Global tuberculosis report 2019

ISBN 978-92-4-156571-4

© World Health Organization 2019

Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC
BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo).

Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is
appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific
organization, products or services. The use of the WHO logo is not permitted. If you adapt the work, then you must license your work
under the same or equivalent Creative Commons licence. If you create a translation of this work, you should add the following
disclaimer along with the suggested citation: “This translation was not created by the World Health Organization (WHO). WHO is not
responsible for the content or accuracy of this translation. The original English edition shall be the binding and authentic edition”.

Any mediation relating to disputes arising under the licence shall be conducted in accordance with the mediation rules of the World
Intellectual Property Organization.

Suggested citation. Global tuberculosis report 2019. Geneva: World Health Organization; 2019. Licence: CC BY-NC-SA 3.0 IGO.

Cataloguing-in-Publication (CIP) data. CIP data are available at http://apps.who.int/iris.

Sales, rights and licensing. To purchase WHO publications, see http://apps.who.int/bookorders. To submit requests for commercial
use and queries on rights and licensing, see http://www.who.int/about/licensing.

Third-party materials. If you wish to reuse material from this work that is attributed to a third party, such as tables, figures or images, it
is your responsibility to determine whether permission is needed for that reuse and to obtain permission from the copyright holder. The
risk of claims resulting from infringement of any third-party-owned component in the work rests solely with the user.

General disclaimers. The designations employed and the presentation of the material in this publication do not imply the expression of
any opinion whatsoever on the part of WHO concerning the legal status of any country, territory, city or area or of its authorities, or
concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which
there may not yet be full agreement.

The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by
WHO in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary
products are distinguished by initial capital letters.

All reasonable precautions have been taken by WHO to verify the information contained in this publication. However, the published
material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of
the material lies with the reader. In no event shall WHO be liable for damages arising from its use.

Designed by minimum graphics

Cover designed by Irwin Law

Printed in France

WHO/CDS/TB/2019.15
Contents

Foreword v
Message from the WHO Global TB Programme vi
Acknowledgements vii
Abbreviations xi
Executive Summary 1
Chapter 1 Introduction 7
Chapter 2 Global commitments to end TB and multisectoral accountability 9
Chapter 3 TB disease burden 27
Chapter 4 TB diagnosis and treatment 73
Chapter 5 TB prevention services 111
Chapter 6 Financing for TB prevention, diagnosis and treatment 123
Chapter 7 Universal health coverage, multisectoral action and
social determinants 141
Chapter 8 TB research and development 165

Annexes
1. The WHO global TB database 183
2. Countrrofileoigurdeountries 189
3. Regionanlobarofiles 251
4. Turdestimatesotificationnreatmenutcomes 261

GLOBAL TUBERCULOSIS REPORT 2019 iii

Foreword

It has been a year since the historic United Nations (UN) high-level meeting on tuberculosis (TB) that
brought together world leaders to accelerate the TB response. The commitments made at the meeting
are currently being translated into action in countries, supportehFind. Treat.
AllEndTBnitiativhorlealtrganization
(WHO)htop TartnershinhlobaunighIDSuberculosind
Malaria.
Thiear’lobaeporevealhaountrierakinrogressbout
7 million people were reported to have been reached with quality TB care in 2018, up from 6.4
million in 2017. In addition, TB-related deaths dropped from 1.6 million in 2017 to 1.5 million in
2018. However, TB remains the top infectious killer worldwide, with 10 million people falling ill
with TB in 2018.
Althougomountrierignificantlcceleratinheiesponseost
WHO regions and many high-burden countries are still not on track to reach the 2020 milestones of
the End TB Strategy. About 3 million people with TB did not access quality care in 2018. The
situation is even more acute for people with drug-resistant TB, with
onlnhreccessinreatmentreventioffortrxpandinueee
intensifiedundinaplosSillionnuallmpedrogreshverall TB response, including TB research.

To ensure that we match our talk with real, lasting change, WHO released a
multisectoraccountabilitrameworhiear’orlealtssemblyelp
countries drive action with accountability across all sectors. Sustained progress will require a
commitment to universal health coverage, based on strong primary health care, as underscored at the
high-level meeting on universal health coverage at the UN General Assembly this year.

Ultimately, the best investment that countries can make to ensure faster progress towards ending
TB is to ensure that TB services are designed and delivered as part of an overall commitment to
universal health coverage, built on the foundation of strong primary health care. WHO is committed
to working with countries to ensure TB services arntegratentationaenefiackagensurhanisseuhe
services they need, or is impoverished by using them.

ThHlobaeporeliverleaessageustainecceleratiofforts
and increased collaboration are urgently required to turn the tide of the TB epidemic. To
maintain momentum, I personally wrote to Heads of State this year urging them to
keehromiseadasear’igh-leveeetinBhiaollowey a
jointatemenithHiviocietaskforceiviocietyartnernffected communities are important drivers of
progress against this top killer.
Our vision is that no one with TB will miss out on the care they need. WHO will stand by every
country, partner, society or person that decides TB has no place in its future. It is time to deliver.
There has never been a better opportunity to make TB history.

Dr Tedros Adhanom Ghebreyesus

Director-General
World Health Organization

GLOBAL TUBERCULOSIS REPORT 2019 v

 Message
from the WHO Global TB Programme

ThiivotaomenohlobaghnuberculosiTB).
Fohrsimeavoliticaommitmenhigheseveroeads
of state, ministers and other leaders. Member States, partners and civil society are all
uniteorkinowardcceleratinhesponsnhorld’op infectious disease killer.

Thiear’lobaeporhowcaselobalegionanountrrogresshile
highlighting that much remains to be done to reach the TB targets set in the World Health
Organization (WHO) End TB Strategy, the United Nations (UN) Sustainable Development
GoalSDGsnholiticaeclaratioasear’igh-leveeetinBs
now imperative to maintain the positive momentum we have achieved.
IhieportHnnouncinhahrsilestonowardnhargets
set in the political declaration at the UN high-level meeting on TB has been achieved:
7 million people were reached with TB care in 2018. Nonetheless, there were still around 3 million
people with TB who either had no access to quality care or were not reported, and only one in three
people with drug-resistant TB accessed care. There has been
an expansion of access to TB preventive treatment, but the numbers currently being reached
fall far short of what is needed to reach the target of providing preventive treatment to at least
30 millioeoplherio018–2022hlobaunight
AIDS, Tuberculosis and Malaria (Global Fund) has recently been replenished with more resources
than ever before for HIV, TB and malaria, but despite this good news, progress continues to be
impeded by shortfalls in domestic and international funding for TB prevention and care, and for TB
research.
WHaeentensifyintffortupporountriecceleratinhB
response, with the engagement of all stakeholders. Actions taken in the past year include high-level
missions to countries to optimize the national response; the development and roll-out of new
guidelines, roadmaps and tools; the implementation of the WHO Director-
General’lagshinitiativeFind. Treat. AllEndTB”ndertakeointly
with the Global Fund and the Stop TB Partnership; strengthened collaboration with civil society;
and implementation of a multisectoral accountability framework for TB to drive sustained action
across all sectors.
As we look forward, 2020 is a critical year when Member States will report to the WHO
Director-General and UN Secretary-General on progress towards the targets of the SDGs, the End
TB Strategy and the UN high-level meeting. As a precursor to the next
criticaearhiear’lobaeporighlighthalthougavchieveuch ihghnBanusetterimriticallnalyseeview

and optimize programmes; strengthen surveillance systems; and move decisively from rhetoric to
action.
WelievhahHlobaeporssentiaohiffortnoigh-
level advocacy, increasing awareness and fundraising. Knowledge and data are powerful
weaponhghgainsBhahhHlobaeporooueat,
know more about TB and act!

