.
²⁰ Ibid, p. 78.
²¹ WHO, “WHO concern over extensive drug resistant TB strains that are virtually
untreatable.” September 5, 2006, at [http://www.who.int/mediacentre/news/notes/2006/
np23/en/index.html ].

Concern about the spread of XDR-TB rose in May 2006 when an outbreak
caused several deaths in Kwazulu-Natal, South Africa. Many health experts were
alarmed by the high mortality rates. South African officials invited CDC and WHO
to assess the situation. Five hundred forty-four patients were studied; 221 were
diagnosed with MDR-TB, including 53 cases determined to be XDR-TB. Forty-four
of the 53 XDR-TB cases were tested for HIV/AIDS; all were HIV/AIDS-positive.
Only one of the 53 patients with XDR-TB survived. On average, the 52 patients died
within 25 days, including those who received anti-retroviral drugs.
WHO has indicated that similar outbreaks of drug resistance with associated
high mortality are taking place in other African countries, but going undetected
because of insufficient laboratory capacity.²² HIV/AIDS patients are not yet routinely
checked for TB in Africa (except in Botswana, Mozambique, and South Africa),
though they are extremely susceptible to the disease. According to latest estimates,

996 of 17,615 MDR-TB cases in South Africa were identified as XDR-TB,

representing some 5.6% of all MDR-TB cases. XDR-TB cases were considerably
higher in Kwazulu-Natal, with some 14% (656 cases) of all MDR-TB cases
identified as XDR-TB. Some observers believe more undetected cases may exist in
the country, asserting that testing results are often inaccurate, testing methods are
outdated, and many patients die before they are diagnosed.
On January 16, 2008, the Government of Botswana confirmed that 100 people
were diagnosed with MDR-TB and an additional two were diagnosed with XDR-
TB.²³ Botswana’s Ministry of Health officials are urging those with chronic coughs
and all who have been exposed to patients with active TB to go to their nearest health
facility to be tested.
WHO has ramped up its XDR-TB efforts in southern Africa.²⁴ A delegation of
WHO officials and its partners visited Lesotho early 2008 to help plan XDR-TB
surveillance and treatment, as well as improve basic TB control. Similar missions
were also held in Malawi and Swaziland in February 2008. In March 2008, a team
of WHO officers began to assist KwaZulu-Natal authorities investigate the origin and
spread of XDR-TB in the province. The team is expected to remain in the country
for several months. Botswana, Lesotho, Malawi, Mozambique, Swaziland, and
Zimbabwe have reportedly submitted national XDR-TB response plans to WHO.
Lesotho has reportedly completed a rapid survey on suspected XDR-TB cases;
Botswana has started one; and Malawi, Mozambique, Namibia and Swaziland intend
to start surveys within a few months. Madagascar, Mozambique, and Tanzania have

²² Information in this paragraph was compiled by CRS from WHO, Anti-Tuberculosis in the
World, 2008, p.91 and Sello Motseta, “Botswana Confirms Cases of Resistant TB.”
Associated Press, January 16, 2008, at [http://ap.google.com/article/ALeqM5hPwuo15khre_
PPVZtGZ72KZSj9pAD8U76PIO0], visited January 18, 2007.
²³ “Drug resistant TB hits Botswana.” Botswana Press Agency, January 16, 2008, at
[ h t t p : / / www.go v.bw/ c gi -b i n / n ews.cgi?d=20080116&i = Dr ug_r esi s t a nt _T B_hi t s _Bot swana] ,
visited January 18, 2007.
²⁴ Information in this paragraph was compiled by CRS from WHO, “XDR-TB: Extensively
Drug -Resistant Tuberculosis.” March 2008. At [http://www.who.int/tb/challenges/
xdr/news_mar07.pdf], accessed on February 4, 2008.

ongoing anti-TB drug resistance surveys; Angola, Lesotho, Malawi, Namibia, South
Africa, and Zimbabwe plan to start surveys by the end of 2008.
U.S. Global TB Efforts
A number of U.S. agencies, centers, and departments implement a range of
programs aimed at treating and containing the global spread of tuberculosis.
Congress designates funds for global TB interventions only to the U.S. Agency for
International Development (USAID), while other agencies and departments draw
from general funds (see Table 5 in the Appendix). Because agencies and
departments might use discretionary funds to support global TB initiatives, some
U.S. international TB activities might not be included here, such as research
conducted by the National Institute of Health (NIH) to develop a new TB drug with
a shorter treatment regimen.²⁵
U.S. Agency for International Development
USAID is the leading U.S. agency involved in anti-TB efforts around the globe.
In more than 35 countries, USAID-supported TB programs train health care workers
on TB response and control, fund research and development of TB drugs and
vaccines, facilitate the coordination and harmonization of TB and HIV/AIDS
interventions, address MDR-TB issues, and improve the procurement and
management of TB treatments. USAID is also a working member of several
international TB partnerships and supports the WHO Global TB Monitoring and
Surveillance project. In FY2004, Congress provided $85.1 million to USAID for
international TB efforts, $92.0 million in FY2005, $91.5 million in FY2006, $94.9
million in FY2007, and $162.2 million in FY2008.²⁶ The Administration requested
$97.1 million for USAID’s FY2009 international TB interventions.
U.S. Centers for Disease Control and Prevention (CDC)
CDC supports global TB efforts by providing epidemiologic, laboratory, and
programmatic support to USAID, WHO, and the International Union Against TB and
Lung Diseases.²⁷ It also assigns expert staff to help implement global TB programs.
CDC helps WHO develop and implement guidelines on TB prevention in resource-
limited settings. Additional global TB technical assistance by CDC includes
strengthening laboratory capacity and referral systems, developing protocols for
epidemiologic studies, and refining information on TB prevalence and incidence.
CDC reports that in each fiscal year since FY2004, it has spent on average some $2
million of its TB appropriation on global TB efforts and anticipates spending the
same amount on global TB in each of FY2008 and FY2009.

