Developinraultisectoraccountabilitrameworkackgrounocumenttakeholder

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).

GLOBAL TUBERCULOSIS REPORT 2019 25

 Nurses at a field site during the
repeat national TB prevalence
survey in Myanmar in 2018.
Irwin Law/WHO

26 GLOBAL TUBERCULOSIS REPORT 2019

Chapter 3
TB disease burden

Key facts and messages

Tuberculosis (TB) remains a major Development Goals (SDGs) and WHO’s Faster reductions in TB incidence and
cause of ill health and is one of the top End TB Strategy. SDG 3 includes a target deaths require improvements in access to
10 causes of death worldwide. to end the global TB epidemic by 2030. diagnosis and care within the context of
The End TB Strategy includes targets of progress towards universal health
An estimated 10.0 million (range, 9.0–
a 90% reduction in TB deaths and an coverage, action on broader determinants
11.1 million) people fell ill with TB in
80% reduction in the TB incidence rate of TB incidence (e.g. levels of
2018, a number that has been relatively
(new and relapse cases per 100 000 undernutrition, poverty, smoking and
stable in recent years.
population per year) between 2015 and diabetes) and a new treatment or vaccine
Globally, there were 1.2 million (range, 2030, with 2020 milestones of a 35% to substantially lower the risk of
1.1–1.3 million) TB deaths among HIV- reduction in TB deaths and a 20% developing TB in people who have a
negative people in 2018 (a 27% reduction in TB incidence rates. latent TB infection.
reduction from 1.7 million in 2000) and
Currently, the world as a whole, most The burden of drug-resistant TB is of
an additional 251 000 deaths (range,
WHO regions and many high TB burden major interest and concern at global,
223 000–281 000) among HIV-positive
people (a 60% reduction from 620 000 in countries are not on track to reach the regional and country levels. In 2018, there
a 2020 milestones of the End TB Strategy. were approximately half a million (range,
2000). Since 2007, TB has been the
417 000–556 000) new cases of
leading cause of death from a single Globally, the average rate of decline in the
rifampicin-resistant TB (of which 78% had
infectious agent, ranking above HIV/ TB incidence rate was 1.6% per year in
multidrug-resistant TB). The three
AIDS. the period 2000−2018, and 2.0% between
countries with the largest share of the
2017 and 2018. The cumulative reduction
TB affects people of both sexes in all age global burden were India (27%), China
between 2015 and 2018 was only 6.3%.
groups but the highest burden is in adult (14%) and the Russian Federation (9%).
The global reduction in the number of TB
men, who accounted for 57% of all TB Globally, 3.4% of new TB cases and 18%
deaths between 2015 and 2018 was 11%.
cases in 2018. By comparison, adult of previously treated cases had MDR/RR-
women accounted for 32% and children TB, with the highest proportions (>50% in
for 11%. Among all TB cases, 8.6% were The WHO European Region is on track to previously treated cases) in countries of
people living with HIV. achieve the 2020 milestones; between the former Soviet Union.
2015 and 2018 the cumulative reduction
Geographically, most TB cases in 2018 Sources of data to inform estimates of
in the incidence rate was 15% and the
were in the World Health Organization TB disease burden have improved
number of TB deaths fell by 24%.
(WHO) regions of South-East Asia (44%), considerably in recent years. Two recent
Incidence and deaths are also falling
Africa (24%) and the Western Pacific examples are repeat national TB
relatively fast in the WHO African Region
(18%), with smaller shares in the Eastern prevalence surveys in Myanmar and
(4.1% and 5.6%, respectively, per year),
Mediterranean (8%), the Americas Viet Nam, which showed impressive
with cumulative reductions of 12% for
(3%) and Europe (3%). Eight countries reductions over a 10-year period.
incidence and 16% for deaths between
accounted for two thirds of the global Nonetheless, improvements are still
2015 and 2018. Seven high TB burden
total: India (27%), China (9%), Indonesia needed, especially in the availability of
countries are on track to achieve the 2020
(8%), the Philippines (6%), Pakistan data to reliably track TB mortality in the
milestones for both incidence and deaths:
(6%), Nigeria (4%), Bangladesh (4%) and WHO African Region.
Kenya, Lesotho, Myanmar, the Russian
South Africa (3%).
Federation, South Africa, the United When an HIV-positive person dies from TB
Global targets and milestones for Republic of Tanzania and Zimbabwe. disease, the underlying cause is classified
reductions in the burden of TB disease as HIV in the international classification of
diseases system (10th edition).
have been set as part of the Sustainable

