https://ojs.wpro.who.int/ 1WPSAR Vol 11, No 4, 2020 | doi: 10.5365/wpsar.2020.11.3.002

Regional Analysis

a End TB and Leprosy Unit, World Health Organization Regional Office for the Western Pacific, Manila, Philippines.
b Prevention, Diagnosis, Treatment, Care and Innovation Unit, Global TB Programme, World Health Organization, Geneva, Switzerland.
c Centre for Research Excellence in Tuberculosis and the Marie Bashir Institute for Infectious Diseases and Biosecurity, University of Sydney, Sydney, Australia.
d Menzies School of Health Research, Charles Darwin University, Darwin, Australia.
Published: 28 December 2020
doi: 10.5365/wpsar.2020.11.3.002

T
uberculosis (TB) continues to be a global public
health problem, which disproportionately affects
poor and marginalized populations who often have

limited health care access. Despite the continued global
effort to end TB, the disease continues to be the leading
infectious killer on the planet. In 2018, an estimated
10 million people fell ill with TB and 1.5 million died
from the disease.1 Geographically, over 85% of TB
cases in 2018 occurred in three WHO regions: 44% in
South-East Asia, 24% in Africa and 18% in the Western
Pacific.1 In total, 30 countries with high burdens of TB
accounted for 87% of the world’s cases.1

In 2014, the Sixty-seventh World Health Assembly
endorsed a global strategy, now commonly known as the
End TB Strategy,2 and targets for TB prevention, care and
control after 2015. The Strategy set the ambitious target

of ending TB by 2035, by reducing the incidence rate by
90% and the number of deaths by 95% from those in
2015. Interim 2020 milestones were defined as reduc-
tions of 20% of the incidence rate and 35% in the number
of deaths, in addition to eliminating catastrophic costs
incurred by TB.2 Since 2014, two global high-level meet-
ings (the WHO Global Ministerial Conference on “ending
TB in the sustainable development era”, held in Moscow,
Russian Federation, in 2017, and the first high-level
meeting on TB at the United Nations General Assembly,
in New York in 2018) created unprecedented political mo-
mentum to accelerate the global TB response.3 The world
is, however, unlikely to achieve the 2020 milestones, with
only a 6.3% reduction in TB incidence and a 5.2% reduc-
tion in TB deaths reported between 2015 and 2018.4
In addition, there is grave concern that the COVID-19
pandemic will set back the modest gains made to date.5

Since 2015, the End TB Strategy and the Regional Framework for Action on Implementation of the End TB Strategy in
the Western Pacific 2016–2020 have guided national tuberculosis (TB) responses in countries and areas of the Region.
This paper provides an overview of the TB epidemiological situation in the Western Pacific Region and of progress
towards the 2020 milestones of the Strategy. A descriptive analysis was conducted of TB surveillance and programme
data reported to WHO and estimates of the TB burden generated by WHO for the period 2000–2018. An estimated
1.8 million people developed TB and 90 000 people died from it in the Region in 2018. Since 2015, the estimated TB
incidence rate and the estimated number of TB deaths in the Region decreased by 3% and 10%, with annual reduction
rates of 1.0% and 3.4%, respectively. With current efforts, the Region is unlikely to achieve the 2020 milestones and
other targets of the Strategy. Major challenges include: (1) wide variation in the geographical distribution and rate of
TB incidence among countries; (2) a substantial proportion (23%) of TB cases that remain unreached, undiagnosed
or unreported; (3) insufficient coverage of drug susceptibility testing (51%) for bacteriologically confirmed cases and
limited use of WHO-recommended rapid diagnostics (11 countries reported <60% coverage); (4) suboptimal treatment
outcomes of TB (60% of countries reported <85% success), of TB/HIV co-infection (79%) and of multidrug- or
rifampicin-resistant TB (59%); (5) limited coverage of TB preventive treatment among people living with HIV (39%)
and child contacts (12%); and (6) substantial proportions (35–70%) of TB-affected families facing catastrophic costs.
For the Region to stay on track to achieve the End TB Strategy targets, an accelerated multisectoral response to TB is
required in every country.

