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WHO Global Tuberculosis Report 2020

WHO Global Tuberculosis Report 2020
Publication date: 
Oct 2020

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Executive summary

Background

Tuberculosis (TB) is a communicable disease that is a major cause of ill health, one of the top 10 causes of death worldwide and the leading cause of death from a single infectious agent (ranking above HIV/AIDS). TB is caused by the bacillus Mycobacterium tuberculosis, which is spread when people who are sick with TB expel bacteria into the air; for example, by coughing. The disease typically affects the lungs (pulmonary TB) but can also affect other sites (extra-pulmonary TB). About a quarter of the world’s population is infected with M. tuberculosis.1

TB can affect anyone anywhere, but most people who develop the disease are adults, there are more cases among men than women, and 30 high TB burden countries account for almost 90% of those who fall sick with TB each year. TB is a disease of poverty, and economic distress, vulnerability, marginalization, stigma and discrimination are often faced by people affected by TB.

TB is curable and preventable. About 85% of people who develop TB disease can be successfully treated with a 6-month drug regimen; treatment has the additional benefit of curtailing onward transmission of infection. Since 2000, TB treatment has averted more than 60 million deaths, although with access still falling short of universal health coverage (UHC), many millions have also missed out on diagnosis and care. Preventive treatment is available for people with TB infection. The number of people developing infection and disease (and thus the number of deaths) can also be reduced through multisectoral action to address TB determinants such as poverty, under-nutrition, HIV infection, smoking and diabetes.

Research breakthroughs (e.g. a new vaccine) are needed to rapidly reduce TB incidence worldwide to the levels already achieved in low-burden countries, where TB is often regarded as a disease of the past.

This report

The World Health Organization (WHO) has published a global TB report every year since 1997. The purpose of the report is to provide a comprehensive and up-to-date assessment of the status of the TB epidemic, and of progress in the response to the epidemic – at global, regional and country levels – in the context of global commitments and strategies. The report is based primarily on data gathered by WHO in annual rounds of data collection. In 2020, data were reported by 198 countries and territories that accounted for more than 99% of the world’s population and estimated number of TB cases.2
 
The 2020 edition complements and expands on the United Nations (UN) Secretary-General’s 2020 progress report on TB, which was prepared with WHO support as requested in the political declaration of the UN high-level meeting on TB in 2018.3

In recognition of the enormous health, social and economic impacts of the COVID-19 pandemic, the report includes a provisional assessment of how the pandemic will affect the TB epidemic, people with TB and progress towards global TB targets.

Global commitments and strategy to end TB

In 2014 and 2015, all Member States of WHO and the UN committed to ending the TB epidemic, through their adoption of WHO’s End TB Strategy and the UN Sustain- able Development Goals (SDGs). The strategy and SDGs include milestones and targets for large reductions in TB incidence, TB deaths and costs faced by TB patients and their households (Table E.1).

Efforts to step up political commitment to the fight against TB intensified in 2017 and 2018.

A WHO global ministerial conference on TB was organized in November 2017. The outcome was the Moscow Declaration to End TB, which was welcomed by all Member States at the World Health Assembly in May 2018. In September 2018, the UN General Assembly held its first-ever high-level meeting on TB, attended by heads of state and government as well as other leaders. The outcome was a political declaration in which commitments to the SDGs and End TB Strategy were reaffirmed and new ones added. Global targets for the funding to be mobilized for TB prevention, care and research, and for the number of people to be treated for TB infection and disease, were set for the first time (Table E.1).4

Status of the TB epidemic

Globally, an estimated 10.0 million (range, 8.9–11.0 million)5 people fell ill with TB in 2019, a number that has been declining very slowly in recent years. There were an estimated 1.2 million (range, 1.1–1.3 million) TB deaths among HIV-negative people in 2019 (a reduction from 1.7 million in 2000), and an additional 208 000 deaths (range, 177 000–242 000)6 among HIV-positive people (a reduction from 678 000 in 2000).

