Global Tuberculosis Report 2019
Global Tuberculosis Report 2019
Global Tuberculosis Report 2019
consultation convened by Global TB Programme, World Health Organization, Chateau de Penthes, Geneva, 1– 2 March
2018. Geneva: World Health Organization; 2018 (https://www.who.int/tb/
TBAccountabilityFramework_Consultation1_2March_BackgroundDocument_20180228.pdf?ua=1, accessed 28 June 2019).
Developinraultisectoraccountabilitrameworkeetineporttakeholdeonsultation
convened by Global TB Programme, World Health Organization, Chateau de Penthes, Geneva, 1– 2 March
2018. Geneva: World Health Organization; 2018 (https://www.who.int/tb/TB_MAF_1_2Marchconsultation_
meetingreport_20180322.pdf?ua=1ccesseun019).
Multisectoral accountability framework to accelerate progress to end tuberculosis by 2030. Geneva: World Health
Organization; 2019 (https://www.who.int/tb/WHO_Multisectoral_Framework_web.pdf?ua=1, accessed 2un019).
World Health Organization Strategic and Technical Advisory Group for TB. Use of high burden country lists for THhost-
201rdiscussioaper)enevaorlealtrganization015
(https://www.who.int/tb/publications/global_report/high_tb_burdencountrylists2016-2020.pdf, accessed 28 June 2019).
Transition from having no quality-approved surveillance data to For 20 countries (shown in Fig. 3.13), estimates of TB mortality
having quality-approved surveillance data for anti-TB drug among HIV-negative people were based on estimates published
resistance in 2017–2019: Greenland, Guyana, Kiribati, by IHME (11). These estimates use data from national and
Micronesia (Federated States of), Saint Kitts and Nevis, Tonga, sample VR systems and from verbal autopsy surveys. Estimates
Trinidad and Tobago, Tuvalu. of TB mortality in South Africa are adjusted by IHME for
miscoding of deaths caused by HIV and TB. IHME estimates
Transition from relying on survey data to approved quality-
used in this report were slightly adjusted from those published by
approved surveillance data for anti-TB drug resistance in 2017–
IHME, to fit WHO estimates of the total number of deaths (i.e. the
2019: Armenia, Azerbaijan, Costa Rica, Egypt, Ethiopia, Ghana,
total mortality envelope). The median country-year envelope ratio
Mongolia, Myanmar, Namibia, Rwanda, Uganda, Uzbekistan,
(WHO/IHME) was 1.04 (interquartile range: 0.96–1.11) among
Viet Nam, Zambia, Zimbabwe.
380 data points.
The estimated incidence of RR-TB in 2018 is based on the
following formula: 3. Findings from national TB epidemiological reviews
Small adjustments to incidence trajectories were made in
Irr = I[(1– f )pn((1 – r) + rρ) + fpr]
various countries based on findings from recent national TB
where I is overall TB incidence, Irr is the incidence of rifampicin epidemiological reviews.
resistance, f is the cumulative risk for incident cases to receive
non-relapse retreatment (following treatment failure or return 4. Inventory studies
after default), r is the proportion of relapses, ρ is the relative Results from an inventory study to assess underreporting of
risk ratio in relapses compared with first episodes of detected TB cases in China allowed updating of incidence
TB, and pn and pr denote the proportion of rifampicin-resistant estimates. The change in estimated incidence was relatively
cases among previously untreated and previously treated small compared with previously published estimates.
patients, respectively.