Dr Tereza Kasaeva
Director, Global Tuberculosis Programme
World Health Organization

vi GLOBAL TUBERCULOSIS REPORT 2019

Acknowledgements
This global TB report was produced by a core team of 18
people: Annabel Baddeley, Anna Dean, Hannah Mon-ica Dias,
Dennis Falzon, Carmen Figueroa, Katherine
Floydnéarciaenaebiaebreselassiehilippe
Glaziou, Marek Lalli, Irwin Law, Cecily Miller, Nobuyuki
Nishikiori, Gita Parwati, Charalambos Sismanidis, Lana Syed,
Hazim Timimi and Yinyin Xia. The team was led by Katherine
Floyd. Overall guidance was provided by the Director of the
Global TB Programme, Tereza Kasaeva.
The data collection forms (long and short versions) were
developed by Philippe Glaziou and Hazim Timimi,
witnpurotahroughouhHlobaro - gramme. Hazim Timimi led and
organized all aspects of data management. The review and
follow-up of data was done by a team of reviewers that included
Annabel Baddeleynneanarmeigueroanéarcía
Baena, Giuliano Gargioni, Medea Gegia, Shagun Khare,
Alexeorobitsynizianasiniomáatasndrea
Pantoja, Gita Parwati, Kefas Samson, Lana Syed, Hazim
Timimi, Olga Tosas Auguet, Eloise Valli and Yinyin Xia.
Data for the European Region were collected and val-idated
jointly by the World Health Organization (WHO)
Regionafficouropnhuropeaentror
DiseasreventionontroECDC)hanar -
ticulasabödmönannerroCDor providinalidateatlenndreadniorgi
Kuchukhidzrom thHegionafficor Europe
for their follow-up and validation of data for all Europe-an
countries. UNAIDS managed the process of data col-lection
from national AIDS programmes and provided access to their
TB/HIV dataset. Review and validation of TB/HIV data was
undertaken in collaboration with
UNAIDtaffheporealsratefueviews oatopecific
countriehaeronevim
Ahmedov, Amna Al-Gallas-Streeter, Kenneth Castro, Thomas
Chiang, Alexander Golubkov and Edmund Rutta.
Many people contributed to the analyses, preparation of
figures and tablesnd writing requireor the main chapterf
theportnlestherwispecified, those
named work in the WHO Global TB Programme. Chapter 1
(Introduction) was written by Katherine
Floyd. She also prepared Chapter 2 (Global commitments to
end TB and multisectoral accountability) and the Exec-utive
Summary, with inputs from Hannah Monica Dias,
JamiutWHonsultant)erezasaevniana Weil.
Chapter 3 (TB disease burden) was prepared by Anna
DeaneteodUniversitheffield)atherine
Floyd, Philippe Glaziou, Irwin Law and Olga Tosas Auget
countrrofilehappeannehegionaro
- indicators for all countries in the latest year for which
(WHonsultant)hhapteuthorrratefuo
AndreabibbSaaffaelcientifinstituteois
contributions to the two boxes on drug resistance sur-veillance,
and to Ikushi Onozaki (WHO Countrffice,
Myanmarntarohationarogrammes
of Myanmar and Viet Nam for their contributions to the boxes
featuring results from the recent national TB prev-alence
surveys in these countries.
Chapter 4 (Diagnosis and treatment of TB, HIV-associated
TB and drug-resistant TB) was prepared by Charalambos
Sismanidis, Hazim Timimi and Yinyin Xia, with contributions
from Annabel Baddeley, Hannah Monica Dias, Dennis Falzon,
Katherine Floyd, Philippe Glaziouiconzalengulorwiawuairzayev
and Lana Syed.
Chapter 5 (TB prevention services) was prepared by Annabel
Baddeley, Dennis Falzon, Carmen Figueroa, Avinash Kanchar
and Yinyin Xia, with contributions from Katherine Floyd and
Hazim Timimi.
Chapter 6 (Financing for TB prevention, diagnosis and
treatmentareparenéarciaenneter
NguhiWHonsultant)itupporroatherine
Floyd and Marek Lalli. Estimates of resource needs that will be
included in thtop TB Partnership’s upcoming Global Plan to
End TB 2018–2022 were kindly provided by
CareretoriuAveniealth).
Chapter 7 (Universal health coverage, multisectoral action
and social determinants) was prepared by Nobuyu-
kishikioritupporroatherinloynnés Garciaenahohirecenefiransfer
scheme in India was written by Amy Collins and Diana Weil, in
consultation with the national TB programme
anHountrfficndiahhapteuthors arratefutarohationarogrammef
Mongolia, Nigeria and the Philippines for their input to and
review of boxes on national TB patient cost surveys and
multisectoral action.
Chapter 8 (TB research and development) was pre-pared by
Dennis Falzon, Nebiat Gebreselassie and Chris-topher Gilpin,
with support for the writing of the chapter from Katherine
Floyd, Irwin Law and Matteo Zignol. Fuad Mirzayev and
Tiziana Masini contributed to review of chapter content.
Irwiaoordinatehnalizatiogurend
tables for all chapters and subsequent review of proofs, was the
focal point for communications with the graphic designer and
designed the report cover.
Annex 1, which provides an overview of the WHO global
TB database, was written by Hazim Timimi. The
GLOBAL TUBERCULOSIS REPORT 2019 vii
filehappeannenhetaileablehow - ing data for key
 information is available (Annex 4) were also prepared by
Hazim Timimi. Thanks are due to Yulia Bakonina, Carmen
Figueroa and Clarisse Veylon Hervet for their assistance with
translating the online versions oountrrofilentussianpanisnrench,
respectively.
in Chapter 6; Gabriela Flores Pentzke Saint-Germain for her
review of Chapter 7; Ann Ginsberg, Kelly Dooley, Mel
Spigelman and Jennifer Woolley for their reviews of Chapter 8;
and several members of the TB team at the United States
Agency for International Development (USAID).

The report was edited by Hilary Cadman.

The preparation of the online technical appendix that
explains the methods used to estimate the burden of dis-ease
caused by TB was led by Philippe Glaziou, with con-
tributionroeteodUniversitheffield).
Whanalérie Roberhlobarogramme’s
monitoring and evaluation unit for impeccable adminis-trative
support, Nicholas Gan, Simone Gigli and Nicolas Jimenez for
excellent information technology support, Doris Ma Fat from
the WHO Mortality and Burden of Dis-ease team for providing
data extracted from the WHO Mortality Database that were
used to estimate TB mor-tality among HIV-negative people,
and Juliana Daher and Mary Mahy (UNAIDS) for providing
epidemiological data that were used to estimate HIV-associated
TB incidence and mortality.
The report team is grateful to various external reviewers for
their useful comments and suggestions on advanced drafts of
the main chapters of the report. Particular thanks are due to
Jessica Ho for her review of Chapter 3; Satvinder Singh for her
review of Chapter 4 and Chapter 5; Carel Pretorius and
Suvanand Sahu for reviewing content that summarizes
estimates of resource needs prepared for the Global Plan to
End TB 2018–2022 and Lucy Cunnama for reviewing content
related to new guidance and data collection on unit costs,
which appears
ThrincipaourcnanciaupporoHO’s
work on global TB monitoring and evaluation is USAID.
Production of the report was also supported by the gov-
ernments of Japan, the Republic of Korea and the Rus-sian
Federation. We acknowledge with gratitude their support.
In addition to the core report team and those men-tioned
above, the report benefited from inputs from
mantaorkinHegionanountrffic - es and hundreds of people
working for national TB pro-grammes or within national
surveillance systems who contributed to the reporting of data
and to the review of report material prior to publication. These
people are listed below, organized by WHO region. We thank
them all for their invaluable contribution and collaboration,
without which this report could not have been produced.
AmonhHtaolreadentionebove,
we thank in particular Muhammad Akhtar, Kenza Ben-nani,
Vineet Bhatia, Michel Gasana, Jean Iragena, Tauhid
Islamafaeópez Olarte, Partha Pratim Mandal, Casimir
Manzengo Mingiedi, Farai Mavhunga, Richard
Mbumbgimbiukushorishitandrdongo - sieme, Wilfred Nkhoma,
Mukta Sharma and Askar Yedil-bayev for their contribution to
data collection and validation, and review and clearance of
report material by countries in advance of publication.

WHO staff in Regional and Country Offices

WHO African Region
Jeaouibenoesthecengnácilvarengaavieramburulaudina Augustruzyodelweaye
Bahariathérinarouanaranmrantuourbaaluirimaamaraastonhitembookou
Mawule Davi, Ndella Diakhate, Noel Djemadji, Ismael Hassen Endris, Louisa Ganda, Michel Gasana, Carolina Cardoso
dilvomesatricazangweélesphorouansoueaieragenahavianioseeuronlonassa
Ketemaristidésiromangoya-Nzonzongelaeoaneharmilareef-Jahomthandazukheleasi -
mianzengo Mingiedibdoulayariamaïssaaraavhungaicharbumbgimbikatekkhondo,
Josepoggaaurenoyengauleugabondrdongosiemekhokhelgwenyaeniskezimanaico -
las Nkiere, Wilfred Nkhoma, Ghislaine Nkhone, Ishmael Nyasulu, Amos Omoniyi, Hermann Ongouo, Joyce Onsongo,
Ouldzeidoune Naceredine, Philip Patrobas, Kafui Senya, Addisalem Yilma Tefera, Susan Tembo, Hubert Wang, Asse-fash Zehaie.

WHO Region of the Americas

Pedrvedilloalerieach-Horneldonoissondwiolastigngriarciaarreffrardranklier - nandez, Sandra Jones, Francisco León Bravo, Rafael
Lopez Olarte, Wilmer Marquiño, Carlyne McKenzie, Ernesto Mon-toro, Jean Marie Rwangabwoba, Katrina Smith, Jorge Victoria,
Marcelo Vila.