Men (aged ≥15 years) accounted for 56% of the people who developed TB in 2019; women accounted for 32% and children (aged <15 years) for 12%. Among all those affected, 8.2% were people living with HIV.

TABLE E.1 Global TB targets set in the SDGs, the End TB Strategy and the political declaration of the UN high-level meeting on TB, for the period up to the SDG deadline of 2030

SDG Target 3.3

By 2030, end the epidemics of AIDS, TB, malaria and neglected tropical diseases, and combat hepatitis, water-borne diseases and other communicable diseases

WHO End TB

Strategy

80% reduction in the TB incidence rate (new and relapse cases per 100 000 population per year) by 2030, compared with 2015

2020 milestone: 20% reduction; 2025 milestone: 50% reduction

90% reduction in the annual number of TB deaths by 2030, compared with 2015

2020 milestone: 35% reduction; 2025 milestone: 75% reduction

No households affected by TB face catastrophic costs by 2020

UN high-level meeting on TB, 2018

40 million people treated for TB from 2018 to 2022, including:

  • 3.5 million children
  • 1.5 million people with drug-resistant TB, including 115 000 children

At least 30 million people provided with TB preventive treatment from 2018 to 2022, including:

  • 6 million people living with HIV
  • 4 million children under 5 years of age and 20 million people in other age groups, who are household contacts of people affected by TB

Funding of at least US$ 13 billion per year for universal access to TB prevention, diagnosis, treatment and care by 2022

Funding of at least US$ 2 billion per year for TB research from 2018 to 2022

AIDS: acquired immunodeficiency syndrome; HIV: human immunodeficiency virus; SDG: Sustainable Development Goal; TB: tuberculosis; UN: United Nations.

Geographically, most people who developed TB in 2019 were in the WHO regions of South-East Asia (44%), Africa (25%) and the Western Pacific (18%), with smaller percentages in the Eastern Mediterranean (8.2%), the Americas (2.9%) and Europe (2.5%). Eight countries accounted for two thirds of the global total: India (26%), Indonesia (8.5%), China (8.4%), the Philippines (6.0%), Pakistan (5.7%), Nigeria (4.4%), Bangladesh (3.6%) and South Africa (3.6%). The other 22 other countries in WHO’s list of 30 high TB burden countries accounted for 21% of the global total.7

The TB incidence rate at national level varies from less than 5 to more than 500 new and relapse cases per 100 000 population per year. In 2019, 54 countries had a low incidence of TB (<10 cases per 100 000 population per year), mostly in the WHO Region of the Americas and European Region, plus a few countries in the Eastern Mediterranean and Western Pacific regions. These countries are well placed to target TB elimination.

Drug-resistant TB continues to be a public health threat. Worldwide in 2019, close to half a million people developed rifampicin resistant TB (RR-TB),8 of which 78% had multidrug-resistant TB (MDR-TB).9 The three countries with the largest share of the global burden were India (27%), China (14%) and the Russian Federation (8%). Globally in 2019, 3.3% of new TB cases and 17.7% of previously treated cases had MDR/RR-TB. The high- est proportions (>50% in previously treated cases) were in countries of the former Soviet Union.

Progress towards the 2020 milestones of the End TB Strategy

Progress is lagging behind what is needed to reach the global targets set at the UN high-level meeting on TB (Fig. E.1b and Fig. E.1c):

  • 14.1 million people were treated for TB in 2018 and 2019, 35% of the 5-year (2018–2022) target of 40 million.
  • 6.3 million people were started on TB preventive treatment in 2018 and 2019, 21% of the 5-year target of 30 million.
  • Funding for TB prevention, diagnosis, treatment and care was US$ 6.5 billion in 2020, 50% of the target of at least US$ 13 billion per year by 2022.
  • Funding for TB research was US$ 906 million in 2018, less than half of the target of US$ 2 billion per year 2018–2022.14

Progress towards the subtargets for TB treatment in 2018 and 2019 was slower than progress overall:

  • 1.04 million children were treated for TB, 30% of the 5-year target of 3.5 million.
  • 333 304 people were treated for MDR/RR-TB, 22% the 5-year target of 1.5 million.
  • 8986 children were treated for MDR/RR-TB, 8% of the 5-year target of 115 000.