²⁵ The program descriptions below were compiled from interviews with Administration
officials.
²⁶ Reported to CRS by USAID’s Budget Office on March 15, 2008.
²⁷ This paragraph was compiled from interviews with CDC officials and the FY2008 HHS
budget justification. [http://www.cdc.gov/fmo/PDFs/FY08_CDC_CJ_Final.pdf]

USAID also transferred $3.4 million in each of FY2006 and FY2007 to CDC
in support of CDC’s technical efforts in other countries. Through its Global AIDS
Program (GAP), CDC supports the Global Fund (the Global Fund is discussed more
comprehensively in the “International TB Efforts” section below) and has technical
staff assigned to positions in the Office of the Global AIDS Coordinator (OGAC),
USAID, the HHS Office of Global Health Affairs and WHO.
Department of State
On January 28, 2003, during his State of the Union Address, President Bush
proposed that the United States spend $15 billion over the next five fiscal years to
combat HIV/AIDS through an initiative he called the President’s Emergency Plan for
AIDS Relief (PEPFAR). The initiative, authorized in May 2003 by P.L. 108-25, the
U.S. Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act, anticipates
channeling $10 billion through the Global HIV/AIDS Initiative (GHAI) to 15 Focus
Countries; directing $4 billion to global TB programs, international HIV/AIDS
research, and bilateral HIV/AIDS programs in more than 100 additional non-Focus
Countries; and reserving $1 billion for U.S. Global Fund contributions.²⁸
Congress appropriates the bulk of PEPFAR funds to the GHAI account, which
was established to streamline funds for global HIV/AIDS, TB, and malaria programs
to the 15 Focus Countries. The Office of the Global AIDS Coordinator (OGAC) at
the U.S. State Department transfers funds from GHAI to implementing agencies and
departments, and international partnerships, such as the Global Fund. OGAC reports
that, in FY2006, it transferred $48.4 million to implementing agencies for TB
projects in the 15 Focus Countries and $131.0 million in FY2007. The
Administration did not request any funds for TB activities for FY2008, though
Congress directed OGAC to provide not less than $150 million for joint HIV/TB
programs through FY2008 Consolidated Appropriations, Division J, Foreign
Operations Appropriations.
International TB Efforts
A number of organizations collaborate to combat TB globally. Most of these
adhere to guidelines and recommendations that WHO and its partners drafted. WHO
is the directing and coordinating authority for health within the United Nations
system. It is responsible for providing leadership on global health matters, shaping
the health research agenda, setting norms and standards, articulating evidence-based
policy options, providing technical support to countries, and monitoring and
assessing health trends.

²⁸ For more information on PEPFAR, see CRS Report RL33771, Trends in Global AIDS
Spending: FY2000-FY2008, and CRS Report RL34192, PEPFAR: From Emergency to
Sustainability, by Tiaji Salaam-Blyther, and White House Fact Sheet, “The President’s
Emergency Plan for AIDS Relief,” January 29, 2003, at [http://www.state.gov/p/af/rls/fs/

17033.htm], visited on January 29, 2008.

World Health Organization and Implementing Partners
In 1991, the World Health Assembly (WHA) — WHO’s decision making body
composed of delegations from all 193 member countries — passed a resolution that
recognized TB as a major global public health problem and established two goals for
TB control: detection of 70% of new smear-positive cases,²⁹ and cure of 85% of such
cases, by the year 2000.³⁰ In 1994, WHO and global health experts developed and
recommended that all health practitioners use the Directly Observed Treatment,
Short-course (DOTS) strategy to combat TB.³¹ DOTS has five key components:
^!Political commitment with increased and sustained financing;
^!TB detection through bacteriology, the recommended method of TB
case detection;
^!Standardized treatment with supervision and patient support;
^!Effective drug supply and management systems; and
^!Monitoring and evaluation systems, and impact measurement.
In 2000, WHO and its partners launched the first Global Plan to Stop TB, which
outlined what actions needed to be taken from 2001 to 2005 to control TB. By 2004,
more than 20 million patients had been treated in DOTS programs worldwide and
more than 16 million of them had been cured. Mortality due to TB has been declining
and incidence diminishing or stabilizing in all regions except sub-Saharan Africa and
eastern Europe. The global treatment success rate among new smear-positive TB
cases had reached 83% by 2003 (just short of the WHA target of 85% by 2005), and
in 2004 the case detection rate, which has accelerated globally since 2001, was 53%
(against the target of 70% by 2005).
In 2005, WHO Member States passed a resolution that advocated Member
States provide sustainable financing for TB control and prevention and commit to
achieve the TB-related targets included in the Millennium Development Goals

²⁹ A smear-positive test detects the presence of TB bacilli in a sputum (material that is
coughed up from the lungs) sample. A smear-negative test detects no TB bacilli in a sputum
sample, though the person carries TB. People who are co-infected with HIV and TB
frequently have smear-negative results and subsequent chest x-rays, if available, may also
look normal. TB diagnoses are often belatedly made in co-infected people, since many with
HIV develop forms of TB outside of the lungs. Culturing the organism can usually provide
a definitive diagnosis, but culturing takes weeks, and requires laboratory capacities that are
usually unavailable in many resource-limited settings. See WHO, 2007 Global Tuberculosis
Control Report; WHO, Improving the Diagnosis of Smear-Negative Pulmonary and
Extrapulmonary Tuberculosis Among Adults and Adolescents, 2006, [http://www.who.int/tb/
publications/2006/tbhiv_recommendations.pdf]; and Schluger, Neil, “Changing Approaches
to the Diagnosis of Tuberculosis,” American Journal of Respiratory and Critical Care
Medicine, Volume 164, Number 11, December 2001. [http://ajrccm.atsjournals.org/
cgi/content/full/164/11/2020]
³⁰ Resolution WHA44.8. Tuberculosis control program. In: Handbook of resolutions and
decisions of the World Health Assembly and the Executive Board. Volume III, 3^rd ed. (1985-

1992). Geneva, World Health Organization, 1993 (WHA44/1991/REC/1):116.

³¹ See WHO’s website on DOTS, at [http://www.who.int/tb/dots/en/index.html].

(MDGs).³² WHO and its partners have also developed additional policies, strategies,
and working groups that facilitate the achievement of global TB control targets.
Innovative mechanisms such as the Global Drug Facility and the Green Light
Committee improve access to quality-assured and affordable drugs in resource-poor
settings. These activities are described below.
WHO estimates that $56 billion would be needed from 2006 through 2015 to
implement its Global Plan to Stop TB (see Table 6 in the Appendix).³³ Of the
estimated $56 billion needed to reverse the incidence of TB, WHO suggests that
$28.9 billion be spent on expanding DOTS, $5.8 billion be spent on DOTS-Plus
initiatives, $6.7 billion be spent on treating people co-infected with HIV/AIDS and
TB, and $9.0 billion be spent on research and development. WHO estimates that
governments and donors will provide about 45% of the funds needed, leaving a
funding gap of an estimated $31 billion.
DOTS-Plus. In areas with moderate to high levels of MDR-TB, WHO and its
partners implement DOTS-Plus, a strategy that provides guidance on issues, such as
the appropriate use of second-line anti-TB drugs. DOTS-Plus is currently operational
in Bolivia, Costa Rica, Estonia, Haiti, Latvia, Malawi, Mexico, Peru, Philippines,
Russia, and Uzbekistan. Additional DOTS-Plus projects have been approved in
Georgia, Honduras, Jordan, Kenya, Kyrgyzstan, Lebanon, Nepal, Nicaragua,
Romania and Syria.
Green Light Committee. The Working Group on DOTS-Plus for MDR-TB
identified access to second-line anti-TB drugs as one of the major obstacles to the
implementation of DOTS-Plus pilot projects. The Working Group made
arrangements with the pharmaceutical industry to provide concessionally priced
second-line anti-TB drugs to DOTS-Plus pilot projects. In some cases, treatment
prices were 99% lower in DOTS-Plus countries compared with retail prices. Before³⁴
second-line TB treatments are provided, the Green Light Committee reviews
requests for treatments through DOTS-Plus projects and determines whether it can³⁵
provide the medication in compliance with international standards of care.
Stop TB Partnership. Established in 2000, the Stop TB Partnership seeks to
achieve universal access to high-quality diagnosis and treatment; reduce the human