GLOBAL TUBERCULOSIS REPORT 2019 27

 Global targets and milestones for reductions in the bur-den of 1
annually, using the latest available data and analytical methods.
tuberculosis (TB) disease have been set as part of the Since 2006, concerted efforts have been made to improve the
Sustainable Development Goals (SDGs) and the World available data and methods used for esti-mations, under the
Healtrganization’WHO’sntrateg Chap-ter 2) (1). SDG 3 umbrella of the WHO Global Task Force on TB Impact
includes a target to end the global TB epidemic by 2030, with Measurement (Box 3.1)ummary
the TB incidence rate (new and relapse cases per of the main updates to available data and methods since the
100 00opulatioeearefined 2018 global TB report (2) is provided in Box 3.2, and full
as the indicator for measurement of progress. The 2030 targets details about methods are provided in an online tech-nical
2
set in the End TB Strategy are a 90% reduction in TB deaths appendix.
and an 80% reduction in the TB incidence rate, compared with For broader context, Box 3.3 provides a high-level
levels in 2015. The End TB Strategy has also set targets for comparison of burden estimates for TB published by WHO and
2035 and milestones for 2020 and 2025 (Table 3.1). the Institute of Health Metrics and Evaluation (IHME)
ahniversitashingtonnitetates
of America. Box 3.3 also provides a short commentary on
TABLE 3.1 annual updates for TB, including how these compare with
regular updates published for other diseases.
Targets for percentage reductions in TB
disease burden set in WHO’s End TB Strategy 3.1 TB incidence
MILESTONES TARGETS 3.1.1 Methods to estimate TB incidence
INDICATORS 2020 2025 2030 2035
TB incidence has never been directly measured at nation-al
Percentage reduction in the
level because it requires a long-term study that enrols and
absolute number of TB deaths
per year 35% 75% 90% 95% follows up with hundreds of thousands of people, which would
(compared with 2015 involve (prohibitively) high costs and chal-
baseline)
lenginogisticsoweverotifications oB casero - vide a good proxy
Percentage reduction in the
indication of TB incidence in countries that have high-
TB incidence rate (new and
relapse cases per 100 000 20% 50% 80% 90% population per year) performance surveillance systems (e.g.
(compared with 2015 witittlnderreportiniagnoseases)nn
baseline) which the quality of and access to health care means that few
cases are not diagnosed.
Thrswectionhihapteresenniscuss The ultimate goal is to directly measure TB incidence
estimates of TB incidence (Section 3.1) and TB mortality anonitorendrootificationloun - tries. This requires a combination
(Section 3.2) at global, regional and country levels for the of strengthened sur-veillanceetteuantificationderreportini.e.
perio000–2018hincludeisaggregatioge
and sex. With estimates for TB incidence and mortality now the number of cases that are missed by surveillance sys-
available fo016–201ell ahaselineaf 2015pecifittentioiveo 3
tems) anniversaealtoveragUHC)ur - veillance checklist
thtaturogress developed by the WHO Global Task Force on TB Impact
towards the 2020 milestones of the End TB Strategy; that is, a Measurement (Box 3.1) defines the
35% reduction in the absolute number of TB deaths and a 20% standardhaeeeootificatioatro - vide a direct measure of TB
reduction in the TB incidence rate compared with levels in 2015 incidence and for national vital registration (VR) data to provide
4
(Table 3.1). a direct measure of TB mortality (3). Between January 2016
The burden of drug-resistant TB is of major interest and and August 2019, 60 countries, including 27 of the 30 high TB
concern at global, regional and country levels. Sec-tion 3.3 burden coun-tries (listed in Table 3.2), used the checklist tssess
provides an overview of the data available to estimate this the performancf theiationaB notificationd VR
burden, along with estimates of the number of cases and deaths
that occurred in 2018 and an analysis of recent trends in systems and to identify weaknesses that needed to be addressed
selected countries. (Fig. 3.1 and Table 3.2). Common recommen-
In many high TB burden countries, a national TB
Thpdateaffechntirimerieac000.
prevalencurveurrentlfferhesethoor Thereforestimateresentehihapteo000−2017
directly measuring the number of TB cases (and their dis- supersede those of previous reports, and direct comparisons
tributioy age and sex). Section 3.4 describes the latest status (e.getweeh01stimatehiepornh017
estimates in the previous report) are not appropriate.
of progress in implementing such surveys and pro-
The online technical appendix is available at
videynthesiendingsesultrowecent http://www.who.int/tb/data.
repeat surveys in Myanmar and Viet Nam, which showed Inventory studies can be used to measure the number of cases that are
diagnosed but not reported. For a guide to inventory
impressive reductions in disease burden over a period of 10 studieseH2019) (4) .
years, are highlighted. One of the standards is that levels of underreporting of detect-ed TB
WHO updates its estimates of the burden of TB disease cases should be minimal.