For TB preventive treatment, the subtarget for peo- ple living with HIV is on track to be achieved ahead of schedule in 2020, while progress towards the subtargets for household contacts of people with TB falls far short of what is needed. In 2018 and 2019, the numbers provided with TB preventive treatment were:

  • 5.3 million people living with HIV, 88% of the 5-year target of 6.0 million.
  • 782 952 children aged under 5 years who were house- hold contacts of people with TB, 20% of the 5-year tar- get of 4 million.
  • 179 051 people in older age groups who were household contacts of people with TB, <1% of the 5-year target of 20 million.

The COVID-19 pandemic and TB – impact and implications

The COVID-19 pandemic threatens to reverse recent progress in reducing the global burden of TB disease.

The global number of TB deaths could increase by around 0.2–0.4 million in 2020 alone, if health services are disrupted to the extent that the number of people with TB who are detected and treated falls by 25–50% over a period of 3 months (Fig. E.2). In India, Indonesia, the Philippines and South Africa, four countries that account for 44% of global TB cases, there were large drops in the reported number of people diagnosed with TB between January and June 2020 (Fig. E.3). Compared with the same 6-month period in 2019, overall reductions in India, Indonesia and the Philippines were in the range 25–30%. The economic impact of the pandemic is predicted to worsen at least two of the key determinants of TB incidence: GDP per capita and under-nutrition (Fig E.4). Modelling has suggested that the number of people developing TB could increase by more than 1 million per year in the period 2020–2025. The impact on livelihoods resulting from lost income or unemployment could also increase the percentage of people with TB and their households facing catastrophic costs.

In line with WHO guidance, actions that countries have reported taking to mitigate impacts on essential TB services include expanded use of digital technologies for remote advice and support (108 countries including 21 high TB burden countries) and reducing the need for visits to health facilities by giving preference to home-based treatment and providing TB patients with a one-month supply of drugs (100 countries including 25 high TB burden countries).

Negative impacts on essential TB services include the reallocation of human, financial and other resources from TB to the COVID-19 response. Many countries have reported the use of GeneXpert machines for COVID-19 testing instead of diagnostic testing for TB (43 countries including 13 high TB burden countries), reassignment of staff in national TB programmes to COVID-19 related duties (85 countries including 20 high TB burden countries), and reallocation of budgets (52 countries including 14 high TB burden countries). Smaller but still considerable numbers of countries reported reducing the number of health facilities providing inpatient and outpatient care for people with TB (35 and 32 countries, respectively). In many countries, data collection and reporting have also been affected.

TB diagnosis and treatment

Globally, 7.1 million people with TB were reported to have been newly diagnosed and notified in 2019, up from 7.0 million in 2018 and a large increase from 6.4 million in 2017 and 5.7–5.8 million annually in the period 2009–2012. Many countries have increased the number of people newly diagnosed with TB since 2013. The biggest contributors to the global increase were India and Indonesia, the two countries that rank first and second worldwide in terms of estimated incident cases per year.15 In India, notifications of people newly diagnosed with TB rose from 1.2 million to 2.2 million between 2013 and 2019 (+74%). In Indonesia, the number rose from 331 703 in 2015 to 562 049 in 2019 (+69%).

Despite increases in TB notifications, there was still a large gap (2.9 million) between the number of people newly diagnosed and reported and the 10 million people estimated to have developed TB in 2019. This gap is due to a combination of underreporting of people diagnosed with TB and under-diagnosis (if people with TB cannot access health care or are not diagnosed when they do).