WHO Eastern Mediterranean Region

Khawaja Laeeq Ahmad, Muhammad Akhtar, Homam Albanna, Mohammad Reza Aloudal, Novera Ansari, Yassine Aqa-chmar,
Kenza Bennani, Alaa Hashish, Mai El Tigany Mohammed, Ghada Oraby, Sindani Ireneaus Sebit, Omid Zamani.

viii GLOBAL TUBERCULOSIS REPORT 2019

WHO European Region
Cassandra Butu, Andrei Dadu, Masoud Dara, Jamshid Gadoev, Aleksandr Goliusov, Stela Gheorghita, Gayane Ghu-kasyan, Ogtay
Gozalov, Viatcheslav Grankov, Sayohat Hasanova, Giorgi Kuchukhidze, Nino Mamulashvili, Artan Mesi, Mahriban Seytliyeva,
Mustafa Bahadir Sucakli, Javahir Suleymanova, Sona Valiyeva, Martin van den Boom, Arkarii Vodianyk, Askar Yedilbayev,
Saltanat Yegeubayeva, Gazmend Zhuri.

WHO South-East Asia Region

Shalala Ahmadova, Vineet Bhatia, Maria Regina Christian, Manjula Danansuriya, Gopinath Deyer, Debashish Kun-du, Partha Pratim
Mandal, Mya Sapal Ngon, O Nam Ju, Ikushi Onozaki, Shushil Dev Pant, Malik Parmar, Kiranku-mar Rade, Ranjani Ramachandran,
Md. Kamar Rezwan, Anupurba Roy Chowdhury, Mukta Sharma, Sabera Sultana, Lungten Wangchuk, Sonam Wangdi.

WHO Western Pacific Region

Zhongdan Chen, Serongkea Deng, Philippe Guyant, Lepaitai Hansell, Anupama Hazarika, Tom Hiatt, Tauhid Islam, Kiyohiko Izumi,
Narantuya Jadambaa, Fukushi Morishita, Anuzaya Prevdagva, Kalpeshsinh Rahevar, Richard Rehan, Jacques Sebert, Vilath
Seevisay, Raj Mohan Singh, Vu Quang Hieu, Rajendra-Prasad Yadav, Subhash Yadav.

National respondents who contributed to reporting and verification of

data WHO African Region
Abderramanbdelrahiarkaadusi-Pokuissoffolabiofianlihalassarlindomámaral,
Andriamamonjazafindranaivuribindersonhmeidjaneeinourtalohamessaoayallayira,
Balloubakarnndamaariangouraorgoearretoilliarrieilfrieekouergisutue -
za, Roxanne Boker, Franck Adae Bonsu, Miguel Camara, Obioma Chijioke-Akaniro, Ernest Cholopray, Adjima Com-
baryatoiépoulibalynoumoaotsèagnrabdoulayiallodamiallombrosiisadidihemba
Dlaminiamueicellaminintointoundvounauayencuresilaakhokallyndorayervé
Gildas Gando, Evariste Gasana, Belaineh Girma, Adulai Gomes Rodrigues, Amanuel Hadgu, Musa B Jallow, Jorge Jone, Kane
Elhadj Malick, Henry Shadreck Kanyerere, Clara Chola Kasapo, Michel Kaswa, Mariam Keita, Mamy Kinkela, Bakary Konate,
Jacquemin Kouakou Kouakou, Felix Kwami Afutu, Adebola Lawanson, Gertrude Lay, Taye Letta, Mar-tin Likambo, Patrick Saili
Lungu, Llang Maama, Jocelyn Mahoumbou, Robert Kaos Majwala, Lerole David Mametja,
Ivaanhiçaselisarataanelasukuakhosazanatsebulaaureeameneincenbassaat - rick Migambi, Louine Morel, James Upile Mpunga,
Beatrice Mutayoba, Lindiwe Mvusi, Ghislain Ndama Makounza, Euphrasie Ndihokubwayo, Deus Ndikumagenge, Jacques Ndion-
ngandzien, Nobert Ndjeka, Dubliss Nguafack Njimoh,
Emmanuekiligiiweugusseerménégildzimenyarancardaikembkombibdelhadumar,
Emile Rakotondramanana, Thato Raleting, Goabaone Rankgoane-Pono, Aiban Ronoh, Rujeedawa Mohammed Fezul, Agbenyegan
Samey, Charles Sandy, Kebba D Sanneh, Marie Sarr Diouf, Hilma Shivolo, Nicholas Siziba, Bonifacio Sou-sa, Manguinga Stredice,
Albertina Martha Thomas, Thusoyaone Titi Tsholofelo, Turyahabwe Stavia, Moses Zayee.

WHO Region of the Americas

Josarógüerumbadoaritguirrehalauddihmeddwiizpurúaochilemáruzisha
Andrewin, Denise Arakaki-Sanchez, Chris Archibald, Dwain Archibald, Carmen Arraya Gironda, Fernando Arrieta Pessolano,
Leticia Artiles Milla Noma, Carlos Alberto Marcos Ayala Luna, Patricia Bartholomay, Marcelino Belkys, Tamara Bobb, Harmony
Brewley-Massiah, Violet Brown, Jose Calderon, Shawn Charles, Karolyn Chong, Eric Com-miesie, Mariela Contrera, Yaren Cruz,
Carlos Vital Cruz Lesage, Dana DaCosta Gomez, Clara De La Cruz, Nadia Esco-baalinasercedespañedeñougo
Fernandezeciliutigueroenitesichellrancois-d’Auvergne,
Gail Gajadhar, Julio Garay Ramos, Anyeli Garcia, Henry Maria, Olga Joglar, Diana Elizabeth Khan, Marie LaFreniere,
Adaangerianawrencelaudileranoloátimeticiunópezugènadurondrevettal - donado Saavedra, , Ma. de Lourdes Martínez Olivares,
Zeidy Mata Azofeifa, Timothy McLaughlin, Angélica Medina, Andrezucenejíaballeroarercedesichelletivier-
Lezamaónicezárdenasicharilo, Leilawatohammedeetendrohanlallrancioreyilly Morose, Pilauñozarcelatielloacquelyn

Newbold, Alice Neymour, Cheryl Peek-Ball, Tomasa Portillo Esquivel, Robert Pratt, Rajamanickam Manohar Singh, Norma
Lucrecia Ramirez Sagastume, Andres Rincom, Julia Rosa Maria Rios Vidal, Ferosa Roache, Maria Rodriguez, Myrian Románatia
Romeroamanta Rosasrelisabeuiuidoateesakhamuriilmealazararitza
Samayoeláezarlaríáncheendozangelaríáncheélezicolkyersanilolanoatalia
Sosaeboratijnbergourdeuarelvarezackurlyuttonichellrotmanuliárujilloelissaldez,
Iyanna Wellington, Keisha Westby, Samuel Williams, Jennifer Wilson, Alesia Worgs, Oritta Zachariah.

GLOBAL TUBERCULOSIS REPORT 2019 ix

 WHO Eastern Mediterranean Region
Mohammad Salama Abouzeid Abdullah, Ahmad Abu-rumman, Shahnaz Ahmadi, Abdullatif Al Khal, Al Saidi Fatmah, Maha
Alalawi, Samer Alaubaidy, Mahmoud Albaour, Abdulbari abdullah Ahmed Al-Hamadi, Nada Almarzouqi, Ebra-him Al-Romaihi,
Esam Moammed wMahyuob Alsabery, Kifah Alshaqeldi, Khalsa Al-Thuhli, Fatma Alyaquobi, Wagdy Amin, Bahnasy Samir,
Mohamed Belkahla, Laila Bouhamidi, Joanne Daghfal, Mousab Elhag, Souad Elhassani, Hazar Zuheir Faroun, Mohamed Furjani,
Amal Galal, Dhikrayet Gamara, Assia Haissama Mohamed, Ahmed Hakawy, Hawa Hassan Guessod, Diaa Hjaija, Nasehi Mahshid,
Maha Nasereldeen, Yassir Piro, Aurangzaib Quadir Baloch, Muhammad Ayuajaohmmahaleeddiqohammeghiar, Sharafi
Saeedhazharkas, Mohemmebena, Yaacoub Hiam, Moinullah Zafari.

WHO European Region

Elmira Jusupbekovna Abdrahmanova, Malik Adenov, Salihjan Alimov, Ekkehardt Altpeter, Sarah Anderson, Elena Arbuzovarude
Margretrnesen, Zazvalianigneakos, Velimir Bereš, Snježanrčkalooliampbell,
Rosa Cano Portero, Isabel Carvalho, Aisoltan Chariyeva, Daniel Chemtob, Mamuka Chincharauli, Domnica Ioana Chi-otan, Nicoleta
Cioran, Andrei Corloteanu, Valeriu Crudu, Edita Davidavičienė, Patrick de Smet, Gerard de Vries, Irène
Demutherarevriesanfrancattoriniiktoasimovajlindjocajislaseriljanrbavčevićen - nady Gurevich, Jean-Paul Guthmann, Walter Haas,
Henrik L. Hansen, Biljana Ilievska Poposka, Sarah Jackson, Aylin Jaspersen, Jerker Jonsson, Erhan Kabasakal, Olim Kabirov,
Kadyrov Abdullaat Samatovich, Ourania Kalkouni, Anush Khachatryanzmitrlimukusinocharyanarissorinchukariorzeniewska-
Kosełaáboovács,
Lionel Lavin, Yana Levin, Nino Lomtadze, Stevan Lučić, Beatrice Mahler, Donika Mema, Violeta Mihailoviucinic, Dace
Mihalovska, Vladimir Milanov, Adriana Moisoiu, Ioana Munteanu, Joan O Donnell, Analita Pace Asciak, Clara Palma Jordana,
Nargiza Parpiyeva, Nita Perumal, Victoria Petrica, Vitaliy Prihodko, Asliddin Rajabzoda, Kateryna Riabchenko, Gabriele Rinaldi,
Jérôme Robert, Elena Sacchini, Gerard Scheiden, Anita Seglina, Firuza Sharipova, Vin-ciane Sizaire, Erika Slump, Hanna Soini,
Ivan Solovic, Sergey Sterlikov, Maja Stosic, Sevinj Taghiyeva, Ian Terleev,
Mariyyufekchievahahnozsmonovaonkarlevarinasilyevaireiikleppalentinilciřallen -
felsanliaryseierreicherdingtefaesołowskiyseguildirimajakoska.

