Global

Tuberculosis
Report
2022
Global tuberculosis report 2022

ISBN 978-92-4-006172-9 (electronic version)

ISBN 978-92-4-006173-6 (print version)

© World Health Organization 2022

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Contents

Acknowledgements vii

Abbreviations xiii

1. Introduction 1

2. Global TB commitments, strategy and targets 3

3. Main findings and messages 5

4. Conclusions 33

References 34

Annex 1. Basic facts about TB 37

Annex 2. The WHO global TB database 39

Annex 3. WHO global lists of high TB burden countries 41

Annex 4. Country, regional and global profiles 44

Annex 5. Updates to estimates of TB disease burden 45

Annex 6. The WHO TB-SDG monitoring framework 49

Global Tuberculosis Report 2022   iii

 Dr Tedros Adhanom Ghebreyesus
Director-General
World Health Organization

“
If the pandemic has taught us anything, it’s that with
solidarity, determination, innovation and the equitable use of
tools, we can overcome severe health threats. Let’s apply those
lessons to tuberculosis. It is time to put a stop to this long-time

”
killer. Working together, we can end TB.
 Dr Tereza Kasaeva
Director
WHO Global TB Programme

“
The report provides important new evidence and makes a
strong case for the need to join forces and urgently redouble
efforts to get the TB response back on track to reach TB targets
and save lives. It will be an essential resource for countries,
partners and civil society in the lead up to the second

”
UN high-level meeting on TB to be held in 2023.
Acknowledgements

The Global tuberculosis report 2022 and accompanying The production of the core report document was
online materials and products were produced by a core coordinated by Katherine Floyd and Irwin Law. The main
team of 15 people: Annabel Baddeley, Saskia den Boon, text was written by Katherine Floyd. Irwin Law organ-
Anna Dean, Hannah Monica Dias, Dennis Falzon, Kath- ized the preparation of all figures and tables, which
erine Floyd, Inés García Baena, Nebiat Gebreselassie, were produced by Anna Dean, Peter Dodd (Sheffield
Philippe Glaziou, Marek Lalli, Irwin Law, Peter Nguhiu, University, United Kingdom of Great Britain and North-
Lana Syed, Hazim Timimi and Takuya Yamanaka. The ern Ireland), Philippe Glaziou, Irwin Law, Peter Nguhiu,
team was led by Katherine Floyd. Overall oversight was Hazim Timimi and Takuya Yamanaka. Annexes 1, 3 and
provided by the Director of the Global TB Programme, 6 were prepared by Katherine Floyd; Annexes 2 and 4 by
Tereza Kasaeva. Hazim Timimi; and Annex 5 by Anna Dean and Katherine
The data collection forms were developed by Floyd, with inputs from Nimalan Arinaminpathy (Impe-
Philippe Glaziou and Hazim Timimi, with input from staff rial College London, United Kingdom) and Peter Dodd
throughout the WHO Global TB Programme. Pedro Ave- (Sheffield University, United Kingdom). The report team
dillo, Marek Lalli, Ernesto Montoro, and Anna Stukalova is very grateful to Nimalan Arinaminpathy and Peter
assisted with translations of new content into French, Dodd for their key contributions to the estimates of TB
Russian and Spanish. Hazim Timimi led and organized disease burden that are included in the report. Nimalan
all aspects of data and code management, including the Arinaminpathy produced all of the estimates of TB inci-
preparation and implementation of the online system dence and mortality in 2020 and 2021 that were based
used for the 2022 round of global TB data collection on country or region-specific dynamic models (27 and
from 215 countries, territories and areas. 26 countries, respectively) and Peter Dodd produced
Data were reviewed by the following people at WHO all of the estimates related to the incidence of rifampic-
headquarters: Annabel Baddeley, Saskia den Boon, in-resistant TB in the period 2015–2021.
Annemieke Brands, Anna Dean, Dennis Falzon, Inés The webpages that accompany the core report doc-
García Baena, Nebiat Gebreselassie, Medea Gegia, Avi- ument include expanded and more detailed content
nash Kanchar, Alexei Korobitsyn, Marek Lalli, Cecily for seven major topics: 1) the COVID-19 pandemic and
Miller, Ernesto Montoro, Carl-Michael Nathanson, Peter TB, prepared by Katherine Floyd and Takuya Yamana-
Nguhiu, Linh Nguyen, Liana Oganezova, Gita Parwati, ka; 2) TB disease burden, comprising TB incidence
Samuel Schumacher, Lana Syed, Hazim Timimi, Sabine (prepared by Katherine Floyd and Irwin Law, based
Verkuijl, Yi Wang and Takuya Yamanaka. Data for the on analyses undertaken by Nimalan Arinaminpathy,
European Region were collected and validated jointly Peter Dodd, Philippe Glaziou and Hazim Timimi), TB
by the WHO Regional Office for Europe and the Europe- mortality (prepared by Katherine Floyd and Irwin Law,
an Centre for Disease Prevention and Control (ECDC). based on analyses undertaken by Nim Arinaminpathy,
UNAIDS managed the process of data collection from Peter Dodd, Philippe Glaziou and Hazim Timimi), drug-
national AIDS programmes and provided access to their resistant TB (prepared by Anna Dean, Peter Dodd and
TB/HIV dataset. Review and validation of TB/HIV data Hazim Timimi) and national TB prevalence surveys (pre-
were both undertaken in collaboration with UNAIDS staff. pared by Katherine Floyd and Irwin Law); 3) TB diagnosis
Doris Ma Fat from the WHO Mortality and Burden of and treatment, prepared by Katherine Floyd and Takuya
Disease team provided data from the WHO Mortality Yamanaka, with contributions from Nazir Ismail, Alexei
Database that were used to estimate TB mortality among Korobitsyn, Fuad Mirzayev and Carl-Michael Nathanson;
HIV-negative people; and Juliana Daher and Mary Mahy 4) TB prevention, prepared by Annabel Baddeley, Saskia
(UNAIDS) provided epidemiological data that were used den Boon, Dennis Falzon and Hazim Timimi; 5) Financ-
to estimate HIV-associated TB incidence and mortality. ing for TB prevention, diagnostic and treatment servic-
Many people contributed to the analysis of data, es, prepared by Peter Nguhiu with contributions from
preparation of figures and tables, and writing required Katherine Floyd and Inés García Baena; 6) Universal
for the core report document and the expanded web- health coverage (UHC) and TB determinants, prepared
based content and mobile app which accompany it. by Takuya Yamanaka with contributions from Katherine
Unless otherwise specified, those named work in the Floyd and Ernesto Jaramillo; and 7) TB research and
WHO Global TB Programme. innovation, prepared by Nebiat Gebreselassie and Irwin

Global Tuberculosis Report 2022   vii

Law, with contributions from Dennis Falzon, Katherine The web-based global, regional and country profiles
Floyd, Medea Gegia, Nazir Ismail, Alexei Korobitsyn, that accompany the core report document were pre-
Tiziana Masini, Cecily Miller and Fuad Mirzayev. The pared by Hazim Timimi. Simplified versions for a more
graphics that appear in the webpages were initially gen- general audience were prepared by Hannah Monica
erated as static images. The interactive versions, which Dias and Yi Wang.
allow users to visualize data values by hovering over The report team is grateful to various WHO staff
data points, were prepared by Takuya Yamanaka with outside the WHO Global TB Programme for their use-
input from Hazim Timimi. ful comments and suggestions on advanced drafts of
The webpages that accompany the core report doc- report content. Particular thanks are due to Wahyu
ument also include content on four featured topics. Retno (Annet) Mahanani for her review of content
These are TB-related innovations during the COVID-19 related to estimates of TB disease burden; Elena Vovc
pandemic, prepared by Dennis Falzon and Nebiat for her review of content related to TB and HIV; and
Gebreselassie; international donor funding for TB, pre- Tessa Tan-Torres Edejer, Gabriela Flores Pentzke Saint-
pared by Peter Nguhiu; ensuring meaningful engage- Germain and Joe Kutzin for their reviews of material
ment of civil society, communities, and people affected related to TB financing, UHC and TB determinants. The
by TB, prepared by Lana Syed with contributions from team is also grateful to various external contributors.
Tauhid Islam, Farai Mavhunga and members of the Particular thanks are due to Gavin Churchyard, Sophia
WHO Civil Society Task Force on TB1; and multisectoral Georghiou, Mikashmi Kohli, Barbara Laughon, Adam
accountability in the TB response, prepared by Hannah Penn-Nicholson, Morten Ruhwald, Mel Spigelman, Zaid
Monica Dias, Sayohat Hasanova, Tereza Kasaeva and Tanvir, Margaretha de Vos and Jennifer Woolley for their
Liana Oganezova. contributions to and reviews of content related to TB
The technical appendix that explains the methods research and innovation.
used to produce estimates of TB disease burden was The principal source of financial support for the
prepared by Anna Dean, Nimalan Arinaminpathy (Impe- report was the United States Agency for International
rial College, London, United Kingdom) and Peter Dodd Development (USAID). Production of the report and
(University of Sheffield, United Kingdom). accompanying materials and products was also sup-
The data and other content provided in the Global ported by the governments of Japan and the Republic
tuberculosis report 2022 mobile app, which includes of Korea.
country, regional and global profiles showing data for In addition to the core report team and those men-
key indicators (including values for the latest available tioned above, the report benefited from inputs from
year for all indicators as well as time series for most many staff working in WHO regional and country offices
indicators) and two slide-sets based on the main find- and hundreds of people working for national TB pro-
ings and messages of the main report that highlight (i) grammes or within national surveillance systems who
key facts and (ii) an overview of progress towards global contributed to the reporting of data and to the review
TB targets, was prepared by Katherine Floyd, Irwin Law of report material prior to publication. These people are
and Hazim Timimi. Translations of new content were listed below, organized by WHO region.
done by Licé Gonzalez Angulo (Spanish), Mathieu Bas- Among the WHO staff listed below, the report team is
tard (French), Marek Lalli (French), and Liana Oganezova particularly grateful to Pedro Avedillo, Kenza Bennani,
(Russian). Marek Lalli was also the main focal point for Vineet Bhatia, Martin Van Den Boom, Po-lin Chan, Maria
communications with the app developer, Adappt. The Regina Christian, Michel Gasana, Jean de Dieu Irage-
app was first developed by the WHO Global Tuberculo- na, Giorgi Kuchukhidze, Ernesto Montoro, Kiran Rade,
sis Programme in collaboration with Adappt in 2019 and Kalpeshsinh Rahevar, Md Kamar Rezwan, Manami Yana-
has subsequently been maintained by Adappt through- gawa and Askar Yedilbayev for their contribution to data
out the year and then updated on an annual basis, in collection and validation, and review and clearance of
conjunction with the release of the report. The report report material by countries in advance of publication.
team is very appreciative of the excellent work done by
Adappt.

1
The membership of the Task Force is described at
https://www.who.int/groups/civil-society-task-force-on-tb.

viii  Global Tuberculosis Report 2022

WHO staff in regional and country offices
WHO African Region
Jean Louis Abena, Esther Aceng-Dokotum, Haruna Adamu, Adjoa Agbodjan-Prince, Javier Aramburu, Fekadeselassie
Mikru Asfaw, Claudina Augusto da Cruz, Nayé Bah, Mariama Baïssa Abdoulaye, Nurbai Calu, Siriman Camara, Lastone
Chitembo, Kokou Mawulé Davi, Teshome Desta Woldehanna, Ndella Diakhate, Noel Djemadji, Ismael Hassen Endris,
Fatimetou Zahra Fall, Louisa Ganda, Boingotlo Gasennelwe, Michel Gasana, Carolina Cardoso da Silva Gomes, Sirak
Hailu Bantiewalu, Telesphore Houansou, Jean de Dieu Iragena, Moses Jeuronlon, Michael Jose, Nzuzi Katondi, Kassa
H Ketema, Aristide Désiré Komangoya-Nzonzo, Sharmila Lareef-Jah, Angela Katherine Lao Seoane, Nomthandazo
Lukhele, David Lukudu, Johnson Lyimo, Simbarashe Mabaya, Casimir Manzengo, Nkateko Mkhondo, Christine
Musanhu, Ahamada Nassuri, Richard Mbumba Ngimbi, Laurent Moyenga, Andre Ndongosième, Benjamin Musembi
Nganda, Mkhokheli Ngwenya, Denise Nkezimana, Nicolas Nkiere, Ghislaine Nkone Asseko, Ajoy Nundoochan,
Ishmael Nyasulu, Eunice Omesa, Amos Omoniyi, Joyce Onsongo, Samuel Ogiri, Muhayimpundu Ribakare, Kafui
Senya, Danièle Simnoue, Susan Tembo, Evelyne Tibananuka, Hubert Wang, Kouadio Yeboue, Addisalem Yilma
Tefera, Assefash Zehaie.

WHO Region of the Americas

Zohra Abaakouk, Angel Alvarez, Fiona Elizabeth Anthony, Miguel Angel Aragón, Pedro Avedillo, Valerie Beach-Horne,
Edwin Bolastig, Susana Borroto, Ana Botello, Olivia Brathwaite, Gemma Chery, Rainier Escalada, Gloria Figueroa,
Ingrid Garcia, Izola Garcia, Harry Geffrard, Guillermo Gonzalvez, Monica Guardo, Percy Halkyer, Franklin Hernandez,
Reynold Hewitt, Ana Maria Jimenez, Sandra Jones, Job Joseph, Francisco Leon, Tezel Lightbourne, Wilmer Marquiño,
Oscar Martin Mesones, Ernesto Montoro, Romeo Montoya, Edmundo Morales, Rodolfo Peña, Enrique Perez Flores,
Soledad Perez, Jean Marie Reangabwoda, Elizabeth Rodriguez, Grisel Rodriguez, Mónica Rondón, Hans Salas, María
Jesús Sánchez, Prabhjot Singh, Nicole Helene Slack-Liburd, Katrina Smith, Aida Soto, Valeska Stempliuk, Alfonso
Tenorio, Jorge Victoria, Franka des Vignes, Marcelo Vila, Kenya Ward, Zerabruk Weres, Anneke Wilson.

WHO South-East Asia Region

Vineet Bhatia, Po-lin Chan, Maria Regina Christian, Deyer Gopinath, Anupama Hazarika, Faiha Ibrahim, O Nam
Ju, Debashish Kundu, Jonathan Marbun, Khin Pa Pa Naing, Shushil Dev Pant, Malik Parmar, Kiran Rade, Ranjani
Ramachandran, Md Kamar Rezwan, Ivonia Mascarenhas Do Rosario, Nazis Arefin Saki, Preshila Samarweera, Khine
Thet Su, Domingas Da Silva, Barsha Thapa, Aye Thida, Sonam Wangdi, Kyaw Ko Ko Win.

WHO European Region

Ana Ciobanu, Andrei Dadu, Georgii Dymov, Soudeh Ehsani, Jamshid Gadoev, Gayane Ghukasyan, Viatcheslav
Grankov, Elmira Gurbanova, Tom Hiatt, Araksya Hovhannesyan, Giorgi Kuchukhidze, Artan Mesi, Andreea Teodora
Popescu, Mustafa Bahadir Sucakli, Javahir Suleymanova, Sona Valiyeva, Askar Yedilbayev, Saltanat Yegeubayeva,
Gazmend Zhuri.

WHO Eastern Mediterranean Region

Khawaja Laeeq Ahmad, Isra Muzamil Ahmed, Ziad Aljarad, Mohammad Reza Aloudal, Ala’a Al-shaikh, Kenza Bennani,
Nahla Gamal Eldin, Salma Gouda, Santosha Kelamane, Adnan Khamasi, Ghada Oraby, Nada Bakri Osman Ali, Ramzi
Ouhichi, Fatouma Salem, Ireneaus Sebit Sindani, Martin Van Den Boom, Omid Zamani.

WHO Western Pacific Region

Nadhir Adi Azahar, Zhongdan Chen, Serongkea Deng, Philippe Guyant, Clarissa Blanca Halum, Vibol Iem, Tauhid
Islam, Narantuya Jadambaa, Fukushi Morishita, Lanique Pitasua, Anuzaya Purevdagva, Kalpeshsinh Rahevar,
Joanne Saimon, Jacques Sebert, Vilath Seevisay, Lia Tanabose, Davidson Teh, Hieu Vu, Christine Whalen, Subhash
Yadav, Rajendra-Prasad Yadav, Manami Yanagawa.

Global Tuberculosis Report 2022   ix

National respondents who contributed to reporting and verification of data
WHO African Region
Abderramane Abdelrahim Barka, Shingiro Achille, Yaw Adusi-Poku, Dissou Affolabi, Arnaud Baurel Akiera, Sofiane
Alihalassa, Soumana Alphazazi, Chukwuma Anyaike, Caroline Asin, Idris Samba Aw, Mamadou Pathe Balde, José
Benedita, Ballé Boubakar, Adama Marie Bangoura, Jorge Noel Barreto, Wilfried Bekou, Annie Prudence Bisso
Ngono, Kahina Bouaziz, Miguel Camara, Obioma Chijioke-Akaniro, Ernest Cholopray, Adjima Combary, Fatou Tiépé
Coulibaly, Abdoul Karim Coulibaly, Isaias Dambe, Bonifacio De Sousa, John Deng, Adama Diallo, Ambrósio Disadidi,
Sicelo Dlamini, Themba Dlamini, Mohammed Fall Dogo, Antoine Etoundi Evouna, Juan Eyene, Yakhokh Fall, Hervé
Gildas Gando, Evariste Gasana, Belaineh Girma, Barnabé Gning, Adulai Gomes Rodrigues, Amanuel Hadgu Mebrahtu,
Santiago Izco, Philip Juach, Vincent Kamara, El Hadj Malick Kane, Clara Chola Kasapo, Michel Kaswa Kayomo, Mariam
Keita, Colette Kinkela, Riziki Kisonga, David Korboi, Jacquemin Kouakou, Felix Kwami Afutu, Taye Letta, Patrick
Lungu, Llang Maama, Raimundo Machava, Mariama Mahmoud, Jocelyn Mahoumbou, Dorothy Maloboka, Bheki
Mamba, Manguinga Guitouka Strédice, Patrick Migambi, Louine Morel, James Mpunga, Robson Mukwiza, Lindiwe
Mvusi, Aboubacar Mzembaba, Euphrasie Ndihokubwayo, Norbert Ndjeka, Nkana Yiki Winnie, Emmanuel Nkiligi,
Tendai Nkomo, Josélyne Nsanzerugeze, Sister Hiwet Nuguse, Franck Okemba-Okombi, Abdelhadi Oumar, Emile
Rakotondramananana, Harolalaina Rakotondrazanany, Thato Raleting, Reesaul Ramprakash, Aiban Ronoh, Kantara
Sacko, Wandifa Samateh, Agbenyegan Samey, Charles Sandy, Kebba Sanneh, Hilarius Shilomboleni, Tienabe Siene,
Bakary Sirageou, Nicholas Siziba, Apal Toby, Daniel Tollo, Thsoyaone Titi Tsholofelo, Stavia Turyahabwe, Justine
Zlahn.

WHO Region of the Americas

Sarita Aguirre, Shalauddin Ahmed, Edwin Alexis Aizpurua, Xochil Alemán de Cruz, Gabriela Amaya, Aisha Andrewin,
Dwain Archibald, Milla Norma Leticia Artiles, Carla Ayala, Carlos Alberto Marcos Ayala Luna, Patricia Bartholomay,
Jose Calderon-Squiabro, Lemus Sandy Sorayda Cano, Shawn Charles, Karolyn Chong, Karolyn April Chong Castillo,
Angel Colon-Semidey, Eric Commiesie, Mariela Contrera, Yaren Cruz, Oscar Andres Cruz Martinez, Tracy Dalton, Jose
Davy, Carlos Andres De la Rocha Guerra, Fernanda Dockhorn Costa Johansen, Melanea Encarnacion, Nadia Escobar
Salinas, Mercedes España Cedeño, Tomasa Portillo Esquivel, Hugo Fernandez, Benites Cecilia Ruth Figueroa, Clarita
Freile, Gail Gajadhar, Julio Garay Ramos, Anyeli Garcia, Alrisa Gardiner, Neela Goswami, Claudia Gutiérrez, Maria
Henry, Diana Khan, Adam Langer, Diana Lawrence, Hazel Laws, Claudia Llerana Polo, Fátima Leticia Luna López,
Eugene Maduro, Andrea Maldonado Saavedra, María de Lourdes Martínez Olivares, Angélica Medina, Caballero
Andea Azucena Mejía, Jeetendra Mohanlall, Francis Morey, Willy Morose, Pilar Muñoz, Franchina Murillo Picado,
Marcela Natiello, Jacquelyn Newbold, Ayoola Oyinloye, Robbie Payne, Robert Pratt, Rajamanickam Manohar Singh,
Richard Milo, Julia Rosa Maria Rios Vidal, Tyrone Roberts, Myrian Román, Samanta Rosas, Arelisabel Ruiz Guido,
Wilmer Salazar, Guillermo Salgado, Peláez Maritza Samayoa, Karla María Sánchez Mendoza, Natalia Sosa, Angela
Starks, Lourdes Suarez Alvarez, Michelle Trotman, Melissa Valdez, Iyanna Wellington, Jennifer Wilson, Alesia Worgs,
Oritta Zachariah, Zeidy Mata Azofeifa.

WHO South-East Asia Region

Md. Khurshid Alam, Ratna Bhattarai, Mizaya Cader, Kum Song Choe, Deepak Dahal, Gracinda de Orleans Tilman,
Rada Dukpa, Aminath Hanaan, Hemantha Herath, Janaka Sanjeewa, Dushani Jayawardhana, Lok Joshi, Rajendra
Joshi, Phalin Kamolwat, Ahmadul Hasan Khan, Constantino Lopes, Endang Lukitosari, Than Than Lwin, Alok Mathur,
Sanjay Mattoo, Tiffany Tiara Pakasi, Jamyang Pema, Wilawan Somsong, SKM Sulistyo, Sanjaya Kumar Thakur.

WHO European Region

Elmira Abdrahmanova, Malik Adenov, Salikhjan Alimov, Thomas Althaus, Ekkehardt Altpeter, Elena Arbuzova, Zaza
Avaliani, Ágnes Bakos, Snjezana Brckalo, Isabel Carvalho, Daniel Chemtob, Mamuka Chincharauli, Nicoleta Cioran,
Andrei Corloteanu, Sharon Cox, Valeriu Crudu, Edita Davidavičienė, Irène Demuth, Jelena Djakovic Devic, Camille
Dorin, Mladen Duronjic, Rovshen Dzjumayev, Lanfranco Fattorini, Federico Giannoni, Gjocaj Majlinda, Marta Gomes,
Biljana Grbavčević, Gennady Gurevich, Jean-Paul Guthmann, Henrik Hansen, Ejebay Ishanowa, Sarah Jackson,
Gulnora Jalilova, Jerker Jonsson, Olim Kabirov, Madamin Karataev, Anush Khachatryan, Dmitry Klimuk, Anders
Koch, Maria Korzeniewska-Koseła, Mitja Košnik, Stefan Kröger, Yana Levin, Nino Lomtadze, Stevan Lucic, Philipp
Ludin, Artak Manukyan, Wanlin Maryse, Paul McKeown, Donika Mema, Ioana Munteanu, Anne Negre, Rustam Nurov,
Joan O’Donnell, Analita Pace Asciak, Nargiza Parpieva, Biljana Ilievska Poposka, Liudmyla Prylepina, Ieva Rimsane,
Jérôme Robert, Vasiljevic Ruzica, Gerard Scheiden, Anita Seglina, Firuza Sharipova, Erika Slump, Hanna Soini, Ivan
Solovič, Aida Spahic, Sergey Sterlikov, Petra Svetina, Silva Tafaj, Sevinj Taghiyeva, Yana Terleyeva, Seher Topluoglu,

x  Global Tuberculosis Report 2022

Liliane Trafelet, Mariona Tuneu Valls, Mariya Tyufekchieva, Shahnoza Usmonova, Jossy van den Boogaard, Irina
Vasilyeva, Anne Vergison, Piret Viiklepp, Valentina Vilc, Jiří Wallenfels, Stefan Wesołowski, Yaneva Angelina, Mine
Yenice, Dmitry Zhurkin, Hasan Zutic.