Five countries accounted for more than half of the global gap: India (17%), Nigeria (11%), Indonesia (10%), Pakistan (8%) and the Philippines (7%). In these countries especially, intensified efforts are required to reduce underreporting and improve access to diagnosis and treatment. As countries intensify efforts to improve TB diagnosis and treatment and close gaps between incidence and notifications, the proportion of notified cases that are bacteriologically confirmed needs to be monitored, to ensure that people are correctly diagnosed and started on the most effective treatment regimen as early as possible. The aim should be to increase bacteriological confirmation by scaling up the use of WHO-recommended diagnostics (e.g. rapid molecular tests) as the initial diagnostic test for TB. In 2019, 57% of pulmonary cases were bacteriologically confirmed, a slight increase from 55% in 2018. In high-income countries with widespread access to the most sensitive diagnostic tests, about 80% of pulmonary TB cases are bacteriologically confirmed.

The percentage of notified TB patients who had a documented HIV test result in 2019 was 69%, up from 64% in 2018. In the WHO African Region, where the burden of HIV-associated TB is highest, 86% of TB patients had a documented HIV test result. A total of 456 426 people with TB co-infected with HIV were reported, of whom 88% were on anti-retroviral therapy.

The treatment success rate for people newly enrolled on treatment in 2018 was 85%.

Drug-resistant TB: diagnosis and treatment

In accordance with WHO guidelines, detection of MDR/ RR-TB requires bacteriological confirmation of TB and testing for drug resistance using rapid molecular tests, culture methods or sequencing technologies. Treatment requires a course of second-line drugs for at least 9 months and up to 20 months, supported by counselling and monitoring for adverse events. WHO recommends expanded access to all-oral regimens.

There was some progress in testing, detection and treatment of MDR/RR-TB between 2018 and 2019. Globally in 2019, 61% of people with bacteriologically confirmed TB were tested for rifampicin resistance, up from 51% in 2017 and 7% in 2012.16 Coverage of testing was 59% for new and 81% for previously treated TB patients. A global total of 206 030 people with MDR/RR-TB were detected and notified in 2019, a 10% increase from 186 883 in 2018, and 177 099 people were enrolled in treatment, up from 156 205 in 2018.

Despite these improvements, the number of people enrolled in treatment in 2019 was equivalent to only 38% of the estimated number of people who developed MDR/ RR-TB in 2019. Closing this wide gap requires one or more of the following: improving detection of TB; increasing bacteriological confirmation among those diagnosed with TB; expanding the coverage of testing for drug resistance among those with bacteriologically confirmed TB; and ensuring that all those diagnosed with MDR/RR-TB are enrolled in treatment.

Ten countries accounted for 77% of the global gap between treatment enrolments and the estimated number of new cases of MDR/RR-TB in 2019, and thus will have a strong influence on progress in closing this gap. China and India accounted for 41% of the global gap.17

The latest treatment outcome data for people with MDR/RR-TB show a global treatment success rate of 57%. Three examples of high MDR-TB burden countries with relatively high TB treatment coverage that have higher treatment success rates for MDR/RR-TB (≥75%) are Ethiopia, Kazakhstan and Myanmar.

TB prevention services

The main health care intervention available to reduce the risk of TB infection progressing to active TB disease is TB preventive treatment.18 Other interventions are TB infection prevention and control; and vaccination of children with the bacille Calmette–Guérin (BCG) vaccine, which can confer protection, especially from severe forms of TB in children.

WHO guidance recommends TB preventive treatment for people living with HIV, household contacts of bacteriologically confirmed pulmonary TB cases and clinical risk groups (e.g. those receiving dialysis). Globally in 2019, TB preventive treatment was provided to 4.1 million people, up from 2.2 million in 2018.

People living with HIV accounted for 85% (3.5 million) of the 2019 total. Of the 3.5 million, three countries – India, the United Republic of Tanzania and South Africa – accounted for 25%, 17% and 14%, respectively.

Numbers of household contacts provided with TB preventive treatment were much smaller: 423 607 in 2018 and 538 396 in 2019. Of these, 81% were children under 5 years (349 796 in 2018 and 433 156 in 2019, equivalent to 27% and 33% of the 1.3 million estimated to be eligible) and 19% were people in older age groups (73 811 in 2018 and 105 240 in 2019). Substantial scale-up will be needed to reach the targets set at the UN high-level meeting on TB. Building synergies with contact tracing efforts related to the COVID-19 pandemic may help.