³² In 2000, world leaders committed to support eight Millennium Development Goals, which
range from halving extreme poverty to halting the spread of HIV/AIDS and providing
universal primary education, all by the target date of 2015. See the list of MDGs at
[http://www.un.org/ millenniumgoals/].
³³ Figures in this section were compiled from The Global Plan to Stop TB: 2006-2015.
[ ht t p: / / www.st opt b.or g/ gl obal pl a n/ pl an_mai n.asp]
³⁴ The Green Light Committee is comprised of CDC, International Union Against
Tuberculosis and Lung Diseases, Medical Research Council of South Africa, National
Tuberculosis Programs of Estonia and Latvia, Partners in Health, and WHO.
³⁵ For more on how the Green Light Committee determines which applications to approve,
see WHO, Instructions for Applying to the Green Light Committee for Access to Second-
Line Anti-Tuberculosis Drugs. 2006. [http://whqlibdoc.who.int/hq/

2006/WHO_HT M_T B_2006.369_eng.pdf]

suffering and socioeconomic burden associated with TB; protect poor and vulnerable
populations from TB, MDR-TB, and TB and HIV/AIDS co-infection; and develop
new TB treatment and diagnostic tools and enable their effective use. The Stop TB
Partnership is comprised of a network of international organizations, countries,
donors, governmental and non-governmental organizations and individuals that have
expressed an interest in eradicating TB.³⁶ Seven Working Groups within the
partnership focus on TB-related issues and facilitate coordinated action. The seven
groups are: Advocacy, Communication, and Social Mobilization; DOTS Expansion;
MDR-TB; New TB Diagnostics; New TB Drugs; New TB Vaccines; and
TB/HIV/AIDS. Each Working Group within the partnership is independently
governed and collectively supports efforts to
^!increase access to accurate diagnoses and effective treatments;
^!expand the availability, affordability and quality of TB drugs;
^!promote research and development for new TB drugs, diagnostics
and vaccines; and
^!ensure appropriate use of and access to affordable new and improved
TB prevention and control tools.
Global Drug Facility (GDF). GDF, housed in WHO and managed by a small
team in the Stop TB Partnership Secretariat, is a financing mechanism that provides
technical assistance in the management and surveillance of TB drug use, as well as³⁷
procurement of high-quality TB drugs at a relatively low price. Countries can
purchase TB treatments directly from GDF at prices below market value or apply for
grants to purchase first-line TB treatments. GDF regularly assesses and monitors the
use of its funds to ensure that grant recipients adequately detect and monitor TB
cases, properly prescribe and oversee the use of medicines, transparently use
finances, and consistently administer drugs without interruption. GDF also works
with grantees to estimate drug needs for the next year of GDF support.
The Global Fund to Fight AIDS, Tuberculosis, and Malaria
The Global Fund, headquartered in Geneva, Switzerland, is an independent
foundation intended to attract and rapidly disburse new resources for fighting the
three diseases.³⁸ The Fund is a financing vehicle, not a development agency, and its
grants are intended to complement existing efforts rather than replace them. As of
March 4, 2008, the Fund approved more than $10 billion in support of nearly 500
grants in 136 countries, making it the single largest donor for TB and malaria control

³⁶ For more on the Stop TB Partnership, see [http://www.stoptb.org/stop_tb_initiative/].
³⁷ [http://www.stoptb.org/gdf/]
³⁸ Information in this paragraph was summarized from Global Fund, Monthly Progress
Update, January 31, 2007, at [http://www.theglobalfund.org/en/files/publications/basics/
progress_update/progressupdate.pdf]. For more information on the Global Fund, see CRS
Report RL33485, U.S. International HIV/AIDS/AIDS, Tuberculosis, and Malaria Spending:
FY2004-FY2008, and CRS Report RL33396, The Global Fund to Fight AIDS, Tuberculosis
and Malaria: Progress Report and Issues for Congress.

and among the three largest donors for HIV/AIDS programs.³⁹ About 17% of Global
Fund grants are targeted at TB control and treatment. According to the Fund’s
website, it has helped to detect 5 million TB cases, supported treatment for 3 million
TB cases using the DOTS strategy, and administered treatment for 24,000 MDR
cases.⁴⁰
Bill and Melinda Gates Foundation
Since the Gates Foundation funded its first grant in 1999, the foundation has
provided $781 million to combat TB globally.⁴¹ The foundation has pledged an
additional $650 million to the Global Fund to Fight AIDS, Tuberculosis, and
Malaria, of which $350 million has been paid to date.⁴² Gates Foundation grants
support projects that focus on four key areas:
^!TB research that focuses on developing more accurate and rapid
diagnostics for resource-poor settings, more effective TB vaccines,
and more effective drugs and shorter regimens to treat active disease;
^!innovative strategies that fight TB, including identifying effective
ways to manage TB in areas heavily affected by HIV/AIDS;
^!new TB control and prevention tools; and
^!advocacy and coordination with an emphasis on joint TB and
HIV/AIDS programs.⁴³
Issues for Congress
Since PEPFAR was launched in FY2004, overall U.S. spending on international
TB initiatives has hovered around $90 million (see Table 5 in the Appendix). In
FY2004, Congress appropriated $85.1 million to USAID for global TB efforts, $92.0
million in FY2005, $91.5 million in FY2006, and $94.9 million in FY2007. In
FY2008, Congress significantly boosted support for global TB programs, providing

³⁹ Global Fund, “Grant Commitments & Disbursements.” February 1, 2008, at
[http://www.theglobalfund.org/en/funds_raised/commitments/], accessed on March 6, 2008.
⁴⁰ Global Fund webpage on tuberculosis, at [http://www.theglobalfund.org/en/about/
tuberculosis/], accessed on March 6, 2008.
⁴¹ Correspondence with Gates Foundation officials on February 4, 2008. Also see Gates
Foundation’s list of TB grants and announcements, at [http://www.gatesfoundation.org/
GlobalHealth/Pri_Diseases/Tuberculosis/], accessed on January 30, 2008.
⁴² Global Fund, Pledges and Contributions, March 4, 2008, at
[http://www.theglobalfund.org/en/files/pledges&contributions.xls], accessed on March 6,

2008.