WHO Eastern Mediterranean Region

Abdikader Youssouf Aden, Idil Abdourahim Abdillahi, Abdulbari Abdullah Al-Hammadi, Faouzi Abid, Suhaib Abu
Failat, Shahnaz Ahmadi, Al Khal Abdullatif, Maha Alalawi, Abeer Albalawi, Mahmoud AlBaour, Samia Ali Alagab, Nada
Almarzouqi, Layth Al-Salihi, Haya Alsenan, Haleema Alserehi, Awatef Alshammeri, Kifah Alshaqeldi, Khalsa Al-Thulhli,
Fatma Alyaquobi, Wagdy Amin, Laila Bouhamidi, Imane Chelloufi, Daghfal Joanne, Driss Daoudi, Hend Farhat,
Mohamed Furjani, Amal Galal, Dia Hjaija, Abdul Wali Khan, Basharat Javed Khan, Ibrahim Maia, Khan Mohammad
Mangal, Ahmed Mankhi, Badeeha Mansoor, Abderraouf Mansouri, Nagi Masoud, Afaf Mohamed, Esam Mohammed
Mahyoub, Samir Mokrani, Nasehi Mahshid, Kubra Nasser, Yassir Piro, Radia Sabouni, Zia Samad, Mohammed Sghiar,
Sharafi Saeed, Hiam Yaacoub, Moinullah Zafari.

WHO Western Pacific Region

Zirwatul Adilah binti Abdul Aziz, Renata Amos, Emosi Bayanivalu, Gerard Belimac, Uranchimeg Borgil, Amy Bright,
Risa Bukbuk, Chang Kwok Chiu, Thilaka Chinnayah, Chou Kuok Hei, Alice Cuenca, Jeffery Lawrence Cutter, Débacre
Jérôme, Pascale Domingue Mena, Du Xin, Ekiek Mayleen, Oyunchimeg Erdeneee, Jenny Eveni, Noraskhin Fadillah,
Angela Fineanganofo, Ludovic Floury, Kyla Galan, Donna Mae Gaviola, Elenoa Gonelevu, Huot Chanyuda, Edna Iavro,
Mohd Ihsani bin Mahmood, U Ka In, Donekham Inthavong, Khalifah Ismail, Noel Itogo, Henry Kako, Margaret Kal,
Seiya Kato, Kim Jin-Sun, Youmi Kim, Phonesavanh Kommanivanh, Khin Mar Kyi Win, Wing Sze Law, Liua Leauma,
Lee Hyewon, Liza Lopez, Diana Mallari, Kesaia Mavoa, Chima Mbakwem, Fatimah Moira Talagi, Grizelda Mokoia, Binh
Hoa Nguyen, Nguyen Viet Nhung, Nou Chanly, Juan Ogarto, Connie Olikong, Asmah Razali, Geoffrey Roche, Evonne
Sablan, Vaimaila Salele, Lai Bun Tai, Joseph Takai, Barbara Tali, Edwina Tangaroa, Annie Teannaki, Tieng Sivanna,
Marou Tikataake, Vivian Toaniso, Kazuhiro Uchimura, Bob Williams, Zhang Hui, Zhao Yanlin.

Global Tuberculosis Report 2022   xi

Abbreviations

AIDS acquired immunodeficiency syndrome

ART antiretroviral therapy
BCG bacille Calmette-Guérin
BRICS Brazil, Russian Federation, India, China and South Africa
CAD computer-aided detection
CFR case fatality ratio
CSV comma-separated value
CI confidence interval
COVID-19 coronavirus disease 2019
DR-TB drug-resistant tuberculosis
ECDC European Centre for Disease Prevention and Control
GDP gross domestic product
GHO Global Health Observatory
Global Fund The Global Fund to Fight AIDS, Tuberculosis and Malaria
Global Plan Global Plan to End TB, 2018–2022
HBC high burden country
HIV human immunodeficiency virus
ICD International classification of diseases
IGRA interferon-gamma release assay
LMICs low- and middle-income countries
MAF-TB multisectoral accountability framework for tuberculosis
MDR/RR-TB multidrug-resistant or rifampicin-resistant tuberculosis
MDR-TB multidrug-resistant tuberculosis
NTP national TB programme
OECD Organisation for Economic Co-operation and Development
RR-TB rifampicin-resistant tuberculosis
SCI service coverage index
SDG Sustainable Development Goal
STAG-TB Strategic and Technical Advisory Group for TB
Task Force WHO Global Task Force on TB Impact Measurement
TB tuberculosis
UNAIDS Joint United Nations Programme on HIV/AIDS
United Kingdom United Kingdom of Great Britain and Northern Ireland
UHC universal health coverage
UI uncertainty interval
UN United Nations
US United States
USAID United States Agency for International Development
VR vital registration
WHO World Health Organization
XDR extensively drug-resistant TB

Global Tuberculosis Report 2022   xiii

 WHO End TB Strategy: 2025 milestones
PERCENTAGE OF PEOPLE WITH TB
TB INCIDENCE RATE NUMBER OF TB DEATHS FACING CATASTROPHIC COSTSa

Milestone: Milestone:

50% 10% 75% 5.9%

Milestone:

Zero 48%
reduction reduction reduction reduction of people with TB
2015–2025 2015–2021 2015–2025 2015–2021 in 2025 face catastrophic
costs

UN high-level meeting on TB: treatment targets

TB TREATMENT TB TREATMENT MDR/RR-TB TREATMENT MDR/RR-TB TREATMENT
(ALL AGES) (CHILDREN) (ALL AGES) (CHILDREN)

Target:
26.3 million
Target:
1.9 million
Target:
649 000 Target:
17 700
(66%) (54%) (43%) (15%)
40 million 3.5 million 1.5 million 115 000
2018–2022 treated in 2018–2022 treated in 2018–2022 treated in 2018–2022 treated in
2018–2021 2018–2021 2018–2021 2018–2021

UN high-level meeting on TB: TB preventive treatment targets

ALL AGES PEOPLE LIVING HOUSEHOLD CONTACTS HOUSEHOLD CONTACTS

WIH HIV AGED <5 YEARS AGED ≥5 YEARS

Target:
12.5 million Target:
10.3 million Target:
1.6 million Target:
0.60 million
(42%) (>100%) (40%) (3.0%)
30 million 6 million 4 million 20 million
2018–2022 treated in 2018–2022 treated in 2018–2022 treated in 2018–2022 treated in
2018–2021 2018–2021 2018–2021 2018–2021

UN high-level meeting on TB: funding targets

UNIVERSAL ACCESS TO TB
PREVENTION, DIAGNOSIS, TB RESEARCH
TREATMENT AND CARE

Target: US$ Target: US$

US$
13 billion
5.4 billion US$
2 billion
915 million
annually in 2021 annually in 2020
by 2022 2018–2022

MDR/RR-TB, multidrug-resistant TB/rifampicin-resistant TB.

a
This indicator is not the same as the SDG indicator for catastrophic health expenditures. See Box 5 for further explanation.
1. Introduction

Tuberculosis (TB) is a communicable disease that is a istries of health in annual rounds of data collection.1 In
major cause of ill health and one of the leading causes of 2022, 202 countries and territories with more than 99%
death worldwide. Until the coronavirus (COVID-19) pan- of the world’s population and TB cases reported data
demic, TB was the leading cause of death from a single (Annex 2).
infectious agent, ranking above HIV/AIDS. During the COVID-19 pandemic, WHO has also col-
TB is caused by the bacillus Mycobacterium tubercu- lected provisional monthly or quarterly national TB
losis, which is spread when people who are sick with case notification data on an ongoing basis from more
TB expel bacteria into the air (e.g. by coughing). About than 100 countries with about 90% of the world’s TB
a quarter of the global population is estimated to have cases, including all high TB burden countries (Annex 3).
been infected with TB (1), but most people will not go The data are visualized and made publicly available as
on to develop TB disease and some will clear the infec- soon as they are reported (5, 6). They are being used for
tion (2, 3). Of the total number of people who develop timely monitoring of the impact of the pandemic on TB
TB each year, about 90% are adults, with more cases case detection, to facilitate timely action in response
among men than women. The disease typically affects to observed disruptions, and as a key input to the esti-
the lungs (pulmonary TB) but can affect other sites as mates of TB disease burden (incidence and mortality)
well. for 2020 and 2021 that are included in this report.
Without treatment, the death rate from TB disease The 2022 edition of the report has been produced in
is high (about 50%) (4). With currently-recommended a format that is optimized for web or app-based access
treatments (a 4–6 months course of anti-TB drugs), about and use. There is a short main report that focuses on
85% of people can be cured. Regimens of 1–6  months key findings and messages (this document); webpages
are available to treat TB infection. Universal health cov- containing more detailed and digitized content, includ-
erage (UHC) is necessary to ensure that all people with ing a large number of interactive graphics;2 and an app
disease or infection can access these treatments. The containing country, regional and global profiles as well
number of people acquiring infection and developing as two slide-sets (Annex 4).3 This format allows content
disease (and in turn the number of deaths caused by to be made available in relatively small and “bite-sized”
TB) can also be reduced through multisectoral action to chunks,4 which facilitates navigation, reading and use,
address TB determinants such as poverty, undernour- especially for the vast majority of people (>90%) who
ishment, HIV infection, smoking and diabetes. access the report via a computer, tablet or mobile
Some countries have already reduced their burden phone, rather than via a printed copy. All content can be
of TB disease to fewer than 10 cases and less than accessed from the report landing page and all data can
one death per 100  000 population per year. Research be downloaded from WHO’s online global TB database
breakthroughs (e.g. a new vaccine) are needed to rap- (5).
idly reduce the number of new cases each year (i.e. TB The top findings and messages of the 2022 report are
incidence) worldwide to the levels already achieved in highlighted in Box 1.
these low-burden countries.
Basic facts about TB and its treatment are provided 1
The data are collected from national TB programmes (NTPs) or
the national entity responsible for TB surveillance.
in Annex 1. 2
The webpages cover seven major topics: the COVID-19 pandemic
The World Health Organization (WHO) has published and TB; TB disease burden; TB diagnosis and treatment; TB
a global TB report every year since 1997. The purpose prevention; TB financing; UHC and TB determinants; and TB
of the report is to provide a comprehensive and up-to- research and innovation. There are also webpages on “featured
topics”, which this year include engagement of communities,
date assessment of the status of the TB epidemic and civil society and people affected by TB in the TB response;
progress in the response at global, regional and nation- international donor funding for TB; multisectoral accountability
al levels, in the context of global commitments, strate- for the TB response; and TB-related innovations during the
COVID-19 pandemic.
gies and targets. 3
The app is free to download and enables users to have access to
The 2022 edition of the report is, as usual, based data for many key indicators at their fingertips.
primarily on data gathered by WHO from national min- 4
In contrast to the format of a single report document of about
200–300 pages, which was used until 2020.

Global Tuberculosis Report 2022   1

Box 1. Top findings and messages in the 2022 report

The COVID-19 pandemic continues to have a damaging high quality and coverage are needed for more accurate
impact on access to TB diagnosis and treatment and estimation in the wake of the pandemic.
the burden of TB disease. Progress made in the years up
Other negative impacts on TB during the COVID-19
to 2019 has slowed, stalled or reversed, and global TB
pandemic include a fall between 2019 and 2020 in the
targets are off track.
number of people provided with treatment for RR-TB
The most obvious and immediate impact was a large and multidrug-resistant TB (MDR-TB)b (–17%, from
global drop in the reported number of people newly 181 533 to 150 469, about 1 in 3 of those in need), with
diagnosed with TB. From a peak of 7.1 million in 2019, a partial recovery (+7.5%) to 161 746 in 2021; and a
this fell to 5.8 million in 2020 (–18%), back to the level decline in global spending on essential TB services (from
last seen in 2012. In 2021, there was a partial recovery, to US$ 6.0 billion in 2019 to US$ 5.4 billion in 2021, less than
6.4 million (the level of 2016–2017). The three countries half of what is needed).
that accounted for most of the reduction in 2020 were
There is a strong and enduring relationship between TB
India, Indonesia and the Philippines (67% of the global
incidence rates per capita and indicators of development
total). They made partial recoveries in 2021, but still
such as average income and undernourishment.
accounted for 60% of the global reduction compared
Economic and financial barriers can affect access
with 2019. Other high TB burden countries with large
to health care for TB diagnosis and completion of
relative year-to-year reductions (>20%) included
TB treatment; about half of TB patients and their
Bangladesh (2020), Lesotho (2020 and 2021), Myanmar
households face catastrophic total costsc due to TB
(2020 and 2021), Mongolia (2021) and Viet Nam (2021).
disease. Progress towards universal health coverage
Reductions in the reported number of people diagnosed (UHC), better levels of social protection and multisectoral
with TB in 2020 and 2021 suggest that the number of action on broader TB determinants are all essential to
people with undiagnosed and untreated TB has grown, reduce the burden of TB disease.
resulting first in an increased number of TB deaths
There are some positive findings and success stories.
and more community transmission of infection and
then, with some lag-time, increased numbers of people ▶ Globally, the success rate for people treated for TB
developing TB. in 2020 was 86%, the same level as 2019, suggesting
that the quality of care was maintained in the first
Globally, the estimated number of deaths from TB
year of the COVID-19 pandemic.
increased between 2019 and 2021, reversing years of
decline between 2005 and 2019. In 2021, there were ▶ In the WHO African Region, the impact of COVID-
an estimated 1.4 million deaths among HIV-negative related disruptions on the reported number of people
people (95% uncertainty interval [UI]: 1.3–1.5 million) newly diagnosed with TB was limited. There was a
and 187 000 deaths (95% UI: 158 000–218 000) among relatively small decrease (–2.3%) from 2019–2020 and
HIV-positive people,a for a combined total of 1.6 million. an increase in 2021.
This was up from best estimates of 1.5 million in 2020
and 1.4 million in 2019, and back to the level of 2017. The ▶ Following large falls in 2020, the reported number of
net reduction from 2015 to 2021 was 5.9%, about one people newly diagnosed with TB in 2021 recovered
sixth of the way to the first milestone of the WHO End TB to 2019 levels (or beyond) in five high TB burden
Strategy. countries: Bangladesh, the Congo, Pakistan, Sierra
Leone and Uganda.
An estimated 10.6 million people (95% UI: 9.9–11 million)
fell ill with TB in 2021, an increase of 4.5% from ▶ The global number of people provided with TB
10.1 million (95% UI: 9.5–10.7 million) in 2020. The TB preventive treatment recovered in 2021, to close to
incidence rate (new cases per 100 000 population per 2019 levels, and the global target for provision of
year) rose by 3.6% between 2020 and 2021, reversing treatment to people living with HIV was surpassed.
declines of about 2% per year for most of the previous ▶ Three high TB burden countries have reached or
2 decades. The net reduction from 2015 to 2021 was 10%, passed the first milestones of the End TB Strategy
only halfway to the first milestone of the End TB Strategy. for both reductions in TB incidence and TB deaths:
The burden of drug-resistant TB (DR-TB) is also estimated Kenya (in 2018), the United Republic of Tanzania (in
to have increased between 2020 and 2021, with 450 000 2019) and Zambia (in 2021). Ethiopia is very close.
(95% UI: 399 000–501 000) new cases of rifampicin- Intensified efforts backed by increased funding are
resistantb TB (RR-TB) in 2021. urgently required to mitigate and reverse the negative
Estimating TB disease burden during the COVID-19 impacts of the COVID-19 pandemic on TB. The need for
pandemic is difficult and relies heavily on country- and action has become even more pressing in the context
region-specific dynamic models for low- and middle- of war in Ukraine, ongoing conflicts in other parts of the
income countries (LMICs). New national population- world, a global energy crisis and associated risks to food
based surveys of TB disease and up-to-date cause-of- security, which are likely to worsen some of the broader
death data from national vital registration systems of determinants of TB.

a
Officially classified as deaths from HIV/AIDS.
b
Rifampicin is the most powerful first-line anti-TB drug. MDR-TB is defined as resistance to rifampicin and isoniazid.
c
Defined as direct medical expenditures, direct nonmedical expenditures and indirect costs (e.g. income losses) that sum to >20% of
household income. This indicator is not the same as the Sustainable Development Goal indicator for catastrophic health expenditures (see
Box 5 for further explanation).

2  Global Tuberculosis Report 2022

2. Global TB commitments,
strategy and targets

In 2014 and 2015, all Member States of WHO and the Unit- per year), the absolute number of TB deaths and costs
ed Nations (UN) committed to ending the TB epidemic, faced by TB patients and their households.
through their adoption of WHO’s End TB Strategy (Box 2) Reaching the milestones and targets for reductions
and the UN Sustainable Development Goals (SDGs) (7, in TB incidence required an annual decline in the TB
8). The strategy included milestones (for 2020 and 2025) incidence rate of 4–5% per year by 2020, accelerating
and targets (for 2030 and 2035) for large reductions in to 10% per year by 2025 and then to an average of 17%
the TB incidence rate (new cases per 100 000 population per year from 2025 to 2035. Reaching the milestones

Box 2. The End TB Strategy at a glance

A WORLD FREE OF TB
VISION
— zero deaths, disease and suffering due to TB
GOAL END THE GLOBAL TB EPIDEMIC
MILESTONES TARGETS
INDICATORS
2020 2025 2030 2035
Percentage reduction in the absolute number of TB deaths a
35% 75% 90% 95%
(compared with 2015 baseline)
Percentage reduction in the TB incidence rate
20% 50% 80% 90%
(compared with 2015 baseline)
Percentage of TB-affected households facing catastrophic
0% 0% 0% 0%
costs due to TB b (level in 2015 unknown)

PRINCIPLES
1. Government stewardship and accountability, with monitoring and evaluation
2. Strong coalition with civil society organizations and communities
3. Protection and promotion of human rights, ethics and equity
4. Adaptation of the strategy and targets at country level, with global collaboration

PILLARS AND COMPONENTS

1. INTEGRATED, PATIENT-CENTRED CARE AND PREVENTION
A. Early diagnosis of TB including universal drug-susceptibility testing, and systematic screening of contacts and
high-risk groups
B. Treatment of all people with TB including drug-resistant TB, and patient support
C. Collaborative TB/HIV activities, and management of comorbidities
D. Preventive treatment of persons at high risk, and vaccination against TB

2. BOLD POLICIES AND SUPPORTIVE SYSTEMS

E. Political commitment with adequate resources for TB care and prevention
F. Engagement of communities, civil society organizations, and public and private care providers
G. Universal health coverage policy, and regulatory frameworks for case notification, vital registration, quality and
rational use of medicines, and infection control
H. Social protection, poverty alleviation and actions on other determinants of TB

3. INTENSIFIED RESEARCH AND INNOVATION

I. Discovery, development and rapid uptake of new tools, interventions and strategies
J. Research to optimize implementation and impact, and promote innovations

a
This indicator is for the combined total of TB deaths in HIV-negative and HIV-positive people. Deaths from TB among HIV-positive people
are officially classified as deaths caused by HIV/AIDS, with TB as a contributory cause.
b
This indicator is not the same as the SDG indicator for catastrophic health expenditures. See Box 5 for further explanation.

Global Tuberculosis Report 2022   3

Table 1
Global targets set in 2018 at the first UN high-level meeting on TB

Indicator Target

40 million people, including:

Number of people with TB disease treated in
"" 3.5 million children
the five years 2018–2022
"" 1.5 million people with drug-resistant TB, including 115 000 children
At least 30 million people, including:
Number of people provided with TB
"" 4 million children under 5 years of age who are household contacts of people diagnosed with TB
preventive treatment in the five years
"" 20 million people in older age groups who are household contacts of people diagnosed with TB
2018–2022
"" 6 million people living with HIV
Annual funding for universal access to
quality prevention, diagnosis, treatment At least US$ 13 billion per year by 2022
and care of TB
Annual funding for TB research US$ 2 billion annually in the five years 2018–2022

and targets for reductions in TB deaths required not ical expenditures and indirect costs (e.g. income losses)
only these declines in TB incidence, but also reductions that sum to >20% of household income.
in the case fatality ratio (CFR; the percentage of peo- Further details about the rationale for the milestones
ple with TB who die from the disease). The global CFR and targets and how they were defined is available else-
needed to fall to 10% by 2020 and then to 6.5% (a level where (9).
already achieved in high-income countries) by 2025. Key Efforts to step up political commitment to the fight
requirements to reach the milestones and targets were against TB intensified in 2017 and 2018.
defined within the three pillars of the End TB Strategy A WHO global ministerial conference on TB was
(Box 2). They included provision of TB prevention, diag- organized in November 2017. The outcome was the Mos-
nostic and treatment services within the context of pro- cow Declaration to End TB (10).
gress towards UHC and social protection; multisectoral In September 2018, the UN General Assembly held its
actions to address broader social and economic deter- first-ever high-level meeting on TB, attended by heads
minants of TB; and technological breakthroughs, such of state and government as well as other leaders. The
as a new TB vaccine by 2025. outcome was a political declaration in which commit-
The third target of the End TB Strategy, that no TB ments to the SDGs and End TB Strategy were reaffirmed
patients and their households face catastrophic total and new ones added (11). Global targets for the funding
costs1 as a result of the disease, was set in recognition of to be mobilized for TB prevention, care and research,
the fact that removal of financial and economic barriers and for the number of people to be treated for TB infec-
to accessing TB diagnosis and treatment is a prerequi- tion and disease, were set for the first time (Table 1).
site for achieving the milestones and targets for reduc- A high-level review of progress achieved by the end of
tions in TB incidence and TB mortality. “Catastrophic” is 2022 is scheduled for 2023 (Box 3).
defined as direct medical expenditures, direct nonmed-

Box 3. Review of progress towards ending TB at a UN high-level meeting in 2023

The UN General Assembly held its first-ever high-level meeting on TB in 2018. The main outcome was a political
declaration (11), which reaffirmed existing commitments to ending the TB epidemic and set new global TB targets
for the period 2018–2022. The declaration requested a progress report in 2020, to be prepared by the UN Secretary-
General with support from WHO; and ended with a commitment to a “comprehensive review by Heads of State and
Government at a high-level meeting in 2023”. The 2020 progress report (12) included 10 priority recommendations
and requested WHO to work with Member States and other stakeholders on the preparations for a second high-level
meeting on TB.
Preparations for a second UN high-level meeting on TB in 2023 are now underway, led by the UN secretariat with
support from WHO. The meeting will be informed by national high-level reviews of progress. WHO’s multisectoral and
multistakeholder platform will be leveraged to support countries to undertake these reviews, in collaboration with
WHO’s Civil Society Taskforce on TB. The meeting is expected to result in a new political declaration.