Epidemiology of tuberculosis in the
Western Pacific Region: Progress towards the
2020 milestones of the End TB Strategy
Fukushi Morishita,a Kerri Viney,b,c Chris Lowbridge,a,d Hend Elsayed,a Kyung Hyun Oh,a Kalpeshsinh Rahevar,a
Ben J Maraisc and Tauhid Islama

Correspondence to Fukushi Morishita (email: morishitaf@who.int)

WPSAR Vol 11, No 4, 2020 | doi: 10.5365/wpsar.2020.11.3.002 https://ojs.wpro.who.int/2

Morishita et alEpidemiology of tuberculosis in the Western Pacific Region

estimated number of incident multidrug- or rifampicin-
resistant TB (MDR/RR-TB) cases, the case detection
rate (the number of laboratory-confirmed MDR/RR-TB
cases divided by the estimated number of incident
cases) and the treatment enrolment rate (the number of
cases enrolled in second-line treatment divided by the
number of laboratory-confirmed cases) were provided
for countries with the highest estimated numbers of
MDR/RR-TB incidence. Indicators of TB prevention
and catastrophic costs due to TB were assessed where
data were available. Catastrophic costs for TB-affected
families are defined as total costs (comprising direct
medical and non-medical costs plus income losses) that
represent 20% or more of annual household income.
We also developed a colour-coded scorecard to summa-
rize indicators of implementation of the End TB Strategy
for each country in the Region. In this paper, “range”
refers to the 95% uncertainty interval. All analyses
were conducted with the statistical software package
R 3.6.1 (Comprehensive R Archive Network at https://
cran.r-project.org/).

Ethical clearance was not required, as this report
was part of a regular evaluation of programme perfor-
mance.

RESULTS

Estimates of TB burden

Since 2000, the estimated incidence of TB in the Region
has decreased steadily, from 135 (range, 109–163)
per 100 000 population (2.3 [range, 1.7–2.8] million
cases) to 96 (range, 79–114) per 100 000 popula-
tion (1.8 [range, 1.5–2.2] million cases) in 2018. The
estimated number of TB deaths more than halved in
the same period, from 209 000 (range, 178 000–242
000) (12 [range, 10–14] deaths per 100 000 popula-
tion) in 2000 to 90 000 (4.7 [4.3–5.1] deaths per 100
000 population) in 2018 (Fig. 1). Since 2015, when
the End TB Strategy and the Regional Framework:
2016–2020 were endorsed, the estimated incidence
rate and number of TB deaths have decreased by 3%
and 10%, with annual reductions of 1.0% and 3.4%,
respectively. The estimated TB incidence and mortality
rates among people living with HIV (PLHIV) have both
remained low in the Region (2.1 [range, 1.5–2.8] and
0.34 [range, 0.25–0.43] per 100 000 population in
2018, respectively).

The WHO Western Pacific Region is home to
1.9 billion people in 37 countries and areas. The Region
is diverse, comprising large countries with populations
of more than 1 billion people and small Pacific island
countries with a few thousand residents, as well as coun-
tries with high and intermediate TB burdens and others
in the pre-elimination stage. The Regional Framework
for Action on Implementation of the End TB Strategy
in the Western Pacific 2016–2020 has guided national
TB responses in countries and areas of the Region by
proposing actions for national TB programmes.6,7 This
paper provides an overview of the epidemiology of TB
in the Region and of progress towards the 2020 interim
milestones of the End TB Strategy and the Regional
Framework.

METHODS

We conducted a descriptive analysis of TB surveillance
and programme data reported by countries and areas to
WHO, and TB burden estimates generated by WHO for
the Western Pacific Region, for the period 2000–2018.
Countries and areas report data on TB to WHO annually
via an electronic platform. The data are then verified
and published in WHO’s Global TB Reports, in which
WHO-generated estimates are also published. A full de-
scription of WHO’s data collection methods is available
in the Global TB Report 2019;1 the methods used to
estimate TB incidence and mortality are provided in an
online technical appendix.8 We used the definitions of
cases and treatment outcome given in the WHO report-
ing framework for TB.8 All data sets are available from
the WHO global TB database.4 In 2019, data for 2018
were reported to WHO by 35 countries and areas in the
Region, accounting for 99.9% of the regional population.

We reviewed trends in TB incidence and mortal-
ity, case notifications, indicators of collaborative TB/
HIV activities and treatment outcomes. In addition to
regional analyses, we also reviewed national data from
the seven countries with high burdens of TB in the
Region (Cambodia, China, the Lao People’s Democratic
Republic, Mongolia, Papua New Guinea, the Philippines
and Viet Nam), which have more than 95% of the Re-
gion’s cases.