⁴³ Gates Foundation, “Grantmaking priorities for Tuberculosis,” accessed on March 6, 2008,
at [http://www.gatesfoundation.org/GlobalHealth/Pri_Diseases/Tuberculosis/TB_
Gr antmaking.htm] .

$162.2 million to USAID for international TB efforts and directing OGAC to provide
not less than $150 million for joint HIV/TB programs. Although Congress voted to
increase support for global TB efforts, some Members expressed concern that the
additional funds might be provided at the expense of other global health programs.
The section below presents some issues Congress might consider as it debates the
appropriate level of funding for global TB initiatives.
Strengthen Health Systems
WHO asserts that weak health systems play a key role in the continued spread
of TB across Africa. Many health practitioners argue that inadequate access to rapid
and accurate diagnostic tests significantly contribute to the rise in new TB cases on
the continent. More than a century after its development, in most developing
countries, TB is primarily identified through microscopic examination of sputum.
This tool, however, only detects from 40% to 60% of TB cases, and as little as 20%
of HIV co-infected cases.⁴⁴ Although sputum testing has limited reliability, this
procedure is the most widely used in developing countries and is usually performed
only after TB treatment has failed — after which the patient could have transmitted
the disease to others. About 85% of all countries who reported TB testing practices
to WHO indicated that all suspected pulmonary TB cases undergo sputum testing.
Of the 22 HBCs, 7 did not meet the minimum requirement of at least one sputum
testing laboratory per 100,000 persons (see Table 7 in the Appendix).
Health experts also advocate for improved access to advanced testing
technology, because sputum tests do not reliably detect smear-negative TB cases,⁴⁵
particularly among HIV-positive patients. Culturing, a process requiring laboratory
diagnosis, is the most definitive method of detecting TB, particularly in smear-
negative cases. WHO recommends that countries have at least one laboratory per 5
million people that is capable of culturing samples. Seven of the 22 high-burden
countries meet this minimum requirement: Brazil (5.1), Cambodia (1.1), China (1.4),
Russia (34.0), South Africa (1.3), Thailand (5.1), and Vietnam (1.0) meet this

⁴⁴ Gates Foundation, “Tuberculosis Backgrounder,” accessed on March 6, 2008.
[ h t t p : / / www.ga t e sf oundat i on.or g/ Gl obal Heal t h / Pr i _Di s ease s / T u b e r c u l o s i s / T B_Backgr ou
nder.htm]
⁴⁵ A smear-positive test detects the presence of TB bacilli in a sputum (material that is
coughed up from the lungs) sample. A smear-negative test detects no TB bacilli in a sputum
sample, though the person carries TB. People who are co-infected with HIV and TB
frequently have smear-negative results and subsequent chest x-rays, if available, may also
look normal. TB diagnoses are often belatedly made in co-infected people, since many with
HIV develop TB outside the lungs. Culturing the organism can usually provide a definitive
diagnosis, but culturing takes weeks, and requires laboratory capacities that are usually
unavailable in many resource-limited settings. See WHO, 2007 Global Tuberculosis
Control Report; WHO, Improving the Diagnosis of Smear-Negative Pulmonary and
Extrapulmonary Tuberculosis Among Adults and Adolescents, 2006, [http://www.who.int/tb/
publications/2006/tbhiv_recommendations.pdf]; and Schluger, Neil, “Changing Approaches
to the Diagnosis of Tuberculosis,” American Journal of Respiratory and Critical Care
Medicine, Volume 164, Number 11, December 2001. [http://ajrccm.atsjournals.org/
cgi/content/full/164/11/2020]

criteria. South Africa is the only country in sub-Saharan Africa that meets this
criteria.
In order to prescribe medications properly, laboratories must be capable of
conducting drug susceptibility tests (DST). Prescribing the wrong medication or
dosage not only minimizes the effectiveness of TB treatments, but can also lead to
drug resistance. WHO recommends that countries have at least one DST lab per 10
million people. Of the 22 high-burden countries, Bangladesh and Nigeria have no
DST labs, nine countries have one DST lab to serve their entire population (about
one-third of high-burden countries), and nine meet the minimum of one per 10
million people: Brazil, Cambodia, China, Indonesia, Russia, South Africa, Thailand,
Uganda, and Vietnam.
In many countries, patients might experience lapses in TB treatments, because
clinics might not have the medicines in stock. Irregular drug deliveries are often
caused by poor data collection, deficient road and transport conditions, and poor-
quality distribution systems. Inconsistent use of medication can reduce the potency
of TB treatments, extend the term of use, and result in drug resistence. Health
advocates argue that in order to boost the impact of TB programs, congressional
support for TB efforts must be accompanied by funding of health systems, including
laboratory systems.
The African Health Capacity Investment Act of 2007 (H.R. 3812/S. 805) aims
to address some of these issues. The bills authorize funds to improve health care
capacity on the continent. Related activities include training African health care
workers, providing incentive to retain health worker, and establishing off-site
HIV/AIDS testing and treatment facilities for health care providers. The bill also
requires the President to develop a strategy that would coordinate health-related
strategies with other donors.
Address Health Worker and Health Center Shortages
Shortages of properly trained health care workers and sufficiently equipped
health centers in high-burden countries, particularly in Africa, complicate efforts to
properly contain and treat TB cases. Most of the 22 high-burden countries do not
have enough health workers to meet the most basic health care needs, including
identifying and treating TB cases and monitoring drug usage (see Table 8 in the⁴⁶
Appendix). In addition, many health centers are unable to contain airborne
infections like TB.⁴⁷

⁴⁶ WHO, 2006 World Health Report: Working Together for Health, at [http://www.who.int/
whr/2006/en/]. The Joint Learning Initiative (JLI), a network of global health leaders,
defines a shortage as less than 2.5 health care professionals per 1,000 people; the minimum
proportion it deemed necessary to provide 80% of a country’s population with basic health
care.
⁴⁷ WHO, 2007 World Health Report, A Safer Future: Global Public Health Security in the

21^st Century. [http://www.who.int/whr/2007/whr07_en.pdf]