1
This indicator is not the same as the SDG indicator for
catastrophic health expenditures (see Box 5 for further
explanation).

4  Global Tuberculosis Report 2022

 3. Main findings and messages

The overarching finding of this report is that the 2019 and 2020, followed by an almost complete recov-
COVID-19 pandemic continues to have a damaging ery in 2021. In the WHO European Region, there was a
impact on access to TB diagnosis and treatment and clear negative impact in 2020, but the reduction from
the burden of TB disease. Progress made in the years 2020–2021 was consistent with the pre-2020 trend. In
up to 2019 has slowed, stalled or reversed, and global the WHO Western Pacific Region, there was no recovery
TB targets are off track. The overarching message is in 2021. The WHO African Region stood out as experi-
that intensified efforts backed by increased funding are encing only a modest negative impact in 2020 (–2.3%),
urgently required to mitigate and reverse the negative and notifications in 2021 were above the 2019 level. The
impacts of the pandemic on TB. The need for action WHO regions of South-East Asia and the Western Pacific
has become even more pressing in the context of war in accounted for most of the global reductions (compared
Ukraine, ongoing conflicts in other parts of the world, a with 2019): 84% of the total in 2020, and 99% in 2021.
global energy crisis and associated risks to food securi- Most (90%) of the global reduction in the reported
ty, which are likely to further worsen some of the broad- number of people newly diagnosed with TB between
er determinants of TB. 2019 and 2020 was accounted for by 10 countries
(Fig.  3a), with the top three (India, Indonesia and the
TB case notifications Philippines) accounting for 67%. In 2021, 90% of the
Big fall in 2020, partial recovery in 2021 reduction compared with 2019 was accounted for by
The most obvious and immediate impact on TB of dis- only five countries (Fig. 3b).
ruptions caused by the COVID-19 pandemic was a large Among the 30 high TB burden and three global TB
global fall in the number of people newly diagnosed watchlist countries (Fig.  4), the largest relative reduc-
with TB and reported (i.e. officially notified) in 2020, tions in annual TB case notifications between 2019
compared with 2019 (Fig. 1). Following large increases and 2020 (ordered according to the size of the relative
between 2017 and 2019, there was a reduction of 18% reduction) were in the Philippines, Lesotho, Indonesia,
between 2019 and 2020, from 7.1 million to 5.8 million. Zimbabwe, India, Myanmar and Bangladesh (all >20%).
There was a partial recovery in 2021, to 6.4 million. In 2021, there was considerable recovery in India, Indo-
A similar pattern of increases in notifications of peo- nesia and the Philippines, although not to 2019 levels.
ple newly diagnosed with TB up to 2019 followed by a In Myanmar, the reduction in TB notifications in 2021
sharp fall in 2020 and some recovery in 2021 is evident was even larger than in 2020. Other countries with large
in two of the six WHO regions: the Americas and South- relative reductions between 2020 and 2021 included
East Asia (Fig.  2). The WHO Eastern Mediterranean Mongolia and three other Asian countries that had been
Region saw a marked reduction in notifications between relatively unaffected in 2020: Cambodia, Thailand and
Viet Nam. In several African countries, notifications in
both 2020 and 2021 were higher than in 2019, with Nige-
FIG.1 ria being the most striking example. Countries in which
Global trend in case notifications of people 2021 notifications recovered to 2019 levels (or beyond)
newly diagnosed with TB, 2015–2021 included Bangladesh, the Congo, Pakistan, Sierra Leone
and Uganda.
7.5 The 30 high TB burden and three global TB watchlist
Notifications per year (millions)

countries can be categorized into six groups, according

7.0 to the timing and degree of disruptions to TB notifica-
tions during the COVID-19 pandemic (Fig. 5). TB detec-
tion in all countries in the first four groups was negatively
6.5
impacted in one or both of 2020 and 2021. Disruptions
to TB detection in 2020 and 2021 in countries in the fifth
6.0
and sixth groups appear to have been nonexistent or
limited; TB notifications either increased in both 2020
5.5 and 2021, or the numbers showed no or only a limited
2015 2016 2017 2018 2019 2020 2021

Global Tuberculosis Report 2022   5

 FIG. 2
Trends in case notifications of people newly diagnosed with TB by WHO region, 2015–2021
African Region Region of the Americas South-East Asia Region
1.50 0.24 3.50
Notifications per year (millions)

1.45 0.23
3.25

1.40 0.22
3.00
1.35 0.21

2.75
1.30 0.20

1.25 0.19 2.50

2015 2016 2017 2018 2019 2020 2021 2015 2016 2017 2018 2019 2020 2021 2015 2016 2017 2018 2019 2020 2021

European Region Eastern Mediterranean Region Western Pacific Region

0.27 0.54 1.45
Notifications per year (millions)

0.52
0.24
1.35
0.50
0.21
0.48 1.25
0.18
0.46
1.15
0.15 0.44

0.12 0.42 1.05

2015 2016 2017 2018 2019 2020 2021 2015 2016 2017 2018 2019 2020 2021 2015 2016 2017 2018 2019 2020 2021

FIG. 3
The top 10 countries that accounted for ≥90% of the global reduction in case notifications of
people newly diagnosed with TB in 2020 and 2021, compared with 2019
Countries that accounted for 90% of the reduction are shown in red.

(a) Reduction in 2020 compared with 2019 (b) Reduction in 2021 compared with 2019
India India
Indonesia Chinaa
Philippines Indonesia
China a
Philippines
Bangladesh Myanmar
Pakistan South Africaa
Myanmar Viet Nam
South Africa a
Russian Federation
Russian Federation Thailand
Kenya Angola

0 10 20 30 40 50 0 10 20 30 40 50
Share of reduction (%) Share of reduction (%)

a
Reductions in China and South Africa were consistent with, or a limited departure from, pre-2020 downward trends. See Fig. 5F.

6  Global Tuberculosis Report 2022

Fig. 4
Case notifications of people newly diagnosed with TB in 2020 and 2021 compared with 2019,
30 high TB burden and 3 global TB watchlist countriesa
The vertical dashed line marks the level of 2019.

Philippines
Lesotho
Indonesia
Zimbabwe
India
Myanmar
Bangladesh
Russian Federation
Pakistan
Namibia
Liberia
Kenya
Angola
China
Sierra Leone
Brazil
Mongolia
Gabon
South Africa
Papua New Guinea
Uganda
Democratic People's Republic of Korea
Congo
Cambodia
Viet Nam
Ethiopia
Thailand
Mozambique
United Republic of Tanzania
Central African Republic
Zambia
Democratic Republic of the Congo
Nigeria

50 60 70 80 90 100 110 120 130 140 150 160 170 180

Number in 2020 and 2021 as a percentage of 2019
2020 2021

a
The three global TB watchlist countries are Cambodia, Russian Federation and Zimbabwe (see Annex 3 for further explanation).

departure from a pre-2020 downward trend. The coun- about the risks of going to health care facilities during
tries in these two latter groups are mostly in the WHO a pandemic; and stigma associated with similarities in
African Region, consistent with the regional data shown the symptoms related to TB and COVID-19.
in Fig. 2. Reasons for region and country variation in TB
The substantial disruptions to TB case detection and notification trends between 2019 and 2021 include
reporting in 2020 and 2021 probably reflect both sup- differences in when they were first affected by the
ply-side and demand-side influences on TB diagnostic COVID-19 pandemic and the timing of subsequent waves
and treatment services. Examples include reduced of infection, the severity of the impact, the extent to
health system capacity to continue to provide services; which restrictions were put in place and adhered to, the
reduced ability to seek care in the context of lockdowns, capacity and resilience of health systems, and trends in
and associated restrictions on movement; concerns the years leading up to the pandemic.

Global Tuberculosis Report 2022   7

 FIG. 5
Case notifications of people newly diagnosed with TB in the 30 high TB burden and 3 global TB
watchlist countries, categorized according to the timing and degree of disruptions during the
COVID-19 pandemic

A. Negative impact in 2020,a partial recovery in 2021

Philippines Indonesia Zimbabwe India Liberia
600 000 30 000 2 500 000 10 000
400 000
2 000 000
7 500
300 000 400 000 20 000
1 500 000
5 000
200 000
1 000 000
200 000 10 000
100 000 2 500
500 000
Notifications per year

0 0 0 0 0
2015 2017 2019 2021 2015 2017 2019 2021 2015 2017 2019 2021 2015 2017 2019 2021 2015 2017 2019 2021

Kenya Brazil Gabon Papua New Guinea

100 000 100 000 6 000
30 000
75 000 75 000
4 000
20 000
50 000 50 000
2 000
25 000 25 000 10 000

0 0 0 0
2015 2017 2019 2021 2015 2017 2019 2021 2015 2017 2019 2021 2015 2017 2019 2021

a
Countries are shown in descending order of the relative decline (%) between 2019 and 2020, which ranged from 37% down to 8.0%.

B. Negative impact in 2020,a recovery to 2019 levels or beyond in 2021

Bangladesh Pakistan Sierra Leone Uganda Congo
400 000 20 000 80 000 12 500
Notifications per year

300 000
10 000
300 000 15 000 60 000

200 000 7 500

200 000 10 000 40 000
5 000
100 000 20 000
100 000 5 000 2 500

0 0 0 0 0
2015 2017 2019 2021 2015 2017 2019 2021 2015 2017 2019 2021 2015 2017 2019 2021 2015 2017 2019 2021

a
Countries are shown in descending order of the relative decline (%) between 2019 and 2020, which ranged from 21% down to 5.3%.

C. Negative impact in 2020,a further decline in 2021

Lesotho Myanmar Russian Federationb Angola Mongolia
8 000 150 000 100 000 80 000 5 000
Notifications per year

4 000
6 000 75 000 60 000
100 000
3 000
4 000 50 000 40 000
2 000
50 000
2 000 25 000 20 000
1 000

0 0 0 0 0
2015 2017 2019 2021 2015 2017 2019 2021 2015 2017 2019 2021 2015 2017 2019 2021 2015 2017 2019 2021

a
Countries are shown in descending order of the relative decline (%) between 2019 and 2020, which ranged from 35% down to 9.7%.
b
The Russian Federation is included here rather than in group (f) because there was a clear discontinuity in the historic trend between 2019 and 2020: the
decrease was 20%, compared with an annual decline that ranged from 6.3% to 8.6% between 2015 and 2019.

D. No or minimal negative impact in 2020,a negative impact in 2021b

Cambodia Viet Nam Thailand

40 000 125 000 100 000
Notifications per year

100 000
30 000 75 000
75 000
20 000 50 000
50 000
10 000 25 000
25 000

0 0 0
2015 2017 2019 2021 2015 2017 2019 2021 2015 2017 2019 2021

a
<5% decline between 2019 and 2020.
b
Countries are shown in descending order of the relative decline (%) between 2020 and 2021, which ranged from 26% down to 17%.

8  Global Tuberculosis Report 2022

 E. Increases in 2020 and 2021
Democratic Republic
Central African Republic of the Congo Mozambique Nigeria United Republic of Tanzania
15 000 250 000 100 000 250 000 100 000

200 000 200 000

75 000 75 000
10 000
150 000 150 000
50 000 50 000
100 000 100 000
5 000
25 000 25 000
50 000 50 000
Notifications per year

0 0 0 0 0
2015 2017 2019 2021 2015 2017 2019 2021 2015 2017 2019 2021 2015 2017 2019 2021 2015 2017 2019 2021

Zambia
50 000

40 000

30 000

20 000

10 000

0
2015 2017 2019 2021

F. No or limited departure from pre-2020 downward trend

Democratic People’s
Chinaa Republic of Korea Ethiopia Namibiaa South Africa
800 000 125 000 150 000 10 000 300 000
Notifications per year

100 000 7 500

600 000
100 000 200 000
75 000
400 000 5 000
50 000
50 000 100 000
200 000 2 500
25 000

0 0 0 0 0
2015 2017 2019 2021 2015 2017 2019 2021 2015 2017 2019 2021 2015 2017 2019 2021 2015 2017 2019 2021

a
China is included here rather than group (c), because although there was some departure from the historic trend between 2019 and 2020 (a 14%
decline compared with a decline of 8.4% between 2018 and 2019), there were also efforts during this period to reduce over-diagnosis. The proportion of
pulmonary cases that were bacteriologically confirmed increased from 47% in 2019 to 55% in 2020 and 58% in 2021. Year-to-year changes in Namibia also
appear related to the proportion of cases that were bacteriologically confirmed.

Deaths caused by TB TB mortality and incidence in these years. These meth-

Global increases in 2020 and 2021 ods rely heavily on country-specific and region-specific
dynamic models and have been extensively reviewed.
Reductions in the reported number of people newly
Key assumptions are that reductions in the reported
diagnosed with TB in 2020 and 2021 suggest that the
number of people newly diagnosed with TB reflect
number of people with undiagnosed and untreated TB
real reductions in TB case detection2 (rather than an
has grown, resulting first in an increased number of TB
increase in the underreporting of cases or a reduction
deaths and more community transmission of infection
in TB incidence) and a 50% reduction in TB transmission
and then, with some lag-time, increased numbers of
during periods of severe restrictions (lockdowns). Fur-
people developing TB.1
ther details are provided in Box 4 and Annex 5.
However, producing estimates of TB disease bur-
Globally, the annual estimated number of deaths
den during the COVID-19 pandemic is difficult. In the
from TB fell between 2005 and 2019, but the estimates
absence of reliable direct measurements of the national
for 2020 and 2021 suggest that this trend has been
number of TB cases and deaths from national disease
reversed (Fig.  6). There were an estimated 1.4  million
surveillance systems, vital registration (VR) systems and
deaths among HIV-negative people (95% uncertain-
population-based surveys in the period 2020–2021 in
ty interval [UI]: 1.3–1.5  million) and 187  000 deaths
most low- and middle-income countries (LMICs), it has
(95% UI: 158 000–218 000) among HIV-positive people in
been necessary to develop new methods for estimating
2021,3 for a combined total of 1.6 million; this represents
an increase from best estimates of 1.5  million in 2020
1
Disruptions to TB detection and treatment affect those who
already have TB disease first; people who remain undiagnosed
and untreated have a higher risk of death compared to those
started on treatment. Most people infected through increased
community transmission will not go on to develop TB disease; 2
This is with the exception of reductions that were consistent with
for those that do, the time between acquisition of infection and a pre-2020 downward trend. Models were not used for countries
the development of TB disease ranges from weeks to decades. that reported declines in notifications that were consistent with
Disruptions to diagnosis and treatment therefore have a more pre-2020 trends.
immediate impact on TB deaths and a more delayed impact on 3
Deaths from TB among HIV-positive people are officially classified
TB incidence. as deaths caused by HIV/AIDS, with TB as a contributory cause.

Global Tuberculosis Report 2022   9

Box 4. Estimation of TB incidence and mortality during the COVID-19 pandemic

During the COVID-19 pandemic, there have been ▶ Strict lockdowns resulted in a 50% reduction
reductions in the reported numbers of people newly in transmission (UI: 25–75%). Reductions in
diagnosed with TB that depart from pre-2020 trends transmission outside periods of strict lockdown
(Fig. 1–Fig. 5). If these numbers reflect real reductions were not assumed, although measures such as mask
in diagnosis (rather than underreporting or a reduction wearing may have had an ongoing impact in some
in TB incidence), there will have been an increase in the countries.
number of people in the community with undiagnosed
Other influential assumptions, drawing on the scientific
and untreated TB. In turn, this is likely to increase the
literature, relate to the number of secondary infections
transmission of infection. Other things being equal, the
per case per year (estimated by model calibration) and
sharper, faster and more prolonged the drop in TB case
the rate of breakdown from TB infection to active TB
detection, the bigger the size of these impacts.
disease, which was informed by a recent (2018) review of
Growth in the number of people with undiagnosed and TB models (17).
untreated TB will result in an increase in the number of
An important limitation is that the models do not yet
deaths from TB within a relatively short time frame. The
account for the impact of the COVID-19 pandemic on
impact of increased transmission on TB incidence (new
broader TB determinants; thus, impacts on TB incidence
cases) will be more delayed, due to the time lag (from
and mortality may be understated.
months to many years) between acquisition of infection
and progression to TB disease. The modelling methods have been extensively discussed
and reviewed; for example, through:
Periods of restrictions during the COVID-19 pandemic
(e.g. lockdowns) as well as adjustments to behaviour ▶ a review by WHO’s Strategic and Technical Advisory
(e.g. wider use of masks) could also have reduced Group for TB (STAG-TB) in June 2021 (18);
TB transmission in 2020 and 2021. Negative impacts
of the pandemic on broader TB determinants (e.g. ▶ a 2-day meeting of a subgroup of the WHO
undernourishment, poverty and income per capita) Global Task Force on TB Impact Measurement
could have influenced both TB incidence and mortality. (the Task Force) in May 2022 (16), which brought
together 32 global experts in mathematical
WHO has collaborated with Imperial College, United modelling, epidemiology and statistics as well as
Kingdom of Great Britain and Northern Ireland (United representatives from national TB programmes (NTPs)
Kingdom) on the development and implementation and partner agencies, with the specific purpose of
of methods to estimate TB incidence and mortality reviewing methods used by WHO to estimate TB
during the COVID-19 pandemic (15, 16). Country- disease burden during the COVID-19 pandemic; and
specific dynamic models were developed to estimate
TB incidence and mortality in 2020 and 2021 for 27 ▶ in an immediate follow-up to the Task Force meeting,
countries. These included 26 countries that reported a further detailed review of model documentation
large absolute reductions in TB notifications in 2020 by several global experts in TB modelling, following
or 2021 that departed from pre-2020 trends: Angola, which comments and suggestions were addressed.
Azerbaijan, Bangladesh, Brazil, Cambodia, China, Further details about the methods used to estimate
Colombia, India, Indonesia, Kazakhstan, Kenya, TB incidence and mortality in 2020 and 2021 (including
Kyrgyzstan, Lesotho, Malaysia, Mexico, Mongolia, methods used for non-modelled countries) and those
Myanmar, Nepal, Pakistan, Papua New Guinea, Peru, the used to produce estimates for 2000–2019 are provided in
Philippines, the Russian Federation, Thailand, Viet Nam Annex 5, the report webpages and a technical appendix.
and Zimbabwe;a plus Timor-Leste.b The models were
fitted to monthly or quarterly TB case notification data Estimates in this report are consistent with those
reported to WHO for the period since January 2020 (5) published in 2021 (15). In countries with the biggest
and calibrated to pre-2020 estimates of TB incidence and reductions in TB notifications compared with pre-2020
mortality.c Region-specific models were used for 26 other trends, the estimates show a slowdown in the rate of
LMICs with reductions in TB notifications that departed decline in TB incidence and an increase in the number of
from pre-2020 trends. TB deaths between 2019 and 2020. Also, as suggested by
the projections included in the 2021 report, the estimates
Key assumptions in the models are: in this report show an increase in TB incidence in 2021
▶ Reductions in TB case notifications in 2020 and 2021 and a further increase in the number of TB deaths.
reflected a negative impact on TB case detection
and led to an increase in the number of people with
undiagnosed and untreated TB in the community.d

a
The models were not used to estimate TB mortality in China and the Russian Federation, because those countries reported data on the
number of deaths caused by TB in the period 2020–2021 based on their national VR systems.
b
A country-specific model was used for Timor-Leste because a regional model was not developed for the South-East Asia Region; most
of the other countries in this region either met the criteria required for development of a country-specific model or notifications were
consistent with pre-2020 trends.
c
Generally, these were estimates previously published by WHO, either for 2019 or for a combination of 2014 and 2019. For India, the
calibration was to country-generated incidence estimates derived from a recently completed national TB prevalence survey, a previous
state-level survey and programmatic data. Further details are provided in Annex 5 and a technical appendix.
d
It is possible that underreporting of detected cases contributed to reductions in case notifications, but there is currently no evidence to
support this.

10  Global Tuberculosis Report 2022

 FIG. 6
Global trends in the estimated number of TB deaths (left) and the mortality rate (right),
2000–2021
The horizontal dashed line shows the 2020 milestone of the End TB Strategy, which was a 35% reduction in the
total number of TB deaths between 2015 and 2020. Shaded areas represent 95% uncertainty intervals.

Total Total
2.0 30

Rate per 100 000 population

Millions per year (log scale)

1.5

per year (log scale)

HIV-negative people HIV-negative people
1.0
2020 milestone
10
0.5

0.3 HIV-positive people

HIV-positive people 3

2000 2005 2010 2015 2020 2000 2005 2010 2015 2020

and 1.4 million in 2019, and a return to the level of 2017.1 FIG. 7

Most of the estimated increase in TB deaths globally Global trends in the estimated number of
was accounted for by four countries: India, Indonesia, deaths caused by TB and HIV, 2000–2021a,b
Myanmar and the Philippines.2 Shaded areas represent 95% uncertainty intervals.
The global number of deaths officially classified as
caused by TB in 2021 (1.4 million) was more than dou-
Millions of deaths per year (log scale)

2.4
ble the number caused by HIV/AIDS (0.65  million), and TB deaths in
HIV-negative people
TB mortality has been much more severely impacted by
the COVID-19 pandemic than HIV/AIDS (Fig.  7). In con- 1.0
trast to TB, deaths from HIV/AIDS continued to decline HIV deaths

between 2019 and 2021 (13). 0.5

The latest year for which WHO has published esti- 0.3
mates of global deaths by cause is 2019 (Fig. 8). In that TB deaths in
year, TB was the 13th leading cause of death worldwide HIV-positive people

and the top cause from a single infectious agent. In 0.1

2020 and 2021, it is anticipated that TB will rank as the 2000 2005 2010 2015 2020
second leading cause of death from a single infectious
a
For HIV/AIDS, the latest estimates of the number of deaths in 2021 that
agent, after COVID-19 (14). have been published by UNAIDS are available at http://www.unaids.org/
The global pattern of a fall in the absolute number of en/ (accessed 15 August 2022). For TB, the estimates for 2021 are those
published in this report.
TB deaths until 2019, followed by increases in 2020 and b
Deaths from TB among HIV-positive people are officially classified as
2021, was evident in four of the six WHO regions (Fig. 9). deaths caused by HIV/AIDS in the International Classification of Diseases.
The two exceptions were the WHO African Region,
where there was a continued decline in both 2020 and
2021, and the Eastern Mediterranean Region, where
an increase between 2019 and 2020 was followed by a
slight decline from 2020 to 2021. The estimated number
of TB deaths increased in 2020 or 2021 in most of the 30
high TB burden countries.3

1
The reduction in the total number of TB deaths between 2000
and 2019 was 41%. The net reduction between 2000 and 2021 was
36%.
2
This is consistent with their contributions to global reductions in
the reported number of people newly diagnosed with TB in 2020
and 2021 (Fig. 3).
3
In 2021, WHO updated its three lists of high burden countries for
TB, MDR/RR-TB and HIV-associated TB. The lists are for 2021–
2025, and they are defined and explained in Annex 3. Further
details about trends in these and all other countries are available
in the report webpages and mobile app.