The cascade of care for TB, drug-resistant TB
(DR-TB) and TB/HIV co-infection was assessed to iden-
tify and quantify gaps in care delivery. For DR-TB, the

WPSAR Vol 11, No 4, 2020 | doi: 10.5365/wpsar.2020.11.3.002https://ojs.wpro.who.int/ 3

Epidemiology of tuberculosis in the Western Pacific RegionMorishita et al

In 2018, six countries had an estimated TB incidence rate
of more than 300 cases per 100 000 population. The
highest incidence rate was recorded in the Philippines
(554 [range, 311–866] cases per 100 000), followed by
the Marshall Islands (434 [range, 332–549] cases per
100 000), Papua New Guinea (432 [range, 352–521]
cases per 100 000), Mongolia (428 [range, 220–703]
cases per 100 000), Kiribati (349 [267–441] cases per
100 000) and Cambodia (302 [range, 169–473] cases
per 100 000) (Fig. 3). Six countries and areas, American
Samoa, Australia, Cook Islands, New Zealand, Samoa
and Wallis and Futuna, had an estimated TB incidence
rate of <10 cases per 100 000 population in 2018.

TB case notifications

The number of case notifications in the Region rose
sharply between 2000 and 2007, mainly reflecting
increased reporting from China, but has since remained
stable, with 1 416 729 new and relapse cases noti-

The decreasing trends in TB incidence and mortal-
ity observed in the Region are broadly in line with global
trends and are driven mainly by improvements in TB
control in China. When data from China are excluded,
the estimated TB incidence rate in 2018 doubles to 196
(range, 121–292) cases per 100 000 population. The
estimated TB incidence rate was lower in the subregion
of the Pacific island countries than in other parts of the
Region, but there has been no decrease in incidence
since 2000, the rate ranging from 54 (range, 43–66)
per 100 000 population in 2002 to 75 (range, 58–94)
per 100 000 population in 2016.

The estimated incidence of TB varies widely among
countries in the Region (Fig. 2). In 2018, nearly 80% of
all estimated TB cases occurred in just two countries,
China (47% or 866 000 [range, 740 000–1 000 000]
cases) and the Philippines (32% or 591 000 [range,
332 000–924 000] cases). A further 9% (174 000
[range, 111 000–251 000] cases) occurred in Viet Nam.

Fig. 1. Trends in estimated TB incidence and total TB deaths at global and regional levels, 2000–2018

Global Western Pacific Region WPR without China Pacific island countries

2000 2009 2018 2000 2009 2018 2000 2009 2018 2000 2009 2018

100

200

300

In
ci

de
nc

e
ra

te
p

er
1

00
0

00
p

op
ul

at
io

Global Western Pacific Region WPR without China Pacific island countries

2000 2009 2018 2000 2009 2018 2000 2009 2018 2000 2009 2018

0.0

0.1

0.2

0.3

100

150

200

250

500

1000

1500

To
ta

l T
B

d
ea

th
s

(th
ou

sa
nd

Estimated incidence and numbers of deaths are shown in blue and those among HIV-positive people in red. The horizontal dashed lines show the 2020 milestones of
the End TB Strategy. Shaded areas represent uncertainty intervals. The grey solid lines show notifications of new and release TB cases for comparison with estimates
of the totl incidence rate.

WPR: Western Pacific Region.

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Morishita et alEpidemiology of tuberculosis in the Western Pacific Region

Fig. 2. Estimated TB incidence rates per 100 000 population in countries and areas in the Western Pacific
Region, 2018

© World Health Organization 2020. All rights reserved.
ASM: American Samoa, COK: Cook Islands, FJI: Fiji, FSM: Micronesia (Federated States of), GUM: Guam, KIR: Kiribati, MHL: Marshall Islands,
MNP: Northern Mariana Islands (Commonwealth of the), NCL: New Caledonia, NIU: Niue, NRU: Nauru, PLW: Palau, PYF: French Polynesia, SLB: Solomon Islands,
TKL: Tokelau, TON: Tonga, TUV: Tuvalu, VUT: Vanuatu, WLF: Wallis and Futuna, WSM: Samoa