WHO South-East Asia Region

Nazirefiakiatnhattaraiizayaderhouonggyeendupadukpaathaatassan,
Janaka Hilakaratne, Md. Shamiul Islam, Dushani Jayawardhana, Phalin Kamolwat, Ahmadul Hasan Khan, Booncherd Kladphaung,
Constantino Lopes, Sanjay Kumar Mattoo, Pronab Kumar Modak, Nurjannah Nurjannah, Nirupa Palle-watte, Imran Pambudi,
Jamyang Pema, Kuldeep Singh Sachdeva, Cho Cho San, Wilawan Somsong, SKM Sulistyo, Bhim Singh, Tinkari, Zaw Tun.

WHO Western Pacific Region

Paul Aia, Zirwatul Adilah Aziz, Mohamed Naim bin Abdul Kadir, Mohd Ihsani bin Mahmood, Uranchimeg Borgil, Risa Bukbuk,
Robert Carney, Chi Kuen Chan, Kwok Chiu Chang, Cynthia Chee, Phonenaly Chittamany, Chou Kuok Hei, Alice Cuenca,
Enkhmandakh Danjaad, Mohammad Fathi DP Hj Alikhan, Du Xin, Ekiek Mayleen Jack, Jenny Eveni, Saen Fanai, Ludovic Floury,
Louise Fonua, Sam Fullman, Anna Marie Celina Garfin, Donna Mae Geocaniga-Gavio-la, Giard Marine, Josephine Aumea Herman
Tepai, Hjh Anie Haryani Hj Abd Rahman, Laurence Holding, Edna Iav-ro, Noel Itogo, Mike Kama, Lisa Kawatsu, Kim Hyerim,
Phonesavanh Kommanivanh, Kong Insik, Khin Mar Kyi Win, Patrick Lambruscini, Christine Lifuka, Leo Lim, Jianjun Liu, Liza
Lopez, Ngoc-Phuong Luu, Shepherd Machekera, Falakiko Manakofaiva Epouse Lenei, Alice D. Manalo, Mao Tan Eang, Chima
Mbakwem, Dominique Megraoua, Mei Jian, Seraoa, Binh Hoa Nguyen, Viet Nhung Nguyen, Nou Chanly, Sandy Nua-
Ahoiaonnilikong, Paron
Seo, Sosaia Penitani, Kate Pennington, Marcelina Rabauliman, Asmah Razali, Bereka Reiher, Jane Short, Phitsada Siphanthong,
Tieng Sivanna, Thepphouthone Sorsavanh, Edwina Tangaroa, Kyaw Thu, Alfred Tonganibeia, Kazuhiro Uchimura, Lalomilo Varea,
Zhang Hui.

x GLOBAL TUBERCULOSIS REPORT 2019

Abbreviations

aDSM active TB drug-safety monitoring and MAF-TB multisectoral accountability framework for
management TB
AIDS acquiremmunodeficiencyndrome MDG Millennium Development Goal
APEC Asia-Pacificonomiooperation MDR multidrug-resistant
ART antiretroviral therapy MDR/RR-TB multidrug-resistant TB or rifampicin-
BCG bacillalmette-Guérin resistant TB
BRICS Brazil, Russian Federation, India, China and MDR-TB multidrug-resistant TB
South Africa M:F malo femalratio)
CAD computer-aided detection MGIT mycobacteria growth indicator tube
CDC Centers for Disease Control and Prevention NIAID National Institute of Allergy and Infectious
(Unitetatemerica) Diseases
CFR case fatality ratio NIH National Institutes of Health
CHOICE CHOosing Interventions that are Cost- NTP national TB programme
Effective (WHO) OECD Organisation for Economic Co-operation and
CHW community health worker Development
CI confidence interval PanACEA Pan-African Consortium for the Evaluation
CRS creditor reporting system of Antituberculosis Antibiotics
CV community volunteer PBMC peripheral blood mononuclear cell
CXR chest X-ray PEPFAR President’mergenclaoIDelief
DAC DevelopmenssistancommitteOECD) PLHIV people living with HIV
DALY disability-adjusted life-year P:N prevalenco notificatioratio)
DFID Department for International Development PPD purified protein derivative
(United King) PPM public–publind public–privatix
DNA deoxyribonucleic acid ReSeqTB Relational Sequencing TB Knowledgebase
DST drug susceptibility testing RNA ribonucleic acid
EECA Eastern Europe and Central Asia RNTCP Revised National TB Control Programme
ELISA enzyme-linked immunosorbent assay (India)
ELISPOT enzyme-linked immunosorbent spot assay RR-TB rifampicin-resistant TB
GDP gross domestic product RT-qPCR reverse transcriptase quantitative PCR
GHCC Global Health Cost Consortium SCI service coverage index
Global Fund The Global Fund to Fight AIDS, Tuberculosis SDG Sustainable Development Goal
and Malaria SHA system of health accounts
GPW 13 Thirteenth General Programme of Work, TAG Treatment Action Group
2019–2023 (WHO) TB tuberculosis
GTB Global TB Programme TB Alliance Global Alliance for TB Drug Development
HBC high-burden country TBTC TB Trial Consortium
HDC Health Data Collaborative TNF tumour necrosis factor
HIV humammunodeficiencirus TST tuberculin skin test
Hr-TB isoniazid-resistant, rifampicin-susceptible TU tuberculin units
TB UHC universal health coverage
ICD-10 Internationalassificatioisease10th UN United Nations
edition)
UNAIDS Joint United Nations Programme on
IFN interferon HIV/AIDS
IGRA interferon gamma release assay US United States
IHME Institute for Health Metrics and Evaluation USA United States of America
IU international units VR vital registration
LAM lipoarabinomannan WHO World Health Organization
LF-LAM lateral flow lipoarabinomannan assay WRD WHO-recommended rapid diagnostic
LTBI latent TB infection XDR-TB extensively drug-resistant TB

GLOBAL TUBERCULOSIS REPORT 2019 xi

 An outreach worker from
Operation ASHA makes a home
visit to a TB patient in Delhi,
India, to check if she is adhering
to her treatment.
Andrew Aitchison/Getty Images