Global Tuberculosis Report 2022   11

 Fig. 8
Top causes of death worldwide in 2019a,b
Deaths from TB among HIV-positive people are shown in grey.

Ischaemic heart disease

Stroke
Chronic obstructive pulmonary disease
Lower respiratory infections
Neonatal conditions
Trachea, bronchus, lung cancers
Alzheimer disease and other dementias
Diarrhoeal diseases
Diabetes mellitus
Kidney diseases
Cirrhosis of the liver
Road injury
Tuberculosis
Hypertensive heart disease
Colon and rectum cancers
Stomach cancer
Self-harm
Falls
HIV/AIDS
Breast cancer

0 2 4 6 8 10
Number of deaths (millions)

a
This is the latest year for which estimates for all causes are currently available. See WHO estimates, available at
https://www.who.int/data/gho/data/themes/mortality-and-global-health-estimates/ghe-leading-causes-of-death
b
Deaths from TB among HIV-positive people are officially classified as deaths caused by HIV/AIDS in the International Classification of Diseases.

FIG. 9
Trends in the estimated absolute number of TB deaths (HIV-positive and HIV-negative) by WHO
region, 2000–2021
The horizontal dashed line shows the first milestone of the End TB Strategy, which was a 35% reduction in the
total number of TB deaths between 2015 and 2020. Shaded areas represent 95% uncertainty intervals.

African Region Region of the Americas South-East Asia Region

1000 40

1000
30
700
Total TB deaths per year (thousands, log scale)

700

20
500
500

European Region Eastern Mediterranean Region Western Pacific Region

70
100 200

50

70 100
30

60 70

2000 2005 2010 2015 2020 2000 2005 2010 2015 2020 2000 2005 2010 2015 2020

12  Global Tuberculosis Report 2022

 FIG. 10
Global trends in the estimated number of incident TB cases (left) and the incidence rate (right),
2000–2021
The horizontal dashed line shows the first milestone of the End TB Strategy, which was a 20% reduction in the
TB incidence rate between 2015 and 2020. Shaded areas represent 95% uncertainty intervals.

Rate per 100 000 population per year

All TB cases
10
Millions per year (log scale)

All TB cases 100

2020 milestone
Notifications of new Notifications of new

(log scale)
and relapse cases and relapse cases
3
30
HIV−positive HIV−positive
TB cases TB cases
1
10

2000 2005 2010 2015 2020 2000 2005 2010 2015 2020

In 2021, 82% of global TB deaths among HIV-negative COVID-19 pandemic (Fig. 1–Fig. 5, Box 4). The more pro-
people occurred in the WHO African and South-East nounced impact of these disruptions on TB incidence in
Asia regions; India alone accounted for 36% of such 2021 compared with 20204 can be explained by time lags
deaths. The WHO African and South-East Asia regions between increases in TB transmission (caused by more
accounted for 82% of the combined total of TB deaths in people having undiagnosed and untreated TB) and sub-
HIV-negative and HIV-positive people; India accounted sequent development of disease among a proportion of
for 32% of such deaths. those newly infected. In 2021, there was an extra year
Of the global TB deaths among HIV-negative people, for the consequences of disruptions in 2020 to manifest,
54% were in men, 32% were in women and 14% were and these earlier disruptions were combined with the
in children (aged <15  years). Of the global TB deaths impact of disruptions in 2021.
among HIV-positive people, 51% were in men, 38% were At regional level, the TB incidence rate increased
in women and 11% were in children. between 2020 and 2021 in five of the six WHO regions
(Fig.  11). The exception was the WHO African Region,
Number of people developing TB where disruptions related to COVID-19 have had little
Global rise in 2021, years of decline reversed impact on the number of people diagnosed and official-
An estimated 10.6  million people (95%  UI: 9.9–11  mil- ly notified with TB (Fig. 2).
lion) fell ill with TB worldwide in 2021, an increase of Geographically, in 2021, most people who developed
4.5% from 10.1  million (95%  UI: 9.5–10.7  million) in TB were in the WHO regions of South-East Asia (45%),
2020,1 reversing many years of slow decline (Fig.  10, Africa (23%) and the Western Pacific (18%), with small-
left panel).2 Similarly, the TB incidence rate (new cases er proportions in the Eastern Mediterranean (8.1%),
per 100  000 population per year) is estimated to have the Americas (2.9%) and Europe (2.2%). The 30 high TB
increased by 3.6% between 2020 and 2021, following burden countries accounted for 87% of all estimated
declines of about 2% per year for most of the past 2 dec- incident cases worldwide, and eight of these countries
ades (Fig. 10, right panel).3 (Fig.  12) accounted for more than two thirds of the
These sharp reversals of progress are consistent global total: India (28%), Indonesia (9.2%), China (7.4%),
with previous projections (15) and reflect the estimated the Philippines (7.0%), Pakistan (5.8%), Nigeria (4.4%),
impact of disruptions to essential TB services during the Bangladesh (3.6%) and the Democratic Republic of the
Congo (2.9%).
1
The global estimate for 2020 is 0.2 million higher than that TB can affect anyone, regardless of age or sex
published in 2021 (15), following an upward revision to estimates
(Fig.  13). The highest burden is in adult men, who
for India for the period 2000–2020. Estimates for India are
currently interim. Further details are provided in Annex 5. accounted for 56.5% of all TB cases in 2021; by compar-
2
The major contributors to the global increase between 2020 and ison, adult women accounted for 32.5% and children
2021 were India, Indonesia and the Philippines. Collectively, TB for 11% of cases. The higher share of TB cases among
incidence rose by about 0.4 million in these three countries. This
is consistent with their contributions to global reductions in the men is consistent with evidence from national TB prev-
reported number of people newly diagnosed with TB in 2020 and
2021 (Fig. 3). 4
TB incidence (both in terms of absolute numbers and per 100 000
3
Globally, the TB incidence rate is estimated to have fallen by 30% population) did not increase between 2019 and 2020, but the
between 2000 and 2020. annual rates of decline slowed slightly (15).

Global Tuberculosis Report 2022   13

 FIG. 11
Trends in estimated TB incidence rates by WHO region, 2000–2021
Total TB incidence rates are shown in blue and incidence rates of HIV-positive TB are shown in light blue.
The black solid lines show notifications of new and relapse cases for comparison with estimates of the total
incidence rate. The horizontal dashed line shows the first milestone of the End TB Strategy, which was a 20%
reduction in the TB incidence rate between 2015 and 2020. Shaded areas represent 95% uncertainty intervals.

African Region Region of the Americas South-East Asia Region

30

100 100
10
Incidence rate per 100 000 population per year (log scale)

10 10
3

1 1 1

European Region Eastern Mediterranean Region Western Pacific Region

100 100
30

10
10
10

1
1 1

2000 2005 2010 2015 2020 2000 2005 2010 2015 2020 2000 2005 2010 2015 2020

FIG. 12
Estimated TB incidence in 2021, for countries with at least 100 000 incident cases
The countries that rank first to eighth in terms of numbers of cases, and that accounted for about two thirds of
global cases in 2021, are labelled.

China
Bangladesh
Philippines
Number of
incident cases
100 000 Pakistan
Nigeria
500 000
India
Democratic Republic Indonesia
1 000 000 of the Congo

2 000 000

14  Global Tuberculosis Report 2022

alence surveys, which show that TB disease affects men FIG. 13
more than women, and that gaps in case detection and Global estimates of TB incidence (black
reporting are higher among men.1 outline) and case notifications of people newly
Among all incident cases of TB in 2021, 6.7% were diagnosed with TB disaggregated by age and
people living with HIV; this proportion has been steadi- sex (female in purple; male in green), 2021
ly declining for several years. The proportion of people
with a new episode of TB who were coinfected with HIV ≥65
was highest in countries in the WHO African Region,
55–64
exceeding 50% in parts of southern Africa.
The severity of national TB epidemics, in terms of the 45–54

Age group (years)

number of incident TB cases per 100 000 population per 35–44
year, varies widely among countries, from less than five
25–34
to more than 500 new and relapse cases per 100  000
population per year (Fig. 14). In 2021, 47 countries had 15–24
a low incidence of TB (<10 cases per 100 000 population 5–14
per year), mostly in the WHO Region of the Americas and
0–4
the European Region, plus a few countries in the WHO
Eastern Mediterranean and Western Pacific regions. 500 000 0 500 000 1 000 000
Countries with a low incidence are well placed to target
Number of TB cases
TB elimination. There were 150‒400 cases per 100 000
population in most of the 30 high TB burden countries,
and more than 500 cases per 100 000 population in the
Central African Republic, Gabon, Lesotho, the Philip- relatively stable between 2015 and 2020, but it grew in
pines and South Africa. 2021 (Fig.  15). There were an estimated 450  000 inci-
Drug-resistant TB (DR-TB) continues to be a public dent cases (95% UI: 399 000–501 000) in 2021, up 3.1%
health threat. Resistance to rifampicin – the most effec- from 437  000 (95% UI: 390  000–483  000) in 2020. The
tive first-line drug – is of greatest concern. Resistance to main explanation for the increase is the overall increase
rifampicin and isoniazid is defined as multidrug-resist- in TB incidence between 2020 and 2021 (Fig. 10), which
ant TB (MDR-TB). Both MDR-TB and rifampicin-resistant is estimated to have been caused by the impact of the
TB (RR-TB) require treatment with second-line drugs. COVID-19 pandemic on TB detection (Fig.  1–Fig.  5,
Globally, the estimated number of people who devel- Box 4).
oped MDR-TB or RR-TB (MDR/RR-TB) each year was In 2021, the estimated proportion of people with

FIG. 14
Estimated TB incidence rates, 2021

Incidence per 100 000

population per year
0–9.9
10–49
50–99
100–299
300–499
≥500
No data
Not applicable

1
For further details, see Section 2.4 of the report webpages.

Global Tuberculosis Report 2022   15

 FIG. 15 TB who had MDR/RR-TB was 3.6% (95%  UI: 2.7–4.4%)
Global trend in the estimated number of among new cases and 18% (95%  UI: 11–26%) among
incident cases of MDR/RR-TB, 2015–2021 those previously treated; the figures in 2015 were 3.9%
The shaded area represents the 95% uncertainty (95% UI: 2.8–5.0%) and 20% (95% UI: 9.5–31%), respec-
interval. tively (Fig. 16).
Three countries accounted for 42% of global cases
600 in 2021 (Fig.  17): India (26%), the Russian Federation
(8.5%) and Pakistan (7.9%). The highest proportions
Thousands per year

(>50% of previously treated cases with MDR/RR-TB) are

400
found in the Russian Federation and in several countries
in Eastern Europe and Central Asia.
200
Milestones for reducing TB disease burden
Mostly not yet reached, some success stories
0
2015 2016 2017 2018 2019 2020 2021 The first End TB Strategy milestones for reductions in
TB disease burden were a 35% reduction in the total
number of TB deaths (the combined total of those in
HIV-negative and HIV-positive people) and a 20% reduc-
FIG. 16 tion in the TB incidence rate, compared with levels in
Global percentage of TB cases estimated to 2015 (Box 2). These milestones were set for 2020 but
have MDR/RR-TB, 2015–2021 have not yet been reached either globally or in most
WHO regions and countries. Reversals of progress dur-
Shaded areas represent 95% uncertainty intervals.
ing the COVID-19 pandemic mean that in 2021 they were
New cases even further away than in 2019.
5
Globally, the reduction in the total number of TB
deaths between 2015 and 2021 was 5.9%, about one
4 sixth of the way to the milestone of 35%. Progress
achieved up to 2019 (a 14% reduction from 2015 to 2019
Percentage

3
and a 41% reduction from 2000 to 2019) was compro-
2 mised by increases in TB deaths in 2020 and 2021 (Fig. 6,
left panel).
1
At regional level, the WHO African Region is now clos-
0 est to reaching the first milestone, with a 26% reduction
2015 2016 2017 2018 2019 2020 2021 between 2015 and 2021 (Fig.  9). The WHO European
Region had previously come close, with a reduction
Previously treated cases of 28% between 2015 and 2019,1 but this progress was
reversed in 2021; the net reduction by 2021 now stands
30 at 21%. The decline compared with 2015 in the WHO
Eastern Mediterranean Region was small, at 1.9%. The
estimated number of TB deaths in 2021 was higher
Percentage

20
than in 2015 in the WHO regions of the Americas (+31%),
South-East Asia (+8.6%) and the Western Pacific (+19%).
10 By 2021, six high TB burden countries had reached
or passed the first milestone of a 35% reduction in
0 TB deaths compared with 2015 (Bangladesh, Kenya,
2015 2016 2017 2018 2019 2020 2021 Mozambique, Uganda, the United Republic of Tanza-
nia and Zambia), as had one of the one of the global TB
watchlist countries (the Russian Federation)2 (Fig.  18).
A seventh high TB burden country, Ethiopia, was very
1
Progress in this region is strongly influenced by trends in the
Russian Federation.
2
Alongside the list of 30 high TB burden countries for 2021–2025,
WHO has established a global TB watchlist. The watchlist
comprises the three countries that have transitioned out of the
previous list for 2016–2020, which warrant continued global
attention: Cambodia, the Russian Federation and Zimbabwe
(Annex 3).

16  Global Tuberculosis Report 2022

 FIG. 17
Estimated incidence of MDR/RR-TB in 2021, for countries with at least 1000 incident cases
The seven countries with the highest burden in terms of numbers of MDR/RR-TB cases, and that accounted for
two thirds of global MDR/RR-TB cases in 2021, are labelled.

Russian Federation

China

Philippines

Pakistan
Number
of cases India
1000 Indonesia
10 000

100 000 South Africa

FIG. 18
High TB burden and global TB watchlist countries estimated to have reached, by 2021, the first
milestone of the End TB Strategy
The horizontal dashed line shows the first milestone of the End TB Strategy, which was a 35% reduction in the
total number of TB deaths between 2015 and 2020. Shaded areas represent 95% uncertainty intervals.

Bangladesh Kenya Mozambique Russian Federation

100 30
100 30
TB deaths (total, in thousands) per year (log scale)

20
20
50
50

30 10 10
30

2000 2005 2010 2015 2020

United Republic of
Uganda Tanzania Zambia

30
30 100
20
20 50

30 10

10

2000 2005 2010 2015 2020 2000 2005 2010 2015 2020 2000 2005 2010 2015 2020

Global Tuberculosis Report 2022   17

 close to doing so, with a reduction of 34%. A total of 25 Lesotho, Namibia, South Africa, the United Republic of
countries reached the milestone by or before 2021. Tanzania and Zambia), as had all three of the global TB
Globally, the cumulative reduction in the TB inci- watchlist countries (Cambodia, the Russian Federation
dence rate from 2015 to 2021 was 10%, exactly halfway and Zimbabwe) (Fig. 19). In total, 77 countries reached
to the first (2020) milestone of 20% (Fig. 10, right panel). the milestone by or before 2021.
There are two success stories at regional level
(Fig.  11). In 2021, the WHO African Region just passed TB deaths and incidence beyond 2021
the first (2020) milestone of the End TB Strategy, with a Further worsening possible
reduction of 22% since 2015. Despite an upturn between The country-specific models developed for 27 coun-
2020 and 2021, the TB incidence rate in the WHO Euro- tries (Box 4) to estimate TB incidence and mortality in
pean Region was still 25% lower in 2021 than in 2015. 2020 and 2021 also allow projections for subsequent
For other regions, the first milestone is still some way years. These models suggest that there could be further
off, with reductions between 2015 and 2021 of 2.3% increases in TB deaths and TB incidence. The faster that
in the WHO Western Pacific Region, 5.3% in the East- TB case detection can be restored (not only back to 2019
ern Mediterranean Region and 11% in the South-East levels but also to address backlogs from 2020 and 2021),
Asia Region. There was an increase of 9.4% in the WHO the more these potential increases can be moderated.
Region of the Americas. The current models might understate the impact of
By 2021, seven high TB burden countries had reached the COVID-19 pandemic on TB disease burden, because
or passed the first milestone of a 20% reduction in the they do not yet account for negative effects on broader
TB incidence rate compared with 2015 (Ethiopia, Kenya,

FIG. 19
High TB burden and global TB watchlist countries estimated to have reached, by 2021, the first
milestone of the End TB Strategy
The horizontal dashed line shows the first milestone of the End TB Strategy, which was a 20% reduction in the
TB incidence rate between 2015 and 2020. Shaded areas represent 95% uncertainty intervals.

Cambodia Ethiopia Kenya Lesotho

1000
1000 2000
1000

500 300 500 1000

300 300
500
Incidence rate per 100 000 population per year (log scale)

100

United Republic of
Namibia Russian Federation South Africa Tanzania

2000 1000
2000

100
1000 1000
300

50
500 500
100
30
2000 2005 2010 2015 2020 2000 2005 2010 2015 2020

Zambia Zimbabwe

1000
1000

500
500
300
300

2000 2005 2010 2015 2020 2000 2005 2010 2015 2020

18  Global Tuberculosis Report 2022

 TB determinants (Box 4). These include average income surveys for the period 2000–2019 to inform estimates of
(measured as gross domestic product [GDP] per capita) the number of TB deaths in 123 countries that account-
and the prevalence of undernourishment, both of which ed for about 60% of the global number of TB deaths
are closely associated with TB incidence (Fig. 20). Wors- among HIV-negative people.
ening trends in these two indicators, and others such For this report, there were only two high TB burden
as levels of poverty, could increase the probability of or global TB watchlist countries for which data on the
developing TB disease among people already infected number of TB deaths in the period 2020–2021 were
with M. tuberculosis and their mortality rate. Declines in available from national VR systems and shared with the
income may also affect health care seeking behaviour WHO Global TB Programme: China and the Russian Fed-
when people become unwell, making delays in TB diag- eration. The only country in which a national TB prev-
nosis and treatment more likely. alence survey has been completed since 2019 is India;
the survey was started in 2019 but was interrupted for
Estimation of TB disease burden several months in 2020 due to the COVID-19 pandemic
New direct measurements needed and then completed in 2021. This survey has informed
Estimating TB disease burden during the COVID-19 interim estimates of TB incidence published as part of
pandemic is difficult and currently relies on country- this report.2
and region-specific dynamic models for many LMICs New national population-based surveys of TB dis-
(Box  4). This is in contrast to the methods used for the ease and up-to-date cause-of-death data from national
period 2000–2019.1 These included use of results from VR systems of high quality and coverage are needed for
population-based surveys of the prevalence of TB dis- more accurate estimation in the wake of the pandemic.
ease that were implemented between 2000 and 2019 Inventory studies to assess the level of underreporting
to inform estimates of TB incidence in 29 countries that of people diagnosed with TB would also be helpful. Two
accounted for about two-thirds of global TB incidence; countries are currently planning a repeat national TB
and use of data from national VR systems or mortality prevalence survey: Cambodia and Pakistan.

FIG. 20
The relationship between GDP per capita and the prevalence of undernourishment, and TB
incidence per 100 000 population, 2021a
1000 1000
Incidence per 100 000 population (log scale)

Incidence per 100 000 population (log scale)

100 100

10 10

1 1
1 10 100 3 10 30
GDP per capita (US$ thousands) Prevalence of undernourishment (% of population)

a
The year of data used for GDP per capita and undernourishment is the latest year for which data are available in the World Bank (https://data.worldbank.
org/) and SDG (https://unstats.un.org/sdgs/dataportal) databases, respectively.

1
For further details, see Section 2.1 and Section 2.2 of the report 2
Further details are provided in Annex 5 and the technical
webpages. appendix.

Global Tuberculosis Report 2022   19

 FIG. 21 TB diagnosis and treatment
Global trends in notifications of people Partial recovery in 2021, targets off track
newly diagnosed with TB (black) and the The gap between the estimated number of people who
estimated number of incident TB cases fell ill with TB (incident cases) and the number of people
(green), 2000–2021 newly diagnosed and reported widened in both 2020 and
The shaded area represents the 95% uncertainty 2021 compared with 2019 (Fig. 21), to best estimates of
interval.
over 4 million in each year. This was a reversal of previ-
ous progress in closing the gap between 2012 and 2019,
when the global number of people newly diagnosed
15 with TB and reported rose from 5.7–5.8 million annually
Millions per year

in the years 2009–2012 to 6.4 million in 2017 and 7.1 mil-

10 lion in 2019, while TB incidence fell slowly. The reported
number of people newly diagnosed with TB in 2020, at
5
5.8 million, took the world back to the level of 2012; the
partial recovery to 6.4  million in 2021 is similar to the
level of 2017.
0
Two of the countries with the largest absolute reduc-
2000 2005 2010 2015 2020
tions in the reported number of people newly diagnosed
with TB between 2019 and 2021 (Fig. 3), India and Indo-
nesia, had previously been the main contributors to the
large global increase that occurred between 2013 and
FIG. 22
2019. Their combined total number of case notifications
The global number of people reported to have per year increased by 1.2 million in that period, but then
been treated for TB disease, 2015–2021 fell by 0.7 million between 2019 and 2020, with a partial
8 recovery (+0.4 million) in 2021.
Globally, these negative trends mean that TB treat-
6 ment coverage (approximated as the reported number
of people newly diagnosed with TB divided by inci-
Millions

4 dence)1 was 61% (95% UI: 57–65%) in 2021, an improve-

ment from 58% in 2019 (95%  UI, 54–61%) but down
from 69% (95% UI: 62–77%) in 2019. Among the six WHO
2
regions, treatment coverage in 2021 was highest in the
Americas (with a best estimate of 69%) and lowest in the
0
2015 2016 2017 2018 2019 2020 2021
Eastern Mediterranean (with a best estimate of 58%). Of
the 30 high TB burden countries, those with the highest
Adults aged ≥15 Children aged 0–14 years
levels of treatment coverage in 2021 included Bangla-
desh, Brazil, China, Uganda and Zambia. Ten high TB
burden countries had worryingly low levels of treat-
ment coverage in 2021, with best estimates of below
50%: the Central African Republic, Gabon, Indonesia,
Lesotho, Liberia, Mongolia, Myanmar, Nigeria, the Phil-
ippines and Viet Nam.
The major reversals of previous progress in increas-
ing the number of people newly diagnosed with TB each
year (Fig.  1) have badly impacted progress towards
the global TB treatment targets set at the UN high-
level meeting in 2018. The cumulative number of people
treated between 2018 and 2021 was 26.3 million,2 equiv-
alent to 66% of the 5-year (2018–2022) target of 40 mil-
lion (Fig. 22, Fig. 23). This included 1.9 million children,
54% of the 5-year target of 3.5 million.
1
Some people who are newly diagnosed and reported may not be
started on treatment, and some people may be diagnosed and
treated but not reported (and thus not included in the number of
case notifications).
2
This number assumes that all those diagnosed and reported were
treated.

