1.2 TB mortality
Box 1.2.1 summarizes the methods used to produce estimates of TB mortality between 2010 and 2019, and the new methods that were needed to produce estimates for 2020–2022. Estimation of TB mortality during the COVID-19 pandemic and its aftermath is much more difficult than previously. The new methods were extensively reviewed in 2021 and 2022, but rely heavily on country and region-specific dynamic models for low and middle-income countries that experienced major COVID-related disruptions to TB diagnosis and treatment, in the absence of reliable and up-to-date mortality data from national vital registration (VR) systems that include coding of causes of death according to international standards (1). Only two of the 30 high TB burden countries (Brazil and China) and one of the global TB watchlist countries (the Russian Federation) reported data to WHO on the number of deaths caused by TB for the period 2020–2022, based on national VR data.
For consistency with international standards (1), this section makes a clear distinction between deaths from TB in people without HIV (classified as deaths caused by TB) and deaths from TB in people with HIV (classified as deaths caused by HIV, with TB as a contributory cause).
Globally, the annual number of deaths caused by TB fell between 2010 and 2019, but this trend was reversed in 2020 and 2021 (Fig. 1.2.1). The estimated increase in the number of deaths caused by TB in these two years was the consequence of disruptions to TB diagnosis and treatment during the COVID-19 pandemic, when the reported number of people newly diagnosed with TB fell from 7.1 million in 2019 to 5.8 million in 2020 and 6.4 million in 2021 (Section 2.1), suggesting a large increase in the number of people with undiagnosed and untreated TB. The estimated decrease in the number of deaths caused by TB in 2022 (a 6.4% reduction compared with 2021) reflects the big global recovery in the number of people newly diagnosed with TB in 2022 (Section 2.1).
Globally in 2022, there were an estimated 1.13 million deaths among HIV-negative people (95% uncertainty interval [UI]: 1.02–1.26 million) and an estimated 167 000 deaths among people with HIV (95% UI: 139 000–198 000). The combined total of 1.3 million is almost back to the level of 2019. However, the net reduction in the total number of deaths caused by TB between 2015 and 2022 was only 19%, far from the 2025 milestone of the End TB Strategy (a 75% reduction between 2015 and 2025).
Shaded areas represent 95% uncertainty intervals. The horizontal dashed
line shows the 2025 milestone of the End TB Strategy, which is a 75%
reduction in the total number of deaths caused by TB between 2015 and
2025.
(a) Number
(b) Rate per 100 000 population
Global estimates of the number of deaths caused by TB have been revised downwards, compared with those published in 2022 (2). The main explanation is that estimates for India have been revised downwards, based on recently published cause-of-death data from the country’s sample registration system (SRS) for 2014–2019.
The increase in TB mortality estimated for 2021 is consistent with projections published in the Global tuberculosis report 2021 (2) and reflects the estimated impact of disruptions to essential TB services during the COVID-19 pandemic: in particular, drops in the number of people with TB who were detected and treated in 2020 and 2021 (Section 2). The death rate for untreated TB is high (about 50%), and therefore the impact of reduced case detection on TB mortality is severe and noticeable within a short time period. The impact on TB incidence is more delayed (Section 1.1).
Disruptions during the COVID-19 pandemic and its aftermath are estimated to have resulted in close to half a million excess deaths from TB in the three years 2020–2022 (Fig. 1.2.2).
The black shaded area represents the
95% uncertainty interval of the actual number of deaths estimated to
have been caused by TB; the red line
shows a counterfactual of the estimated number of deaths that would have
been caused by TB in the absence of the COVID-19 pandemic; the red shaded area shows the excess number of
deaths caused by TB due to disruptions associated with the COVID-19
pandemic.
In 2022, most of the estimated deaths caused by TB among HIV-negative people occurred in the WHO regions of South-East Asia (53%) and Africa (27%), with smaller shares in the Western Pacific (8.5%), the Eastern Mediterranean (7.2%), the Americas (2.1%) and Europe (1.5%); most of the TB deaths among people with HIV occurred in the African Region (68%) (Table 1.2.1).