xii GLOBAL TUBERCULOSIS REPORT 2019

Executive summary
Background
Tuberculosis (TB) is ommunicable disease thas a major cause
of ill health, one of the top 10 causes of death worldwide and
the leading cause of death from a single
infectiougenrankinbovIV/AIDS)aused
by the bacillus Mycobacterium tuberculosis, which is spread
when people who are sick with TB expel bacteria
inthiroxampleoughingypicallffects
thungpulmonarBualsffectheites
(extrapulmonarB)bouuartehorld’op - ulation is infected with
M. tuberculosis and thus at risk of developing TB disease.
1 in the TB incidence rate. The strate-gy also includes a 2020
Witimeliagnosinreatmenitrst-line
antibiotics for 6 months, most people who develop TB can be
cured and onward transmission of infection cur-tailed. The
number of TB cases occurring each year (and thus the number
of TB-related deaths) can also be driven down by reducing the
prevalence of health-related risk
factoroe.gmokingiabetenInfection),
providing preventive treatment to people with a latent TB
infection, and taking multisectoral action on broader
determinants of TB infection and disease (e.g. poverty,
housinualitnndernutrition).
This report
The World Health Organization (WHO) has published a global
TB report every year since 1997. Its purpose is to provide a
comprehensive and up-to-date assessment 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, and
databases main-tained by other multilateral agencies. In 2019,
data were reported by 202 countries and territories that account
for morha9% ohorld’opulationd estimated number of TB cases.
Global commitments to end TB
and multisectoral accountability
On 26 September 2018, the United Nations (UN) held its first-
eveigh-leveeetinBlevatiniscussion
about the status of the TB epidemic and how to end it to the
level of heads of state and government. It followed
thrslobainisteriaonferencostey
WHO and the Russian government in November 2017. The
outcome was a political declaration agreed by all UN Member
States, in which existing commitments to the
for 57% of all TB cases in 2018. By comparison, women
accounted for 32% and children (aged <15 years) for 11%.
SustainablevelopmenoalSDGsnHO’nd
Ttrategereaffirmednenedded.
SDG Target 3.3 includes ending the TB epidemic by
2030hntrategefineilestonefo020
and 2025) and targets (for 2030 and 2035) for reductions in TB
cases and deaths. The targets for 2030 are a 90% reduc-tion in
the number of TB deaths and an 80% reduction in the TB
incidence rate (new cases per 100 000 population per year)
compared with levels in 2015. The milestones for 2020 are a
35% reduction in the number of TB deaths and a 20% reduction
milestone that no TB patients and their households face
catastrophic costs as a result of TB disease.
The political declaration included four new global tar-gets:
treat 40 million people for TB disease in the 5-year period
2018–2022;
reach at least 30 million people with TB preventive treatment
for a latent TB infection in the 5-year period 2018–2022;
mobilize at least US$ 13 billion annually for universal access
to TB diagnosis, treatment and care by 2022; and
mobilize at least US$ 2 billion annually for TB research.
The political declaration also requested the UN Secretary-
General, with support from WHO, to provide a report in 2020 to
the General Assembly on global and national progress, as the
basis for a comprehensive review at a high-level meeting in
2023. The Director-General of WHO was requested to continue
to develop a multisectoral accountability framework for TB
(MAF-TB) and to ensure its timely implementation.
Status of the TB epidemic
2
Globally, an estimated 10.0 milliorange.0–11.1  mil-lion)
people fell ill with TB in 2018, a number that has been
relatively stable in recent years. The burden of dis-ease varies
enormously among countries, from fewer
thavorha0easee00  000 popula-tion per year, with the global
average being around 130.
There were an estimated 1.2 milliorange.1–1.3  mil-lion) TB
deaths among HIV-negative people in 2018 (a 27% reduction
from 1.7 million in 2000), and an addition-al 251 000 deaths
3
(range, 223 000–281 000) among HIV-positive people (a 60%
reduction from 620 00000).
Tffecteoplotexelgroupuhe
highesurdeeage1ears)hccounted
GLOBAL TUBERCULOSIS REPORT 2019 1
Among all TB cases, 8.6% were people living with HIV
(PLHIV).
 Geographically, most TB cases in 2018 were in the financingervicelivernd sociarotectiohaill
WHegionouth-Eassi44%)fric24%nd reduce these costs. A further 37 surveys are underway or
thesteracifi18%)itmalleercentagen planne019–2020.
thasterediterranea8%)hmerica3%nd
Europ3%)ighountrieccounteowhirdf TB diagnosis and treatment
thlobaotalndi27%)hin9%)ndonesi8%), Achieving the UN high-level meeting target of treating
thhilippine6%)akista6%)igeri4%)an - 40 million people with TB between 2018 and 2022 requires
glades4%noutfric3%)hesnther countrieHO’isigurdeountries treating about 7 million people in 2018 and about 8 mil-lion
people in subsequent years. The targets were built on
4 Drug-resistant TB continues to be a public health thHlagshinitiativFind. Treat. AllEndTB”.
accounteo7horld’ases.
BaseasotificatioateporteHOhe
5 target for 2018 was achieved. Globally, 7.0 million new cas-es
threat. In 2018, there were about half a million new cases of
rifampicin-resistant TB (of which 78% had multidrug-resistant of TB were notified in 2018 – an increase from 6.4 mil-
6
TB). The three countries with the largest share lio01nargncreasroh.7–5.8 million notifiennuallherio009–2012.
ohlobaurdeerndi27%)hin14%nd thussiaederatio9%)lobally.4eB
Moshncreaslobal notificationf Tases
cases and 18% of previously treated cases had multidrug- since 2013 is explained by trends in India and Indonesia,
resistanifampicin-resistanMDR/RR-TB), thwountriehaanrsnhirorldwidn
with the highest proportions (>50% in previously treated cases) 8
terms of estimated incident cases per year. In India, noti-
in countries of the former Soviet Union. ficationeaseosro.2  million to 2.0 million
betwee01n01+60%)ndonesiaotifications
Progress towards the 2020 milestones of rose from 331 703 in 2015 to 563 879 in 2018 (+70%), includ-
the End TB Strategy ing an increase of 121 707 (+28%) between 2017 and 2018.
Currently, the world as a whole, most WHO regions and many Despite increases iotificationshertill
high TB burden countries are not on track to reach the 2020 a large gap between the number of new cases reported (7.0
milestones of the End TB Strategy. million) and the estimated 10.0 milliorange.0–
Globally, the average rate of decline in the TB inci- 11.1 million) incident cases in 2018. This gap is due to a
dencata.6eeaherio000−2018, combination of underreporting of detected cases and
and 2.0% between 2017 and 2018. The cumulative reduc-tion underdiagnosis (i.e. people witB doccess health
between 2015 and 2018 was only 6.3%, considerably short of carroiagnoseheheo).
the End TB Strategy milestone of a 20% reduction between Ten countries accounted for about 80% of the gap, with
2015 and 2020. The global reduction in the total number of TB Indi25%)igeri12%)ndonesi10%nhhil - ippines (8%) accounting
7 9
deaths between 2015 and 2018 was 11%, also less than one for more than half of the total.
third of the way towards the End TB Strategy milestone of a Ihesountriearticularntensifieffortre
35% reduction by 2020. required to improve reporting of detected TB cases and access
The good news is that the WHO European Region is on to diagnosis and treatment.
track to achieve the 2020 milestones for reductions in cases and As countries intensiffforto improve TB diag -
deaths. Between 2015 and 2018, the incidence rate fell 15% and nosis and treatment and close gaps between incidence
the number of TB deaths fell by 24%. Incidence and deaths are anotificationshroportiootifieasehat
also falling relatively fast in the WHO African Region (4.1% aracteriologicallonfirmeeedonitored,
and 5.6%, respectively, per year)itumulativeduction2oncidence to ensure that people are correctly diagnosed and start-
ehosffectivreatmenegimearls
and 16% for deaths between 2015 and 2018. Seven high TB possible. The aim should be to increase the percentage
burden countries are on track to achieve the 2020 mile-stones: oaseonfirmeacteriologicallcalinhe
Kenya, Lesotho, Myanmar, the Russian Federa-tion, South use oecommendeiagnostics (e.gapiolecular
Africa, the United Republic of Tanzania and Zimbabwe. tests) that are more sensitive than smear microscopy. In 2018,
55% of pulmonary cases were bacteriologically
From 2016 to 2019, 14 countries (including seven high TB confirmedlighecreasro6017igh-
burden countries) completed a national facility-based survey of income countries with widespread access to the most sensitive
costs faced by TB patients and their house-holds. Best estimates diagnostic tests, about 80% of pulmonary TB
of the percentage facing total costs that were catastrophic caseracteriologicallonfirmed.
ranged from 27% to 83% for all forms of TB, and from 67% to Thercentagotifieatienthaoc -
100% for drug-resistant TB. Survey results are being used to umented HIV test result in 2018 was 64%, up from 60% in
inform approaches to 2017. In the WHO African Region, where the burden of HIV-
associated TB is highest, 87% of TB patients had a documented
HIV test result. A total of 477 461 TB cases among HIV-
positive people were reported, of which 86% were on
antiretroviral therapy.

