Morbidity and Mortality Weekly Report

Weekly / Vol. 69 / No. 11 March 20, 2020

Global Epidemiology of Tuberculosis

World TB Day — March 24, 2020
and Progress Toward Meeting Global
World TB Day is observed each year on March 24, Targets — Worldwide, 2018
providing an opportunity to increase awareness about
tuberculosis (TB) and the actions needed to find, treat, Adam MacNeil, PhD1; Philippe Glaziou, MD2; Charalambos Sismanidis,
and prevent this devastating disease. PhD2; Anand Date, MD1; Susan Maloney, MD1; Katherine Floyd, PhD2
In 2019, a provisional total of 8,920 TB cases were reported in
the United States (incidence = 2.7 cases per 100,000 persons) (1), Worldwide, tuberculosis (TB) is the leading cause of death
a 1.1% decrease from the 9,021 cases reported during 2018 and from a single infectious disease agent (1), including among
the lowest number of U.S. cases recorded since reporting began persons living with human immunodeficiency virus (HIV)
in 1953. Increased diagnosis and treatment of latent TB infec- infection (2). A World Health Organization (WHO) initia-
tion remains essential for eliminating TB in the United States. tive, The End Tuberculosis Strategy, set ambitious targets for
An analysis of global TB surveillance data found that in 2020–2035, including 20% reduction in TB incidence and
2018, an estimated 10 million persons with incident TB and 35% reduction in the absolute number of TB deaths by 2020
1.5 million TB-related deaths occurred worldwide, represent- and 90% reduction in TB incidence and 95% reduction in TB
ing 2% and 5% declines from 2017. Among the estimated deaths by 2035, compared with 2015 (3). This report evaluated
10 million persons with TB, 70% were reported to WHO in global progress toward these targets based on data reported by
2018, a 9.4% increase from 2017 (2). Approximately 862,000
reported TB cases occurred among persons living with human
immunodeficiency virus (HIV) infection. In 2018, 1.8 million INSIDE
persons with HIV began TB preventive treatment (TPT), a
286 Tuberculosis — United States, 2019
88% increase in treatment initiation from 2017. Less progress
290 Drug and Opioid-Involved Overdose Deaths —
in TPT implementation was reported among children aged
United States, 2017–2018
<5 years than among persons living with HIV infection. TPT
298 Variation in Adult Outpatient Opioid Prescription
has been demonstrated to decrease morbidity and mortality
Dispensing by Age and Sex — United States,
among persons with HIV infection. Full implementation 2008–2018
of effective strategies, including TPT, is crucial for reaching 303 Delayed Identification of Infants Who Are Deaf or
global targets. Hard of Hearing — Minnesota, 2012–2016
CDC is working with partners to diagnose, treat, and 307 Evaluation of the Effectiveness of Surveillance and
prevent TB in the United States and globally. Additional Containment Measures for the First 100 Patients
information is available at https://www.cdc.gov/tb/worldt- with COVID-19 in Singapore — January 2–
bday/ and https://www.cdc.gov/globalhivtb/who-we-are/ February 29, 2020
events/world-tb-day/worldtbday.html. 312 Initial Investigation of Transmission of COVID-19
Among Crew Members During Quarantine of a
References
Cruise Ship — Yokohama, Japan, February 2020
1. Schwartz NG, Price SF, Pratt RH, Langer AJ. Tuberculosis—United 314 QuickStats
States, 2019. MMWR Morb Mortal Wkly Rep 2020;69:286–90.
2. MacNeil A, Glaziou P, Sismanidis C, et al. Global epidemiology of
tuberculosis and progress toward meeting global targets—worldwide,
Continuing Education examination available at
2018. MMWR Morb Mortal Wkly Rep 2020;69:281–5.
https://www.cdc.gov/mmwr/mmwr_continuingEducation.html

U.S. Department of Health and Human Services

Centers for Disease Control and Prevention
 Morbidity and Mortality Weekly Report