20  Global Tuberculosis Report 2022

Fig. 23
Global progress in the number of people treated for TB between 2018 and 2021, compared with
cumulative targets set for 2018–2022 at the UN high-level meeting on TB

TB TREATMENT TB TREATMENT
(ALL AGES) (CHILDREN)

Target:
26.3million Target:
1.9million
(66%) (54%)
40 million 3.5 million
2018–2022 treated in 2018–2022 treated in
2018–2021 2018–2021

MDR/RR-TB TREATMENT MDR/RR-TB TREATMENT

(ALL AGES) (CHILDREN)

Target:
649 000 Target:
17 700
(43%) (15%)
1.5 million 115 000
2018–2022 treated in 2018–2022 treated in
2018–2021 2018–2021

In 2021, 10 countries collectively accounted for 75% combination of underreporting of people diagnosed
of the global gap between estimated TB incidence and with TB and underdiagnosis (owing to people with TB
the reported number of people newly diagnosed with being unable to access health care or not being diag-
TB (Fig. 24). The top five contributors were India, Indo- nosed when they do). From a global perspective, efforts
nesia, the Philippines, Pakistan and Nigeria (24%, 13%, to increase levels of case detection are of particular
10%, 6.6% and 6.3%, respectively). Gaps are due to a importance in these countries.

FIG. 24
The ten countries with the largest gaps between notifications of new and relapse (incident) TB
cases and the best estimates of TB incidence,a,b 2021

China
Viet Nam

Philippines

Pakistan
Size of gap Nigeria India
70 000
Myanmar
500 000 Democratic Republic Indonesia
of the Congo

1 000 000 South Africa

a
The ten countries ranked in order of the size of the gap between notified cases and the best estimates of TB incidence in 2021 are: India, Indonesia, the
Philippines, Pakistan, Nigeria, China, South Africa, Myanmar, Viet Nam and the Democratic Republic of the Congo.
b
Incidence estimates for India are interim and subject to finalization, in consultation with the Ministry of Health & Family Welfare, India.

Global Tuberculosis Report 2022   21

 FIG. 25
Percentage of people newly diagnosed with pulmonary TB who were bacteriologically
confirmed, globally and for WHO regions,a 2000–2021
Global African Region Region of the Americas South-East Asia Region
100

80

60
Percentage bacteriologically confirmed

40

20

0
2000 2005 2010 2015 2020
European Region Eastern Mediterranean Region Western Pacific Region
100

80

60

40

20

0
2000 2005 2010 2015 2020 2000 2005 2010 2015 2020 2000 2005 2010 2015 2020

a
Data are for notified cases. The calculation for years prior to 2013 is based on smear results, except for the European Region where data on confirmation
by culture was also available for the period 2002–2012.

In many countries, there is also a need to increase tries, those with the highest proportions (above 90%)
the percentage of cases confirmed bacteriologically by included Namibia, Viet Nam and Zambia. Among the 49
scaling up the use of recommended diagnostics, in line countries in one of the three global lists of high burden
with WHO guidelines (19). The microbiological detection countries (for TB, HIV-associated TB and MDR/RR-TB),1
of TB is critical because it allows people to be correct- 26 reported that a WHO-recommended rapid diagnostic
ly diagnosed, is necessary to test for drug resistance test had been used as the initial test for more than half
and ensures that the most effective treatment regimen of their notified TB cases in 2021, up from 21 in 2020 and
(depending on the pattern of drug resistance) can be 18 in 2019.
selected as early as possible. The global coverage of HIV testing among people
Of the 5.3 million people diagnosed with pulmonary diagnosed with TB remained high in 2021, at 76% (up
TB worldwide in 2021, 63% were bacteriologically con- from 73% in 2020). At regional level, the highest cov-
firmed (Fig. 25). This was an increase from 59% (2.8 mil- erage in 2021 was achieved in the WHO African Region
lion out of a total of 4.8 million) in 2020. There was some (89%) and the WHO European Region (94%). In 119
variation among the six WHO regions, with the highest countries and territories, at least 90% of people diag-
percentage achieved in the Americas (79%) and the nosed with TB knew their HIV status.
lowest in the Western Pacific (56%). There was also con- Among people living with HIV who develop TB, both
siderable variation among countries. In general, levels TB treatment and antiretroviral therapy (ART) for HIV
of confirmation were lowest in low-income countries are required to prevent unnecessary deaths from TB
(median, 69%), and highest in high-income countries and HIV. The global coverage of ART for people living
(median, 89%) where there is wide access to the most with HIV who were newly diagnosed and reported with
sensitive diagnostic tests. TB has been maintained at the high level of 89% since
The use of rapid tests remains far too limited. A 2019. However, when compared with the total number
WHO-recommended rapid molecular test was used as of people living with HIV estimated to have developed
the initial diagnostic test for only 38% (2.5 million) of the TB in 2021, coverage was only 46% (the same level as in
6.4 million people newly diagnosed with TB in 2021, up 2020). This was far below the overall level of coverage
from 33% (1.9/5.8 million) in 2020 and 28% (2.0/7.1 mil- of ART for people living with HIV, which was 75% at the
lion) in 2019. There was substantial variation among
countries (Fig. 26). Among the 30 high TB burden coun- 1
See Annex 3.

22  Global Tuberculosis Report 2022

FIG. 26
Percentage of people newly diagnosed with TB who were initially tested with a WHO-
recommended rapid test at country level,a 2021

Percentage (%)
<25
25–49
50–75
76–90
>90
No data
Not applicable

a
Data are for notified cases.

end of 2021 (20). The main reason for the relatively low FIG. 27
coverage was the big gap between the estimated num- Global success rates for people treated for TB,
ber of people living with HIV who developed TB in 2021 2012–2020a
(a best estimate of 703 000) and the reported number 100
diagnosed with TB in 2021 (368 641).
Treatment success rate (%)

A positive finding for the first full year of the COVID-19 90

pandemic is that 86% of those started on first-line TB 80

People newly diagnosed with TB (new and relapse
treatment in 2020 had a successful outcome; this was cases) and enrolled on first-line treatment
70
the same level as in 2019 and slightly better than the
85% seen in 2017 and 2018 (Fig. 27). This finding shows 60
that, despite the many disruptions caused by the pan-
50
demic, the quality of treatment for those diagnosed People diagnosed with MDR/RR-TB and enrolled
on an MDR/RR-TB treatment regimen
with TB was maintained in 2020. Treatment success 40
rates remain lower among people living with HIV (77% 2012 2013 2014 2015 2016 2017 2018 2019 2020
globally in 2020), although there have been steady Year started on treatment
improvements over time. The treatment success rate a
2012 is the first year for which WHO collected data about treatment
for children (aged 0–14 years) was 88% in 2020, the same outcomes for MDR/RR-TB.
level as in 2019.
Provision of TB treatment and ART to people living
with HIV who were diagnosed with TB is estimated to
have averted 74 million deaths between 2000 and 2021
(Table 2).

Drug-resistant TB: diagnosis and treatment

Partial recovery in 2021, targets off track
WHO uses five categories to classify cases of DR-TB: iso-
niazid-resistant TB, RR-TB and MDR-TB (defined above),

Global Tuberculosis Report 2022   23

 Table 2
Cumulative number of deaths averted by TB and TB/HIV interventions 2000–2021 (in millions),
globally and by WHO regiona

HIV-NEGATIVE PEOPLE HIV-POSITIVE PEOPLE TOTAL

UNCERTAINTY UNCERTAINTY UNCERTAINTY
BEST ESTIMATE BEST ESTIMATE BEST ESTIMATE
WHO REGION INTERVAL INTERVAL INTERVAL
African Region 7.1 6.0–8.3 8.5 7.2–9.8 16 14–17
Region of the Americas 1.9 1.8–2.1 0.36 0.33–0.39 2.3 2.1–2.4
South-East Asia Region 30 25–34 2.9 2.0–3.8 32 28–37
European Region 2.1 1.9–2.4 0.32 0.28–0.35 2.4 2.2–2.7
Eastern Mediterranean Region 5.2 4.6–5.8 0.10 0.08–0.12 5.3 4.7–5.9
Western Pacific Region 16 14–17 0.50 0.42–0.59 16 15–18
Global 62 55–69 13 11–14 74 67–81
a
Numbers shown to two significant figures.

plus extensively drug-resistant TB (XDR-TB) and pre- Globally in 2021, 71% of people (2.4/3.4 million) diag-
XDR-TB. Pre-XDR-TB is TB that is resistant to rifampicin nosed with bacteriologically confirmed pulmonary TB
and any fluoroquinolone (a class of second-line anti-TB were tested for rifampicin resistance, the same level of
drug), whereas XDR-TB is TB that is resistant to rifampic- coverage as in 2020 (2.1/3.0  million) and up from 61%
in, plus any fluoroquinolone, plus at least one of the (2.2/3.6  million) in 2019. Among those tested, 141 953
drugs bedaquiline and linezolid. cases of MDR/RR-TB and 25  038 cases of pre-XDR-TB
Detection of drug resistance requires bacteriological or XDR-TB were detected, giving a combined total of
confirmation of TB and testing for drug resistance using 166 991. This was an increase (6.4%) from the combined
rapid molecular tests, culture methods or sequenc- total of 156 982 in 2020, but less than the 9.7% increase
ing technologies. Treatment requires a course of sec- in the overall number of people diagnosed and reported
ond-line drugs. Novel all-oral regimens for MDR/RR-TB with TB between 2020 and 2021. It was also still consid-
and pre-XDR-TB can now reduce treatment duration erably lower (by 17%) than the total of 201 997 in 2019.
to only 6 months, compared with older regimens last- Worldwide, 161 746 people with MDR/RR-TB were
ing 20 months or more. WHO recommends expanded enrolled on treatment in 2021, up 7.5% from 150 469 in
access to all-oral regimens, supported by counselling 2020 but still considerably lower (by 11%) than the total
and monitoring for adverse events (21). of 181 533 in 2019 (Fig. 28, Fig. 29). This level of enrol-

FIG. 28 FIG. 29
Global number of people diagnosed with The global number of people reported to have
MDR/RR-TB (blue) and number enrolled on been enrolled on treatment for MDR/RR-TB,
an MDR/RR-TB treatment regimen (red), 2015–2021a
compared with estimates of the global
200
number of incident cases of MDR/RR-TB
(green), 2015–2021
150
The shaded area represents the 95% uncertainty
interval.
Thousands

100

600 000
50
Number per year

400 000 0
2015 2016 2017 2018 2019 2020 2021

All ages
200 000
Adults aged ≥15 years or age not reported
Children aged 0–14 years

0 a
Global data disaggregated by age are not available for the years before
2015 2016 2017 2018 2019 2020 2021 2018.

24  Global Tuberculosis Report 2022

ment is equivalent to about one in three of the people TB prevention
who develop MDR/RR-TB each year (Fig. 15, Fig. 28). Recovery in 2021 but targets mostly off track
Reversals in progress in the number of people
The main health care intervention available to reduce
enrolled on treatment mean that the global targets set
the risk of TB infection progressing to active TB disease
at the UN high-level meeting now appear to be out of
is TB preventive treatment.3 Other preventive inter-
reach (Fig. 23). The cumulative number of people with
ventions are TB infection prevention and control, and
MDR/RR-TB who were reported as being enrolled on
vaccination of children with the bacille Calmette-Guérin
treatment from 2018 to 2021 was 649 000, only 43% of
(BCG) vaccine, which can confer protection, especially
the 5-year target (2018–2022) of 1.5  million. Consider-
from severe forms of TB in children. WHO guidance
ing children specifically, the cumulative number was
recommends TB preventive treatment for people living
17 700, only 15% of the 5-year target of 115 000.
with HIV, household contacts of bacteriologically con-
There are 10 countries that account for about 70% of
firmed pulmonary TB cases and clinical risk groups (e.g.
the global gap between the estimated global incidence
those receiving dialysis) (22).4
of MDR/RR-TB each year and the number of people
The global number of people provided with TB pre-
enrolled in treatment in 2021: China, the Democratic
ventive treatment in 2021 was 3.5 million – still slightly
Republic of the Congo, India, Indonesia, Nigeria, Paki-
below the level of 3.6 million that was reached in 2019
stan, the Philippines, the Russian Federation, South
but a good recovery from 3.2 million in 2020 and much
Africa and Viet  Nam. Substantial gains in treatment
higher than 1.0 million in 2015 (Fig. 30). The combined
coverage at the global level requires efforts to improve
total of 12.5  million in 2018–2021 is only 42% of the
testing and diagnosis of DR-TB, and access to treatment
target of 30  million for the 5-year period 2018–2022
in these countries.
(Fig. 31).
More positively, there have been improvements in
the treatment success rate for MDR/RR-TB (Fig.  27).
Globally in 2019 (the latest patient cohort for which
data are available), the treatment success rate was FIG. 30
60%, reflecting steady improvements in recent years The global number of people provided with TB
from 50% in 2012.1 Among WHO regions, the treatment preventive treatment, 2015–2021
success rate in 2019 ranged from 57% in Europe to 72%
4
in the Eastern Mediterranean.
By the end of 2021, 124 countries were using bedaq-
3
uiline as part of treatment regimens for DR-TB (up from
110 in 2020). A total of 109 countries were using all-oral
Millions

longer regimens (up from 92 in 2020) for the treatment 2

of MDR/RR-TB, and 92 were using shorter regimens (up
from 65 in 2020). 1
There was considerable variation in the coverage of
testing for RR-TB among countries in 2021. Of the 30 0
high MDR/RR-TB burden countries,2 20 reached testing 2015 2016 2017 2018 2019 2020 2021
coverage of more than 80%: Azerbaijan, Belarus, China, People living with HIV
Kazakhstan, Kyrgyzstan, Mongolia, Mozambique, Household contacts aged <5 years
Household contacts aged ≥5 years
Myanmar, Pakistan, Peru, the Philippines, the Republic
of Moldova, the Russian Federation, South Africa,
Tajikistan, Ukraine, Uzbekistan, Viet Nam, Zambia and
Zimbabwe.
Most of those provided with TB preventive treatment
The global coverage of testing for resistance to fluo-
to date have been people living with HIV. Globally, the
roquinolones remains much lower, being 50% in 2021.
annual number increased from fewer than 30  000 in
Coverage was close to 100% in the WHO European
2005 to 2.8 million in 2021. This figure included 10.3 mil-
Region, and lowest in the Western Pacific Region (below
lion in the years 2018–2021, meaning that the global
20%).
subtarget of providing TB preventive treatment to
6 million people living with HIV between 2018 and 2022
was not only achieved but far exceeded, well ahead

3
The drug regimens currently recommended by WHO are
explained in Annex 1.
1
2012 is the first year for which WHO collected data on outcomes 4
Addressing broader determinants that influence TB epidemics
for people enrolled on treatment for MDR/RR-TB. can also help to prevent TB infection and disease. These are
2
See Annex 3. discussed below.

Global Tuberculosis Report 2022   25

Fig. 31
Global progress in provision of TB preventive treatment between 2018 and 2021, compared with
cumulative targets set for 2018–2022 at the UN high-level meeting on TB
ALL AGES PEOPLE LIVING WITH HIV

Target:
12.5million Target:
10.3million
(42%) (>100%)
30 million 6 million
2018–2022 treated in 2018–2022 treated in
2018–2021 2018–2021

HOUSEHOLD CONTACTS HOUSEHOLD CONTACTS

AGED <5 YEARS AGED ≥5 YEARS

Target:
1.6million Target:
0.60million
(40%) (3.0%)
4 million 20 million
2018–2022 treated in 2018–2022 treated in
2018–2021 2018–2021

of schedule (Fig.  31). Seven countries – India, Nigeria, rifapentine-containing regimens, up from 25  657 in 37
South Africa, Uganda, the United Republic of Tanzania, countries in 2020.
Zambia and Zimbabwe – collectively accounted for 82% The ratio of the TB notification rate among health
of those started on treatment in 2021. In 20 countries care workers to the TB notification rate in the general
that reported outcomes, the median completion rate adult population reflects the effectiveness of TB infec-
for those who started treatment in 2020 was 87%, up tion control in health facilities. The ratio should be
from 84% in 2019. about 1, but in 2021 it was greater than 1 in 14 countries
The number of household contacts of people diag- that reported five or more TB cases among health care
nosed with TB who were provided with TB preventive workers.
treatment remained low in 2021 (Fig. 30), at 0.7 million. There were concerning declines in the global cover-
However, this was an improvement from 0.5 million in age of BCG vaccination in 2020 and 2021. This fell from
2020 and was also above the level of 0.6 million in 2019. 88% in 2019 to 84% in 2021, probably due to disruptions
The cumulative number of contacts initiated on TB pre- to health services caused by the COVID-19 pandemic.
ventive treatment in the 4-year period 2018–2021, at
2.2 million, is only 9.2% of the 5-year target of 24 million Funding for essential TB services
for the period 2018–2022; this number included 1.6 mil- Spending down since 2019, far below target
lion children aged under 5  years (40% of the 5-year Progress in reducing the burden of TB disease requires
subtarget of 4  million) and 0.6  million people in older adequate funding for TB diagnostic, treatment and
age groups (3.0% of the 5-year subtarget of 20 million) prevention services, sustained over many years. How-
(Fig.  31). In 76 countries that reported outcomes, the ever, funding in LMICs that account for 98% of report-
median completion rate for those who started treat- ed TB cases falls far short of what is needed, and it fell
ment in 2020 was 86%, the same as in 2019. between 2019 and 2021.1
A substantial intensification and expansion of efforts In 2021, estimated spending on TB diagnostic, treat-
and investment is needed to improve the provision of ment and prevention services in LMICs was US$ 5.4 bil-
TB preventive treatment. This includes providing more lion (Fig.  32).2 This was slightly less than the total of
TB screening at household level (especially among peo- US$ 5.5 billion in 2020 and down 10% from US$ 6.0 bil-
ple aged ≥5  years), strengthening the follow-up to TB
screening at household level and among people living 1
All amounts quoted in this subsection are in constant 2021 US$.
with HIV, and increasing access to shorter (1–3 months) 2
These amounts include spending reported to WHO by national
rifamycin-based regimens. Treatment using these TB programmes (NTPs) and estimates (produced by the WHO
Global TB Programme) of the resources used to provide inpatient
shorter regimens is expanding: in 2021, 185 350 people and outpatient care to the reported number of people newly
in 52 countries were reported to have been treated with diagnosed with TB (Fig. 1).

26  Global Tuberculosis Report 2022

lion in 2019. The total of US$ 5.4 billion is only 42% of FIG. 32
the global target of US$  13  billion annually by 2022 Spending on TB prevention, diagnostic and
(Table 1) and only 35% of the US$ 15.6 billion estimated treatment services in 136 low- and middle-
to be required in 2021 in the Stop TB Partnership’s Glob- income countries,a,b,c 2015–2021
al Plan to End TB, 2018–2022 (23).
15
The decline in spending on TB services between 2019

Billions (constant 2021 US$)

and 2021 probably reflects several factors associated Target set at UN high-level meeting on TB
with the COVID-19 pandemic. These include reductions 10
in the global number of people reported as diagnosed
with TB between 2019 and 2021 (Fig.  1), changes to
models of service delivery (e.g. fewer visits to health 5
facilities and more reliance on remote support during
treatment) and reallocation of resources to the COV-
ID-19 response. 0
Of the total of US$  5.4  billion spent on TB services 2015 2016 2017 2018 2019 2020 2021
in 2021, US$ 3.2 billion was for diagnosis and first-line Domestic funding International donor funding

treatment of TB (including outpatient and inpatient

a
Sources: data reported by NTPs and estimates produced by the WHO
care) and US$  2.0  billion was for diagnosis and treat- Global TB Programme.
ment of MDR/RR-TB (including outpatient and inpa- b
The data sources, boundaries, accounting rules, and estimation
methods used in this report are different from those of the System of
tient care). Both these amounts are less than half of Health Accounts 2011 (SHA2011). The TB expenditure data reported here
the requirements for 2021 that were estimated in the are thus not comparable with the disease expenditure data, including for
TB, that are reported in WHO’s Global Health Expenditure Database.
Global Plan (23). The remaining amount (US$ 0.2 billion) c
The 136 countries accounted for 98% of the world’s officially reported TB
includes spending on TB preventive treatment (covering cases in 2021.

drugs only), interventions specifically related to HIV-as-

sociated TB and miscellaneous items.1
As in the previous 10 years, most of the funding used
al Fund), with a contribution that ranged from 69% (in
in 2021 (US$  4.3  billion from a total of US$  5.4  billion;
2010) to 83% (in 2017) of the reported total; in 2021, it
i.e. 79%) was from domestic sources (Fig. 33), with the
was 76%. The United States Government is the largest
aggregate figure strongly influenced by Brazil, the Rus-
contributor of funding to the Global Fund and is also the
sian Federation, India, China and South Africa (BRICS).
largest bilateral donor; overall, it contributes close to
Together, these five countries accounted for US$ 2.7 bil-
50% of international donor funding for TB.
lion (64%) of the total of US$  4.3  billion that was pro-
Increases in both domestic and international funding
vided from domestic sources in 2021. Overall, domestic
for TB are urgently required. Variation in the share of
sources accounted for 93% of the funding for TB diag-
funding from domestic sources within a given income
nostic, treatment and prevention services in BRICS and
group suggests that there is scope to increase domestic
all of the funding used in Brazil, China and the Russian
funding in some high TB burden and global TB watchlist
Federation.
countries.
In other LMICs, international donor funding remains
crucial (Fig.  33). For example, it accounted for 50% of
UHC and TB determinants
the funding available for TB services in the 26 high TB
burden and the two global TB watchlist countries (Cam- Faster progress required, TB target off track
bodia and Zimbabwe) outside BRICS, and 42% of the Global TB targets for reductions in TB disease burden
funding available in low-income countries in 2021. can only be achieved if TB diagnostic, treatment and
The total amount of international donor funding prevention services are provided within the context
reported by national TB programmes (NTPs) in LMICs to of progress towards UHC, and if there is multisectoral
WHO has been around US$ 1 billion per year in the peri- action to address the broader determinants that influ-
od since 2010 (Fig. 33).2 The main source is the Global ence TB epidemics and their socioeconomic impact.
Fund to Fight AIDS, Tuberculosis and Malaria (the Glob- For example, the second End TB Strategy milestone
of a 75% reduction in TB deaths (compared with 2015)
requires that only 6.5% of people who develop TB dis-
1
WHO uses an “other” category to capture spending on
miscellaneous items. ease die from it;3 this is only feasible if everyone with TB
2
Data on TB expenditures and funding that are reported to WHO can promptly access diagnostic and treatment services.
by NTPs do not include all the international donor funding that is UHC means that everyone can obtain the health
provided to LMICs (e.g. funding channelled to entities outside the
NTP). A comprehensive analysis of international donor funding services they need without suffering financial hardship
for TB, based on donor reports to the Organisation for Economic
Co-operation and Development (OECD), is one of the “featured 3
See also Section 2 of this report. The estimated percentage in
topics” on the report webpages. 2020 and 2021 was 15%.

