Global, regional, and national age-specific progress towards the 2020 milestones of the WHO End TB Strategy: a systematic analysis for the Global Burden of Disease Study 2021 - 20/03/24

Doi : 10.1016/S1473-3099(24)00007-0

GBD 2021 Tuberculosis Collaborators^{^†}
Collaborators are listed at the end of the Article

Jorge R Ledesma, Jianing Ma, Meixin Zhang, Ann V L Basting, Huong Thi Chu, Avina Vongpradith, Amanda Novotney, Kate E LeGrand, Yvonne Yiru Xu, Xiaochen Dai, Sneha Ingle Nicholson, Lauryn K Stafford, Austin Carter, Jennifer M Ross, Hedayat Abbastabar, Meriem Abdoun, Deldar Morad Abdulah, Richard Gyan Aboagye, Hassan Abolhassani, Woldu Aberhe Abrha, Hiwa Abubaker Ali, Eman Abu-Gharbieh, Salahdein Aburuz, Isaac Yeboah Addo, Abiola Victor Adepoju, Kishor Adhikari, Qorinah Estiningtyas Sakilah Adnani, Saryia Adra, Abel Afework, Shahin Aghamiri, Williams Agyemang-Duah, Bright Opoku Ahinkorah, Danish Ahmad, Sajjad Ahmad, Amir Mahmoud Ahmadzade, Haroon Ahmed, Mohammed Ahmed, Ayman Ahmed, Karolina Akinosoglou, Tareq Mohammed Ali AL-Ahdal, Nazmul Alam, Mohammed Albashtawy, Mohammad T AlBataineh, Adel Ali Saeed Al-Gheethi, Abid Ali, Endale Alemayehu Ali, Liaqat Ali, Zahid Ali, Syed Shujait Shujait Ali, Kasim Allel, Awais Altaf, Jaffar A Al-Tawfiq, Nelson Alvis-Guzman, Nelson J. Alvis-Zakzuk, Reza Amani, Ganiyu Adeniyi Amusa, Jimoh Amzat, Jason R Andrews, Abhishek Anil, Razique Anwer, Aleksandr Y Aravkin, Damelash Areda, Anton A Artamonov, Raphael Taiwo Aruleba, Mulusew A Asemahagn, Sachin R Atre, Avinash Aujayeb, Davood Azadi, Sina Azadnajafabad, Ahmed Y Azzam, Muhammad Badar, Ashish D Badiye, Sara Bagherieh, Saeed Bahadorikhalili, Atif Amin Baig, Maciej Banach, Biswajit Banik, Mainak Bardhan, Hiba Jawdat Barqawi, Zarrin Basharat, Pritish Baskaran, Saurav Basu, Maryam Beiranvand, Melaku Ashagrie Belete, Makda Abate Belew, Uzma Iqbal Belgaumi, Apostolos Beloukas, Paulo J G Bettencourt, Akshaya Srikanth Bhagavathula, Nikha Bhardwaj, Pankaj Bhardwaj, Ashish Bhargava, Vivek Bhat, Jasvinder Singh Bhatti, Gurjit Kaur Bhatti, Boris Bikbov, Veera R Bitra, Vesna Bjegovic-Mikanovic, Danilo Buonsenso, Katrin Burkart, Yasser Bustanji, Zahid A Butt, Paulo Camargos, Yu Cao, Sinclair Carr, Felix Carvalho, Luca Cegolon, Muthia Cenderadewi, Muge Cevik, Yaacoub Chahine, Vijay Kumar Chattu, Patrick R Ching, Hitesh Chopra, Eunice Chung, Mareli M Claassens, Kaleb Coberly, Natália Cruz-Martins, Bashir Dabo, Sriharsha Dadana, Omid Dadras, Isaac Darban, Jiregna Darega Gela, Aso Mohammad Darwesh, Mahmood Dashti, Berecha Hundessa Demessa, Biniyam Demisse, Solomon Demissie, Awoke Masrie Asrat Derese, Kebede Deribe, Hardik Dineshbhai Desai, Vinoth Gnana Chellaiyan Devanbu, Arkadeep Dhali, Kuldeep Dhama, Sameer Dhingra, Thao Huynh Phuong Do, Deepa Dongarwar, Haneil Larson Dsouza, John Dube, Arkadiusz Marian Dziedzic, Abdelaziz Ed-Dra, Ferry