WHO (1). Annual TB data routinely reported to WHO by TPT (the most common global regimen consists of daily
194 member states were used to estimate TB incidence and isoniazid for ≥6 months) has been demonstrated to prevent TB
mortality overall and among persons with HIV infection, disease among persons who might be infected with TB and are
TB-preventive treatment (TPT) initiation, and drug-resistant at risk for TB disease (4). Current WHO recommendations
TB for 2018 (1). In 2018, an estimated 10 million persons advise providing a course of TPT to all persons living with HIV
had incident TB, and 1.5 million TB-related deaths occurred, and to all household contacts of persons with bacteriologically
representing 2% and 5% declines from 2017, respectively. confirmed pulmonary TB disease (5).
The number of persons with both incident and prevalent TB TB data are reported to WHO annually by 194 member
remained highest in the WHO South-East Asia and African states and are reviewed and validated in collaboration with
regions. Decreases in the European region were on track reporting entities (1,6). For each country, 2018 disease inci-
to meet 2020 targets. Globally, among persons living with dence (per 100,000 HIV-negative persons and per 100 persons
HIV, 862,000 incident TB cases occurred, and 1.8 million living with HIV) was estimated from 1) TB prevalence surveys;
persons initiated TPT. Rifampicin-resistant or multidrug- 2) notifications from country surveillance systems adjusted by
resistant TB occurred among 3.4% of persons with new TB a standard factor to account for underreporting, overdiagnosis,
and 18% among persons who were previously treated for and underdiagnosis; 3) national inventory studies that mea-
TB (overall, among 4.8% of persons with TB). The modest sure the level of underreporting of detected persons with TB
decreases in the number of persons with TB and the number combined with capture-recapture modeling; and 4) national
of TB-related deaths were consistent with recent trends, and notification data supplemented with expert opinion about case-
new and substantial progress was observed in increased TPT detection gaps. Among HIV-negative persons, TB mortality
initiation among persons living with HIV. However, to meet rate estimates were based on all-cause mortality data from civil
the global targets for 2035, more intensive efforts are needed registration and vital statistics, mortality surveys, or the prod-
by public health partners to decrease TB incidence and deaths uct of TB incidence and case fatality rate (CFR) (1). Among
and increase the number of persons receiving TB curative and persons living with HIV, TB mortality rates were derived from
preventive treatment. Innovative approaches to case finding, the product of incidence and CFR. Data on persons receiving
scale-up of TB preventive treatment, use of newer TB treatment TPT represent numbers directly reported to WHO.
regimens, and prevention and control of HIV will contribute In 2018, an estimated 10 million persons had incident
to decreasing TB. TB (132 per 100,000 population), a 2% decline from 2017
(Figure 1). Incidence has declined by an average of 1.6% per

The MMWR series of publications is published by the Center for Surveillance, Epidemiology, and Laboratory Services, Centers for Disease Control and Prevention (CDC),
U.S. Department of Health and Human Services, Atlanta, GA 30329-4027.
Suggested citation: [Author names; first three, then et al., if more than six.] [Report title]. MMWR Morb Mortal Wkly Rep 2020;69:[inclusive page numbers].
Centers for Disease Control and Prevention
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Chesley L. Richards, MD, MPH, Deputy Director for Public Health Science and Surveillance
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Michael F. Iademarco, MD, MPH, Director, Center for Surveillance, Epidemiology, and Laboratory Services
MMWR Editorial and Production Staff (Weekly)
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Jeff Niederdeppe, PhD

282 MMWR / March 20, 2020 / Vol. 69 / No. 11 US Department of Health and Human Services/Centers for Disease Control and Prevention
 Morbidity and Mortality Weekly Report

FIGURE 1. Trends in estimated incident tuberculosis (TB) among all persons and among persons living with human immunodeficiency virus
(HIV-positive persons) — worldwide, 2000–2018
12

10

All TB cases
TB cases among
8 HIV-positive persons
No. of TB cases (millions)

0
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018
Year
Source: Adapted with permission from World Health Organization. Global tuberculosis report 2019. Geneva, Switzerland: World Health Organization; 2019.