The COVID-19 pandemic has also highlighted the importance of infection prevention and control in health care facilities and congregate settings, for both health care workers and people seeking care.

In 2019, 153 countries reported providing BCG vaccination as a standard part of childhood immunization programmes, of which 87 reported coverage of ≥90%.

Financing for TB prevention, diagnosis and treatment

Funding for the provision of TB prevention, diagnostic and treatment services has doubled since 2006 but still falls far short of what is needed (Fig. E.1c).

In 121 low- and middle-income countries that reported data (and accounted for 98% of reported TB cases globally), funding is projected to reach US$ 6.5 billion in 2020. This is higher than estimated expenditures of US$ 6.0–6.1 bil- lion annually in these countries between 2017 and 2019, but still only 50% of the global target of at least US$ 13 billion annually by 2022. Moreover, the final amount may be lower due to reallocation of funding for the COVID-19 response. As in previous years, most of the funding (85%) available in 2020 is from domestic sources. This aggregate figure is strongly influenced by the BRICS group of countries (Brazil, Russian Federation, India, China and South Africa). The BRICS countries account for 57% of the available funding in 2020, and 97% of their funding is from domestic sources.

In other low- and middle-income countries, international donor funding remains crucial, accounting for 44% of the funding available in the 25 high TB burden countries outside BRICS and 57% of the funding available in low-income countries.

International donor funding, as reported by nation- al TB programmes (NTPs), increased from US$ 0.9 bil- lion in 2019 to US$ 1.0 billion in 2020. The single largest source (77% of the total in 2020) is the Global Fund to Fight AIDS, Tuberculosis and Malaria (the Global Fund). The largest bilateral donor is the US government, which provides almost 50% of total international donor funding for TB, when combined with funds channelled through and allocated by the Global Fund.

Universal health coverage, multisectoral action and social determinants

The End TB Strategy milestones for 2020 and 2025 can only be achieved if TB diagnosis, treatment and prevention services are provided within the context of progress towards UHC, and if there is multisectoral action and accountability to address the broader determinants that influence TB epidemics and their socioeconomic impact. UHC means that everyone can obtain the health services they need without suffering financial hardship. SDG Target 3.8 is to achieve UHC by 2030; the two indicators to monitor progress are a UHC service coverage index (SCI), and the percentage of the population experiencing household expenditures on health care that are large in relation to household expenditures or income.

The global SCI increased steadily between 2000 and 2017, from 45 (out of 100) in 2000 to 66 in 2017. Improvements were made in all WHO regions and all World Bank income groups. However, values of the SCI in 2017 in the 30 high TB burden countries were mostly in the range of 40–60.

In 2015, at least 930 million people, or 12.7% of the world’s population, faced out-of-pocket expenditures on health care that accounted for 10% or more of their household expenditure or income (a threshold used within the SDG framework to define direct expenditures on health in the general population as catastrophic), up from 9.4% in 2010.

Among high TB burden countries, Thailand stands out as having a high SCI of 80 and a low level of catastrophic health expenditures (2% of households). Brazil and China both had a relatively high SCI of 79.

Many new cases of TB are attributable to five risk factors: under nutrition, HIV infection, alcohol use disorders, smoking (especially among men) and diabetes. In 2019, the estimated numbers of cases attributable to these risk factors were 2.2 million, 0.76 million, 0.72 million, 0.70 million and 0.35 million, respectively. In the context of the COVID-19 pandemic, multisectoral action to address these and other determinants of TB and its consequences, including GDP per capita, poverty and social protection, is more important than ever (Fig. E.4).

Following the request to the WHO Director-General at the UN high-level meeting, a multisectoral accountability framework for TB (MAF-TB) was released by WHO in May 2019. The framework has four major components: commitments; actions; monitoring and reporting; and review. These apply at the global/regional level, and at national (including subnational) level.