Efendi, Diyan Ermawan Effendi, Aziz Eftekharimehrabad, Nopryan Ekadinata, Temitope Cyrus Ekundayo, Muhammed Elhadi, Legesse Tesfaye Elilo, Theophilus I Emeto, Luchuo Engelbert Bain, Adeniyi Francis Fagbamigbe, Ayesha Fahim, Alireza Feizkhah, Getahun Fetensa, Florian Fischer, Abduzhappar Gaipov, Aravind P Gandhi, Rupesh K Gautam, Miglas W Gebregergis, Mesfin Gebrehiwot, Kahsu Gebrekirstos Gebrekidan, Kazem Ghaffari, Fariba Ghassemi, Ramy Mohamed Ghazy, Amador Goodridge, Anmol Goyal, Shi-Yang Guan, Mesay Dechasa Gudeta, Rashid Abdi Guled, Novianti Br Gultom, Veer Bala Gupta, Vivek Kumar Gupta, Sapna Gupta, Hailey Hagins, Semira Goitom Hailu, Wase Benti Hailu, Samer Hamidi, Asif Hanif, Harapan Harapan, Rumina Syeda Hasan, Shoaib Hassan, Johannes Haubold, Kamal Hezam, Sung Hwi Hong, Nobuyuki Horita, Md. Belal Hossain, Mehdi Hosseinzadeh, Mihaela Hostiuc, Sorin Hostiuc, Hong-Han Huynh, Segun Emmanuel Ibitoye, Kevin S Ikuta, Irena M. Ilic, Milena D. Ilic, Md. Rabiul Islam, Nahlah Elkudssiah Ismail, Faisal Ismail, Abdollah Jafarzadeh, Mihajlo Jakovljevic, Mahsa Jalili, Manthan Dilipkumar Janodia, Nabi Jomehzadeh, Jost B Jonas, Nitin Joseph, Charity Ehimwenma Joshua, Zubair Kabir, Bhushan Dattatray Kamble, Tanuj Kanchan, Himal Kandel, Kehinde Kazeem Kanmodi, Rami S Kantar, Ibraheem M Karaye, Arman Karimi Behnagh, Gebrehiwot G Kassa, Rimple Jeet Kaur, Navjot Kaur, Himanshu Khajuria, Faham Khamesipour, Yusra H Khan, M Nuruzzaman Khan, Mahammed Ziauddin Khan Suheb, Khaled Khatab, Fatemeh Khatami, Min Seo Kim, Soewarta Kosen, Parvaiz A Koul, Sindhura Lakshmi Koulmane Laxminarayana, Kewal Krishan, Burcu Kucuk Bicer, Md Abdul Kuddus, Mukhtar Kulimbet, Nithin Kumar, Dharmesh Kumar Lal, Iván Landires, Kamaluddin Latief, Trang Diep Thanh Le, Thao Thi Thu Le, Caterina Ledda, Munjae Lee, Seung Won Lee, Temesgen L Lerango, Stephen S Lim, Chaojie Liu, Xuefeng Liu, Platon D Lopukhov, Hong Luo, Hengliang Lv, Preetam Bhalchandra Mahajan, Amir Ali Mahboobipour, Azeem Majeed, Elaheh Malakan Rad, Kashish Malhotra, Muhammad Sajeel Ahmed Malik, Lesibana Anthony Malinga, Tauqeer Hussain Mallhi, Aseer Manilal, Bernardo Alfonso Martinez-Guerra, Francisco Rogerlândio Martins-Melo, Roy Rillera Marzo, Hossein Masoumi-Asl, Vasundhara Mathur, Richard James Maude, Ravi Mehrotra, Ziad A Memish, Walter Mendoza, Ritesh G Menezes, Muayad Aghali Merza, Tomislav Mestrovic, Laurette Mhlanga, Sanjeev Misra, Arup Kumar Misra, Prasanna Mithra, Babak Moazen, Hussen Mohammed, Ali H Mokdad, Lorenzo Monasta, Catrin E Moore, Parsa Mousavi, Francesk Mulita, Fungai Musaigwa, Raman Muthusamy, Ahamarshan Jayaraman Nagarajan, Pirouz Naghavi, Ganesh R Naik, Gurudatta Naik, Sanjeev Nair, Tapas Sadasivan Nair, Zuhair S Natto, Biswa Prakash Nayak, Hadush Negash, Dang H Nguyen, Van Thanh Nguyen, Robina Khan Niazi, Chukwudi A Nnaji, Lawrence Achilles Nnyanzi, Efaq Ali