year since 2000. In 2018, 7.0 million persons globally were persons living with HIV with TB worldwide, similar to 2017.
notified of their TB-positive results, representing 70% of the In the European region, TB incidence declined 15% since 2015
estimated number of persons with incident TB, an increase to 28 per 100,000 population. However, the proportion of
from the 6.4 million persons (64%) notified in 2017. In 2018, persons with rifampicin-resistant or multidrug–resistant TB in
69% of all persons with incident TB received anti-TB treat- this region (30%) remained substantially higher than that in
ment, compared with 64% in 2017. The estimated number of all other regions (range = 3.1%–5.4%), and overall incidence
TB-related deaths declined 5%, from 1.57 million in 2017 to of rifampicin-resistant or multidrug–resistant TB is similar to
1.49 million in 2018 (CFR = 15%) (Figure 2). An estimated the Africa and South-East Asia regions.
862,000 persons living with HIV had incident TB in 2018, In 2018, 65 countries reported data on TPT use among
accounting for 8.6% of all persons with TB. Within this group, eligible persons living with HIV and 109 countries among
the estimated annual TB incidences were 6% in 2000, 2.5% in children aged <5 years. Among these countries, 1.8 million per-
2017, and 2.3% in 2018. In 2018, an estimated 251,000 TB sons living with HIV received TPT in 2018 (an 88% increase
deaths among persons living with HIV occurred (CFR = 29%). from 960,000 in 2017). Less progress was observed among
Overall, an estimated 484,000 persons had incident rifampicin- eligible children aged <5 years: 350,000 children received TPT
resistant or multidrug–resistant TB in 2018, representing in 2018, a 20% increase compared with 292,000 in 2017.
4.8% of all persons with TB, 3.4% of persons with a new TB
Discussion
diagnosis, and 18% of persons previously treated for TB. An
estimated 214,000 persons died of either rifampicin-resistant WHO’s initiative, The End TB Strategy (3), has ambitious
or multidrug–resistant TB (CFR = 44%) in 2018. Among targets for 2020–2035, and the 2018 United Nations High
persons with rifampicin-resistant TB, 78% were estimated to Level Meeting on TB (UNHLM-TB) declaration established
have multidrug–resistant TB. targets for 2022 that included providing TB treatment for
The WHO region of South-East Asia accounted for the high- 40 million persons infected with TB and providing TPT to
est percentage of TB cases (44% of all persons with TB) in 2018 30 million persons, including 6 million persons living with
(TB incidence = 220 per 100,000 population) (Table). TB HIV (7). Although some progress was made in 2018 toward
incidence also was high in the African region (231 per 100,000 meeting global targets, the overall number of persons with TB
population) and, in 2018, this region accounted for 71% of all and TB-associated deaths decreased only slightly from 2017.

US Department of Health and Human Services/Centers for Disease Control and Prevention MMWR / March 20, 2020 / Vol. 69 / No. 11 283
 Morbidity and Mortality Weekly Report

FIGURE 2. Trends in the estimated number of tuberculosis (TB)-related deaths among persons living with human immunodeficiency virus
(HIV-positive persons) and HIV-negative persons — worldwide, 2000–2018
2

1.8

1.6

1.4 Deaths in HIV-negative patients

No. of TB deaths (millions)

Deaths in HIV-positive patients

1.2

0.8

0.6

0.4

0.2

0
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018
Year
Source: Adapted with permission from World Health Organization. Global tuberculosis report 2019. Geneva, Switzerland: World Health Organization; 2019.