High HIV prevalence in some parts of Africa further complicates shortage
issues, because HIV and TB patients are usually housed within close proximity of
each other in poorly equipped facilities. WHO maintains that in order for countries
to effectively control TB and prevent increases in MDR-TB and XDR-TB cases,
HIV/AIDS and TB patients should be housed separately and teams of health workers
should be trained specifically to manage drug resistance and work in hospitals or
isolation units dedicated to TB patients. Another challenge is that in some countries
with high HIV prevalence, a significant number of health workers are HIV-positive,
posing a risk to themselves and their patients. WHO contends that all of these issues
converge to cause the extremely high mortality in KwaZulu-Natal.⁴⁸
It is widely understood that MDR-TB is caused in large part by poor treatment
adherence. Health worker shortages lessen the likelihood that the dispensing of
medication will be properly supervised. WHO fears that the inability to manage
sufficiently first- and second-line treatments will lead to a rise in XDR-TB cases.⁴⁹
Global health advocates urge Congress to increase support for health worker training,
fund initiatives that supplement the salaries and provide incentives for indigenous
health workers, and stop recruiting health practitioners from countries with shortages
to fill U.S. health positions.
Integrate HIV/AIDS and TB Programs
Global health experts are concerned about how HIV/AIDS and TB are
converging to worsen mortality rates, particularly in Africa. Early diagnosis and
treatment of both diseases can extend life expectancy and, in the case of TB, decrease
transmission rates. Greater awareness about the intersection of these diseases has led
many health practitioners to routinely test TB patients for HIV. While WHO
applauds those efforts, it has expressed concern that HIV patients are not yet
routinely tested for TB in most high-burden countries. WHO asserts that countries
could significantly improve TB case identification if health professionals would
routinely test all those newly diagnosed with HIV for TB. Proponents of this idea
contend that the practice could ameliorate outcomes of HIV and TB programs, reduce
overall program costs, and make TB and HIV/AIDS efforts more efficient. In
FY2006, OGAC reportedly spent nearly $50 million on TB efforts in the 15 Focus
Countries and about $120 million on addressing HIV/TB co-infection in FY2007.
Health advocates urge Congress to increase funding for programs that integrate
HIV/AIDS and TB responses. Congress directed OGAC to spend not less than $150
million of the $4.7 billion appropriated to OGAC on joint HIV/TB programs through
FY2008 Consolidated Appropriations, Division J, Foreign Operations
Appropriations.

⁴⁸ Ibid.
⁴⁹ WHO, 2007 World Health Report, A Safer Future: Global Public Health Security in the

21^st Century. [http://www.who.int/whr/2007/whr07_en.pdf]

Provide Additional Funds for Research
Treatments. Many health experts urge Congress to increase support for TB
research that could lead to the development of treatments with shorter regimens,
which might improve adherence. On average, patients must take their medicines daily
for six-to-eight months to be fully cured. Supporters contend that improved
adherence might reduce the incidence of emergent drug-resistant TB strains. WHO
and others are seeking to develop new TB treatments that will be effective against
MDR-TB, can cure patients between one and two months, and will cure latent TB
infection. Researchers are also attempting to develop drugs that will be affordable
and easily managed in resource-limited settings.
Vaccines. Advocates maintain that congressional support for TB research
should include TB vaccine research. Health experts assert that Bacille Calmette-
Guerin (BCG), a vaccine currently administered to millions of newborns around the
world, effectively prevents TB in childhood, but not in adulthood. Proponents urge
Congress to support organizations like Aeras Global TB Vaccine Foundation, which⁵⁰
are seeking to develop a vaccine that protects the innoculated throughout their lives.
Diagnostic Tools. TB experts stress the need for new diagnostic tests that
could be more easily used in low-resource settings. At present, culturing is required
to provide a definitive diagnosis. Culturing, however, takes weeks and requires
laboratory capacities that are usually unavailable in many resource-limited settings.
Advocates urge Congress to support efforts, such as WHO’s Tuberculosis
Diagnostics Initiative (TBDI), which forms partnerships with the private sector,
academic researchers, and national and local health officials to facilitate and⁵¹
accelerate the development of diagnostic tools.
In 2007, Representatives Gene Green and Sherrod Brown introduced H.R. 1532
and S. 1551, the Comprehensive Tuberculosis Elimination Act of 2007. The bills
amend Section 317E of the Public Health Service Act (42 U.S.C. 247b-6) to
authorize funds for the research and development of TB vaccines, new treatments,
and more effective diagnosis tools that could be used in low-resource settings. In
October 2007, the House passed and the Senate Foreign Relations Committees
reported out companion TB bills, S. 968 and H.R. 1567, the Stop Tuberculosis (TB)
Now Act. The bills are aimed at fighting tuberculosis overseas and authorize $330
million in FY2008 and $450 million in FY2009 for related foreign assistance
programs. They also authorize $70 million in FY2008 and $100 million in FY2009
for anti-TB programs at CDC.

⁵⁰ See Aeras Global TB Vaccine Foundation, [http://www.aeras.org/about-tb/need.php].
⁵¹ For more information on TBDI, see [http://www.who.int/tdr/diseases/tb/tbdi.htm]. Other
TB research initiatives include Center for Tuberculosis Research at Johns Hopkins
University, [http://www.jhsph.edu/dept/IH/Centers/TB_Research.html]; Consortium to
Respond Effectively to the AIDS TB Epidemic (CREATE), [http://www.tbhiv-create.org/];
Global Tuberculosis Research Initiative (GTRI) at WHO, [http://www.who.int/
tdr/diseases/tb/gtri.htm]; and The Action TB Program at University of Cape Town,
[http://web.uct.ac.za/depts/mmi/lsteyn/glaxo.html ].

Consider Involuntary Detention
Debate about whether to forcefully detain those infected with XDR-TB has
intensified, particularly in South Africa. In January 2007, WHO issued a statement
indicating that “if a patient wilfully refuses treatment and, as a result, is a danger to
the public, the serious threat posed by XDR-TB means that limiting that individual’s
human rights may be necessary to protect the wider public.”⁵² Forcefully detaining
people carrying XDR-TB has a number of human rights implications. The low
quality of some health facilities in high-burden countries complicates arguments
about involuntary detention. A number of individuals being forcefully isolated in
South African health centers reportedly held protests and walked out of facilities,
complaining of poor treatment and prison-like conditions. One patient was
reportedly shot while attempting to leave the premises.⁵³ Several provinces in South
Africa have reportedly taken legal action to force drug resistant TB patients to stay
in hospitals in isolation units surrounded by wire fences and protected by guards.⁵⁴
The South African Medical Research Council (MRC) asserts that forcibly
quarantining individuals is a complicated issue, because MDR- and XDR-TB patients
might never be cured (MDR- and XDR-TB are difficult to cure in low-resource
settings), forcing the patients to be confined until death. MRC does not support
coerced treatment, because of “the lower success rate of [resistant forms of TB] and
the reduced life expectancy of MDR-TB patients.”⁵⁵
Some observers point out that forced isolation is also complicated by socio-
economic factors.⁵⁶ About 10 million South Africans — about 25% of the population
— receive some form of social welfare. South African policy mandates that those
who are hospitalized at the country’s expense lose their government assistance.
Many MDR-TB patients choose not to stay in hospitals, in part because they can not
earn money or receive assistance while hospitalized and MDR-TB treatment takes
between 18 and 24 months.