5. Estimates of the burden of TB in children
Improvements in the estimation of ρ were implemented in March
Methods used to derive age-specific incidence were revised to
2019 and reflected in the publication of updated estimates
address previous inconsistencies in the estimated gap between
online. The main consequence was lower estimates of the
incidence and notifications. A fundamental difficulty with
incidence of MDR/RR-TB in countries in which there is a
estimating childhood TB disease burden is the lack of quality
relatively small difference between the prevalence of rifampicin
data based on consistent and strict case definitions, particularly
resistance in new cases and the prevalence of rifampicin
in high TB burden countries. Cases are often notified based on
resistance in previously treated cases. In turn, these country
inconsistent criteria for childhood TB disease, leading to
updates had an impact on the global estimate, and explain why
instances of overreporting, whereas other cases may be
the global estimate in this report has been revised downwards
diagnosed in paediatric hospitals
(by about 10%) compared with that published in the 2018 global
and not reported to public health authorities, leading to
TB report (2).Estimates in this report are consistent with the
underreporting. The scarcity of nationwide population-based
updated estimates that were incorporated in online datasets in
survey data results in great uncertainty in incidence stratified by
March 2019 (http://www. who.int/tb/data).
age group (reflected in large uncertainty bounds), limiting their
usefulness for activities related to programme planning and
evaluation. Greater priority should be given to the quality
Sources of data available to inform estimates of TB disease burden in the 30 high TB burden
countries, 2000–2018. Green indicates that a source is available, orange indicates it will be available in the
near future, and red indicates that a source is not available.
STANDARDS AND NATIONAL NATIONAL TB NATIONAL DRUG
NOTIFICATION NATIONAL VR DATA OR
COUNTRY BENCHMARKS INVENTORY PREVALENCE RESISTANCE e
DATA a b c d MORTALITY SURVEY
ASSESSMENT STUDY SURVEY SURVEY
Angola 2000–2018 2016 – – – –
Bangladesh 2000–2018 2014 – 2015 2011, 2019 –
Brazil 2000–2018 2018 – NA 2008 2000–2016
Cambodia 2000–2018 2018 – 2002, 2011 2007, 2018 –
Central African Republic 2000–2018 – – – 2009 –
China 2000–2018 – 2018 2000, 2010 2007, 2013 2004–2018
Congo 2000–2018 2019 – – – –
DPR Korea 2000–2018 2017 – 2016 2014 –
DR Congo 2000–2018 2017 – – 2017 –
Ethiopia 2000–2018 2013, 2016 – 2011 2005 –
India 2000–2018 – 2011 – 2016 2000–2014
Indonesia 2000–2018 2013, 2017 2017 2013–2014 2018 2006–2007, 2009–2015
Kenya 2000–2018 2013, 2017 2013 2015 2014 –
Lesotho 2000–2018 2014, 2017 – – 2014 –
Liberia 2000–2018 2015, 2019 – – – –
Mozambique 2000–2018 2013 – – 2007 –
Myanmar 2000–2018 2014, 2017 – 2009, 2018 2008, 2013 –
Namibia 2000–2018 2016 – 2017–2018 2008, 2015 –
Nigeria 2000–2018 2013, 2017 – 2012 2010 –
Pakistan 2000–2018 2016, 2019 2012, 2016 2011 2013 2006, 2007, 2010
Papua New Guinea 2000–2018 2017 – – 2014 –
Philippines 2000–2018 2013, 2016 – 2007, 2016 2012, 2019 2000–2011
Russian Federation 2000–2018 2017 – NA 2016–2018 2000–2018
Sierra Leone 2000–2018 2015 – – – –
South Africa 2000–2018 2015 – – 2014 2000–2017
Thailand 2000–2018 2013 – 2012 2012, 2018 2000–2016
UR Tanzania 2000–2018 2013, 2018 – 2012 2018 –
Viet Nam 2000–2018 2013, 2019 2017 2007, 2017 2006, 2012 –
Zambia 2000–2018 2014, 2016 – 2014 2000, 2008 –
Zimbabwe 2000–2018 2016, 2019 – 2014 2016 –
The WHO TB surveillance checklist of standards and benchmarks is designed to assess the quality and coverage of notification data (based on 9 core standards) and VR data (1
standard). An assessment is scheduled in Central African Republic in 2019 and a partial assessment has been done in China. If more than two assessments have been done
(Pakistan and Zimbabwe), the years of the last two only are shown.
Studies in Philippines, South Africa and United Republic of Tanzania are being implemented in 2019.