Noman, Shuhei Nomura, Bogdan Oancea, Kehinde O Obamiro, Ismail A Odetokun, Daniel Bogale Odo Odo, Oluwakemi Ololade Odukoya, In-Hwan Oh, Chukwuma O Okereke, Osaretin Christabel Okonji, Eyal Oren, Edgar Ortiz-Brizuela, Uchechukwu Levi Osuagwu, Amel Ouyahia, Mahesh Padukudru P A, Pragyan Paramita Parija, Romil R Parikh, Seoyeon Park, Ashwaghosha Parthasarathi, Shankargouda Patil, Shrikant Pawar, Minjin Peng, Veincent Christian Filipino Pepito, Prince Peprah, João Perdigão, Norberto Perico, Hoang Tran Pham, Maarten J Postma, Attur Ravindra Attur Prabhu, Manya Prasad, Akila Prashant, Elton Junio Sady Prates, Fakher Rahim, Mosiur Rahman, Muhammad Aziz Rahman, Masoud Rahmati, Sathish Rajaa, Shakthi Kumaran Ramasamy, Indu Ramachandra Rao, Sowmya J Rao, Deepthi Rapaka, Ahmed Mustafa Rashid, Zubair Ahmed Ratan, Nakul Ravikumar, Salman Rawaf, Murali Mohan Rama Krishna Reddy, Elrashdy Moustafa Mohamed Redwan, Giuseppe Remuzzi, Luis Felipe Reyes, Nazila Rezaei, Mohsen Rezaeian, Omid Rezahosseini, Mónica Rodrigues, Priyanka Roy, Guilherme de Andrade Ruela, Siamak Sabour, Basema Saddik, Umar Saeed, Sher Zaman Safi, Narjes Saheb Sharif-Askari, Fatemeh Saheb Sharif-Askari, Amirhossein Sahebkar, Biniyam Sahiledengle, Soumya Swaroop Sahoo, Nasir Salam, Afeez Abolarinwa Salami, Samreen Saleem, Mohamed A Saleh, Hossein Samadi Kafil, Sara Samadzadeh, Yoseph Leonardo Samodra, Rama Krishna Sanjeev, Aswini Saravanan, Susan M Sawyer, Siddharthan Selvaraj, Sabyasachi Senapati, Subramanian Senthilkumaran, Pritik A Shah, Samiah Shahid, Masood Ali Shaikh, Sunder Sham, Mohammad Ali Shamshirgaran, Mohd Shanawaz, Medha Sharath, Samendra P Sherchan, Ranjitha S Shetty, Hesamaddin Shirzad-Aski, Aminu Shittu, Emmanuel Edwar Siddig, João Pedro Silva, Surjit Singh, Paramdeep Singh, Harpreet Singh, Jasvinder A Singh, Md Shahjahan Siraj, Siswanto Siswanto, Ranjan Solanki, Yonatan Solomon, Joan B Soriano, Chandrashekhar T Sreeramareddy, Vijay Kumar Srivastava, Paschalis Steiropoulos, Chandan Kumar Swain, Takahiro Tabuchi, Mircea Tampa, Jacques JL Lukenze Tamuzi, Nathan Y Tat, Razieh Tavakoli Oliaee, Gebrehiwot Teklay, Edosa Geta Tesfaye, Belay Tessema, Pugazhenthan Thangaraju, Rekha Thapar, Chern Choong Chern Thum, Jansje Henny Vera Ticoalu, Imad M Tleyjeh, Ruoyan Tobe-Gai, Temesgen Mohammed Toma, Khai Hoan Tram, Aniefiok John Udoakang, Tungki Pratama Umar, Chukwuma David Umeokonkwo, Seyed Mohammad Vahabi, Asokan Govindaraj Vaithinathan, Job F M van Boven, Shoban Babu Varthya, Ziyue Wang, Muktar S A Warsame, Ronny Westerman, Tewodros Eshete Wonde, Sajad Yaghoubi, Siyan Yi, Vahit Yiğit, Dong Keon Yon, Naohiro Yonemoto, Chuanhua Yu, Fathiah Zakham, Moein Zangiabadian, Francis Zeukeng, Haijun Zhang, Yang Zhao, Peng Zheng, Magdalena Zielińska, Joshua A Salomon, Robert C Reiner Jr, Mohsen Naghavi, Theo Vos, Simon I Hay, Christopher J L Murray, Hmwe Hmwe Kyu ⁎