Global Tuberculosis Report 2022   27

 FIG. 33
Spending on TB prevention, diagnostic and treatment services in 136 low and middle-income
countries and 3 other country groups,a,b 2010–2021

All low and middle-income countriesc (n=136) BRICS (n=5)

6 4
Billions (constant 2021 US$)

Billions (constant 2021 US$)

5
3
4

3 2

2
1
1

0 0
2010 2012 2014 2016 2018 2020 2010 2012 2014 2016 2018 2020

High TB burden and global TB watchlist countries

outside BRICSd (n=28) Other low and middle-income countries (n=103)
0.8
1.6
Billions (constant 2021 US$)

0.6 Billions (constant 2021 US$)

1.2

0.4
0.8

0.2 0.4

0 0
2010 2012 2014 2016 2018 2020 2010 2012 2014 2016 2018 2020

Domestic funding International donor funding

BRICS: Brazil, Russian Federation, India, China, South Africa.

a
Sources: data reported by NTPs and estimates produced by the WHO Global TB Programme.
b
The data sources, boundaries, accounting rules, and estimation methods used in this report are different from those of the System of Health Accounts
2011 (SHA2011). The TB expenditure data reported here are thus not comparable with the disease expenditure data, including for TB, that are reported in
WHO’s Global Health Expenditure Database.
c
The 136 countries accounted for 98% of the world’s officially reported TB cases in 2021.
d
The two global TB watchlist countries included are Cambodia and Zimbabwe.

(24). Through their adoption of the SDGs, all countries the monitoring of Indicator 3.8.2 by WHO and the World
have committed to achieving UHC by 2030: Target 3.8 Bank, direct medical expenditures that account for 10%
is “Achieve universal health coverage, including finan- or more of household expenditure or income are classi-
cial risk protection, access to quality essential health- fied as “catastrophic” (24–26).
care services and access to safe, effective, quality and The latest published data for the two UHC indicators
affordable essential medicines and vaccines for all” (7). are for 2019 (SCI) and 2017 (catastrophic expenditures
The two indicators to monitor progress towards this on health care) (25, 26). Globally, the SCI was 67 (out of
target are a UHC service coverage index (SCI) (Indica- 100) in 2019, up from 45 in 2000. The proportion of the
tor 3.8.1), and the percentage of the population experi- general population facing catastrophic expenditures on
encing household expenditures on health care that are health care (using a threshold of >10% annual house-
“large” in relation to household expenditures or income hold income or expenditure) rose from 9.4% in 2000 to
(Indicator 3.8.2).1 The SCI can take values from 0 (worst) 13% (996 million people) in 2017.
to 100 (best) and is calculated using 16 tracer indica- Values for both indicators in the 30 high TB burden
tors, one of which is the coverage of TB treatment. In and three global TB watchlist countries show that there
is a long way to go before the SDG targets for UHC are
1
Indicator 3.8.2 is a measure of financial hardship rather than achieved in most of those countries (Fig.  34). Among
financial barriers to accessing health care. The existence of out- high TB burden countries, Thailand stands out as hav-
of-pocket payments may deter many people from seeking care.

28  Global Tuberculosis Report 2022

 FIG. 34
UHC service coverage index (SDG 3.8.1)a and percentage of the general population facing
catastrophic health expenditures (SDG 3.8.2),b 30 high TB burden countries and three global TB
watchlist countries,c stratified by income groupd
Low-income
Percentage of the general population facing catastrophic health expenditure (SDG 3.8.2)

40
Central Democratic
African Republic of the
Republic Congo
20
Sierra Leone Uganda
Liberia Mozambique Zimbabwe
Ethiopia United Republic of Tanzania
0
30 40 50 60 70 80

Lower-middle-income

40
Angola
Myanmar
Bangladesh
20
Nigeria India Cambodia
Lesotho Philippines Kenya
Mongolia Viet Nam
Pakistan Zambia Indonesia
0
30 40 50 60 70 80
Upper-middle-income

40

China
20
South Brazil
Africa Russian Federation
Gabon Namibia Thailand
0
30 40 50 60 70 80
UHC service coverage index (SDG 3.8.1)

a
The SCI can take values from 0 (worst) to 100 (best) and is calculated using 16 tracer indicators, one of which is the coverage of TB treatment. Values shown
for the SCI are estimates for the latest year for which data for SDG 3.8.2 are available.
b
Defined as ≥10% of total household consumption or income. The latest available year ranges from 2007 to 2019 for the 30 high TB burden countries.
c
The three global TB watchlist countries are Cambodia, Russian Federation and Zimbabwe. Data were not available for Congo, Democratic People’s
Republic of Korea and Papua New Guinea.
d
The classification is for the latest year for which data for SDG 3.8.2 are available.
Source: Global Health Observatory (https://www.who.int/data/gho).

ing a high SCI (80) and a low level of catastrophic health indirect costs such as income losses) above 20% of
expenditures (2% of households). A Universal Coverage household income. The key differences between this
Scheme (UCS) was established in 2002 to provide an indicator and the SDG indicator for catastrophic health
explicit benefit to all citizens of Thailand not already expenditures (Indicator 3.8.2) are explained in Box 5.
covered by a health insurance scheme in the formal Since 2015, a total of 29 countries have completed
sector, supported by domestic funding and a strong pri- a national survey of costs faced by TB patients and
mary health care system (27). Although data post-2019 their households, of which 27 (including 16 of the 30
are not yet available, the COVID-19 pandemic is likely to high TB burden countries and one of the three glob-
have caused progress towards UHC to stall or reverse in al TB watchlist countries)1 have reported results. The
2020 and 2021 in many countries. percentage facing catastrophic costs ranged from 13%
Given the importance of UHC to targets for reduc- (95% confidence interval [CI]: 10–17%) in El Salvador to
tions in TB incidence and mortality, the End TB Strategy 92% (95%  CI: 86–97%) in Solomon Islands; the pooled
included a third target, which was that no TB patients average, weighted for each country’s number of notified
and their households face total costs that are cata- cases, was 48% (95%  CI: 36–61%) (Fig.  35). Among 23
strophic (8). The definition of catastrophic used for this countries that reported disaggregated data, the per-
TB-specific indicator is total costs (comprising direct centage facing catastrophic total costs was much high-
medical expenditures, nonmedical expenditures and
1
See Annex 3.

Global Tuberculosis Report 2022   29

Box 5. The difference between “catastrophic total costs” for TB patients and their
households, and the SDG indicator of catastrophic expenditures on health care

It is important to distinguish between the indicator of that they needed. Hence, the SDG indicator cannot
“the proportion of the population with large household be used as a measure of financial barriers to access to
expenditures on health as a share of total household health care.
expenditure or income”, which is used within the SDG
Due to the nature of the illness, TB patients and their
monitoring framework (SDG Indicator 3.8.2), and the
households can face severe direct and indirect financial
indicator of “the percentage of TB patients and their
and economic costs. These pose barriers that can greatly
households facing catastrophic costs due to TB”, which is
affect their ability to access diagnosis and treatment, and
part of the WHO End TB Strategy.
to complete treatment successfully. Costs included in
The SDG indicator is for the general population. the TB-specific indicator include not only direct medical
Household expenditures on health are defined as direct payments for diagnosis and treatment, but also direct
expenditures on health by all household members who nonmedical payments (e.g. transportation and lodging)
seek any type of care (preventive, curative, rehabilitative, and indirect costs (e.g. lost income). In contrast to SDG
long-term) for any type of disease, illness or health Indicator 3.8.2, the TB-specific indicator is restricted to a
condition, in any type of setting (outpatient, inpatient, particular population: people diagnosed with TB who are
at home). They include both formal and informal users of health services that are part of NTP networks.
expenditures. The indicator attempts to capture
Given these conceptual differences, the percentage of
the impact of household expenditures on health on
TB patients facing “catastrophic total costs” (defined as
household ability to spend on other basic needs. The
costs that account for >20% of their household income)
denominator of the total population includes many
is expected to be much higher than the percentage of the
people who had no contact with the health system and
general population facing catastrophic expenditures on
thus had zero expenditures on health. Although these
health care. Hence, the two indicators cannot and should
people did not experience financial hardship because of
not be compared directly.
direct expenditures on health care, they may nonetheless
have faced financial barriers to accessing health services

er for people with DR-TB, with a pooled average of 82% enables national assessments of the status of the main
(95% CI: 75–90%). elements of the MAF-TB (30).
Survey results are being used to inform approaches Results from implementation of the checklist show
to health financing, service delivery and social protec- that progress is being made in adaptation and imple-
tion that will reduce these costs.1 mentation of the MAF-TB. However, engagement of
Many new cases of TB are attributable to five risk all relevant sectors (including civil society) requires
factors: undernourishment, HIV infection, alcohol use strengthening, as do mechanisms for high-level review.
disorders, smoking (especially among men) and diabe- Given the impact of the COVID-19 pandemic, full imple-
tes (Fig. 36). In the context of the COVID-19 pandemic as mentation of all components of the MAF-TB could help to
well as war in Ukraine, ongoing conflicts in other parts ensure the recovery of essential TB services, enhanced
of the world, a global energy crisis and associated risks social protection and faster progress towards global TB
to food security, multisectoral action to address these targets.3 In line with the global part of the MAF-TB, WHO
and other determinants of TB, such as GDP per capita will continue to lead the coordination of global moni-
(Fig. 20) and poverty, is more important than ever.2 toring, reporting and review, and to provide technical
Addressing broader determinants of the TB epidemic support and guidance to countries and partners.
requires multisectoral accountability. The political dec-
laration at the UN high-level meeting on TB requested TB research and innovation
the WHO Director-General to develop a multisectoral Slow progress, much more investment needed
accountability framework for TB (MAF-TB) and ensure The End TB Strategy targets set for 2030 and 2035
its timely implementation. Following extensive devel- (Box 2) cannot be met without intensified research and
opment work, WHO finalized the framework and pub- innovation. When these targets were first established,
lished it in 2019 (29). To support Member States to adapt it was highlighted that technological breakthroughs
and use it, WHO has also developed a checklist that would be needed by 2025, so that the annual decline
1
Comprehensive documentation of the results and policy in the global TB incidence rate could be accelerated to
implications of the 21 surveys completed between 2015 and 2021
is available in a separate WHO publication (28). 3
For more analysis of the latest status of progress in adapting and
2
SDG targets and indicators that are associated with TB incidence using the MAF-TB, see one of the “featured topics” on the report
are described in Annex 6. webpages.

30  Global Tuberculosis Report 2022

FIG. 35
Estimates of the percentage of TB patients and their households facing catastrophic costs,a
national surveys completed 2016–2022
All TB Drug-resistant TBb

Solomon Islands Solomon Islands NA

Timor-Leste Timor-Leste NA
Zimbabwe Zimbabwe
Niger Nigerc
Nigeria Nigeria
Mongolia Mongolia
Ghana Ghana
Lao People's Democratic Republic Lao People's Democratic Republic
Viet Nam Viet Nam
Myanmar Myanmar
Democratic Republic of the Congo Democratic Republic of the Congo
South Africa South Africa
Burkina Faso Burkina Faso
Uganda Uganda
Colombia Colombia
Mali Mali
Brazil Brazil
United Republic of Tanzania United Republic of Tanzania
Philippines Philippines
Fiji Fiji NA
Indonesia Indonesia
Benin Benin
Papua New Guinea Papua New Guinea
Thailand Thailand
Kenya Kenya
Lesotho Lesotho
El Salvador El Salvador NA
Pooled average Pooled average

0 25 50 75 100 0 25 50 75 100
Percentage Percentage

NA – not available.
a
Defined as direct medical expenditures, direct nonmedical expenditures and indirect costs (e.g. income losses) that sum to >20% of household income.
This indicator is not the same as the SDG indicator for catastrophic health expenditures; see Box 5 for further explanation.
b
Estimates for drug-resistant TB specifically were only available for 23 countries. The calculation of confidence intervals for Mali and Uganda did not
account for sampling design.
c
Since a 95% confidence interval was not included in the national survey report, a simple binomial confidence interval was calculated based on the survey
sample size.

Fig. 36
Global estimates of the number of incident TB cases attributable to selected risk factors, 2021a

Undernourishment

HIV infection

Alcohol use disorders

Smoking

Diabetes

0 0.5 1.0 1.5 2.0

Number of cases (millions)

a
Sources of data used to produce estimates were: Imtiaz S et al. Eur Resp Jour (2017); Hayashi S et al. Trop Med Int Health (2018); Lönnroth K et al.
Lancet (2010); World Bank Sustainable Development Goals Database (http://datatopics.worldbank.org/sdgs/); WHO Global Health Observatory
(https://www.who.int/data/gho); and WHO Global TB Programme.

Global Tuberculosis Report 2022   31

 Fig. 37 detection of TB disease. Three new antigen-based skin
Funding for TB research, 2015–2020 tests for TB infection that perform better than tubercu-
2.0
lin skin tests (particularly in terms of specificity) were
Target set at UN high-level meeting on TB evaluated and recommended by WHO in 2022: the Cy-Tb
skin test (Serum Institute of India, India), C-TST (Anhui
Billions (current US$)

1.5
Zhifei Longcom Biopharmaceutical Co. Ltd, China) and
Diaskintest (JSC Generium, the Russian Federation).
1.0
WHO plans to evaluate the following tests in the com-
ing year: culture-free, targeted-sequencing solutions
0.5 to test for drug resistance directly from sputum speci-
mens; broth microdilution methods for drug suscepti-
0 bility testing; and new IGRAs to test for TB infection.
2015 2016 2017 2018 2019 2020
In September 2022, there were 26 drugs for the
Source: Treatment Action Group, Stop TB Partnership. Tuberculosis treatment of TB disease in Phase I, Phase II or Phase III
research funding trends 2005–2020. New York: Treatment Action Group; trials. These drugs comprise 17 new chemical entities,
2021 (https://www.treatmentactiongroup.org/resources/tbrd-report/tbrd-
report-2021/) two drugs that have received accelerated regulatory
approval, one drug that was recently approved by the
United States (US) Food and Drug Administration under
the limited population pathway for antibacterial and
an average of 17% per year between 2025 and 2035 (9). antifungal drugs, and six repurposed drugs. Various
Reductions in TB incidence achieved between 2015 and combination regimens with new or repurposed drugs,
2021 fell far short of the first 2020 milestone of the strat- as well as host-directed therapies, are in Phase II or
egy (10% compared with 20%); coupled with the impact Phase III trials.
of the COVID-19 pandemic on TB incidence in 2020 and In September 2022, at least 22 clinical trials to evalu-
2021 (Fig.  10, Fig.  11), this means that an even faster ate drugs and drug regimens for treatment of TB infec-
rate of decline will now be required to reach the targets. tion were being implemented. Examples included trials
Priorities include a vaccine to lower the risk of infection, for the prevention of DR-TB among high-risk household
a vaccine or new drug treatment to cut the risk of TB contacts of TB patients with MDR-TB and trials to assess
disease in people already infected, rapid diagnostics how to optimize the administration of short-course TB
for accurate detection of TB disease at the point of care, preventive treatment for very young children and peo-
and simpler, shorter treatments for TB disease. ple living with HIV.
There is progress in the development of new TB In September 2022, there were 16 vaccine candidates
diagnostics, drugs and vaccines.1 However, this is con- in clinical trials: four in Phase I, eight in Phase II and four
strained by the overall level of investment. The most in Phase III. They included candidates to prevent TB
recently published data show a total of US$ 0.9 billion infection and TB disease, and to help improve the out-
in 2020 (31), less than half the global target of US$ 2 bil- comes of treatment for TB disease.
lion per year that was set for the period 2018–2022 at Effective vaccines are critical to achieve annual glob-
the first UN high-level meeting on TB (Fig. 37). The total al and national reductions in TB incidence and mortali-
falls even further short of the estimated requirement in ty that are much faster than those achieved historically.
the Stop TB Partnership’s Global Plan to End TB, 2023– WHO has commissioned a full-value assessment of new
2030 (32), which is US$ 5 billion per year. TB vaccines to guide investments in late-stage research
In recent years, the diagnostic pipeline has expanded as well as the subsequent introduction and implementa-
considerably in terms of the number of tests, products tion of any that are licensed for use. Preliminary results
or methods in development. These include molecular suggest that vaccine products which meet the preferred
tests for the detection of TB disease and drug resist- product characteristics of new TB vaccines would have
ance, interferon-gamma release assays (IGRAs) for the substantive and positive health and economic impacts.
detection of TB infection, biomarker-based assays for This initiative as well as other recent or current efforts
detection of TB disease, computer-aided detection by WHO to support TB research and innovation are sum-
(CAD) for TB screening using digital chest radiography, marized in Box 6.
and a new class of aerosol-capture technologies for

1
A high-level summary of the status of the pipelines for new TB
diagnostics, drugs and vaccines is provided in this subsection.
The report webpages (Section 7) provide more details, including
graphics showing the products in each pipeline and links to
websites that provide information about the clinical trials that are
underway.

32  Global Tuberculosis Report 2022

Box 6. Recent or current efforts by WHO to support TB research and innovation

Recent or current efforts by WHO to support TB research and innovation include:

▶ Preparing for a high-level summit on how to accelerate progress in the development of new TB vaccines, drawing
on lessons learned during the COVID-19 pandemic. It is anticipated that the summit will be held in early 2023.
▶ Preparing a report on the health and economic benefits of new TB vaccines, to guide investments in late-stage
research and the introduction and implementation of new TB vaccines. The report will build on a previous
publication (33) and associated journal articles.
▶ In March 2022, convening a multistakeholder consultation to discuss the emerging needs of Member States for
policy guidance, evidence gaps for policy-making, and challenges in the translation of research evidence into policy
(34). The aim is to guide decision-makers who fund and implement research, to better focus their research agendas
on the priorities of TB programmes and affected populations.
▶ In May 2022, submitting a progress report to the 75th World Health Assembly (35) on the implementation of
the Global Strategy for TB Research and Innovation (36).
▶ Preparing and publishing a consolidated assessment of gaps in TB research that have emerged during the process
of reviewing evidence to inform WHO guideline development (37).
▶ Continuing engagement in meetings of the BRICS TB Research Network (38).
In the context of the COVID-19 pandemic, WHO has also established a compendium of research studies related to
TB and COVID-19 (39). Innovative programmatic responses to the impact of the pandemic on TB is one of the topics
featured on the webpages that accompany this report.

4. Conclusions

All Member States of the UN and WHO have committed death worldwide from a single infectious agent, replac-
to “ending the global TB epidemic” by 2030, with con- ing COVID-19.
crete milestones and targets included in the WHO End Intensified efforts backed by increased funding for
TB Strategy (adopted in 2014) and the political decla- essential TB services as well as research are urgently
ration that was the key outcome of the first-ever UN required to mitigate and reverse the negative impacts
high-level meeting on TB in 2018. of the COVID-19 pandemic on TB. The top priority is to
This report shows that the COVID-19 pandemic has restore access to and provision of essential TB services,
had a damaging impact on access to TB diagnosis and so that levels of TB case detection and treatment can
treatment and the burden of TB disease. Progress made recover to at least 2019 levels.
in the years up to 2019 has slowed, stalled or reversed, The need for action has become even more pressing
and global TB targets are off track. in the context of war in Ukraine, ongoing conflicts in
The most obvious impact has been a substantial other parts of the world, a global energy crisis and asso-
reduction (compared with 2019) in the reported num- ciated risks to food security. These are likely to further
ber of people newly diagnosed with TB in both 2020 and worsen some of the broader determinants of TB, such
2021, suggesting an increase in the number of people as levels of income and undernourishment.
with undiagnosed and untreated TB. The most severe The comprehensive review by heads of state and gov-
consequence has been an estimated increase in the ernment of the status of the TB epidemic and progress
number of people dying from TB. In 2021, the estimated in response efforts at a UN high-level meeting in 2023
number of deaths caused by TB was more than double provides an opportunity for renewed global commit-
the number caused by HIV/AIDS. In the near future, it is ments and actions towards the goal of ending TB.
possible that TB will once again be the leading cause of

Global Tuberculosis Report 2022   33

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35. Global Strategy for Tuberculosis Research and Innovation (A75/10). Consolidated report by the Director-General.
Seventy-fifth World Health Assembly. Geneva: World Health Organization; 2022 (https://apps.who.int/gb/ebwha/pdf_
files/WHA75/A75_10Rev1-en.pdf).
36. Global Strategy for Tuberculosis Research and Innovation (WHA73.3). Seventy-third World Health Assembly. Geneva:
World Health Organization; 2020 (https://apps.who.int/gb/ebwha/pdf_files/WHA73/A73_R3-en.pdf).
37. Evidence and research gaps identified during development of policy guidelines for tuberculosis [website]. Geneva: World
Health Organization; 2021 (https://www.who.int/publications/i/item/9789240040472).
38. BRICS TB Research Network [website]. Cape Town: BRICS TB Research Network Secretariat; 2022
(https://bricstb.samrc.ac.za/).
39. Compendium of TB/COVID-19 studies. Geneva: World Health Organization; 2022 (https://www.who.int/teams/global-
tuberculosis-programme/covid-19/compendium).

