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Countries with TB – High & low burden countries

A country’s burden of TB

How much a country is affected by TB is generally referred to as a country’s burden of TB. A  country’s burden of TB can be described by saying how many cases of TB they have in a year. It can also be described by saying how many people in the country die of TB each year. A third way of describing it is to say how many cases of TB there are at any given point in time. The burden of TB` is also sometimes related to the population size.

TB high burden countries

There are 22 countries that since 1998 have been considered to be the TB “high burden” countries (HBCs). These are the countries that have been given the highest priority at global level. In addition to India, Indonisia and China, the other countries are Nigeria, Pakistan, South Africa, Bangladesh, Philippines, DR Congo, Ethiopia, Myanmar, UR Tanzania, Mozambique, Viet Nam, Russian Federation, Thailand, Kenya, Brazil, Uganda, Afghanistan, Cambodia & Zimbabwe.

The 22 HBCs accounted for 83% of all estimated incident cases worldwide in 2014. The incidence is the number of new cases of active TB disease in a population during a year.

TB low burden countries

The United States is a country with a low burden of TB

The United States is a country with a low burden of TB

The number of incident TB cases relative to the population size of a country varies greatly among countries. The lowest rates, that is the countries least affected by TB are found mostly in high income countries, including most countries in Western Europe. Canada, the United States of America, Australia & New Zealand also have among the lowest rates. In these countries the incident rate is less than 10 cases per 100,000 population per year.

Countries with a very low incident rate tend to have different aims with regard to TB, compared to the high incidence countries. For example, in the United States of America, the aim is the eradication of TB. However, it is realised that there is a need for high income low incidence countries to help other countries particularly low income countries, where there is a much higher burden of TB. There is more about TB in the United States.

Lists of high burden countries

For some time there have been three lists of HBCs. These are the main list, a second list of high burden TB/HIV co-infection countries and a third list of high burden MDR-TB countries.

Initial lists of HBCs

In 1998 the initial list of 22 HBCs was defined based on the burden of TB in absolute terms. At this time TB was barely on the global health agenda. The aim in creating the list was to highlight the scale of the global TB epidemic, by focusing on a small number of countries responsible for 80% of the total number of TB cases worldwide. The 22 HBCs were defined as those countries with the highest absolute burden of TB in respect of the estimated number of incident cases. Subsequently Peru was removed from the list and replaced by Mozambique.

TB & HIV

TB & HIV

Then in 2004 the WHO issued its first guidance on the implementation of 12 collaborative TB/HIV activities. The aim was to jointly address the co-epidemics of TB and HIV. Subsequently in 2005 a list of 41 TB/HIV HBCs was agreed. The countries in the list made up 97% of the estimated global burden of TB among people living with HIV. This list was then used to promote the scaling up of TB and HIV activities and to help advocate for Global Fund support for these activities. The list was updated each year until 2009.

In 2008 it was decided that a list of high MDR-TB burden countries was important. After some debate the criteria was agreed. The list would consist of countries that collectively accounted for 85% of the estimated global total. Every country in the list was also required to either have more than 4,000 estimated TB cases a year and/or greater than or equal to 10% of new TB cases needed to be of MDR-TB. The list was used in advocating for Global Fund support for MDR-TB activities. This was especially the case for middle income countries with a high MDR-TB burden in central Asia and Eastern Europe. These were countries that would not otherwise be eligible for support. There were 27 countries in the list.

Revising the three high burden country lists

By 2015 it has been realised that there were advantages but also disadvantages to the lists. One particular disadvantage is that the main HBC list is based on absolute burden, so countries with very high rates per head of population are not included. So it was decided in 2015 that the lists would be revised. After a period of consultation it was decided that there would still be three lists for the next five years.

It was also decided that each list would contain 30 countries using a “20 + 10” approach. This meant that the countries would be the top 20 in terms of absolute numbers of incident cases, plus the ten countries with the most severe burden in relative terms that did not already appear in the top 20. There would also be a threshold of a minimum number of 10,000 cases per year for TB and 1,000 per year for TB/HIV and MDR-TB. This would avoid any of the lists including countries with a very small number of cases.

With several countries appearing in more than one list, in total the three lists include 48 countries. Of these 48 countries 15 had decided by the end of 2015 to use the Xpert TB test as the initial diagnostic test for people suspected of having pulmonary TB. These countries accounted for 10% of the estimated global number of TB incident cases in 2015.

Revised high burden country lists

The three lists are as follows and are to be used from 2016.

The 30 TB high burden countries

China is a country that appears in all three high burden TB lists

China is a country that appears in all three high burden TB lists

Top 20 by estimated absolute number (in alphabetical order)

Angola, Bangladesh, Brazil, China, DPR Korea, DR Congo, Ethiopia, India, Indonesia, Kenya, Mozambique, Myanmar, Nigeria, Pakistan, Philippines, Russian Federation, South Africa, Thailand, UR Tanzania, Viet Nam

Additional 10 by estimated incidence rate (in alphabetical order)

Cambodia, Central African Republic, Congo, Lesotho, Liberia, Namibia, Papua New Guinea, Sierra Leone, Zambia, Zimbabwe

The TB statistics page has the estimated TB incidence for each of these countries. There is also more about TB in India, TB in China & TB in South Africa.

The 30 high TB/HIV burden countries

Top 20 by estimated absolute number (in alphabetical order)

Angola, Brazil, Cameroon, China, DR Congo, Ethiopia, India, Indonesia, Kenya, Lesotho, Malawi, Mozambique, Myanmar, Nigeria, South Africa, Thailand, Uganda, UR Tanzania, Zambia, Zimbabwe

Additional 10 by estimated incidence rate (in alphabetical order)

Botswana, Central African Republic, Chad, Congo, Ghana, Guinea-Bissau, Liberia, Namibia, Papua New Guinea, Swaziland

The 30 high MDR-TB burden countries

Top 20 by estimated absolute number (in alphabetical order)

Bangladesh, China, DPR Korea, DR Congo, Ethiopia, India, Indonesia, Kazakhstan, Kenya, Mozambique, Myanmar, Nigeria, Pakistan, Philippines, Russian Federation, South Africa, Thailand, Ukraine, Uzbekistan, Viet Nam

Additional 10 by estimated incidence rate (in alphabetical order)

Angola, Azerbaijan, Belarus, Kyrgyzstan, Papua New Guinea, Peru, Republic of Moldova, Somalia, Tajikistan, Zimbabwe

Major Sources for Countries with TB

Global Tuberculosis Control 2016, WHO, Geneva, 2016 www.who.int/tb/publications/global_report/en/

Use of high burden country lists for TB by WHO in the post-2015 era High-burden-country-lists