2 GLOBAL TUBERCULOSIS REPORT 2019

The latest treatment outcome data for new cases of TB show from 81% in 2016. The improvement was mainly due to progress in
a global treatment success rate of 85% in 2017, an increase India.
Drug-resistant TB: diagnosis and treatment
The political declaration at the UN high-level meeting on TB
included commitments to improve the coverage and quality of
diagnosis, treatment and care for people with drug-resistant TB.
Detection of MDR/RR-TB requires bacteriological
confirmationestinoruesistancsing
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, support-ed by
counselling and monitoring for adverse events.
There was some progress in testing, detection and treatment
of MDR/RR-TB between 2017 and 2018. Global-
l0181eoplitacteriologicallonfirmed
TB were tested for rifampicin resistance, up from 41% in
10
2017. Coverage of testing was 46% for new and 83% for
previously treated TB patients. A global total of 186 772
caseDR/RR-Teretectenotifie018,
up from 160 684 in 2017, and 156 071 cases were enrolled in
treatment, up from 139 114 in 2017.
Despite these improvements, the number of people enrolled
in treatment in 2018 was equivalent to only one in three of the
approximately half a million people who developed MDR/RR-
TB in 2018. Closing this wide gap requires one or more of the
following to be increased: detection of TB cases, the proportion
of TB cases bac-teriologicallonfirmedoveragestinorug
resistancmonacteriologicallonfirmeasend
coverage of treatment for those diagnosed with MDR/ RR-TB.
Ten countries accounted for 75% of the global gap between
treatment enrolments and the estimated num-ber of new cases
of MDR/RR-TB in 2018, and thus will
havtronnfluencrogreslosinhiap.
Those 10 countries were China, India, Indonesia, Mozam-bique,
Myanmar, Nigeria, Pakistan, the Philippines, the Russian
Federation and Viet Nam. China and India alone accounted for
43% of the global gap.
The latest treatment outcome data for people with MDR/RR-
TB show a global treatment success rate of 56%. Examples of
high MDR-TB burden countries with better treatment success
rates (>70%) are Bangladesh, Ethiopia, Kazakhstan and
Myanmar.
TB prevention services
The main health care intervention available to reduce the risk of
a latent TB infection progressing to active TB disease is TB
11
preventive treatment. Vaccination of chil-dreithacillalmette–
GuériBCGaccinan
also confer protection, especially from severe forms of TB in
children.
WHO guidance issued in 2018 recommends TB preven-tive
treatment for PLHIV, household contacts of bacterio-
lion in 2019, with 73% of that amount coming from the Global
Fund to Fight AIDS, Tuberculosis and Malaria (the Global
logicallonfirmeulmonarasenlinicaisk
groupe.ghoseceivinialysis)hreakdown
of the target to reach 30 million people with TB preven-
tivreatmenh-yeaerio018–202ehe
UN high-level meeting on TB was 6 million PLHIV and 24
million household contacts (4 million children aged under 5
years, and 20 milliotheouseholontacts).
Globally in 2018, 65 countries reported initiating TB
preventive treatment for 1.8 million PLHIV (61% in South
Africa)rousnde million in 2017. The 2018
number suggests that the target of 6 million in the period 2018–
202achievedhigB/HIV
burden countries that reported providing treatment, cov-erage
ranged from 10% of PLHIV newly enrolled in care in Indonesia
to 97% in the Russian Federation. Overall, in 66 countries for
which it could be calculated, coverage was 49%.
The number of household contacts initiated on TB preventive
treatment in 2018 was much smaller: 349 487 children aged
under 5 years (a 20% increase from 292 182 i017)quivalen7h.3
million estimated to
be eligible; and 79 195 people in other age groups (a 30%
decrease from 103 34017)ubstantiacale-uill
be needed to reach the targets set at the UN high-level meeting.
In 2018, 153 countries reported providing BCG vac-cination
as a standard part of childhood immunization
programmeshic1eporteoverag90%.
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.
In 119 low- and middle-income countries that reported data
(and accounted for 97% of reported TB cases glob-
ally)undineacheS$ 6.8 billion in 2019, up from
US$ 6.4 billion in 2018 and US$ 3.5 billion in 2006. How-ever,
the amount in 2019 is US$ 3.3 billion less than the US$ 10.1
billion estimated to be required in the Stop TB Partnershs
Global Plan to End TB 2018–2022, and only just over half of
the global target of at least US$ 13 billion per year by 2022 that
was agreed at the UN high-level meeting on TB.
As in previous years, most of the funding (87%) avail-able in
2019 is from domestic sources. This aggregate
figurtronglnfluencehRICrououn - tries (Brazil, Russian
Federation, India, China and South
Africa)hRICountrieccouno3hvail - able funding in 2019, and
95% of their funding is from domestic sources. In India,
domestic funding quadrupled between 2016 and 2019.
In other low- and middle-income countries, interna-tional
donor funding remains crucial, accounting for 38% of the
funding available in the 25 high TB burden countries outside
BRICS and 49% of the funding available in low-income
countries.
International donor funding amounts to US$ 0.9 bil-
GLOBAL TUBERCULOSIS REPORT 2019 3
Fund). This total is far below the annual require-ment of
US$ 2.7 billion estimated in the Global Plan. The largest
 bilateral donor is the US government, which pro-vides 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 preven-tion services
are provided within the context of progress towards universal
health coverage (UHC), and if there is multisectoral action to
address the broader determinants
thanfluencpidemicnheiocioeconomic impact.
UHC means that everyone can obtain the health ser-
viceheeeithouufferinnanciaardshipDG
Target 3.8 is to achieve UHC by 2030; the two indicators to
monitor progress are a UHC service coverage index
(SCI)nhercentaghopulatioxperiencing
household expenditures on health care that are large in relation
to household expenditures or income.
The SCI increased steadily between 2000 and 2017, from a
global value of 45 (out of 100) in 2000 to 66 in 2017. The SCI
in the 30 high TB burden countries (with 87% of global TB
cases) was mostly in the range 40–60howing that much remains
to be done to achieve UHC in these
settingsighealuerazi79)hin79nhai - care and for TB research needs to approximately dou-ble, access
land (80) are encouraging.
In 2015, at least 930 million people or 12.7% of the
world’opulatioaceatastrophixpendituren
healtardefine0ornnuaousehold expenditurncome)ro.4010.
In 2018, an estimated 2.3 million TB cases were attrib-
utable to undernourishment, 0.9 million to smoking (of
which 0.8 millioermonen).8 million to alco - hol abuse, 0.8
million to HIV infection and 0.4 million to diabetes.
Following the request to the WHO Director-General at the
UN high-level meeting, a MAF-TB was released in May 2019.
Countries are being supported to adapt and use the framework.
TB research and development
The SDG and End TB Strategy targets set for 2030 cannot
beithountensifieesearcnevelopment.
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 1.7 billion people
already latently infected, rapid diag-nostics for use at the point
of care, and simpler, shorter drug regimens for treating TB
disease.
The diagnostic pipeline appears robust in terms of the
4 GLOBAL TUBERCULOSIS REPORT 2019
number of tests, but no new technology emerged in 2019. As of
August 2019, there were 23 drugs, various combi-nation
regimens and 14 vaccine candidates in clinical trials. Recently,
the M72/AS01E vaccine candidate was found to be protective
against TB disease in a Phase IIb trial among individuals with
evidence of latent TB infec-tionhndingronfirmehase III trial,
this vaccinoulransforlobareventiofforts.
The latest data published by Treatment Action Group
showed funding of US$ 772 million for TB research and
development in 2017, much less than the target of at least US$ 2
billion per year set at the UN high-level meeting on TB.
Conclusion
Leaderlembetateavommitteend -
inhlobapidemic030ackeon - crete milestones and targets.
Progress is being made. Global indicators for reduc-tions in
TB cases and deaths, improved access to TB pre-
ventionarnncreasenancinrovinn
the right direction. One WHO region and seven high TB burden
countries are on track to reach 2020 milestones for reductions in
TB cases and deaths.
Nonetheless, the pace of progress worldwide and in most
regions and countries is not yet fast enough. In the
nexearsnnuanancinoreventiond
to TB care and preventive treatment needs to expand,
substantial costs faced by TB patients and their households must
be mitigated and multisectoral action on the broader
determinants of the TB epidemic needs to intensify.
Thecretary-General’eporheneral
Assembly in 2020, to be prepared with WHO support, will
provide the next opportunity to assess progress towards agreed
TB targets and milestones.
Thifetimisbou–10%.
Hernlsewhererangeeferh5ncertainty
interval.
When an HIV-positive person dies from TB disease, the underlying
cause is coded as HIV in the International Classi-fication of
Diseaseystem.
The other 22 countries are Angola, Brazil, Cambodia, Central
Africaepublichongohemocratieople’epub - lic of Korea, the
Democratic Republic of the Congo, Ethiopia, Kenya, Lesotho,
Liberia, Mozambique, Myanmar, Namibia, Papua New Guinea, the
Russian Federation, Sierra Leone, Thailand, the United Republic of
Tanzania, Viet Nam, Zambia and Zimbabwe.
Th5ncertaintnterva200–5600.
Defineesistancifampicinsoniazid.
Including TB deaths among both HIV-negative and HIV-positive
people.
Otheountrieitargelativncrease016–201re
shown in Fig. 4.2.
The other six countries are shown in Fig. 4.20.
The numbers cited refer to pulmonary cases.
The four drug regimens currently recommended by WHO are
explained in Chapter 5.
Progress towards End TB Strategy milestones for 2020
and the four global targets set in the political declaration at the
a
UN high-level meeting on TB: latest status

Milestone or Target
20% reduction
TB incidence by 2020 (compared
with 2015)
35% reduction
TB deaths by 2020 (compared
with 2015)
TB patients not 100% of TB
facing catastrophic patients by 2020
costs

40 million people,
TB treatment 2018–2022

TB preventive At least 30 million

treatment people, 2018–2022

Funding for TB US$ 13 billion

prevention and care annually by 2022

Funding for TB US$ 2 billion

research annually, 2018–2022

End of 2018 except for funding for TB prevention and care (2019) and funding for TB research (2017).