Global Tuberculosis Report 2022   35

Annex 1

Basic facts about TB

Tuberculosis (TB) is an old disease. Studies of human ble TB (both pulmonary and extrapulmonary): all four
skeletons show that it has affected humans for thou- drugs for the first two months, followed by H and R for
sands of years (1). Its cause remained unknown until 24 the remaining 4 months. They also include new recom-
March 1882, when Dr Robert Koch announced his dis- mendations that people aged 12 years and older with
covery of the bacillus responsible, subsequently named drug-susceptible pulmonary TB may be treated with a
Mycobacterium tuberculosis (2). The disease is spread 4-month regimen of rifapentine (P), H, Z and moxiflox-
when people who are sick with TB expel bacteria into acin (M), and that children and adolescents between
the air (e.g. by coughing). TB typically affects the lungs 3 months and 16 years of age with non-severe TB (and
(pulmonary TB) but can also affect other sites (extrapul- without suspicion or evidence of resistance to R and
monary TB). Most people who develop the disease H) may be treated with a 4-month regimen (2 months
(about 90%) are adults and there are more cases among of H, R, Z and sometimes also E, followed by 2 months
men than women. of H and R). Treatment success rates of at least 85% for
Diagnostic tests for TB disease have improved sub- people enrolled on the 6-month regimen are regularly
stantially in recent years. There are now several rapid reported to WHO by its 194 Member States.
molecular tests that are recommended by WHO as the Treatment for people diagnosed with R-resistant TB
initial diagnostic test for TB, some of which can detect (RR-TB) and multidrug-resistant TB (MDR-TB, defined
drug resistance simultaneously (3). These tests can be as resistance to H and R) is more difficult and requires
used at the lower levels of the health system. There are drugs that cause more side-effects (6). Nationally, treat-
also rapid molecular tests specifically for the detection ment success rates for RR-TB are typically in the range
of resistance to several first- and second-line anti-TB of 50–75%; the global average has been improving in
drugs, and sequencing technologies that can provide recent years, reaching 60% in the most recent patient
a comprehensive individual profile of drug resistance. cohort for which data are available. Treatment for
The older method of sputum smear microscopy (devel- pre-extensively drug-resistant TB (pre-XDR-TB, defined
oped >100 years ago) is still widely used for TB diagnosis as TB that is resistant to R and any fluoroquinolone) and
in low and middle-income countries but is increasingly XDR-TB (resistance to R, any fluoroquinolone and at
being replaced with rapid tests. Culture testing remains least one of bedaquiline or linezolid) is even more diffi-
the reference standard for TB diagnosis. Following diag- cult and treatment success rates are typically low.
nosis, smear or culture (as opposed to rapid molecular A global modelling study published in 2016 estimated
tests) are necessary to monitor an individual’s response that about a quarter of the world’s population had been
to treatment. In addition, culture is required for the infected with M.  tuberculosis (7). Recent analyses and
detection of resistance to newer anti-TB drugs and may commentary suggest that the number of those current-
also be used as a confirmatory test in settings and situ- ly infected is lower, given that some people will clear
ations in which people have a low pre-test probability of the infection (8, 9). An older modelling study published
having TB disease. in 2000 estimated that about 5–10% of people infected
Without treatment, the mortality rate from TB is with TB will go on to develop TB disease at some point
high. Studies of the natural history of TB disease in the during their lifetime (10). The probability of developing
absence of treatment with anti-TB drugs (conducted TB disease is much higher among people living with
before drug treatments became available) found that HIV, and among people affected by risk factors such
about 70% of individuals with sputum smear-positive as undernutrition, diabetes, smoking and alcohol con-
pulmonary TB died within 10 years of being diagnosed, sumption.
as did about 20% of people with culture-positive (but Preventive treatment is available for people with
smear-negative) pulmonary TB (4). TB infection. Recommended options include: a weekly
Effective drug treatments were first developed in dose of H and P for 3 months (3HP), a daily dose of H and
the 1940s. The latest WHO guidelines published in 2022 R for 3 months (3HR), a daily dose of H and P for 1 month
(5) include a strong recommendation for a 6-month (1HP), a daily dose of R for 4  months (4R), and a daily
regimen of isoniazid (H), rifampicin (R), ethambutol (E) dose of H for 6 months (6H) or longer.
and pyrazinamide (Z) for people with drug-suscepti- The only licensed vaccine for prevention of TB dis-

Global Tuberculosis Report 2022   37

ease is the bacille Calmette-Guérin (BCG) vaccine. The in preventing TB disease in adults, either before or after
BCG vaccine was developed almost 100 years ago, pre- exposure to TB infection; however, results from a Phase
vents severe forms of TB in children and is widely used. II trial of the M72/AS01E candidate are promising (11).
There is currently no licenced vaccine that is effective

References
1. 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 15 August 2022).
2. 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 15 August 2022).
3. WHO consolidated guidelines on tuberculosis. Module 3: Diagnosis – rapid diagnostics for tuberculosis detection 2021
update. Geneva: World Health Organization; 2021 (https://www.who.int/publications/i/item/9789240029415).
4. 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 15 August 2022).
5. WHO consolidated guidelines on tuberculosis, Module 4. Treatment – drug-susceptible tuberculosis treatment. Geneva:
World Health Organization; 2022 (https://www.who.int/publications/i/item/9789240048126)
6. WHO consolidated guidelines on tuberculosis, Module 4: Treatment – drug-resistant tuberculosis treatment. Geneva:
World Health Organization; 2020 (https://www.who.int/publications/i/item/9789240007048).
7. Houben RMGJ, Dodd PJ. The Global Burden of Latent Tuberculosis Infection: A Re-estimation Using Mathematical
Modelling. PloS Medicine 2016 (https://doi.org/10.1371/journal.pmed.1002152, accessed 15 August 2022).
8. Emery JC, Richards AS, Dale KD, McQuaid FC, White RG, Denholm JT and Houben RMGJ. Self-clearance of Mycobacterium
tuberculosis infection: implications for lifetime risk and population at-risk of tuberculosis disease. Proceedings of the
Royal Society B 2021 (https://royalsocietypublishing.org/doi/full/10.1098/rspb.2020.1635, accessed 15 August 2022).
9. Behr MA, Edelstein PH, Ramakrishnan L. Is Mycobacterium tuberculosis infection life long? BMJ 2019;367:l5770
(https://www.bmj.com/content/367/bmj.l5770, accessed 15 August 2022).
10. Vynnycky E, Fine PE. Lifetime risks, incubation period, and serial interval of tuberculosis. American journal of
epidemiology. 2000;152(3):247–63.
11. Tait DR, Hatherill M, Van Der Meeren O, Ginsberg AM, Van Brakel E, Salaun B et al. Final analysis of a trial of M72/AS01E
vaccine to prevent tuberculosis. N Eng J Med. 2019;381(25):2429–39 (https://pubmed.ncbi.nlm.nih.gov/31661198/,
accessed 15 August 2022).

38  Global Tuberculosis Report 2022

Annex 2

The WHO global TB database

A2.1 Database contents Table A2.1

The 2022 global tuberculosis (TB) report is based on Reporting of data in the 2022 round of global
data collected annually from 215 countries and are- TB data collection
as, including all 194 World Health Organization (WHO)
Countries WHO
Member States. The Global TB Programme has imple- and areas Member States

mented annual rounds of data collection since 1995, Number Number

that that
Number Number
with an online system used since 2009. Data are stored reported reported
data data
in a global TB database that is managed by the TB mon-
African Region 47 47 47 47
itoring, evaluation and strategic information unit of the
Region of the Americas 45 40 35 34
Global TB Programme, at WHO headquarters.
South-East Asia Region 11 11 11 11
The topics on which data have been collected have
been consistent for many years. In 2022, as in previ- European Region 54 48 53 47

ous years, data were collected on the following: TB Eastern Mediterranean 22 22 21 21

Region
case notifications and treatment outcomes, includ-
Western Pacific Region 36 34 27 27
ing breakdowns by TB case type, age, sex, HIV status
Global 215 202 194 187
and drug resistance; laboratory diagnostic services;
monitoring and evaluation, including surveillance and
surveys specifically related to drug-resistant TB; con- Prevention and Control (ECDC). Data from TESSy were
tact screening and TB preventive treatment; digital uploaded into the global TB database.
systems; TB infection control; engagement of all public Additional data about the provision and completion
and private care providers in TB prevention and care; of TB preventive treatment to people newly or current-
community engagement; specific elements of the WHO ly enrolled in HIV care, detection of TB among people
multisectoral accountability framework for TB; budgets newly enrolled in HIV care, and provision of antiretrovi-
of national TB control programmes (NTPs); use of gener- ral therapy for HIV-positive TB patients were collected
al health services (hospitalization and outpatient visits) by the Joint United Nations Programme on HIV/AIDS
during treatment; and NTP expenditures. A shortened (UNAIDS). These data were jointly validated by UNAIDS
version of the questionnaire was used for high-income and the WHO’s Global TB Programme and HIV depart-
countries (i.e. countries with a gross national income ment, and were uploaded into the global TB database.
per capita of ≥US$ 12 696 in 2020, as defined by the Following review and follow-up with countries, the
World Bank)1 or low-incidence countries (defined as data used for the main part of this report were those
countries with an incidence rate of <20 cases per 100 that were available on 29 August 2022. Table A2.1
000 population or <10 cases in total in 2020). shows the number of countries and territories that had
The main round of data collection took place in April reported data by 29 August 2022.
and May 2022. Indicators in the Sustainable Development Goals
High TB burden countries and selected other region- associated with TB incidence were imported into the
al priority countries were also asked to report monthly global TB database on 30 June 2022. Table A2.2 shows
or quarterly provisional notification data on a regular the data sources used.
basis for 2021 and 2022 to allow assessment of trends in
the context of the COVID-19 pandemic. A2.2 Accessing TB data using the WHO Global
Countries and areas reported data via a dedicated TB Programme website
website,2 which was opened for reporting in April 2022. Most of the data held in the global TB database are
Countries in the European Union submitted data on available online.3 The web page provides access to
notifications and treatment outcomes to the TESSy comma-separated value (CSV) data files and data
system managed by the European Centre for Disease visualizations, as well as country, regional and global
profiles (Annex A4).
1
https://datahelpdesk.worldbank.org/knowledgebase/
articles/906519-world-bank-country-and-lending-groups 3
https://www.who.int/teams/global-tuberculosis-programme/
2
https://extranet.who.int/tme data

Global Tuberculosis Report 2022   39

Table A2.2
Data sources for indicators in the Sustainable Development Goals associated with TB incidence

SDG indicator Display name in profile Data source Name at source Source URL

1.1.1 Population living below the UN SDG Proportion of population below https://unstats.un.org/SDGAPI/v1/sdg/
international poverty line (% of database the international poverty line of Series/Data?seriesCode=SI_POV_DAY1
population) US$1.90 per day
1.3.1 Population covered by social World Bank Coverage of social protection http://data.worldbank.org/indicator/
protection floors/systems (% of and labor programs (% of per_allsp.cov_pop_tot
population) population)
2.1.1 Prevalence of undernourishment World Bank Prevalence of http://data.worldbank.org/indicator/
(% of population) undernourishment (% of SN.ITK.DEFC.ZS
population)
3.3.1 HIV prevalence (% of population WHO-GHO Prevalence of HIV among adults https://ghoapi.azureedge.net/api/
(alternative) aged 15-49 years) aged 15 to 49 (%) MDG_0000000029
3.4.1 Diabetes prevalence (% of WHO-GHO Raised fasting blood glucose https://ghoapi.azureedge.net/api/NCD_
(alternative) population aged ≥ 18 years) (≥7.0 mmol/L or on medication) GLUC_04
(age-standardized estimate)
3.5.2 Alcohol use disorders, 12 month WHO-GHO Alcohol use disorders (15+), 12 https://ghoapi.azureedge.net/api/
(alternative) prevalence (% of population month prevalence (%) with 95% SA_0000001462
aged ≥ 15 years)
3.a.1 Smoking prevalence (% of WHO-GHO Estimate of current tobacco https://ghoapi.azureedge.net/api/M_Est_
(alternative) population aged ≥ 15 years) smoking prevalence (%) (age- smk_curr_std
standardized rate)
3.8.1 UHC index of essential service WHO-GHO UHC index of essential service https://ghoapi.azureedge.net/api/UHC_
coverage (based on 14 tracer coverage INDEX_REPORTED
indicators including TB
treatment)
3.8.2 Greater than 10% of total WHO-GHO Catastrophic out-of-pocket https://ghoapi.azureedge.net/api/
household expenditure health spending (SDG indicator FINPROTECTION_CATA_TOT_10_POP
or income on health (% of 3.8.2)
population)
3.8.2 Health expenditure per capita, WHO-GHO Current health expenditure https://ghoapi.azureedge.net/api/GHED_
(alternative) PPP (current international $) (CHE) per capita in PPP int $ CHE_pc_PPP_SHA2011
7.1.2 Access to clean fuels and World Bank Access to clean fuels and http://data.worldbank.org/indicator/
technologies for cooking (% of technologies for cooking (% of EG.CFT.ACCS.ZS
population) population)
8.1.1 GDP per capita, PPP (constant World Bank GDP per capita, PPP (constant http://data.worldbank.org/indicator/
(alternative) 2011 international $) 2011 international $) NY.GDP.PCAP.PP.KD
10.1.1 GINI index (0=perfect equality, World Bank GINI index (World Bank http://data.worldbank.org/indicator/
(alternative) 100=perfect inequality) estimate) SI.POV.GINI
11.1.1 Population living in slums (% of UN SDG Proportion of urban population https://unstats.un.org/SDGAPI/v1/sdg/
urban population) database living in slums (%) Series/Data?seriesCode=EN_LND_SLUM

The CSV data files are the primary resource for any- A2.3 Accessing TB data using the WHO Global
one interested in conducting their own analyses of the Health Observatory
records in the global TB database. Data reported by The WHO Global Health Observatory (GHO)1 is a portal
countries (e.g. time series for case notifications and that provides access to data and analyses for monitor-
treatment outcomes), and WHO’s estimates of TB dis- ing the global health situation; it includes a data repos-
ease burden), can be downloaded as CSV files covering itory.
all years for which data are available. These CSV files Data from WHO’s global TB database can be viewed,
can be imported into many applications (e.g. spread- filtered, aggregated and downloaded from within the
sheets, databases and statistical analysis software). GHO data repository.2
A data dictionary that defines each of the variables There is also an application programme interface
available in the CSV files is also available and can be (API)3 using the open data protocol. The API allows ana-
downloaded. lysts and programmers to use GHO data directly in their
The CSV files are generated on-demand directly software applications.
from the global TB database, and may therefore include
updates received after publication of the global TB
report.
1
https://www.who.int/data/gho
2
https://www.who.int/data/gho/data/themes/tuberculosis
3
https://www.who.int/data/gho/info/gho-odata-api

40  Global Tuberculosis Report 2022

Annex 3

WHO global lists of high TB burden countries

A3.1 Background WHO conducted a consultation process in 2020 and

During the period 1998 to 2015, the concept of a “high early 2021, as the basis for defining updated global HBC
burden country” (HBC) became familiar and widely lists for 2021–2025.
used in the context of tuberculosis (TB). The first global
list developed by WHO consisted of 22 HBCs with A3.2 Global HBC lists to be used by WHO,
approximately 80% of the world’s TB cases; this was 2021–2025
established in 1998. Subsequently two other HBC lists, Three global HBC lists for 2021–2025 have been estab-
for HIV-associated TB and multidrug-resistant TB (MDR- lished: one for TB, one for HIV-associated TB and one
TB), were defined. for MDR/rifampicin-resistant TB (MDR/RR-TB). The lists
In 2015, three WHO global lists of HBCs – for TB, TB/HIV were defined using the same criteria as those agreed for
and MDR-TB – were in use. With a new era of the the 2016–2020 lists, in combination with the WHO esti-
United Nations (UN) Sustainable Development Goals mates (for 2019) of the incidence of TB, HIV-associated
(SDGs) and the WHO End TB Strategy starting in 2016, TB and rifampicin-resistant TB that were published in
a thorough review of the three lists was undertaken by WHO’s Global Tuberculosis Report 2020. Full details are
the WHO Global TB Programme in 2015 (1). This included available in a background document (2).
consideration of whether the lists should be modified The criteria for all three lists are the same:
(and if so how) or whether they should be discontinued. "" the top 20 countries in terms of their estimated abso-
The outcome of the review was the definition of three lute number of new (incident) cases in 2019; plus
new global HBC lists, of 30 countries each, for the period
2016–2020: one for TB, one for TB/HIV and one for "" the 10 countries with the most severe burden in terms
MDR-TB. of the incidence rate (new cases per 100 000 popula-

Fig. A3.1
The three global lists of high-burden countries for TB, HIV-associated TB and MDR/RR-TB to be
used by WHO in the period 2021–2025, and their areas of overlap

Brazil
Central African Republic China
Congo Democratic Republic Angola
Ethiopia of the Congo Bangladesh
Gabon India Democratic People’s
Kenya Indonesia Republic of Korea
Lesotho Mozambique Mongolia
Liberia Myanmar Pakistan
Namibia Nigeria Papua New Guinea
Thailand Philippines Viet Nam

MDR/RR-TB
Uganda South Africa
United Republic of Tanzania Zambia

TB/HIV
Azerbaijan
Belarus
Botswana Kazakhstan
Cameroon Nepal
Eswatini Peru
Guinea Republic of Moldova
Guinea-Bissau Sierra Leone Russian Federation
Malawi Somalia
Russian Federation Tajikistan
Zimbabwe Ukraine
Uzbekistan
Zimbabwe

TB

Global Tuberculosis Report 2022   41

 tion in 2019) that are not already in the top 20, Table A3.1
and that meet a minimum threshold in terms of Countries in the three global lists of high-burden
their absolute number of cases. The thresholds countries for TB, HIV-associated TB and MDR/RR-
are 10 000 new cases per year for TB; and 1000 TB to be used by WHO in the period 2021–2025.
new cases per year for HIV-associated TB and The red square indicates that a country is in a list.
rifampicin-resistant TB.
MDR/
Country TB TB/HIV
The 30 countries that are in each of the three lists RR-TB

are shown in Fig. A3.1 and Table A3.1. There is Angola  

overlap among the three lists, but 49 countries Azerbaijan 

are in at least one of them. Each list accounted for Bangladesh  

86–90% of the estimated global incidence in 2019. Belarus 

The main changes compared with the previous Botswana 

lists for 2016–2020 are: Brazil  

Cameroon 
"" The 30 high TB burden countries. Cambodia, Central African Republic  
the Russian Federation and Zimbabwe transi- China   
tioned out of the list; Gabon, Mongolia and Ugan- Congo  
da joined the list. Democratic People’s Republic of Korea  
"" The 30 high TB/HIV burden countries. Ango- Democratic Republic of the Congo   
la, Chad, Ghana and Papua New Guinea transi- Eswatini 
tioned out of the list; Gabon, Guinea, Philippines Ethiopia  
and the Russian Federation joined the list. Gabon  
Guinea 
"" The 30 high MDR/RR-TB burden countries.
Guinea-Bissau 
Ethiopia, Kenya and Thailand transitioned out of
India   
the list; Mongolia, Nepal and Zambia joined the
Indonesia   
list.
Kazakhstan 
The lists provide a focus for global action on TB, Kenya  
HIV-associated TB and drug-resistant TB in the Kyrgyzstan 
countries where progress is most needed to achieve Lesotho  
the targets set in WHO’s End TB Strategy, the polit- Liberia  
ical declaration of the UN high-level meeting on TB Malawi 
held in 2018 and the UN SDGs (Table 1). They also Mongolia  
help to build and sustain national political commit- Mozambique   
ment and funding in the countries with the highest Myanmar   
burden in terms of absolute numbers or severity Namibia  
and promote global monitoring of progress in a Nepal 
well-defined set of countries. Nigeria   
The 30 high TB burden countries are given par- Pakistan  
ticular attention in the report. Where estimates of Papua New Guinea  

disease burden and assessment of progress in the Peru 

response are for HIV-associated TB or MDR/RR-TB Philippines   

specifically, the countries in the other two lists Republic of Moldova 

are given particular attention. Country profiles for Russian Federation  

all countries are available online, including in the Sierra Leone 

mobile app that accompanies the report (Annex 4). Somalia 

South Africa   

A3.3 Global TB watchlist Tajikistan 

Thailand  
Alongside the three updated global HBC lists, WHO
Uganda  
has established a “global TB watchlist”. This con-
Ukraine 
sists of the three countries that exited the global list
United Republic of Tanzania  
of 30 high TB burden countries in 2021, but which
Uzbekistan 
nonetheless warrant continued attention and will
Viet Nam  
remain a priority in terms of support from WHO. The
Zambia   
three countries in the watchlist are Cambodia, the
Zimbabwe  
Russian Federation and Zimbabwe.

42  Global Tuberculosis Report 2022

 In future, other countries may be considered for inclusion
on this watchlist – for example, based on evidence about the
impact of the COVID-19 pandemic on TB services and dis-
ease burden.

References
1. World Health Organization. Use of high burden country
lists for TB by WHO in the post-2015 era (discussion
paper). Geneva: World Health Organization; 2015
(https://www.who.int/tb/publications/global_report/
high_tb_burdencountrylists2016-2020.pdf).
2. World Health Organization. WHO global lists of high
burden countries for tuberculosis (TB), TB/HIV and
multidrug/rifampicin-resistant TB (MDR/RR-TB),
2021–2025: background document. Geneva. World
Health Organization; 2021 (https://apps.who.int/iris/
handle/10665/341980).

Global Tuberculosis Report 2022   43

Annex 4  

Country, regional and global profiles

Country, regional and global profiles as well as data for A4.2 Online country profiles and other
all key indicators for all countries and areas are avail- reports
able in the WHO TB Report mobile app and on the TB TB data profiles are available online for all 215 countries
Data web page.1 and areas that report TB data to WHO each year, as are
aggregate profiles for WHO regions and globally.1 The
A4.1 The WHO TB Report mobile app profiles are available in English, French, Spanish and
The free WHO TB Report mobile app includes country, Russian. They are generated on-demand directly from
regional and global profiles from the global TB data- the global TB database (Annex 2) and may therefore
base, as well as a summary of the key facts and messag- include updates received after publication of the global
es from the report and an overview of progress towards TB report. Estimates of TB cases attributable to five risk
global TB targets. The app allows users to easily view, factors and indicators in the Sustainable Development
query and visualize data, and to define queries, includ- Goals (SDGs) that are associated with TB incidence are
ing those for specific country groups. Once installed, available for all 215 countries and territories. TB finan-
the app works offline so that data can be accessed with- cial profiles are available for more than 100 countries
out an ongoing internet connection. The app is availa- and territories that report detailed TB financial data to
ble for Android devices through Google Play and for iOS WHO.
devices, such as iPhones and iPads, through the Apple
Store.2,3 It is available in English, French, Spanish and
Russian.

1
https://www.who.int/teams/global-tuberculosis-programme/
data
2
https://play.google.com/store/apps/details?id=uk.co.adappt.
whotbreport
3
https://apps.apple.com/us/app/tb-report/id1483112411

44  Global Tuberculosis Report 2022

ANNEX 5

Updates to estimates of TB disease burden

The report includes estimates of tuberculosis (TB) inci- 3. Updated estimates of TB incidence in India for
dence and mortality for the period 2000–2021; esti- the period 2000–2019. This update was based on
mates of TB incidence and mortality disaggregated by the availability of new survey and programmatic
age and sex for 2021; and estimates of the incidence data but remains interim in nature.
of rifampicin-resistant TB (RR-TB) for the period 2015–
4. Production of time series of estimates of the inci-
2021. This annex summarizes the main updates to the
dence of RR-TB. Previous global TB reports from
methods used to produce these estimates, compared
the World Health Organization (WHO) included esti-
with those used for the Global tuberculosis report 2021
mates for the latest calendar year only. New meth-
(1, 2). Details are provided in a technical appendix.
ods were developed in 2022 to allow the production
There were four major updates for this report:
of time series of estimates for the period 2015–2021.
1. Expanded use of country-specific dynamic mod- The time series are for the absolute number of inci-
els to estimate TB incidence and mortality in dent RR-TB cases and the proportions of TB cases
2020 and 2021. Models were used for 27 countries, (new and previously treated) that have RR-TB.
up from 16 the previous year. Countries for which
Estimates of TB incidence and mortality in all high-
models were used were those with large absolute
income countries in 2020 and 2021 were produced
reductions in the reported number of people newly
using the same methods as those used pre-2020; that
diagnosed with TB in 2020 or 2021 (case notifica-
is, notification data with a standard adjustment for inci-
tions) relative to pre-2020 trends; these reductions
dence, and vital registration (VR) data for mortality.2 For
were interpreted as being due to reduced detection
low- and middle-income countries (LMIC) that were not
of people with TB, in turn resulting in an increase
modelled (i.e. those for which case notifications in 2020
in the number of people with undiagnosed and
and 2021 did not show a substantial reduction relative
untreated TB in the community. Models were
to pre-2020 trends), the methods used to estimate TB
needed to produce estimates of TB incidence and
incidence and mortality before 2020 were retained for
mortality that accounted for these disruptions to
use in 2020 and 2021, with the assumption that pre-2020
TB diagnosis and treatment, in the absence of any
trends continued in 2020 and 2021.
direct measurements of TB disease burden in these
years.1
Country-specific and region-specific dynamic
2. Use of region-specific dynamic models to esti- models
mate TB incidence and mortality in 2020 and The models were developed through a collaboration
2021. Although individual countries may have between WHO and Imperial College, London (United
reported large relative reductions in case notifica- Kingdom of Great Britain and Northern Ireland) (1–3).
tions, in absolute terms these reductions may not Key assumptions used in the models are:
have been sufficient to warrant their inclusion in
the country-specific modelling described above. "" Reductions in TB case notifications reflect reduced
Instead, region-specific models were used for any case detection. It is possible that underreporting of
such countries that reported a cumulative reduc- detected cases may contribute to reductions in case
tion in TB case notifications of 10% or more in 2020 notifications, but there is currently no evidence to
to 2021 inclusive, relative to pre-2020 trends. A total support this.
of 26 countries met this criterion. This method was "" Strict lockdowns resulted in a 50% reduction in trans-
used in place of the statistical model used in 2021 mission (with an uncertainty interval of 25–75%).
(2). Reductions in transmission outside periods of strict
lockdown were not assumed, although measures
such as mask wearing may have had an ongoing
1
For two of the modelled countries, China and the Russian effect on transmission in some countries.
Federation, national vital registration (VR) data on the number
of deaths caused by TB were reported to the World Health
Organization (WHO) in the period 2020–2021. These data were 2
If VR data for 2020 and 2021 were not available, it was assumed
used in preference to modelled estimates. that pre-2020 trends were sustained.