28 GLOBAL TUBERCULOSIS REPORT 2019

BOX 3.1

The WHO Global Task Force on TB Impact Measurement

Establishment and progress made, 2006–2015 To guide, promote and support the analysis and use of TB
The WHO Global Task Force on TB Impact Measurement (the data for policy, planning and programmatic action.
Task Force) was established in 2006 and is convened by the TB The five strategic areas of work are as follows:
Monitoring and Evaluation unit of WHO’s Global TB Programme.
Strengthening of national notification systems for direct
The original aim of the Task Force was to ensure a rigorous,
measurement of TB cases, including drug-resistant TB and
robust and consensus-based assessment of whether 2015
HIV-associated TB specifically.
targets set in the context of the Millennium Development Goals
Strengthening of national VR systems for direct
(MDGs) were achieved at global, regional and country levels.
measurement of TB deaths.
The Task Force pursued three strategic areas of work:
Priority studies to periodically measure TB disease burden,
including surveys on:
strengthening routine surveillance of TB cases (via national national TB prevalence;
notification systems) and TB deaths (via national vital drug resistance;
registration [VR] systems) in all countries; mortality; and
undertaking national TB prevalence surveys in 22 global costs faced by TB patients and their households.
focus countries; and Periodic review of methods used by WHO to estimate the
periodically reviewing methods used to produce TB disease burden of TB disease and latent TB infection.
burden estimates. Analysis and use of TB data at country level, including:
Work on strengthened surveillance included the following: disaggregated analyses (e.g. by age, sex and location) to
assess inequalities and equity;
Development of a TB surveillance checklist of standards
projections of disease burden; and
and benchmarks (with 10 core standards and three
guidance, tools and capacity-building.
supplementary ones) (3). This checklist can be used to
systematically assess the extent to which a surveillance The SDG and End TB Strategy targets and milestones referred
system meets the standards required for notification and to in the mandate are the targets (2030, 2035) and milestones
VR data to provide a direct measurement of TB incidence (2020, 2025) set for the three high-level indicators; that is, TB
and mortality, respectively. incidence, the number of TB deaths and the percentage of TB-
Electronic recording and reporting. Case-based electronic affected households that face catastrophic costs as a result of
databases are the reference standard for recording and TB disease (Chapter 2).
reporting TB surveillance data. A guide to their design and
Strategic areas of work 1–3 are focused on direct measure ment
implementation was produced in 2011 (5).
of TB disease burden (epidemiological and, in the case of cost
Development of a guide on inventory studies to measure
surveys, economic). The underlying principle for the Task
underreporting of detected TB cases (4), and support of
Force’s work since 2006 has been that estimates of the level of
such studies in priority countries. An inventory study can be
and trends in disease burden should be based on direct
used to quantify the number of cases that are detected but
measurements from routine surveillance and surveys as much as
not reported to national surveillance systems, and can serve
possible (as opposed to indirect estimates based on modelling
as a basis for improving estimates of TB incidence and
and expert opinion). However, strategic area of work 4 remains
addressing gaps in reporting.
necessary because indirect estimates will be required until all
Expanded use of data from VR systems and mortality
countries have the surveillance systems or the periodic studies
surveys to produce estimates of the number of TB deaths,
required to provide direct measurements. Strategic area of work
and contributions to wider efforts to promote VR systems.
5 recognizes the importance of analysing and using TB data at
There was substantial success in the implementation of country level (as well as generating data, as in strategic areas of
national TB prevalence surveys in the period 2007–2015 work 1–3), including the disaggregated analyses that are now
(Section 3.4). A Task Force subgroup undertook two major given much greater attention in the SDGs and End TB Strategy.
reviews of methods used to produce TB disease burden
estimates (the first in 2008–2009 and the second in 2015). The
In the years up to 2020, the top priorities for the Task Force are
latter achieved consensus on methods to be used for the
strengthening of national notification and VR systems as the
assessment of 2015 targets published in WHO’s 2015 global
basis for direct measurement of TB incidence and TB mortality.
TB report (6).
The global status of progress in using the WHO TB surveillance
Updated strategic areas of work, 2016–2020 checklist to assess the performance of notification and
VR systems is shown in Fig. 3.1. The status of progress in
In the context of a new era of the SDGs and WHO’s End TB
implementing case-based electronic surveillance is discussed in
Strategy, the Task Force met in April 2016 to review and reshape
Chapter 4. The global status of progress in implementation of
its mandate and strategic areas of work for the post-2015 era. An
inventory studies is shown in Fig. 3.1. The number of countries
updated mandate and five strategic areas of work for the period
for which VR data are used to estimate the number of TB deaths
2016–2020 were agreed (7).
is shown in Fig. 3.13.
The updated mandate is as follows:
Further details about the work of the Task Force are available
To ensure that assessments of progress towards End TB online (8); an up-to-date summary is provided in the latest
Strategy and SDG targets and milestones at global, regional brochure about its work (9).
and country levels are as rigorous, robust and consensus-
based as possible.