At global level, actions taken by WHO include: the development of a MAF-TB checklist; high-level missions; the WHO Director-General Initiative Find.Treat.All#EndTB; engagement of civil society (e.g. the WHO Civil Society Task Force on TB) and youth; updating of guidelines and tools; and development and release of a global strategy for TB research and innovation. Global monitoring, reporting and review has been ensured through annual rounds of data collection, the WHO global TB report, TB reports to the World Health Assembly and the UN Secretary-General 2020 progress report on TB.

Countries have started to adapt and use the MAF-TB. In terms of actions in 2020, 25/30 high TB burden countries reported that they had developed or updated a national strategic plan for TB since the UN high-level meeting on TB, with countries reporting the involvement of civil society and affected communities in 29/30. Most high TB burden countries (27/30) reported that they produce an annual TB report. High-level review mechanisms were stated to be in place in 16/30 countries. More detailed assessments of the status of accountability using the checklist developed by WHO are underway.

TB research and innovation

The SDG and End TB Strategy targets set for 2030 cannot be met without intensified research and innovation. Technological breakthroughs are needed by 2025, so that the annual decline in the global TB incidence rate can be accelerated to an average of 17% per year. Priorities include a vaccine to lower the risk of infection, a vaccine or new drug treatment to cut the risk of TB disease in the approximately 2 billion people already infected, rapid diagnostics for use at the point of care, and simpler, shorter treatments for TB disease.

The diagnostic pipeline appears robust in terms of the number of tests, products or methods in development. Examples include several cartridge-based technologies for the detection of drug resistance; next-generation sequencing (NGS) assays for detecting drug-resistant TB directly from sputum specimens; and newer skin tests and interferon gamma release assays (IGRA) to test for TB infection.

As of August 2020, there were 22 drugs, various combination regimens and 14 vaccine candidates in clinical trials.

Final results from a Phase IIb trial of the M72/AS01E vaccine candidate showed a 50% (90% CI: 12–71%) point estimate for vaccine efficacy for people with TB infection after 3 years of follow-up. If the findings are confirmed in a Phase III trial, this vaccine could transform global TB prevention efforts. In 2020, the Gates Medical Research Institute obtained a license to develop M72/AS01E for use in low-income countries.

A Global Strategy for TB Research and Innovation was adopted by all WHO Member States through a World Health Assembly resolution in August 2020. The strategy aims to support countries and relevant stakeholders to translate commitments in the Moscow Declaration and the political declaration of the UN high-level meeting on TB into concrete actions. WHO has also developed a TB/ COVID-19 research compendium and launched a toolkit to support expanded use of digital technologies in TB care.

Summary of tuberculosis deaths per high burden country (2019)*

  Population in millions (M) Total TB Incidence HIV+ TB Incidence TB Mortality (HIV+ and HIV-)
Angola   31.8 M 112 000 8 500 43 000
Bangladesh   163 M 361 000 700 39 500
Brazil   211 M 96 000 11 000 22 900
Cambodia   16.5 M 47 000 1 300 7 000
Central African Rep.    4.75 M 26 000 6 500 33 600
China   1 430 M 833 000 14 000 53 000
Congo   5.38 M 20 000 5 800 24 800
DPR Korea   25.7 M 132 000    
DR Congo   86.8 M 278 000 30 000 139 000
Ethiopia   112 M 157 000 10 000 49 000
India   1 370 M 2 640 000 71 000 531 000
Indonesia   271 M 845 000 19 000 139 000
Kenya   52.6 M 140 000 37 000 150 000
Lesotho   2.13 M 14 000 8 600 37 200
Liberia   4.94 M 15 000 2 200 11 400
Mozambique   30.4 M 110 000 37 000 61 800
Myanmar   54 M 174 000 14 000 50 000
Namibia   2.49 M 12 000 3 900 14 400
Nigeria   201 M 440 000 46 000 397 000
Pakistan   217 M 570 000 5 100 61 000
Papua New Guinea   8.78 M 38 000 1 500 7 200
Philippines   108 M 599 000 11 000 35 100
Russian Federation  146 M 73 000 17 000 21 400
Sierra Leone  7.81 M 23 000 3 000 9 200
South Africa   58.6 M 360 000 209 000 382 000
Thailand  69.6 M 105 000 10 000 28 600
UR Tanzania  58 M 137 000 33 000 140 000
Vietnam  96.5 M 170 000 5 500 29 400
Zambia  17.9 M 59 000 28 000 100 900
Zimbabwe  14.6 M 29 000 17 000 47 700