ASM

COK

FJI

FSM

GUM

KIR

MHL

MNP

NCL
NIU

NRU

PLW

PYF

SLB TKL

TON

TUV

VUT
WLF WSM

Incidence rate per 100 000 population
0−19

20−69

70−119

120−399

400+

Not applicable

Fig. 3. Estimated numbers of incident TB cases and TB incidence rates per 100 000 population in countries
and areas in the Western Pacific Region, 2018

554

182

302

432

66
92

428

162

67
47

6.6

54
74

349

7.3

434

108

49
22

270

109

6.4 10

54
71

0 0
31

0
0

100

200

300

400

500

600

100

1000

10 000

100 000

1 000 000

E
st

im
at

ed
in

ci
de

nc
e

ra
te

p
er

1
00

0
00

p
op

ul
at

io
n

Number Rate per 100 000 population

E
st

im
at

ed
n

um
be

r
of

c
as

es
(l

og
s

ca
le

)

La
o P

eo
ple

’s
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cra

tic
R

ep
ub

lic

No
rth

er
n M

ar
ian

a I
sla

nd
s (

Co
mm

on
we

alt
h o

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e)

W
all

is
an

d F
utu

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Epidemiology of tuberculosis in the Western Pacific RegionMorishita et al

Drug-resistant TB

Between 2015 and 2018, the numbers of laboratory-
confirmed MDR/RR-TB cases and of patients enrolled
in second-line treatment increased by 50% and 47%,
respectively. During the same period, drug susceptibility
testing (DST) coverage of bacteriologically confirmed
cases rose from 28% in 2015 to 51% in 2018 but still
remains far below the 100% target.

China had the highest estimated number of MDR/
RR-TB cases (66 000 [range, 50 000–85 000]) in 2018,
followed by the Philippines (n = 18 000 [range, 7700–
32 000]), Viet Nam (n = 8600 [range, 5400–13 000]),
Papua New Guinea (n = 2000 [range, 1200–2900]),
the Republic of Korea (n = 1500 [range, 1300–1700]),
Cambodia (n = 1000 [range, 460–1900]), Mongolia
(n = 720 [range, 340–1200]), Japan (n = 510 [range,
220–930]), Malaysia (n = 480 [range, 360–620]) and
the Lao People’s Democratic Republic (n = 160 [range,
65–280]) (Fig. 5). These 10 countries accounted for

fied in 2018 (a case notification rate of 74 per 100
000 population) (Fig. 4a). Trends in case notification
from countries vary widely. During the past decade in
the seven focus countries, decreasing case notification
rates were observed in Cambodia, China and Mongolia,
and increasing rates were reported in the Lao People’s
Democratic Republic, Papua New Guinea and the Phil-
ippines (Fig. 4b).

In the Region, the highest TB notification rate was
for males aged ≥65 years (202 cases per 100 000
population), with a general tendency to higher case
notification rates for older age groups (Fig. 4c). The ex-
ceptions were Mongolia and Papua New Guinea, where
the proportions of younger people (0–24 years) among
total cases were still high (32% and 46%, respectively),
suggesting high rates of transmission in the general
community. The male-to-female ratio of TB cases was
high in adults (from 1.5 in those aged 15–24 years to
2.5 in those aged 45–54 years), with the largest differ-
ences being observed in older groups.

Fig. 4a and 4b show both total numbers of new and relapse cases and cases with an unknown TB treatment history. Fig. 4c presents total numbers of new and
relapse cases.

PDR, People’s Democratic Republic.

Fig. 4. Case notifications of all forms of TB in the Western Pacific Region and in the seven focus countries,
2000–2018

Cambodia China Lao PDR Mongolia Papua New Guinea Philippines Viet Nam Western Pacific Region

0
50

0
10

0
25

50
75

10
0

0
10

0
20

0
30

0
10

0
1

2
3

4
5

0
2

4
6

0
25

0
50

0
75

0
10

20
30

40
A

bs
ol

ut
e

nu
m

be
r (

th
ou

sa
nd

(4a) Number of TB cases notified, 2000−2018

Cambodia China Lao PDR Mongolia Papua New Guinea Philippines Viet Nam Western Pacific Region

2000 2009 2018 2000 2009 2018 2000 2009 2018 2000 2009 2018 2000 2009 2018 2000 2009 2018 2000 2009 2018 2000 2009 2018