⁵² WHO, “WHO Guidance on Human Rights and Involuntary Detention for XDR-TB
Control.” Press Release. January, 24, 2007, at [http://www.who.int/tb/xdr/involuntary_
treatment/en/print.html], visited on January 31, 2008.
⁵³ Adele Baleta, “Forced Isolation of Tuberculosis Patients in South Africa.” The Lancet.
Volume 7, Number 12, December 2007, at [http://download.thelancet.com/pdfs/journals/

1473-3099/PIIS1473309907702815.pdf], visited on January 31, 2008.

⁵⁴ Jerome Sing et al., “XDR-TB in South Africa: No Time for Denial or Complacency.”
PLoS Medicine. Volume 4, Issue 1, January 2007, at [http://medicine.plosjournals.org/
perlserv?request=get-document&doi=10.1371/journal.pmed.0040050], visited on January

31, 2008.

⁵⁵ MRC, “Managing Multi-Drug Resistent Tuberculosis: Legal Implications.” Policy Brief.
January 2006, at [http://www.mrc.ac.za/policybriefs/managingTB.pdf], visited on January

31, 2008.

⁵⁶ Information in this paragraph was compiled by CRS from, Jerome Sing et al., “XDR-TB
in South Africa: No Time for Denial or Complacency.” PLoS Medicine. Volume 4, Issue

1, January 2007, at [http://medicine.plosjournals.org/perlserv?request=get-document&doi=

10.1371/journal.pmed.0040050], visited on January 31, 2008.

Address Poverty
Tuberculosis experts are increasingly studying the intersection of poverty and
tuberculosis. The Stop TB Partnership has recently commissioned the World Bank
to study the economic impacts of TB at the household and macro level in Africa. At
the household level, some analysts contend that people sickened by TB experience
reduced earning potential, which in impoverished areas might induce them to avoid
or discontinue treatment as soon as symptoms abate. At the macro level, observers
assert that the crowded, poorly planned, unsanitary conditions that often characterize
urban slums facilitate transmission of TB. Some 1 billion people are believed to live
in urban slums, and the figure is expected to reach 2 billion in the next 30 years. In
the world’s poorest countries, about 80% of the urban population live in slums.
Some health advocates are beginning to argue that TB control should be considered
an integral part of poverty reduction strategies.

CRS-20
Appendix. Tables and Figures
Figure 1. 22 High Burden Countries and 27 MDR-TB Priority Countries

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CRS-21
Table 1. Tuberculosis Cases in the 22 High-Burden Countries, 2006
^New^T^B^Ca^ses^{Percentage of Previous}^ly^T^B^{-Related Deaths}
^Co^unt^ry^T^rea^{ted T}^B^Ca^{ses M}^DR-T^B^N^u^m^b^er^{# p}^{er 100,000}^%^HI^V^-^Posⁱ^ti^ve^%^M^D^R^-^T^B^N^u^m^b^er^{# p}^{er 100,000}
^a¹^,933^168.0¹^.2^2.8^17.0^325.0^28.0
ⁱⁿ^a¹^,311^99.0⁰^.3^5.0^26.0^201.0^15.0
^esⁱ^a⁵³⁴^234.0⁰^.6^2.0^19.0^88.0^38.0
^t^h^A^f^ri^ca⁴⁵⁴^940.0^44.0¹^.8^6.7^105.0^218.0
^e^ri^a⁴⁵⁰^311.0⁹^.6^1.9⁹^.3^117.0^81.0
^g^l^ades^h³⁵¹^225.0⁰^.0^3.6^19.0^70.0^45.0
ⁱ^opi^a³⁰⁶^378.0⁶^.3^1.6^12.0^68.0^83.0
ⁱ^s^t^an²⁹²^181.0⁰^.3^3.4^36.0^55.0^34.0
ⁱ^{ki/CRS-RL34246}^lⁱ^ppiⁿ^e^s²⁴⁸^287.0⁰^.1^4.0^21.0^39.0^45.0
^g/w^C^oⁿ^g^o²³⁷^392.0⁹^.2^2.4⁹^.1^51.0^84.0
^s^.or^s^sⁱ^a¹⁵³^107.0³^.8^13.0^49.0^24.0^17.0
^le^akⁿ^a^m¹⁴⁹^173.0⁵^.0^2.7^19.0²⁰^23.0
^://wikiⁿ^y^a¹⁴¹^384.0^52.0⁰^.0^0.0^26.0^72.0
^h^ttp^zanⁱ^a¹²³^312.0^18.0¹^.1^0.0^26.0^66.0
^an^da¹⁰⁶^355.0^16.0⁰^.5^4.4^25.0^84.0
^l^94.0^50.0^12.0⁰^.9^5.4⁷^.6^4.0
^bi^qu^e^93.0^443.0^30.0³^.5^3.3^24.0^117.0
^ai^l^aⁿ^d^90.0^142.0^11.0¹^.7^35.0^13.0^20.0
^rm^a^83.0^171.0²^.6^4.0^16.0⁶^.1^13.0
^b^abw^e^74.0^557.0^43.0¹^.9^8.3^17.0^131.0
^bodi^a^71.0^500.0⁹^.6^0.0³^.1^13.0^92.0
^h^aⁿⁱ^s^t^an^42.0^161.0⁰^.0^3.4^37.0⁸^32.0
^W^HO,^{2008 G}^l^obal^T^uber^c^ul^osⁱ^s^C^ont^r^o^l^Repor^t^.

CRS-22
Table 2. Global Tuberculosis Cases (Regional), 2006
TB-HIV/AIDS
New TB CasesCo-infectedTB-Related Deaths
Number TB-# TB-HIV/AIDS
# per# per# perHIV/AIDS Co-infected per
Region Num b e r 100,000 Number 100,000 Number 100,000 Co-inf ected 100,000
2,807,688 363 605,989 78.0 639,089 83.0 204,559 26.0
e Americas330,7243721,2652.440,6004.53,876<1.0
569,708 105 6,538 1.2 107,895 20.0 2,737 <1.0
433,261 49 12,842 1.4 62,197 7.0 2,335 <1.0
ⁱ^{ki/CRS-RL34246} 3,100,355 180 39,556 2.3 514,699 30.0 10,805 <1.0
^g/w
^s^.or 1,915,285 109 22,823 1.3 291,240 17.0 6,545 <1.0
^le^akobal 9,157,021 139 709,013 11.0 1,655,720 25.0 230,857 4.0
^://wiki
^h^ttp^W^HO,^{2008 G}^l^obal^T^uber^c^ul^osⁱ^s^C^ont^r^o^l^Repor^t^.