GLOBAL TUBERCULOSIS REPORT 2019 5

 BOX 1.1

Basic facts about tuberculosis

Tuberculosis (TB) is an old disease – weeks to provide results but remain States. Treatment for people with
studies of human skeletons show that it the reference standard. TB that is rifampicin-resistant TB (RR-TB) and
has affected humans for thousands of resistant to first-line and second-line d
multidrug-resistant TB (MDR-TB) is  

years – but its cause remained
unknown until 24 March 1882, when Dr
Robert Koch announced his discovery
of the bacillus subsequently named
a,b
Mycobacterium tuberculosis. The
disease is spread when people who are
sick with TB expel bacteria into the air;
for example, by coughing. It typically
affects the lungs (pulmonary TB) but
can also affect other sites
(extrapulmonary TB).
A relatively small proportion (5–10%) of
the estimated 1.7 billion people
infected with M. tuberculosis will
develop TB disease during their
lifetime. However, the probability of
developing TB disease is much higher
among people living with HIV; it is also
higher among people affected by risk
factors such as undernutrition,
diabetes, smoking and alcohol
consumption.
Diagnostic tests for TB disease include
sputum smear microscopy (developed
more than 100 years ago), rapid
molecular tests (first endorsed by
WHO in 2010) and culture-based
methods; the latter take up to 12
anti-TB drugs can be detected using
rapid tests, culture methods and
sequencing technologies.
Without treatment, the mortality rate
from TB is high. Studies of the natural
history of TB disease in the absence of
treatment with anti-TB drugs
(conducted before drug treatments
became available) found that about
70% of individuals with sputum smear-
positive pulmonary TB died within 10
years of being diagnosed, as did about
20% of people with culture-positive
(but smear-negative) pulmonary TB.
c months.
Effective drug treatments were first
developed in the 1940s. The currently
recommended treatment for cases of
drug-susceptible TB disease is a 6-
month regimen of four first-line drugs:
isoniazid, rifampicin, ethambutol and
pyrazinamide. The Global TB Drug
Facility supplies a complete 6-month
course for about US$ 40 per person.
Treatment success rates of at least
85% for cases of drug-susceptible TB
are regularly reported to WHO by its
194 Member
longer, and requires drugs that are
more expensive (≥US$ 1000 per
person) and more toxic. The latest
data reported to WHO show a
treatment success rate for MDR-TB of
56% globally.
Four options for treatment of a latent
TB infection are available: a weekly
dose of rifapentine and isoniazid for
3 months; a daily dose of rifampicin
plus isoniazid for 3 months; a daily
dose of rifampicin for 3–4 months; and
a daily dose of isoniazid for at least 6
The only licensed vaccine for
prevention of TB disease is the bacille
Calmette-Guérin (BCG) vaccine. The
BCG vaccine was developed almost
100 years ago, prevents severe forms
of TB in children and is widely used.
There is currently no vaccine that is
effective in preventing TB disease in
adults, either before or after exposure
to TB infection, although results from a
Phase II trial of the M72/AS01E
e
candidate are promising.

Hershkovitz I, Donoghue HD, Minnikin DE, May H, Lee OY, Feldman M, et al. Tuberculosis origin: the Neolithic scenario. Tuberculosis.
2015;95 Suppl 1:S122–6 (https://www.ncbi.nlm.nih.gov/pubmed/25726364, accessed 3 July 2019).
Sakula A. Robert Koch: centenary of the discovery of the tubercle bacillus, 1882. Thorax. 1982;37(4):246–51 (https://www.ncbi.nlm.nih.
gov/pubmed/6180494, accessed 3 July 2019).
Tiemersma EW, van der Werf MJ, Borgdorff MW, Williams BG, Nagelkerke NJ. Natural history of tuberculosis: duration and fatality of
untreated pulmonary tuberculosis in HIV negative patients: a systematic review. PLoS One. 2011;6(4):e17601 (https://www.ncbi.nlm.
nih.gov/pubmed/21483732, accessed 3 July 2019).
Defined as resistance to isoniazid and rifampicin, the two most powerful anti-TB drugs.
Further details are provided in Chapter 8.

6 GLOBAL TUBERCULOSIS REPORT 2019

Chapter 1
Introduction
Worldwide, around 10 million people fall ill with tuber-culosis
(TB) each year. TB is one of the top 10 causes of death, and the
leading cause from a single infectious agent (Mycobacterium
tuberculosis), ranking above HIV/
AIDShiseasaffecnyonnywhereut
most people who develop TB (about 90%) are adults, the
male:female ratio is 2:1, and case rates at national level vary
from less than 50 to more than 5000 per 1 million population
per year. Almost 90% of cases each year are in 30 high TB
burden countries. Globally, an estimated 1.7 billion people are
infected with M. tuberculosis and are thus at risk of developing
the disease.
With a timely diagnosis and treatment with antibi-otics, most
people who develop TB can be cured and onward transmission
curtailed. The number of cases occurring each year (and thus
the number of TB-related deaths) can also be driven down by
reducing the preva-lence of health-related risk factors for TB
(e.g. smoking,
diabetenInfection)rovidinreventive treat - ment to people with a
latent TB infection, and action on broader determinants of TB
infection and disease (e.g. povertyousinualitnndernutrition).
In 2014 and 2015, all Member States of the World Health
Organization (WHO) and the United Nations (UN) committed
to ending the TB epidemic. They did this by
unanimouslndorsinHO’ntrateghe
World Health Assembly in May 2014, and by adopting the UN
Sustainable Development Goals (SDGs) in September 2015.
SDG Target 3.3 includes ending the TB epidemic by
2030hntrategefineilestonefo020
and 2025) and targets (for 2030 and 2035) for reductions in TB
cases and deaths. The targets for 2030 are a 90% reduc-tion in
the number of TB deaths and an 80% reduction in the TB
incidence rate (new cases per 100 000 population per year)
compared with levels in 2015. The milestones for 2020 are
reductions of 35% and 20%, respectively.
In 2017 and 2018, political commitment to ending TB was
stepped up.
ThrslobainisteriaonferencndinB
was held in November 2017, jointly hosted by WHO and
the government of the Russian Federation. The outcome
was the Moscow Declaration to End TB, which in May
201aelcomelHO’9embetatet
the World Health Assembly.
Oeptembe018heltrst-ever
high-level meeting on TB; the meeting was attended by heads
of state and government, and the outcome was a political
declaration agreed by all UN Member States. Existing
commitments to the SDGs and End TB Strategy
wereaffirmeneneddedlobaargetor
the funding to be mobilized for TB prevention and care
(aeasS$  13 billion per year by 2022) and TB research and
development (US$ illioeearerefineor
thrsimeneargeteohotaumberf
people to be reached with treatment for disease (40 mil-lion
globally) and infection (30 million globally) between 2018 and
2022. The political declaration also requested the UN Secretary-
General, with support from WHO, to provide a report to the
General Assembly in 2020 on glob-al and national progress, as
the basis for a comprehen-sive review at a high-level meeting in
2023.
WHO has published a global TB report every year since
1997. Its purpose is to provide a comprehensive and up-to-date
assessment of the TB epidemic and of progress in the response
at global, regional and country levels, in the context of global
commitments and strategies. The report is based primarily on
data gathered by WHO from countries in annual rounds of data
1
collection, and data bases maintained by other multilateral
agencies. This 2019 edition provides a strong foundation for the
UN Secretary-General’rogresepor020.
The main chapters of the report provide an overview of the
SDGs, the End TB Strategy and political declara-
tionelateChapte)stimateisease burde000–
201Chapte)hatesateported
to WHO on TB diagnosis and treatment services (Chap-ter 4)
and on prevention services (Chapter 5) and recent
trendshatesateporteHnancinor
TB prevention, diagnosis and treatment and trends since
200Chapte)ssessmenrogresowardni - versal health coverage and
the status of broader deter-minantncidencChapte)nummarf
the development pipelines for new TB diagnostics, drugs,
druegimennaccinef Augus01Chapte). Chapter–
ivpecifittentiorogresowards
the 2020 milestones of the End TB Strategy and the new global
targets set in the political declaration at the UN high-level
meeting on TB.
Theport’nnexeomprisxplanatiof
sources of data used for the report and how to access
WHO’nlinlobaatabaserofileoigB
burdeountrienHO’iegionsnatoey
indicators for all countries, for the latest available year.
Basic facts about TB are provided in Box 1.1.
In the 2019 round of global TB data collection, 202 countries
anerritorieitorha9% of thorld’opulation
and estimated number of TB cases reported data. Further details are
provided in Annex 1.
GLOBAL TUBERCULOSIS REPORT 2019 7