10
0

20
0

30
0

R
at

e
pe

r 1
00

0
00

p
op

ul
at

io
n

(4b) TB case notification rate, 2000−2018

Cambodia China Lao PDR Mongolia Papua New Guinea Philippines Viet Nam Western Pacific Region

0−
14

15
−2
4

25
−3
4

35
−4
4

45
−5
4

55
−6
4

65
+

0−
14

15
−2
4

25
−3
4

35
−4
4

45
−5
4

55
−6
4

65
+

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−2
4

25
−3
4

35
−4
4

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−5
4

55
−6
4

65
+

0−
14

15
−2
4

25
−3
4

35
−4
4

45
−5
4

55
−6
4

65
+

0−
14

15
−2
4

25
−3
4

35
−4
4

45
−5
4

55
−6
4

65
+

0−
14

15
−2
4

25
−3
4

35
−4
4

45
−5
4

55
−6
4

65
+

0−
14

15
−2
4

25
−3
4

35
−4
4

45
−5
4

55
−6
4

65
+

0−
14

15
−2
4

25
−3
4

35
−4
4

45
−5
4

55
−6
4

65
+

0
50

10
0

15
0

20
0

0
10

0
20

0
30

0
40

0
50

0
1,

00
0

1,
50

0
10

0
20

0
30

0
40

0
50

10
0

15
0

20
0

0
20

0
40

0
60

0
50

10
0

15
0

0
25

0
50

0
75

0
R

at
e

pe
r 1

00
0

00
p

op
ul

at
io

Female Male(4c) Age- and sex-specific TB case notification rate, 2018

WPSAR Vol 11, No 4, 2020 | doi: 10.5365/wpsar.2020.11.3.002 https://ojs.wpro.who.int/6

Morishita et alEpidemiology of tuberculosis in the Western Pacific Region

is also below the 100% target and does not include
delays in initiation, as many countries still do not meet
this reporting requirement. Coverage of TB preventive
treatment (TPT) in PLHIV remains at <50% (based on
reports from only eight countries).

Treatment outcomes

A TB treatment success rate (new and relapse cases)
of >90% has been maintained at regional level for over
a decade (Fig. 7). The rate is due mainly to high treat-
ment success rates in a few countries with large TB
caseloads, including China (93%) and Viet Nam (92%),
which tends to hide poor rates in many smaller coun-
tries. Overall, 20 of 32 reporting countries and areas
(>60%) had treatment success rates of <85%, and
success rates of <70% were reported by countries and
areas such as Hong Kong SAR (China) and Japan, where
TB predominantly affects the elderly, but also in some
Pacific island countries such as Papua New Guinea and
Tuvalu, which have younger populations. The treatment
outcomes of patients with TB/HIV co-infection and
MDR/RR-TB remain suboptimal in most countries and

more than 99% of the total estimated MDR/RR-TB case
load in 2018 (n = 99 000). Importantly, case detection
rates remained low in all these countries, ranging from
13% in Cambodia to 52% in the Republic of Korea.
The rates of enrolment in treatment after diagnosis were
excellent in Cambodia (100%), the Republic of Korea
(100%) and Viet Nam (99%) but suboptimal in China
(61%), Japan (63%) and Malaysia (71%).

Indicators of collaborative TB/HIV activities

Key indicators for TB-HIV care and collaborative activi-
ties have improved over time (Fig. 6). The proportion
of TB cases with known HIV status increased substan-
tially, from 12% in 2009 to 54% in 2018, although the
proportion remains well below the target of 100% and
the global average of 64%. The HIV prevalence among
tested TB cases fell from a high of 13% in 2006 to
<3% in 2016, which has been maintained, reflecting
more comprehensive screening. The proportion of TB/
HIV co-infected patients receiving antiretroviral therapy
(ART) has increased over time, reaching 84% in 2018
(based on reporting from 13 countries); however, this

Fig. 5. Estimated numbers of MDR/RR-TB incidence and detection and treatment enrolment rates for MDR/
RR-TB in the 10 most-affected countries in the Western Pacific Region, 2018

66 000 18 000 8600 2000 1500 1000 720 510 480 160

22%

40%
36%

22%

52%

13%

23%
18%

40%

33%

61%

82%

99%

83%

100% 100%

63%

71%

85%

20%

40%

60%

80%

100%

20 000

40 000

60 000

80 000

China Philippines Viet Nam Papua New
Guinea

Republic of
Korea

Cambodia Mongolia Japan Malaysia Lao PDR

D
et

ec
tio

n
an

d
en

ro
lm

en
t

ra
te

s
(%

)

E
st

im
at

ed
n

um
be

r o
f R

R
/M

D
R

-T
B

c
as

Estimated RR/MDR-TB Detection rate (%) Enrolment rate (%)

“Case detection rate” is defined as the number of laboratory-confirmed MDR/RR-TB cases divided by the estimated number of incident MDR/RR-TB cases. “Treat-
ment enrolment rate” is defined as the number of cases enrolled in second-line treatment divided by the number of laboratory-confirmed cases.