GLOBAL TUBERCULOSIS REPORT 2019 29

 BOX 3.2

Updates to estimates of TB disease burden in this report and anticipated updates

Updates in this report Newly reported data and updated estimates
Estimates of TB incidence and mortality in this report cover the from other agencies
period 2000–2018. Estimates of incidence and mortality for New cause-of-death data from national VR systems were
drug-resistant TB are for 2018. The main country-specific reported to WHO between mid-2017 and mid-2018. Several
updates in this report are for estimates of TB incidence in countries reported historical data that were previously missing,
Viet Nam (Box 3.6) and Myanmar (Box 3.7). or made corrections to previously reported data. In total, 1986
country-year data points from the WHO mortality database
1. Drug-resistant TB were retained for analysis.
Between August 2018 and August 2019, new data on levels of
Updated estimates of HIV prevalence and mortality were
drug resistance were reported for the following countries:
obtained from the Joint United Nations Programme on HIV/ AIDS
First-ever national anti-TB drug resistance survey completed in (UNAIDS) in July 2019 (10). In combination with new data from
2017–2019: Cameroon (2017), Eritrea (2018), Indonesia (2018), routine HIV testing of people diagnosed with TB, these resulted
Lao People’s Democratic Republic (2018), Togo (2018). in revisions to estimates of the number of TB cases and deaths
among HIV-positive people for years prior to 2018.
Repeat national anti-TB drug resistance survey completed in
2017–2019: Bangladesh (2019), Cambodia (2018), Eswatini In most instances, any resulting changes to TB burden
(2018), the Philippines (2019), Sri Lanka (2018), Tajikistan estimates were well within the uncertainty intervals of
(2017), Thailand (2018), Turkmenistan (2018), the United previously published estimates, and trends were generally
Republic of Tanzania (2018). consistent.