8 GLOBAL TUBERCULOSIS REPORT 2019
The first UN high-level meeting on TB was held
on 26 September 2018. The theme of the
meeting was “United to end TB: an urgent
global response to a global epidemic”.
Ben Hartschuh/WHO
Chapter 2
Global commitments to end TB
and multisectoral accountability
From 200015, global, regional anationafforts
to reduchurden ouberculosis (TB) disease focused
on achieving targets set within the context of the Mil-
lenniuevelopmenoalMDGs)hDGere
established by the United Nations (UN) in 2000, and tar-
getereo015argeDahalnd
reverse” TB incidence. The StTB Partnership adopt - ed this
target and set two additional targets: to halve TB prevalence and
TB mortality rates by 2015 compared with their levels in 1990.
The global TB strategy developed by the World Health
Organization (WHO) for the decade 2006‒201htop Ttrategy
ahverall goaf
reaching all three of these targets. In October 2015, WHO
published its assessment of whether the 2015 global TB targets
for reductions in TB incidence, prevalence and mortality had
been achieved (1).
For the period 2016–2035lobal, regional and national
efforteduchurdeiseasavhmbi
tiouiendinhpidemic”ithihontext
ohN’gendoustainablevelopmentnd
baseHO’ntrategyhustainablevel
opment Goals (SDGs) and their associated indicators and
targets were adopted by all UN Member States in Septem-
be015hDGoveherio016–2030 (2) , and the End TB Strategy is
for the period 2016–2035 (3). In 2017 and 2018, TB
commitments included in the SDGs and End
Ttrategereaffirmehrst-evelobain - isterial conference on TB
(held in Moscow in November 2017) (4)nhrst-eveigh-
leveeetinB
(held at UN headquarters in New York in September 2018) (5).
Targets for TB that are consistent with those set in the End TB
Strategy have been included in WHO’s Thirteenth
Generarogrammork019–202GP3) (6) . This chapter provides
the broad context for the rest of
this report. It starts with an overview of the SDGs (Sec-
tion 2.1) and the End TB Strategy (Section 2.2)hen
describehoscoeclaratiorohrslobal
ministerial conference on TB (Section 2.3)holitical
declaratiohrsigh-leveeetin Sec-
tion 2.4)nhargetncludeHO’PW  13
(Section 2.5). Section 2.6 describes a multisectoral
accountability framework for TB, developed under the
leadership of WHO between January 2018 and April 2019, in
response to commitments made in the Moscow Dec-laration, a
TB resolution at the World Health Assembly in 2018 and the
political declaration at the UN high-level meeting. Section 2.7
identifies anxplains countries defineHigurdefoBIV-associated
Trug-resistanB)hesountrieriveartic -
ular attention throughout the report.
2.1 The Sustainable Development Goals
The 17 SDGs are shown in Box 2.1.
The consolidated goal for health is SDG 3, which
iefineEnsurealthivenromotell-
being for all at all ages”. Thirteen targets have been set for this
goal (Box 2.2)nnhesargetsarget
3.3xplicitlentionBB030nhpidemics
of AIDS, tuberculosis, malaria and neglected tropical diseases
and combat hepatitis, water-borne diseases and
otheommunicabliseases”hanguagending
epidemicsrominenlemenlobaealttrat - egies developed by WHO
and the Joint United Nations Programme on HIV/AIDS
(UNAIDS) for the SDG era (7),
including the End TB Strategy (Section 2.2)hndi - cator for
- Target 3.3 is the TB incidence rate (i.e. new TB cases per
100 00opulatioeear).
SDG 3 also includes a target (Target 3.8) related to uni-
- versaealtoveragUHChapecificallentions
TB. UHC means that everyone can obtain the health ser-
viceheeeithouufferinnanciaardship (8,
9). Target 3.8 includes an indicator for the coverage of essential
prevention, treatment and care interventions. This is a composite
1
indicator based on the coverage of 16 “tracer interventions”,
one of which is TB treatment.
The SDGs include considerable emphasis on disaggre-gated
analysis and reporting of data (as well as report-
inontirountry)ependinhndicator,
examples include disaggregation by age, sex, location and
economic status (e.g. bottom 40%, or bottom versus
top incomuintiles)omndicatorlsivtten -
tiopecifiubpopulationsucregnanom -
en, people with disabilities, victims of work injuries and
migrants.
In support of the requirement for disaggregation for many
indicators, SDG 17 includes two targets and asso-
ciatendicatorndehubheadinDataon -
itorinnccountability”hicpecificallefer
to disaggregated data and the mechanisms needed to generate
such data (Table 2.1). Emphasis is also given to the importance
of death registration within national
1
Therrany differenreventionreatmennterven - tions. SDG Indicator
3.8.1 is based on the coverage of 16 inter-
ventionhaaveeelectetracersossessment
of progress towards UHC for all interventions. Further details are
provided in Chapter 7.
GLOBAL TUBERCULOSIS REPORT 2019 9
 BOX 2.1

The Sustainable Development Goals

Goal 1. End poverty in all its forms everywhere

Goal 2. End hunger, achieve food security and improved nutrition and promote sustainable agriculture Goal
3. Ensure healthy lives and promote well-being for all at all ages
Goal 4. Ensure inclusive and equitable quality education and promote lifelong learning opportunities for all Goal 5.
Achieve gender equality and empower all women and girls
Goal 6. Ensure availability and sustainable management of water and sanitation for all Goal
7. Ensure access to affordable, reliable, sustainable and modern energy for all
Goal 8. Promote sustained, inclusive and sustainable economic growth, full and productive employment and
decent work for all
Goal 9. Build resilient infrastructure, promote inclusive and sustainable industrialization and foster innovation Goal
10. Reduce inequality within and among countries
Goal 11. Make cities and human settlements inclusive, safe, resilient and sustainable
Goal 12. Ensure sustainable consumption and production patterns Goal 13. Take urgent
a
action to combat climate change and its impacts

Goal 14. Conserve and sustainably use the oceans, seas and marine resources for sustainable development
Goal 15. Protect, restore and promote sustainable use of terrestrial ecosystems, sustainably manage forests,
combat desertification, and halt and reverse land degradation and halt biodiversity loss
Goal 16. Promote peaceful and inclusive societies for sustainable development, provide access to justice for all and
build effective, accountable and inclusive institutions at all levels
Goal 17. Strengthen the means of implementation and revitalize the Global Partnership for Sustainable
Development

Acknowledging that the United Nations Framework Convention on Climate Change is the primary international, intergovernmental forum for
negotiating the global response to climate change.

10 GLOBAL TUBERCULOSIS REPORT 2019

BOX 2.2

Sustainable Development Goal 3 and its 13 targets

SDG 3: Ensure healthy lives and promote well-being for all at all ages

Targets
3.1 By 2030, reduce the global maternal mortality ratio to less than 70 per 100 000 live births
3.2 By 2030, end preventable deaths of newborns and children under 5 years of age, with all countries aiming to reduce
neonatal mortality to at least as low as 12 per 1000 live births and under-5 mortality to at least as low as 25 per 1000 live
births
3.3 By 2030, end the epidemics of AIDS, tuberculosis, malaria and neglected tropical diseases and combat hepatitis,
water-borne diseases and other communicable diseases
3.4 By 2030, reduce by one third premature mortality from non-communicable diseases through prevention and
treatment and promote mental health and well-being
3.5 Strengthen the prevention and treatment of substance abuse, including narcotic drug abuse and harmful use of
alcohol
3.6 By 2020, halve the number of global deaths and injuries from road traffic accidents
3.7 By 2030, ensure universal access to sexual and reproductive health-care services, including for family planning,
information and education, and the integration of reproductive health into national strategies and programmes
3.8 Achieve universal health coverage, including financial risk protection, access to quality essential health-care services and
access to safe, effective, quality and affordable essential medicines and vaccines for all
3.9 By 2030, substantially reduce the number of deaths and illnesses from hazardous chemicals and air, water and soil
pollution and contamination
3.a Strengthen the implementation of the World Health Organization Framework Convention on Tobacco Control in all
countries, as appropriate
3.b Support the research and development of vaccines and medicines for the communicable and non-communicable
diseases that primarily affect developing countries, provide access to affordable essential medicines and vaccines, in
accordance with the Doha Declaration on the TRIPS Agreement and Public Health, which affirms the right of developing
countries to use to the full the provisions in the Agreement on Trade-Related Aspects of Intellectual Property Rights
regarding flexibilities to protect public health, and, in particular, provide access to medicines for all
3.c Substantially increase health financing and the recruitment, development, training and retention of the health
workforce in developing countries, especially in least developed countries and small island developing States
3.d Strengthen the capacity of all countries, in particular developing countries, for early warning, risk reduction and
management of national and global health risks

TRIPS, Trade-Related Aspects of Intellectual Property Rights

TABLE 2.1

SDG 17, and targets and indicators related to data, monitoring and accountability

SDG 17: Strengthen the means of implementation and revitalize the global partnership for sustainable development

TARGETS INDICATORS

17.18 By 2020, enhance capacity-building support to developing
countries, including for least developed countries and small island
developing States, to increase significantly the availability of
high-quality, timely and reliable data disaggregated by income,
gender, age, race, ethnicity, migratory status, disability, geographic
location and other characteristics relevant in national contexts
17.18.1 Proportion of sustainable development indicators
produced at the national level with full disaggregation
when relevant to the target, in accordance with the
Fundamental Principles of Official Statistics

17.19 By 2030, build on existing initiatives to develop 17.19.2 Proportion of countries that (a) have conducted
measurements of progress on sustainable development that at least one population and housing census in the last 10
complement gross domestic product, and support statistical years; and (b) have achieved 100 per cent birth registration
capacity-building in developing countries and 80 per cent death registration
GLOBAL TUBERCULOSIS
REPORT 2019 11