Lesotho, Mozambique and South Africa will complete surveys in 2019 and India is scheduled to implement a survey 2019–2020. Brazil and Russian Federation do not meet
the criteria recommended by the WHO Global Task Force on TB Impact Measurement for implementing a national TB prevalence survey. The burden of TB disease is too low
(making sample sizes prohibitive) and both countries have strong notification and VR systems.
The surveys in Brazil, Central African Republic, Democratic People’s Republic of Korea and Papua New Guinea were subnational. Data for Russian Federation are from routine
diagnostic testing of cases (as opposed to a national survey). In addition to national survey data, six countries (Ethiopia, Myanmar, Namibia, Viet Nam, Zambia and Zimbabwe)
reported surveillance data from routine diagnostic testing for the first time in 2018. If more than two surveys have been done (Cambodia, Thailand, Philippines), the years of the
last two only are shown. A survey in Angola is scheduled for 2020.
Years of data availability for India, Indonesia, Pakistan and South Africa were provided to WHO by IHME.
28 of the 60 assessments completed since 2016 were repeat assessments, including 12 in high TB burden countries (details in Table 3.2).
(b) National inventory studies of the underreporting of detected TB cases implemented 2000–2019 or planned
Main method
Case notifications,
expert opinion
Case notifications,
standard adjustment
Inventory study
Prevalence survey
No data
Not applicable
Results from national inventory studies that mea-sured through mortality data, surveys of the annual risk of infection
the level of underreporting of detected TB cases. This or exponential interpolation using estimates of case-detection
method is used for seven countries: China, Egypt, Indonesia, gaps for 3 years. In this report, this method is used for 43
Iraq, the Netherlands, the United Kingdom and Yemen. countries that accounted for 16% of the estimated global
These countries accounted for 18% of the estimated global number of incident cases in 2018.
number of incident cases
1
in 2018. Of the four methods, the last one is the least preferred and it is
Case notificatioatombineitxpert opin - ion about case-
relied on only if none of the other three meth-ods can be used.
detection gaps. Expert opinion, elic-ited through regional
As explained in Box 3.1, the underlying principle for the WHO
workshops or country missions, is used to estimate levels of
Global Task Force on TB Impact Measurement since its
underreporting, over diagnosis and underdiagnosis. Trends
establishment in 2006 has been that, as far as possible, estimates
are estimated of the level of and trends in TB disease burden should be based
on direct measurements from routine surveillance and surveys,
1
The studies in Egypt, Indonesia, Iraq, the Netherlands, the United as opposed to indirect estimates that rely on modelling and
Kingdom and Yemen included use capture– recapture modelling to
estimate incidence. This approach is
expert opinion. Sources of data available to estimate the burden
possible iissumptionret: (i) all cases are observ - able; (ii) the of TB disease in the 30 high TB burden countries are
proportion of mismatches and matching fail-ures in record-linkage is summarized in Table 3.2.
low, which typically requires a large samplinraction; (iii) there is a
closed population during thtuderiotypicall–onths); (iv) if S represents
Estimates of TB incidence in children (aged <15 years) are
the number of case lists or data sources available, then at based on dynamic modelling (12). Results for the 0–
leashreatourcervailable (S≥3nheiepen - dencies are accounted for in 14 yeagrou0–n–14 years) in each country
the model design, while the full S-way interaction between are further disaggregated using outputs from an estab-lished
sourcessumed null; (v) there
deterministic model (12), followed by disaggrega-tion by sex
is homogeneity of within-source observation probabilities
acrosubpopulatioroupsuchosefineocio - economic and demographic using results from a meta-analysis of the male
characteristics; (vi) the case definitioncrosatourceronsistenteigB temalM:Fotificatioatio.
Estimates of TB incidence in adults are derived by
burden countries are expected to be able to implement inven-
tortudiehaileehesissumptionuffi - firsubtracting incidence ihildren froncidence
cient degree. in all ages. The estimates for adults are then disaggre-