Low and high are the 5th and 95th percentiles of the uncertainty
interval (UI).
| Region or country group | Best estimate | Low | High | Best estimate | Low | High | Best estimate | Low | High | Best estimate | Low | High |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| African Region | 310 | 264 | 360 | 114 | 86 | 144 | 26 | 22 | 30 | 9.5 | 7.3 | 12 |
| Region of the Americas | 24 | 22 | 25 | 11 | 9.6 | 13 | 2.3 | 2.2 | 2.4 | 1.1 | 0.93 | 1.2 |
| Eastern Mediterranean Region | 82 | 69 | 95 | 2.1 | 1.7 | 2.6 | 10 | 8.9 | 12 | 0.27 | 0.22 | 0.33 |
| European Region | 18 | 17 | 18 | 6.3 | 3.9 | 9.4 | 1.9 | 1.8 | 2.0 | 0.68 | 0.42 | 1.0 |
| South-East Asia Region | 606 | 505 | 716 | 26 | 23 | 30 | 29 | 24 | 35 | 1.3 | 1.1 | 1.5 |
| Western Pacific Region | 96 | 90 | 102 | 7.5 | 6.4 | 8.6 | 5.0 | 4.6 | 5.3 | 0.39 | 0.33 | 0.44 |
| High TB burden countries | 967 | 855 | 1 090 | 125 | 98 | 156 | 20 | 17 | 22 | 2.5 | 2.0 | 3.2 |
| Global | 1 130 | 1 020 | 1 260 | 167 | 139 | 198 | 14 | 13 | 16 | 2.1 | 1.7 | 2.5 |
Globally in 2022, 52% of the HIV-negative people who died from TB were men, 32% were women and 16% were children (aged <15 years) (Fig. 1.2.3). The higher share for children compared with their estimated share of cases (12%) suggests poorer access to diagnosis and treatment. Of the TB deaths among people with HIV, 47% were men, 35% were women and 18% were children.
(a) Among HIV-negative people
(b) Among people with HIV
In 2022, an estimated total of 665 000 adult men (aged ≥15 years) died from TB (95% UI: 593 000–742 000): 587 000 among those HIV-negative (95% UI: 528 000–649 000) and 78 000 among those with HIV (95% UI: 65 000–92 000). An estimated total of 423 000 adult women (aged ≥15 years) died from TB (95% UI: 377 000–473 000): 365 000 among those HIV-negative (95% UI: 328 000–404 000) and 58 000 among those with HIV (95% UI: 48 000–69 000).
In 2022, an estimated total of 214 000 children and young adolescents (<15 years) died from TB (95% UI: 190 000–239 000): 183 000 among those HIV-negative (95% UI: 164 000–202 000) and 31 000 among those with HIV (95% UI: 26 000–37 000). Among HIV-negative children and young adolescents, the estimated number of TB deaths in 2022 was 139 000 among children aged <5 years (95% UI: 125 000–154 000); and 44 000 in older children and young adolescents aged 5–14 years (95% UI: 39 000–49 000).
The latest year for which WHO has published estimates of global deaths by cause remains 2019, when TB was the top cause of death from a single infectious agent and the 13th leading cause of death worldwide (Fig. 1.2.4). In 2022, it is anticipated that TB will rank second as a cause of death from a single infectious agent, after COVID-19 (3).
Deaths from TB among people with HIV are shown in grey.
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 people with HIV are officially classified as deaths caused by HIV/AIDS in the International Classification of Diseases.
b Deaths from TB among people with HIV are officially classified as deaths caused by HIV/AIDS in the International Classification of Diseases.
The estimated number of deaths officially classified as caused by TB (i.e. those among HIV-negative people) in 2022, at 1.1 million, was almost double the number of deaths caused by HIV/AIDS (0.63 million) (Fig. 1.2.5).
Deaths from TB among people with HIV are shown in grey.
a For HIV/AIDS, the latest estimates of the number of deaths
in 2022 that have been published by UNAIDS are available at http://www.unaids.org/en/ (accessed 15 August 2023). For
TB, the estimates for 2022 are those published in this report.
b Deaths from TB among people with HIV are officially classified as deaths caused by HIV/AIDS in the International Classification of Diseases.
b Deaths from TB among people with HIV are officially classified as deaths caused by HIV/AIDS in the International Classification of Diseases.