^*Correspondence to: Dr Hmwe H Kyu, Department of Health Metrics Sciences, School of Medicine, Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA 98195, USADepartment of Health Metrics SciencesSchool of MedicineInstitute for Health Metrics and EvaluationUniversity of WashingtonSeattleWA98195USA

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Summary

Background

Global evaluations of the progress towards the WHO End TB Strategy 2020 interim milestones on mortality (35% reduction) and incidence (20% reduction) have not been age specific. We aimed to assess global, regional, and national-level burdens of and trends in tuberculosis and its risk factors across five separate age groups, from 1990 to 2021, and to report on age-specific progress between 2015 and 2020.

Methods

We used the Global Burden of Diseases, Injuries, and Risk Factors Study 2021 (GBD 2021) analytical framework to compute age-specific tuberculosis mortality and incidence estimates for 204 countries and territories (1990–2021 inclusive). We quantified tuberculosis mortality among individuals without HIV co-infection using 22 603 site-years of vital registration data, 1718 site-years of verbal autopsy data, 825 site-years of sample-based vital registration data, 680 site-years of mortality surveillance data, and 9 site-years of minimally invasive tissue sample (MITS) diagnoses data as inputs into the Cause of Death Ensemble modelling platform. Age-specific HIV and tuberculosis deaths were established with a population attributable fraction approach. We analysed all available population-based data sources, including prevalence surveys, annual case notifications, tuberculin surveys, and tuberculosis mortality, in DisMod-MR 2.1 to produce internally consistent age-specific estimates of tuberculosis incidence, prevalence, and mortality. We also estimated age-specific tuberculosis mortality without HIV co-infection that is attributable to the independent and combined effects of three risk factors (smoking, alcohol use, and diabetes). As a secondary analysis, we examined the potential impact of the COVID-19 pandemic on tuberculosis mortality without HIV co-infection by comparing expected tuberculosis deaths, modelled with trends in tuberculosis deaths from 2015 to 2019 in vital registration data, with observed tuberculosis deaths in 2020 and 2021 for countries with available cause-specific mortality data.

Findings

We estimated 9·40 million (95% uncertainty interval [UI] 8·36 to 10·5) tuberculosis incident cases and 1·35 million (1·23 to 1·52) deaths due to tuberculosis in 2021. At the global level, the all-age tuberculosis incidence rate declined by 6·26% (5·27 to 7·25) between 2015 and 2020 (the WHO End TB strategy evaluation period). 15 of 204 countries achieved a 20% decrease in all-age tuberculosis incidence between 2015 and 2020, eight of which were in western sub-Saharan Africa. When stratified by age, global tuberculosis incidence rates decreased by 16·5% (14·8 to 18·4) in children younger than 5 years, 16·2% (14·2 to 17·9) in those aged 5–14 years, 6·29% (5·05 to 7·70) in those aged 15–49 years, 5·72% (4·02 to 7·39) in those aged 50–69 years, and 8·48% (6·74 to 10·4) in those aged 70 years and older, from 2015 to 2020. Global tuberculosis deaths decreased by 11·9% (5·77 to 17·0) from 2015 to 2020. 17 countries attained a 35% reduction in deaths due to tuberculosis between 2015 and 2020, most of which were in eastern Europe (six countries) and central Europe (four countries). There was variable progress by age: a 35·3% (26·7 to 41·7) decrease in tuberculosis deaths in children younger than 5 years, a 29·5% (25·5 to 34·1) decrease in those aged 5–14 years, a 15·2% (10·0 to 20·2) decrease in those aged 15–49 years, a 7·97% (0·472 to 14·1) decrease in those aged 50–69 years, and a 3·29% (–5·56 to 9·07) decrease in those aged 70 years and older. Removing the combined effects of the three attributable risk factors would have reduced the number of all-age tuberculosis deaths from 1·39 million (1·28 to 1·54) to 1·00 million (0·703 to 1·23) in 2020, representing a 36·5% (21·5 to 54·8) reduction in tuberculosis deaths compared to those observed in 2015. 41 countries were included in our analysis of the impact of the COVID-19 pandemic on tuberculosis deaths without HIV co-infection in 2020, and 20 countries were included in the analysis for 2021. In 2020, 50 900 (95% CI 49 700 to 52 400) deaths were expected across all ages, compared to an observed 45 500 deaths, corresponding to 5340 (4070 to 6920) fewer deaths; in 2021, 39 600 (38 300 to 41 100) deaths were expected across all ages compared to an observed 39 000 deaths, corresponding to 657 (–713 to 2180) fewer deaths.

Interpretation

Despite accelerated progress in reducing the global burden of tuberculosis in the past decade, the world did not attain the first interim milestones of the WHO End TB Strategy in 2020. The pace of decline has been unequal with respect to age, with older adults (ie, those aged >50 years) having the slowest progress. As countries refine their national tuberculosis programmes and recalibrate for achieving the 2035 targets, they could consider learning from the strategies of countries that achieved the 2020 milestones, as well as consider targeted interventions to improve outcomes in older age groups.