Table 3. MDR-TB Cases in 27 Global Priority Countries, 2006
Percentage of All
TB Cases withNumber of MDR-TB
Count ry M DR- TB Cas e s
China8.3130,548
India4.9110,132
Russia 19.0 36,037
Paki stan 5.0 15,233
Bangladesh 4.0 14,583
South Africa2.614,034
Ukraine 22.0 13,429
Indonesia 2.2 12,142
Philippines 4.6 11,848
Nige ria 2.3 11,171
Uzbeki stan 24.0 9,829
DR Congo2.87,044
K a za khstan 25.0 6,608
Vietnam4.06,421
Ethiopia 1.9 5,825
Burma4.84,251
T a j i ki stan 20.0 3,204
Azerbaij an 29.0 2,397
Republic of Moldova27.02,035
K yrgyzstan 18.0 1,368
Belarus 16.0 1,096
Georgia12.0652
Bulgaria13.0451
Lithuania 17.0 425
Armenia14.0381
Latvia14.0218
Estonia20.0128
Global MDR-TB Priority5.6421,490
Countries
Global 4.8 489,140
^Source:^W^HO,^{2008 G}^l^obal^T^uber^c^ul^osⁱ^s^Repor^t^{, p. 51.}

Table 4. MDR-TB Cases Among All TB Cases (Regional), 2006
Percentage of allPercentage of
WHO RegionTB CasesMDR-TB Cases% MDR-TB
Established Market105,7951,3171.2
Economies
Central Europe50,5021,2012.4
Eastern Europe416,31680,05719.2
Latin America349,27812,0703.5
Eastern Mediterranean 601,22525,4754.2
Africa (low HIV375,8018,4152.2
incidence)
Africa (high HIV2,656,42258,2962.2
incidence)
Southeast Asia3,464,313149,6154.3
Western Pacific2,173,333152,6947.0
All Countries10,192,985489,1405.1
^Source:^W^HO,^An^ti-^Tu^b^e^rcu^l^o^s^{is in}^th^{e W}^o^rld^{, 2008, p. 73.}

Table 5. U.S. International Tuberculosis Spending:
FY2004-FY2009
(current U.S. $ millions)
^{Agency or}^FY²⁰⁰⁴^FY²⁰⁰⁵^FY²⁰⁰⁶^FY²⁰⁰⁷^FY²⁰⁰⁸^FY²⁰⁰⁸^FY²⁰⁰⁹
^Depa^rt^m^e^nt^Actua^l^Actua^l^Actua^l^E^s^ti^m^a^te^Request^E^s^ti^m^a^te^Request
^U^S^A^I^D^$85.1^$92.0^$91.5^$94.9^$89.9^$162.2^$97.1
^D^e^part^m^eⁿ^t^ofⁿ^/^a^$26.2^$48.4^$131.0^$0.0^$150.0^$0.0
^State
^C^D^C^$2.0^$2.3^$2.2^$1.9^$0.0^$2.0^T^BD
^Source:^A^p^p^r^o^p^r^iatioⁿ^s^legⁱ^slatioⁿ^an^dⁱⁿ^ter^v^iew^s^w^ith^A^d^mⁱⁿⁱ^str^a^tioⁿ^o^f^fⁱ^{cials. T}^h^{e State}
^D^e^part^m^eⁿ^t^report^s^t^h^atⁱⁿ^F^Y^{2004, i}^t^di^{d n}^o^t^col^l^ect^dat^a^on^T^B^/^H^IV^f^uⁿ^dⁱⁿ^gⁱⁿ^F^Y^2004.
Table 6. Global TB Financing Needs and Outcomes: 2006-2015
^Sub-^Sa^ha^ra^{n Af}^rica
^Needs
^Program⁽^t^ho^usa^nds)^E^st^im^a^t^{ed Result}^s
^DOT^{S ex}^pan^s^ion^$13,278^{16.9 m}^illion^{treated f}^o^{r T}^B
^D^O^T^S^-^Pl^u^s^$71^{29.0 t}^h^ou^s^aⁿ^d^t^r^eat^{ed f}^o^{r T}^B^{, i}ⁿ^cl^u^dⁱⁿ^g^MD^R^-^T^B
^T^B^/HI^V^/A^I^D^S^$⁴^,⁹⁴⁰²^.⁷^m^illioⁿ^tr^eated^f^o^r^HI^V/A^I^DS/A^I^D^S
^O^t^h^e^{r Prog}^ram^s^$1,111
^{Africa T}^o^tal^$19,400^{Avert 4.4 m}^{illion deaths}
^E^a^s^t^{ern E}^u^rope
^Needs
^Program⁽^t^ho^usa^nds)^E^st^im^a^t^{ed Result}^s
^DOT^{S ex}^p^aⁿ^s^ioⁿ^$⁴^,⁸⁰⁹²^.²^m^illioⁿ^tr^eated^f^o^r^T^B
^D^O^T^S^-^Pl^u^s^$3,928^{410.0 t}^h^ou^s^aⁿ^d^t^r^eat^{ed f}^o^{r T}^B^{, i}ⁿ^cl^u^dⁱⁿ^g^MD^R^-^T^B
^T^B^/^H^IV^/^A^ID^S^$186^{31.0 t}^h^ou^s^aⁿ^d^t^r^eat^{ed f}^o^{r H}^I^V^/^A^I^D^S^/^A^ID^S
^O^t^h^e^{r Prog}^ram^s^$177
^E^a^s^t^{ern E}^u^rope^$9,100^A^v^{ert 218 th}^ou^s^aⁿ^d^d^e^ath^s
^To^t^a^l
^So^ut^hea^s^t^Asia
^Needs
^Program⁽^t^ho^usa^nds)^E^st^im^a^t^{ed Result}^s
^DOT^{S ex}^p^aⁿ^s^ioⁿ^$³^,⁷⁷⁸¹⁶^.⁰^m^illioⁿ^tr^eated^f^o^r^T^B
^D^O^T^S^-^Pl^u^s^$678^{145.0 t}^h^ou^s^aⁿ^d^t^r^eat^{ed f}^o^{r T}^B^{, i}ⁿ^cl^u^dⁱⁿ^g^MD^R^-^T^B
^T^B^/^H^IV^/^A^ID^S^$1,112^{31.0 t}^h^ou^s^aⁿ^d^t^r^eat^{ed f}^o^{r H}^I^V^/^A^I^D^S^/^A^ID^S
^O^t^h^e^{r Prog}^ram^s^$631
^So^ut^hea^s^t^Asia^$6,199^Av^ert⁵^.¹^m^illio^{n dea}^t^hs
^To^t^a^l
^Source:^W^HO,^T^h^{e G}^l^obal^Pl^{an t}^o^St^{op T}^B^{2006 - 2015}^.