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

30 GLOBAL TUBERCULOSIS REPORT 2019

 BOX 3.2 BOX 3.3

WHO estimates for TB

disease burden in the
of TB notification data for children, the consistency of case
definitions and coverage of reporting. Inventory studies
context of other estimates
specific to childhood TB would help to improve the quality of Global estimates of TB incidence and mortality
TB disease burden estimates for children, and should be published by WHO and IHME are similar. For example,
prioritized. the best estimate for TB incidence in 2017 from IHME
(the latest year for which estimates had been published
Updates anticipated in the near future
in August 2019) is 10.3 million (11), compared with
Updates to estimates of disease burden are expected 10.1 million (range, 9.0–11 million) in 2017 in this
towards the end of 2019 or in 2020 for Eswatini, Lesotho, report. The best estimate of the number of TB deaths
Mozambique, Nepal and South Africa, following the among HIV-negative people in 2017 published by IHME
completion of national TB prevalence surveys. Estimates of is 1.2 million, compared with 1.3 million (range 1.2–
TB burden in India will be updated once results from a 1.4 million) in this report.
national TB prevalence survey being implemented in 2019–
2020 become available. Updates to MDR/RR-TB estimates There is general consistency in mortality estimates in
are expected for Albania, Angola, Burundi, Chad, Ethiopia, countries with good-quality VR systems and standard
Guinea, Haiti, Malawi, Mali, Mozambique, Myanmar, Timor- coding of causes of deaths, and in incidence estimates in
Leste and Zambia, based on new national surveys. countries with strong health care and notification
systems. Discrepancies are most apparent for countries
where the underlying data are weaker, owing to
differences in the indirect estimation methods that are
used.
dations include making or improving the transition from When annual updates for TB are published by both WHO
aggregated paper-based recording and reporting of TB cases to and IHME, entire time series (starting in 2000 for WHO
electronic case-based surveillance; measuring the level of and 1990 for IHME) are updated. New information or
refinements to methods used to produce estimates can
underreporting and taking corrective actions
result in changes to the estimates for earlier years given
basendingsnstablishintrengtheninR systems.
in previous publications. This is an expected feature of
disease burden estimation updates, and also occurs with
Methods currently used by WHO to estimate TB incidence disease burden estimates published for other diseases,
can be grouped into four major categories (Fig. 3.2), as such as HIV and malaria. For example, global estimates
follows: for 2015 for HIV, malaria and TB published by WHO,
UNAIDS and IHME in consecutive years (2015 and
Results from TB prevalence surveys. Incidence is esti-
mated using prevalence survey results and estimates of the 2016) by the same agency have been within about 2–
duration of disease, with the latter derived from a model that 8% of each other. Global estimates of TB disease
accounts for the impact of HIV coinfec-tion and burden in 2015 published by WHO in this and the
antiretroviral therapy (ART) on the distribu-tion of disease previous two global TB reports are within 4–5% of
1 each other.
duration. This method is used for 24 countries, of which 23
have national survey data and one – India – has a survey in Country-specific estimates of TB disease burden
one state. The 24 countries accounted for 60% of the published by WHO are generally consistent from year
estimated global number of incident cases in 2018. to year. In WHO reports published in 2014–2018,
updates that have been apparent at global level have
been due to updates for three countries: Nigeria
Notificationdjustetandaractoccou
(2014 report, following results from the country’s first
for underreporting, overdiagnosis and underdiagno-sis.
national TB prevalence survey in 2012), Indonesia (2015
This method is used for a total of 142 countries: all high- report, following completion of a national TB prevalence
income countries except the Netherlands and the United survey in 2013–2014) and India (2016 report, following
Kingdom; and selected middle-income coun-tries with low accumulation of evidence from both survey and
levels of underreporting, including Brazil and the Russian surveillance data).
Federation. These 142 countries accounted for 6% of the As the availability and quality of data continue to
estimated global number of incident cases in 2018. improve, variability for the same year in consecutive
reports will decrease, and estimates published by
WHO should converge with those published by other
1 agencies. Ideally, estimates of TB incidence and
Estimation of prevalence from incidence is not straight-forward. For
mortality are based on national notification and VR
example, it requires assumptions about the
duration of diseasoifferenategories of caseincrev - systems that meet quality and coverage standards.
alencurveyocuacteriologicallonfirmen
adults, adjustments to include children and extrapulmonary TB are
needed.

GLOBAL TUBERCULOSIS REPORT 2019 31

 TABLE 3.2

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.

32 GLOBAL TUBERCULOSIS REPORT 2019

FIG. 3.1

Strengthening national TB surveillance (status in August 2019)

Assessment of the performance of TB surveillance using the WHO checklist of standards and
a
benchmarks since January 2016

Completed in 2016–2017 (n=32)

Completed in 2018–2019 (n=28)
Planned for 2019–2020 (n=16)
Not planned
Not applicable

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

Completed prior to 2017 (n=8)

Completed in 2017–2018 (n=10)
Underway/planned (n=3)
Not planned
Not applicable

GLOBAL TUBERCULOSIS REPORT 2019 33

FIG. 3.2

Main methods used to estimate TB incidence

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-