*Adapted from TABLE 4.3 Estimated epidemiological burden of TB in 2019 for 30 high TB burden countries, WHO regions and globally, page 32

Conclusion

Leaders of all UN Member States have committed to “ending the global TB epidemic” by 2030, backed up by concrete milestones and targets.

Progress is being made. At the end of 2019, global indicators for reductions in TB disease burden, improved access to TB prevention and care and increased financing were all moving in the right direction. The WHO European Region and several high TB burden countries are on track to reach 2020 milestones for reductions in TB cases and deaths. However, agreed milestones and targets are not on track to be met globally and the COVID-19 pandemic now threatens to stall or reverse the progress that has been achieved. The UN Secretary-General’s 2020 progress report on TB urges countries to implement 10 priority recommendations needed to reach targets and reduce the enormous human and societal toll caused by TB (Fig. E.5). The overarching message of this report and that of the UN Secretary-General’s 2020 progress report on TB is the same. High-level commitments have galvanized global, regional and national progress towards ending TB, but urgent and more ambitious investments and actions are required to put the world on track to reach targets, especially in the context of the COVID-19 pandemic.


1 For these people, the lifetime risk of developing TB disease is about 5–10%.

2 WHO’s annual rounds of global TB data collection and the annual WHO Global TB Report are key elements of “monitoring and reporting” in the WHO multisectoral accountability framework for TB.

3 The UN Secretary General’s report was released in October 2020.

4 The treatment targets were built on the WHO Flagship Initiative “Find. Treat. All. #EndTB” and the funding targets were based on the Stop TB Partnership’s Global Plan to End TB, 2018–2022.

5 Here and elsewhere, “range” in the context of estimates of TB disease burden refers to the 95% uncertainty interval.

6 When an HIV-positive person dies from TB disease, the under- lying cause is coded as HIV in the International Classification of Diseases system.

7 The other 22 countries are Angola, Brazil, Cambodia, Central African Republic, the Congo, the Democratic People’s Republic of Korea, the Democratic Republic of the Congo, Ethiopia, Ken- ya, Lesotho, Liberia, Mozambique, Myanmar, Namibia, Papua New Guinea, the Russian Federation, Sierra Leone, Thailand, the United Republic of Tanzania, Viet Nam, Zambia and Zimbabwe.

8 The 95% uncertainty interval is 400 000–535 000.

9 MDR-TB is defined as resistance to rifampicin and isoniazid.

10 Reductions in other WHO regions were 3.5% in the Eastern Mediterranean Region, 8.7% in the South-East Asia Region and 6.1% in the Western Pacific Region. In the WHO Region of the Amer- icas, incidence is slowly increasing, owing to an upward trend in Brazil.

11 Including TB deaths among both HIV-negative and HIV-positive people.

12 Reductions in other WHO regions were 6.1% in the Americas, 11% in the Eastern Mediterranean, 10% in South-East Asia and 17% in the Western Pacific.

13 Calculated as the sum of direct medical expenditures, non-medical expenditures and income losses.

14 Funding for TB research is monitored by Treatment Action Group; the latest data are from their 2019 report.

15 Other countries with large relative increases in 2017–2019 are shown in Fig. 5.2.

16 The numbers cited refer to pulmonary cases.

17 The other 8 countries were the Democratic Republic of the Con- go, Indonesia, Myanmar, Nigeria, Pakistan, the Philippines, the Russian Federation and Viet Nam.

18 The drug regimens currently recommended by WHO are explained in Chapter 6.