Global Tuberculosis Report 2022   45

 The time periods for which reductions in transmis- those published in the Global tuberculosis report 2021
sion were modelled were based on compilation of coun- (1).
try-specific data about the durations of lockdowns. Following discussions and consultations among the
Other influential assumptions, drawing on the sci- NTEP, ICMR and WHO during August and September
entific literature, relate to the number of secondary 2022, the provisional incidence estimates for 2015–2019
infections per case per year (estimated by model cali- were combined with the use of the WHO country-
bration); and the rate of breakdown from TB infection specific model for India that was developed to esti-
to active TB disease, which was informed by a recent mate TB incidence and mortality in 2020 and 2021 (as
(2018) review of TB models (4). described above).1 Estimates for the period 2000–2014
An important limitation is that the models do not yet were then adjusted upwards compared with those pub-
account for the impact of the coronavirus (COVID-19) lished in previous WHO reports, for consistency with
pandemic on broader TB determinants, such as under- updated estimates for the period 2015–2019.
nourishment, poverty and other factors known to be The methods used to estimate TB mortality in India
associated with TB. Impacts on TB incidence and mor- remain unchanged from those used in 2021.
tality may thus be understated. Estimates of TB incidence and mortality in India for
For countries for which region-specific models were 2000–2021 are interim and subject to finalization, in
used, it was assumed that they experienced the same consultation with India’s Ministry of Health & Family
changes to annual incidence and mortality, relative to Welfare.
2019 levels, as those modelled at the regional level.
The modelling methods were extensively discussed Estimates of the incidence of multidrug-
and reviewed in 2021 and 2022. These activities includ- resistant TB or RR-TB, 2015–2021
ed: Until this report, estimates of the number of incident
"" a review by WHO’s Strategic and Technical Advisory cases of multidrug-resistant TB (MDR-TB) or RR-TB
Group for TB (STAG-TB) in June 2021 (5); (MDR/RR-TB) were produced for the latest complete cal-
endar year only, using the most recent data point from
"" a 2-day meeting of a subgroup of the WHO Global each country. In 2022, new methods were developed to
Task Force on TB Impact Measurement (the Task produce a time series of estimates for the period 2015–
Force) in May 2022 (3), which brought together 32 2021. These methods have been extensively discussed
global experts in mathematical modelling, epidemi- and reviewed (3, 6).
ology and statistics as well as representatives from For the first time, the proportions of new and previ-
national TB programmes (NTPs) and partner agen- ously treated TB cases that had MDR/RR-TB at global,
cies, with the specific purpose of reviewing methods regional and country levels were estimated for the peri-
used by WHO to estimate TB disease burden during od 2015–2021. The general approach for estimation of
the COVID-19 pandemic and new methods for pro- these proportions was to use hierarchical regression
ducing time series of estimates for the incidence of models fitted within a Bayesian paradigm to all nation-
RR-TB (see below); and al-level surveillance and survey data since 2000 that
"" in an immediate follow-up to the Task Force meeting, met pre-defined quality criteria (described in the tech-
a further detailed review of model documentation by nical appendix).
several global experts in TB modelling, after which The estimates of the proportions of new and previ-
comments and suggestions were addressed. ously treated TB cases with RR-TB for each year over
the period 2015–2021 were then used in combination
Estimates of TB incidence in India, 2000–2019 with the formula that has been previously used by WHO
A national TB prevalence survey was implemented in to produce estimates of RR-TB incidence for a single
2019–2021. The results were released in March 2022. year. The formula includes parameters related to TB
Subsequently, the Indian Council of Medical Research incidence overall, the proportion of TB cases that are
(ICMR), which led implementation of the survey and diagnosed with a relapse episode of TB, the risk that
analysis of results, worked with India’s national TB an incident case of TB will fail treatment or be lost to
elimination programme (NTEP) in the Ministry of Health follow-up, and the relative risk of RR-TB in relapse cases
& Family Welfare and with the WHO Country Office to compared with new cases (6).
produce provisional estimates of TB incidence for the
period 2015–2021. These estimates used the national
survey results in combination with a previous state- 1
This was done because the ICMR-led analysis does not currently
level survey (in Gujarat in 2011) and programmatic data incorporate the impact of disruptions related to the COVID-19
pandemic to TB case detection in 2020 and 2021. In 2021, TB case
for 2015–2021. They suggest estimates of TB incidence notifications in India fell by 25% compared with 2019; there was a
that are higher in each year (by about 0.2 million) than partial recovery in 2021 (see Fig. 3 and Fig. 4 of this report).

46  Global Tuberculosis Report 2022

Other updates Overview of data sources available to inform
New data on TB mortality were reported to WHO estimates of TB disease burden in high TB
between mid-2020 and mid-2021. Several countries burden and global TB watchlist countries
reported historical data that were previously missing or A summary of the main data sources currently availa-
made corrections to previously reported data. Updat- ble to inform estimates of TB disease burden in the 30
ed estimates of HIV prevalence and mortality were high TB burden countries and three global TB watchlist
obtained from the Joint United Nations Programme on countries is shown in Table A5.1. Maps that illustrate
HIV/AIDS (UNAIDS) in July 2022. the main methods used to estimate TB incidence and
mortality for the periods 2000–2019 and 2020–2021 are
provided on the report web pages (Section 2.1 and
Section 2.2).

References
1. Global tuberculosis report 2021. Geneva: World Health Organization; 2021 (https://www.who.int/publications/i/
item/9789240037021).
2. Methods used by WHO to estimate the global burden of TB disease. Geneva: World Health Organization; 2021
(https://www.who.int/publications/m/item/methods-used-by-who-to-estimate-the-global-burden-of-tb-disease).
3. Report of a subgroup meeting of the WHO Task Force on TB Impact Measurement: methods used by WHO to estimate TB
disease burden. Geneva: World Health Organization; 2022 (https://apps.who.int/iris/handle/10665/363428).
4. Menzies NA, Wolf E, Connors D, Bellerose M, Sbarra AN, Cohen T et al. Progression from latent infection to active disease
in dynamic tuberculosis transmission models: a systematic review of the validity of modelling assumptions. Lancet
Infect Dis. 2018;18(8):e228–e38. doi: https://doi.org/10.1016/S1473-3099(18)30134-8.
5. Strategic and Technical Advisory Group for Tuberculosis (STAG-TB): report of the 21st meeting, 21–23 June 2021. Geneva:
World Health Organization; 2021 (https://apps.who.int/iris/handle/10665/351132).
6. Methods for estimating the incidence of drug-resistant TB (background document 2). Subgroup meeting of the WHO
Task Force on TB Impact Measurement: methods used by WHO to estimate TB disease burden. Geneva: World Health
Organization; 2022 (https://cdn.who.int/media/docs/default-source/hq-tuberculosis/global-task-force-on-tb-impact-
measurement/meetings/2022-05/tf-2022-05-2-background--document-2--dr-tb.pdf?sfvrsn=a8757cfa_3).

Global Tuberculosis Report 2022   47

Table A5.1
Sources of data available to inform estimates of TB disease burden in the 30 high TB burden
countries and the 3 global TB watchlist countries, 2000–2021. Blue 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 TB NATIONAL DRUG NATIONAL VR DATA

NATIONAL
COUNTRY NOTIFICATION DATA BENCHMARK PREVALENCE RESISTANCE SURVEY OR MORTALITY
INVENTORY STUDY b
ASSESSMENTa SURVEYc OR SURVEILLANCEd SURVEYe

Angola 2000–2021 2016, 2019 – – – –

Bangladesh 2000–2021 2014, 2019 – 2015 2011, 2019 –
Brazil 2000–2021 2018 – NA 2008 2000–2019
Cambodia 2000–2021 2018 – 2002, 2011 2007, 2018 –
Central African
2000–2021 2019 – – 2009 –
Republic
China 2000–2021 – 2018 2000, 2010 2007, 2013, 2020– 2004–2020
Congo 2000–2021 2019 – – – –
Democratic People’s
2000–2021 2017 – 2016 2014 –
Republic of Korea
Democratic Republic
2000–2021 2017, 2019 – – 2017 –
of the Congo
Ethiopia 2000–2021 2013, 2016 – 2011 2005, 2018, 2018– –
Gabon 2000–2021 2018, 2020 – – – –
India 2000–2021 2019 2016 2019–2021 2016, 2020– 2000–2014
2006–2007,
Indonesia 2000–2021 2017, 2019 2017 2013–2014 2018
2009–2015
Kenya 2000–2021 2017, 2021 2013 2015 2014, 2020– –
Lesotho 2000–2021 2014, 2017 – 2019 2014, 2019– –
Liberia 2000–2021 2015, 2019 – – – –
Mongolia 2000–2021 2015, 2018 2023 2014–2015 2007, 2016, 2018– 2016
Mozambique 2000–2021 2013 – 2017–2019 2007, 2021, 2021– –
Myanmar 2000–2021 2014, 2017 – 2009, 2018 2013, 2018–, 2020 –
Namibia 2000–2021 2016, 2019 – 2017–2018 2008, 2015, 2018– –
Nigeria 2000–2021 2017, 2020 – 2012 2010 –
Pakistan 2000–2021 2016, 2019 2012, 2017 2011 2013 2006, 2007, 2010
Papua New Guinea 2000–2021 2017 – – 2014 –
Philippines 2000–2021 2016, 2019 2023 2007, 2016 2012, 2019, 2021– 2000–2014
Russian Federation 2000–2021 2017 – NA 2000– 2000–2021
Sierra Leone 2000–2021 2015, 2020 – – – –
South Africa 2000–2021 2015, 2019 2019–2022 2017–2019 2002, 2014, 2021– 2000–2017
Thailand 2000–2021 2013 – 2012 2012, 2018 2000–2019
Uganda 2000–2021 2013, 2019 – 2014–2015 2011, 2018– –
United Republic of
2000–2021 2013, 2018 – 2012 2007, 2018, 2021– –
Tanzania
Viet Nam 2000–2021 2013, 2019 2017 2007, 2017–2018 2006, 2012, 2018– –
Zambia 2000–2021 2016, 2020 – 2014 2008, 2018–, 2020 –
Zimbabwe 2000–2021 2016, 2019 – 2014 2016, 2018– –

NA, not applicable; VR, vital registration

a
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), VR data (1 standard) and data for drug-resistant TB, HIV co-infection and TB in children (3 supplementary standards). A partial assessment has
been done in China. If more than two assessments have been done (Indonesia, Kenya, Nigeria, Pakistan, Philippines, Zambia and Zimbabwe), the years of
the last two only are shown.
b
A study is currently underway in South Africa. Studies are planned in Mongolia and the Philippines in 2023. Prioritization of TB inventory studies is
recommended in countries where a large share of TB care is provided outside the existing NTP network.
c
Brazil and Russian Federation do not meet the following criteria recommended by the WHO Global Task Force on TB Impact Measurement for
implementing a national prevalence survey: TB incidence ≥150 per 100 000 population per year, no vital registration system and under-5 mortality rate
(probability of dying by age of 5 per 1000 live births) is >10.
d
Data are available from continuous surveillance (indicated by “-” in blue cell) based on routine diagnostic testing in China, Ethiopia, India, Kenya, Lesotho,
Mongolia, Mozambique, Myanmar, Namibia, Philippines, South Africa, Uganda, United Republic of Tanzania, Viet Nam, Zambia and Zimbabwe. The surveys
in Brazil, Central African Republic, Democratic People’s Republic of Korea and Papua New Guinea were subnational. If more than two national surveys
have been done (Myanmar, Thailand, Philippines, Zambia), the years of the last two only are shown.
e
Years of data availability for India, Indonesia, Pakistan and South Africa were provided to WHO by IHME.

48  Global Tuberculosis Report 2022

Annex 6

The WHO TB-SDG monitoring framework

In 2017, the World Health Organization (WHO) developed "" prevalence of undernourishment;
a framework for monitoring of indicators in the United "" proportion of the population with primary reliance
Nations (UN) Sustainable Development Goals (SDGs) on clean fuels and technology;
that are strongly associated with tuberculosis (TB) inci- "" gross domestic product (GDP) per capita;
dence. This was done as part of the preparations for the "" Gini index for income inequality; and
first global ministerial conference on TB (1), building on "" proportion of the urban population living in slums.
previously published work that identified clear linkages
Collection and reporting of data for the 14 indicators
between a range of social, economic and health-related
does not require any additional data collection and
indicators and TB incidence (2–5).
reporting efforts by national TB programmes (NTPs).
The TB-SDG monitoring framework comprises 14
Nor does it require data collection and reporting efforts
indicators under seven SDGs (Table A6.1).
that go beyond those to which countries have already
For SDG 3, the framework includes seven indicators:
committed in the context of the SDGs. At the global
"" coverage of essential health services; level, the UN has established a monitoring system for
"" proportion of the population with large household SDG indicators, and countries are expected to report
expenditures on health as a share of total household data on an annual basis via the appropriate UN agen-
expenditure or income; cies (including WHO). Therefore, analysis of the status
"" current health expenditure per capita; of, and trends in, the 14 indicators related to TB can be
"" HIV prevalence; based primarily on data held in the UN’s SDG database.
"" prevalence of smoking; In some cases, the official SDG indicator was not
"" prevalence of diabetes; and considered the best metric, and a better (but closely
"" prevalence of alcohol use disorder. related) alternative was identified and justified (five
indicators under SDG 3, one under SDG 8 and one under
For SDGs 1, 2, 7, 8, 10 and 11, the seven indicators select-
SDG 10). In such cases, the data sources are one of the
ed for monitoring are:
following: WHO, the Organisation for Economic Co-op-
"" proportion of the population living below the inter- eration and Development (OECD), the Joint United
national poverty line; Nations Programme on HIV/AIDS (UNAIDS) or the World
"" proportion of the population covered by social pro- Bank.
tection floors or systems;

References
1. Monitoring and evaluation of TB in the context of the Sustainable Development Goals in Policy Briefs: WHO Global
Ministerial Conference Ending TB in the Sustainable Development Era: Multisectoral Response. Geneva: World Health
Organization; 2017. (https://www.who.int/conferences/tb-global-ministerial-conference/Ministerial_Conference_policy_
briefs.pdf)
2. Lienhardt C, Glaziou P, Uplekar M, Lönnroth K, Getahun H, Raviglione M. Global tuberculosis control: lessons learnt and
future prospects. Nat Rev Microbiol. 2012;10(6):407 (https://www.ncbi.nlm.nih.gov/pubmed/22580364,).
3. Lönnroth K, Castro KG, Chakaya JM, Chauhan LS, Floyd K, Glaziou P et al. Tuberculosis control and elimination 2010–50:
cure, care, and social development. Lancet. 2010;375(9728):1814–29 (https://www.ncbi.nlm.nih.gov/pubmed/20488524).
4. Lönnroth K, Jaramillo E, Williams B, Dye C, Raviglione M. Tuberculosis: the role of risk factors and social determinants.
In: Blas E & Kurup A (eds.), Equity, social determinants and public health programmes. 2010 (https://apps.who.
int/iris/bitstream/handle/10665/44289/9789241563970_eng.pdf;jsessionid=067BC8BA3F7A5366C05BE34404
F9D8F6?sequence=1).
5. Lönnroth K, Jaramillo E, Williams BG, Dye C, Raviglione M. Drivers of tuberculosis epidemics: the role of risk factors and
social determinants. Soc Sci Med. 2009;68(12):2240–6 (https://www.ncbi.nlm.nih.gov/pubmed/19394122).

Global Tuberculosis Report 2022   49

Table A6.1
TB-SDG monitoring framework: indicators to monitor within SDG 3

SDG 3: Ensure healthy lives and promote well-being for all at all ages
Alternative Collect data
Data
SDG targets for 2030 SDG indicators indicators to Rationale for TB patients
source
monitor specifically?

3.3 End the epidemics 3.3.1  Number of new HIV prevalence HIV is a strong risk factor for UNAIDS Yes, already
of AIDS, TB, malaria HIV infections per 1000 development of TB disease WHO routinely collected.
and neglected tropical uninfected population and is associated with poorer NA
diseases and combat 3.3.2  TB incidence per treatment outcomes. HIV
hepatitis, water-borne 100  000 population prevalence is selected in
diseases and other preference to HIV incidence
communicable diseases because it is directly measured.

3.4 Reduce premature 3.4.1 Mortality Prevalence of Diabetes is a strong risk WHO Could be

mortality by one third rate attributed to diabetes factor for development of TB considered at
from non-communicable cardiovascular disease, disease, although a link with country level, to
diseases and promote cancer, diabetes or TB incidence at the national inform planning
mental health and well- chronic respiratory (as opposed to individual) level of care for
being disease has been difficult to establish comorbidities.
due to confounding. Diabetes
prevalence is more relevant than
mortality for TB since it directly
influences the risk of developing
TB.

3.5 Strengthen 3.5.2 Alcohol Prevalence of Alcohol use is a strong risk WHO Could be

prevention and consumption per capita alcohol use disorder factor for TB disease and poorer considered at
treatment of substance per year (in litres of pure treatment outcomes at the country level, to
abuse, including alcohol) among those individual level, although a link inform planning
narcotic drug abuse and aged ≥15 years (harmful with TB incidence at the national of care for
harmful use of alcohol level defined nationally) (as opposed to individual) level comorbidities.
has been hard to establish due to
confounding. The prevalence of
alcohol use disorder is the most
relevant indicator in the context
of TB.
3.8 Achieve UHC, 3.8.1 Coverage of NA Achieving UHC is required to WHO No
including financial risk essential health achieve the three high-level
protection, access to services (defined as targets of the End TB Strategy for
quality essential health- the average coverage reductions in the TB incidence
care services and access of essential services NA rate, reductions in the number
to safe, effective, quality based on 16 tracer of TB deaths and elimination
and affordable essential interventions). of catastrophic costs for TB
medicines and vaccines 3.8.2 Proportion of patients and their households.
for all population with large TB treatment coverage has been
household expenditures monitored for years and is one of
on health as a share the 16 tracer indicators that have
of total household been selected to measure SDG
expenditure or income indicator 3.8.1.

3.a Strengthen 3.a.1 Age-standardized Prevalence of Smoking is a strong risk factor WHO Could be

implementation of prevalence of current smoking among for TB disease at the individual considered (e.g. to
the WHO Framework tobacco use among those aged ≥15 years level, although a link with TB inform access to
Convention on Tobacco those aged ≥15 years (%) incidence at the national (as smoking cessation
Control opposed to individual) level has interventions).
been difficult to establish due to
confounding.
3.c Substantially 3.c.1  Health worker Current health Health expenditure per capita WHO No
increase health density and distribution expenditure per is negatively correlated with TB
financing and capita incidence.
the recruitment,
development, training
and retention of the
health workforce in
developing countries,
especially in least
developed countries and
small island developing
States

AIDS, acquired immune deficiency syndrome; HIV, human immunodeficiency virus; NA, not applicable; SDG, Sustainable Development Goal; TB, tuberculosis;
UHC, universal health coverage; UNAIDS, Joint United Nations Programme on HIV/AIDS; WHO, World Health Organization

50  Global Tuberculosis Report 2022

Table 8.2b
TB-SDG monitoring framework: indicators to monitor beyond SDG 3

SDG 1: End poverty in all its forms everywhere

Alternative Collect data
Data
SDG targets for 2030 SDG indicators indicators to Rationale for TB patients
source
monitor specifically?

1.1  Eradicate extreme 1.1.1 Proportion NA Poverty is a strong risk factor for UN SDG No
poverty for all people of population living TB, operating through several database, Could be considered
everywhere, currently below the international NA pathways. Reducing poverty World (e.g. to facilitate
measured as people poverty line should also facilitate prompt Bank access to social
living on less than $1.25 1.3.1 Proportion of health-care seeking. Countries protection).
a day population covered with higher levels of social
1.3  Implement by social protection protection have lower TB burden.
nationally appropriate floors/systems Progress on both indicators
social protection will help to achieve the End TB
systems and measures Strategy target to eliminate
for all, including floors, catastrophic costs for TB patients
and achieve substantial and their households.
coverage of the poor and
vulnerable

SDG 2: End hunger, achieve food security and improved nutrition and promote sustainable agriculture
2.1  End hunger and 2.1.1 Prevalence of NA Undernutrition weakens the UN SDG Could be considered
ensure access by all undernourishment body’s defence against infections database (e.g. to plan food
people, in particular and is a strong risk factor for TB support).
the poor and people in at the national and individual
vulnerable situations, level.
including infants, to
safe, nutritious and
sufficient food year-
round

SDG 7: Ensure access to affordable, reliable, sustainable, and modern energy for all
7.1 Ensure universal 7.1.2 Proportion NA Indoor air pollution is a risk factor WHO No
access to affordable, of population with for TB disease at the individual
reliable and modern primary reliance level. There has been limited
energy services on clean fuels and study of ambient air pollution but
technology it is plausible that it is linked to
TB incidence.

SDG 8: Promote sustained, inclusive and sustainable economic growth, full and productive employment and
decent work for all
8.1 Sustain per capita 8.1.1 Annual growth GDP per capita Historic trends in TB incidence World No
growth in accordance rate of real GDP per are closely correlated with Bank
with national capita changes in the absolute level of
circumstances and, in GDP per capita (but not with the
particular, at least 7% growth rate).
GDP growth per year
in the least developed
countries

SDG 10: Reduce inequality within and among countries

10.1 Achieve and 10.1.1  Growth rates of Gini index for income TB is a disease of poverty. World No
sustain income growth household expenditure inequality Decreasing income inequalities Bank
of the bottom 40% of or income per capita, combined with economic growth OECD
the population at a rate overall and for the should have an effect on the TB
higher than the national bottom 40% of the epidemic.
average population

SDG 11: Make cities and human settlements inclusive, safe, resilient and sustainable
11.1 Ensure access for 11.1.1 Proportion NA Living in a slum is a risk factor for UN SDG No
all to adequate, safe of urban population TB transmission due to its link database
and affordable housing living in slums, with overcrowding. It is also a risk
and basic services and informal settlements or factor for developing TB disease,
upgrade slums inadequate housing due to links with air pollution and
undernutrition.

GDP, gross domestic product; NA, not applicable; OECD, Organisation for Economic Co-operation and Development; SDG, Sustainable Development Goal; TB,
tuberculosis; UN, United Nations; WHO, World Health Organization.

Global Tuberculosis Report 2022   51