TABLE. Estimated number of incident tuberculosis (TB) cases, TB incidence, and number of TB-associated deaths among all persons and persons
living with human immunodeficiency virus (HIV-positive persons) and number of TB patients with rifampicin-resistant TB, by World Health
Organization (WHO) region — Worldwide, 2018
No. of TB cases No. of TB deaths
No. of among HIV- among HIV- No. rifampicin- Incidence of % of TB cases
persons with No. of deaths positive persons positive persons resistant TB rifampicin- rifampicin-
WHO region TB (x 1,000) Incidence* (x 1,000) (%) (x 1,000) (x 1,000) (%) cases (x 1,000) resistant TB† resistant†
Global (all regions) 10,000 132 1,493 (15) 862 251 (29) 484 9.3 4.8
African 2,450 231 609 (25) 615 211 (34) 77 7.3 3.1
Americas 289 29 23 (8) 29 5.9 (20) 11 1.0 3.8
Eastern Mediterranean 810 115 79 (10) 7 2.2 (32) 38 5.5 4.7
Europe 259 28 27 (10) 30 4.4 (15) 77 8.3 29.7
South-East Asia 4,370 220 658 (15) 140 21 (15) 182 9.2 4.1
Western Pacific 1,840 96 97 (5) 41 6.5 (16) 99 5.2 5.4
Source: Adapted with permission from World Health Organization. Global tuberculosis report 2019. Geneva, Switzerland: World Health Organization; 2019.
* Cases per 100,000 persons.
† Includes multidrug-resistant TB.

Notable highlights in progress include an increased propor- multidrug–resistant TB remains a substantial challenge. Recent
tion of persons notified of TB-positive results, increased TPT progress in the development of new treatment regimens for TB
among persons living with HIV, and decreased TB incidence and updated WHO guidelines suggest that all persons with
in the European region. rifampicin-resistant or multidrug–resistant TB could benefit
The African region continues to have the highest HIV from effective all-oral treatment regimens (8).
prevalence; thus, a large proportion of the TB cases in this A key UNHLM-TB target is to initiate 30 million persons on
region were associated with HIV. Similarly, the TB CFR TPT by 2022. Although the overall number of TPT initiations
among persons living with HIV continues to be high, and remains well below the target, including among household
consequently, overall TB CFR was highest in this region. members of persons with TB, the number of persons living
Whereas the European region is on track to meet 2020 targets, with HIV who initiated TPT nearly doubled from 2017 to
the overall proportion of persons with rifampicin-resistant or 2018 and appears on track to meet the target of 6 million

284 MMWR / March 20, 2020 / Vol. 69 / No. 11 US Department of Health and Human Services/Centers for Disease Control and Prevention
 Morbidity and Mortality Weekly Report

Acknowledgments
Summary
World Health Organization member states; USAID.
What is already known about this topic?
Corresponding author: Adam MacNeil, [email protected], 404-639-8169.
Targets for reducing tuberculosis (TB) have been set in a World
Health Organization (WHO) initiative, The End TB Strategy. 1 Division ofGlobal HIV and TB, Center for Global Health, CDC;
Achieving these targets will require substantial annual reduc- 2TuberculosisMonitoring and Evaluation, Global Tuberculosis Programme,
tions in the incidence of TB and the number of TB deaths. World Health Organization.
What is added by this report? All authors have completed and submitted the International
In 2018, an estimated 10 million incident TB cases and Committee of Medical Journal Editors form for disclosure of potential
1.5 million TB deaths occurred, reductions of 2% and 5%, conflicts of interest. No potential conflicts of interest were disclosed.
respectively, from 2017. TB epidemiology varied by WHO region.
References
What are the implications for public health practice?
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the UNHLM-TB targets. Although daily isoniazid has been end-tb/en/
the primary TPT regimen globally, an alternative regimen of 4. Badje A, Moh R, Gabillard D, et al.; Temprano ANRS 12136 Study
a 12-dose, once-weekly combination of isoniazid and rifa- Group. Effect of isoniazid preventive therapy on risk of death in west
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follow-up of the Temprano ANRS 12136 trial. Lancet Glob Health
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The findings in this report are subject to at least two limita- 5. World Health Organization. Latent TB infection: updated and
consolidated guidelines for programmatic management. Geneva,
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death among millions of persons. Although progress continues 8. World Health Organization. Rapid communication: key changes to the
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surveillance, initiation of TPT among eligible persons, and
effective treatment need to continue to improve. Much more
intensive efforts to find, cure, and prevent all cases of TB are
necessary to meet global targets and end the public health
burden of TB.

US Department of Health and Human Services/Centers for Disease Control and Prevention MMWR / March 20, 2020 / Vol. 69 / No. 11 285