Table 7. Laboratory Capacity in High-Burden Countries, 2006
^L^a^{boratory Diagnos}^{tic Services}
^Sput^um^Sm^ea^r^C^ult^u^re^DST
^P^o^pula^t^ioⁿ^{# of}^{# p}^e^r^{# of}^{# p}^e^r^{# of}^{# per}
^Co^unt^ry⁽^t^ho^usa^nds)^La^bs^100,000^La^bs⁵^M^illioⁿ^La^bs¹⁰^M^illioⁿ
^In^di^a¹^,151,751^11,968^1.0⁸⁰^.03⁸^0.07
^C^hⁱⁿ^a¹^,320,864^3,010^0.2³⁶⁰^1.40⁹⁰^2.70
^In^don^esⁱ^a^228,864^4,858^2.1⁴¹^0.90¹¹^1.80
^S^o^u^t^h^A^f^ri^ca^48,282¹⁴³^0..3¹³^1.30⁸^2.70
^Nⁱ^g^e^ri^a^144,720⁶⁹⁴^0.5⁰^0.00⁰⁰^.00
^Ban^g^l^ades^h^155,991⁶⁸⁷^0.4³^0.10⁰⁰^.20
^Et^hⁱ^opi^a^81,021⁷¹³^0.9¹^0.10¹⁰^.10
^Pakⁱ^s^t^an^160,943⁹⁸²^0.6³^0.10¹⁰^.20
^Phⁱ^lⁱ^ppiⁿ^e^s^86,264^2,374^2.8³⁰^.20³^0.30
^D^R^C^oⁿ^g^o^60,644^1,069^1.8¹⁰^.10¹^0.20
^R^u^s^sⁱ^a^143,221^4,953^3.5⁹⁷⁸^34.00³⁰²^68.00
^Vⁱ^etⁿ^a^m^86,206⁸⁷⁴^1.0¹⁸^1.00²^2.10
^K^eⁿ^y^a^36,553⁷⁷⁰^2.1²⁰^.30²^0.50
^T^aⁿ^zanⁱ^a^39,459⁶⁹⁰^1.7³⁰^.40¹^0.80
^U^g^an^da^29,899⁷²⁶^2.4³⁰^.⁵⁰²^1.00
^Brazi^l^189,323^4,044^2.1¹⁹³^5.10³⁸^10.00
^Mozam^bi^qu^e^20,971²⁵⁰^1.2¹⁰^.20¹^0.50
^T^h^ai^l^aⁿ^d^63,444⁹³⁷^1.5⁶⁵^5.10¹⁸^10.00
^Bu^rm^a^48,379³⁹¹^0.8²^0.20¹⁰^.40
^Zⁱ^m^b^abw^e^13,228¹⁸⁰^1.4¹⁰^.40¹^0.80
^C^a^m^bodi^a^14,197¹⁸⁶^1.3³^1.10¹^2.10
^A^f^g^h^aⁿⁱ^s^t^an^26,088⁵⁰⁰^1.9¹⁰^.20¹^0.40
^Source:^W^HO,^{2008 G}^l^obal^T^uber^c^ul^osⁱ^s^C^ont^r^o^l^Repor^t^.

Table 8. Health Workers in High-Burden Countries and the
United States
^P^o^pula^t^io^n,^Phys^icians^Nurs^es^Pharm^a^cis^t^s
²⁰⁰⁵^Yea^r^Da^ta^{# p}^e^r^{# p}^e^r^{# p}^e^r
^Co^unt^ry^(th^ou^s^aⁿ^d^s⁾^Collected^Num^b^er^1,000^N^u^m^b^er^1,000^N^u^m^b^er^1,000
^In^di^a¹^,103,371^645,825^0.60^865,135^0.80^592,577^0.56²⁰⁰³
^C^hⁱⁿ^a¹^,315,844^1,364,000^1.06^1,358,000^1.05^359,000^0.28²⁰⁰¹
^In^don^esⁱ^a^222,781^29,499^0.13^135,705^0.62^7,580^0.03²⁰⁰³
^S^o^u^t^h^A^f^ri^ca^47,432^34,829^0.77^184,459^4.08^12,521^0.28²⁰⁰⁴
^Nⁱ^g^e^ri^a^131,530^34,923^0.28^210,306^1.70^6,344^0.05²⁰⁰⁴
^Ban^g^l^ades^h^141,822^38,485^0.26^20,334^0.14^9,411^0.06²⁰⁰⁴
^Et^hⁱ^opi^a^77,431^1,936^0.03^14,893^0.21^1,343^0.02²⁰⁰³
^Pakⁱ^s^t^an^157,935^116,298^0.74^71,764^0.46^8,102^0.05²⁰⁰⁴
^Phⁱ^lⁱ^ppiⁿ^e^s^83,054^44,287^0.58^127,595^1.69^2,482^0.03²⁰⁰⁰
^D^R^C^oⁿ^g^o^57,549^5,827^0.11^28,789^0.53^1,200^0.02²⁰⁰⁴
^R^u^s^sⁱ^a^143,202^60,9043^4.25^1,153,683^8.05^11,404^0.08²⁰⁰³
^Vⁱ^etⁿ^a^m^84,238^42,327^0.53^44,539^0.56^5,977^0.08²⁰⁰¹
^K^eⁿ^y^a^34,256^4,506^0.14^37,113^1.14^3,094^0.01²⁰⁰⁴
^T^aⁿ^zanⁱ^a^38,329⁸²²^0.02^13,292^0.37³⁶⁵^0.01²⁰⁰²
^U^g^an^da^28,816^2,209^0.08^16,221^0.61⁶⁸⁸^0.03²⁰⁰⁴
^Brazi^l^186,405^198,153^1.15^659,111^3.84^51,317^0.30²⁰⁰⁰
^Mozam^bi^qu^e^19,792⁵¹⁴^0.03^3,954^0.21⁶¹⁸^0.03²⁰⁰⁴
^T^h^ai^l^aⁿ^d^64,233^22,435^0.37^171,605^2.82^15,480^0.25²⁰⁰⁰
^Bu^rm^a^50,519^17,791^0.36^19,254^0.38¹²⁷^0.00²⁰⁰⁴
^Zⁱ^m^b^abw^e^13,010^2,086^0.16^9,357^0.72⁸⁸³^0.07²⁰⁰⁴
^C^a^m^bodi^a^14,071^2,047^0.16^8,085^0.61⁵⁶⁴^0.04²⁰⁰⁰
^A^f^g^h^aⁿⁱ^s^t^an^29,863^4,104^0.19^4,752^0.22⁵²⁵^0.02²⁰⁰¹
^Un^ited
^S^t^at^es^295,410^730,801^2.56^2,669,603^9.37^249,642^0.88²⁰⁰⁰
^Source:^W^HO,^{2006 W}^o^r^l^{d H}^e^al^t^h^Repor^t^.