Compared with HIV, deaths from TB have been much more severely impacted by the COVID-19 pandemic (Fig. 1.2.6). In contrast to TB, deaths from HIV/AIDS continued to decline between 2019 and 2022 (4).
Shaded areas represent 95% uncertainty intervals.
a For HIV/AIDS, the latest estimates of the number of deaths
in 2022 that have been published by UNAIDS are available at http://www.unaids.org/en/ (accessed 15 August 2023). For
TB, the estimates for 2022 are those published in this report.
b Deaths from TB among people with HIV are officially classified as deaths caused by HIV/AIDS in the International Classification of Diseases.
b Deaths from TB among people with HIV are officially classified as deaths caused by HIV/AIDS in the International Classification of Diseases.
In 2022, the TB mortality rate fell in two WHO regions (the African and the Eastern Mediterranean regions) but increased in the Region of the Americas, and was relatively stable in the European, South–East Asia and Western Pacific regions (Fig. 1.2.7).
Estimated TB mortality rates among HIV-negative people are shown in
blue and estimated mortality rates
among people with HIV are shown in light
blue. Shaded areas represent 95% uncertainty intervals.
Trends in the absolute number of TB deaths at regional level also vary (Fig. 1.2.8). The global pattern of a fall in the absolute number of deaths caused by TB (including those among people with HIV) until 2019, followed by increases in 2020–2021 and then a reversal in 2022, was also evident in the WHO Eastern Mediterranean and European regions. In the South–East Asia and Western Pacific regions, the estimated number of deaths caused by TB was stable in 2022 compared with 2021. In the Region of the Americas, the estimated number of deaths caused by TB continued to rise in 2022. In the African Region, the estimated number of deaths caused by TB fell up to 2019, was stable from 2019–2020 and then started to fall again.
Shaded areas represent 95% uncertainty intervals. The horizontal dashed
line shows the 2025 milestone of the End TB Strategy, which is a 75%
reduction in the total number of deaths caused by TB between 2015 and
2025.
The African Region and the European Region are the closest to reaching the 2025 milestone of the End TB Strategy, with reductions of 38% and 32% respectively between 2015 and 2022. The four other regions are still far from the 2025 milestone of the End TB Strategy, with progress up to 2019 set back by disruptions during the COVID-19 pandemic and its aftermath.
The regional distribution of TB deaths by age and sex in 2022 varies by WHO region (Fig. 1.2.9).
Progress in reducing the total number of deaths caused by TB (among people with and without HIV) at country level is highly variable (Fig. 1.2.10). A total of 47 countries have reached or surpassed the first (2020) milestone of the End TB Strategy, which was a 35% reduction compared with a baseline of 2015. At the other extreme, the number of deaths caused by TB has increased in some countries, mainly related to disruptions caused by the COVID-19 pandemic. This is particularly true in the WHO Region of the Americas.
The last two categories (decrease 35-49%, and decrease ≥50%) distinguish
the countries that have made the most progress towards the second
milestone of the End TB strategy, which is a 75% reduction in the total
number of deaths caused by TB between 2015 and 2025.
Trends in the total number of deaths caused by TB (among people with and without HIV) in the 30 high TB burden countries are also highly variable. Between 2019 and 2021, striking increases are estimated to have occurred in countries with major shortfalls in TB notifications in 2020 and 2021 (e.g. Indonesia, Myanmar, the Philippines), while in others previous declines have slowed or stabilized. The countries estimated to have made the best progress between 2015 and 2022 are Kenya, Mozambique, Uganda, the United Republic of Tanzania and Zambia (Fig. 1.2.11).
Shaded areas represent 95% uncertainty intervals. The horizontal dashed
line shows the 2025 milestone of the End TB Strategy, which is a 75%
reduction in the total number of deaths caused by TB between 2015 and
2025.
Of the three global TB watchlist countries, the Russian Federation is well on the way to reach the 2025 milestone (Fig. 1.2.12), with a cumulative reduction of 56% between 2015 and 2022.
Shaded areas represent 95% uncertainty intervals. The horizontal dashed
line shows the 2025 milestone of the End TB Strategy, which is a 75%
reduction in the total number of deaths caused by TB between 2015 and
2025.
There is considerable national variation in the TB mortality rate; in 2022, most of the countries with the highest rates were in the African Region (Fig. 1.2.13).
There is also considerable variation in the case fatality ratio (CFR) i.e. the estimated proportion of people who develop TB that die from the disease (Fig. 1.2.14). Globally, the CFR was 12.3% in 2022, down from 13.5% in 2021 and lower than the 13% estimated for 2019.
Box 1.2.1
Methods used by WHO to estimate TB mortality
The main methods used by WHO to estimate TB mortality at country level in the periods 2010–2019 and 2020–2022 are shown in (Fig. 1.2.15) and (Fig. 1.2.16). These methods adhere to global guidelines for accurate and transparent reporting of health estimates (5) and are described in detail in a technical appendix.
For 124 countries, estimates of the number of deaths caused by TB among HIV-negative people for the period 2010-2019 are based on data on causes of death from national vital registration (VR) systems or mortality surveys (Fig. 1.2.15), which collectively accounted for 60% of the estimated global number of deaths caused by TB (among HIV-negative people) in 2019. For 20 of these countries, analyses of VR data and resulting estimates of TB deaths published by the Institute of Health Metrics and Evaluation (IHME) were used (6). For all other countries, TB mortality among HIV-negative people was estimated indirectly as the product of TB incidence and the case fatality ratio (CFR), with the CFR derived from a literature review and adjusted to account for TB treatment (treated or untreated). For all countries, TB mortality among people with HIV was estimated as the product of TB incidence and the CFR, with the latter accounting for TB treatment (started or not started), antiretroviral treatment (ART, started or not started) and the duration of ART.
To produce estimates of TB disease burden in the period 2020–2022, country-specific dynamic models were developed for the 26 countries with the biggest absolute reductions in TB notifications during the COVID-19 pandemic (when these reductions departed from pre-2020 trends). However, for four of these countries, data on the number of deaths caused by TB that were recorded in national VR systems and reported to the WHO Global Tuberculosis Programme as part of the annual process of reviewing draft TB country profiles were used instead of model-based estimates (Fig. 1.2.16). For other low and middle-income countries, region-specific dynamic models or the indirect method described above (i.e. the product of estimates of TB incidence and the CFR) were used. Estimates for high-income countries were based on the same methods as those used up to 2019 i.e. data from national VR systems, with the assumption that the pre-2020 trend was sustained.
Estimates of the annual number of deaths caused by TB in India have been revised downwards, compared with previous estimates published by WHO. This follows the availability of new cause-of-death data from the country’s sample registration system (SRS) for the period 2014–2019. For more details, see Box 4 of the Global tuberculosis report 2023.
Fig. 1.2.15 Main methods used to estimate TB mortality in HIV-negative people, 2010–2019
IHME: Institute of Health Metrics and Evaluation, Seattle, USA. VR:
Vital registration of causes of deaths.
VR: Vital registration of causes of deaths.
Country-specific details are available in the Global tuberculosis report app and country profiles.
Note : All of the percentage reductions or increases referred to in the text of this webpage were calculated based on unrounded numbers, as opposed to the rounded numbers that appear in the interactive graphics.
References
International statistical classification of diseases and health related problems (The) ICD-10. Geneva: World Health Organization; 2016 (https://icd.who.int/browse10/2016/en).
Global tuberculosis report 2022. Geneva: World Health Organization; 2022 (https://iris.who.int/handle/10665/363752).
Coronavirus (COVID-19) dashboard. Geneva: World Health Organization. (https://covid19.who.int/).
AIDS info [website]. 2023 (http://aidsinfo.unaids.org/).
Guidelines for Accurate and Transparent Health Estimates Reporting (GATHER) [website]. Geneva: World Health Organization; 2021 (http://gather-statement.org/).
GBD results tool [website]. Global Health Data Exchange; 2020 (http://ghdx.healthdata.org/gbd-results-tool).