PDR, People’s Democratic Republic.

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Epidemiology of tuberculosis in the Western Pacific RegionMorishita et al

Fig. 6. Trends in key indicators of collaborative TB/HIV activities in the Western Pacific Region, 2003–2018

Fig. 7. Trends in TB treatment success rates for different patient categories in the Western Pacific Region,
2000–2017

ART: antiretroviral therapy; TB: tuberculosis; TPT: TB preventive treatment.

TPT: TB preventive treatment

“Known HIV status” is calculated as the number of patients with new and relapse TB patients and documented HIV status divided by the number of patients with
new and relapse TB notified in the same year, expressed as a percentage. “HIV prevalence in TB patients” is the proportion of TB patients tested for HIV whose
results were positive.

As treatment outcomes for cases of drug-susceptible TB are reported to WHO 1 year after notification, data for 2017 were the latest available at the time this
report was written.

As treatment outcomes for cases of MDR/RR-TB and extensively drug-resistant (XDR) TB are reported to WHO 2 years after notification, data for 2017 were
not available at the time this report was written.

Known HIV status HIV prevalence in TB patients ART coverage in TB/HIV patients TPT coverage in HIV-positive people

2003 2006 2009 2012 2015 20182003 2006 2009 2012 2015 20182003 2006 2009 2012 2015 20182003 2006 2009 2012 2015 2018

100

P
er

ce
nt

ag
e

(%
)

100

2000 2005 2010 2015

P
er

ce
nt

ag
e

(%
)

New and relapse
Retreatment, excluding relapse
HIV−positive
MDR/RR−TB
XDR−TB

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Morishita et alEpidemiology of tuberculosis in the Western Pacific Region

confirmed case of pulmonary TB was estimated to be
very low (12%) from data for 14 countries.

Patient costs due to TB

Eight countries in the Region have conducted national
TB patient cost surveys and have established a baseline
from which to monitor progress towards elimination of
catastrophic costs due to TB. In the surveys, 35–70% of
TB-affected families reported facing catastrophic costs.

Proposed “top-10” indicator scorecard

Table 1 represents a proposed colour-coded score-
card of the “top-10” TB indicators of programme
performance towards the End TB Strategy targets. In
2018, treatment coverage remained low (<60%) in
some countries with a high TB burden (Cambodia,
Lao People’s Democratic Republic, Mongolia and Viet
Nam), and low treatment success rates were reported in
Japan (68%), Hong Kong SAR (China) (65%) and some
Pacific island countries, including Papua New Guinea
(68%) and Tuvalu (68%). The proportion of TB patients
tested with a WHO-recommended rapid diagnostic test
(molecular techniques to detect TB among people with
signs or symptoms of TB, such as Xpert MTB/RIF®) at
the time of diagnosis remained low in many countries
(11 countries reported <60%). DST coverage was
extremely low (<5% of bacteriologically confirmed TB
cases) in Cambodia, the Philippines, Papua New Guinea
and Solomon Islands, while many with successful Xpert
MTB/RIF® roll-out programmes reported high coverage.

at regional level (Fig. 8), the proportions being 79% and
59%, respectively, in 2018 (reflecting the 2017 and the
2016 patient cohorts, respectively).

TB care cascade

Fig. 9 shows gaps in the cascade of care for TB, DR-TB
and TB/HIV co-infection in the Western Pacific Region.
Of an estimated 1.8 million (range, 1.5–2.2 million)
incident cases of TB in 2018, 5.4% (n = 99 228)
were estimated to be MDR/RR-TB and 2.2% (n = 40
638) to be co-infected with HIV. Gaps in the TB care
cascade in the Region remain substantial, especially for
DR-TB and TB/HIV. Treatment coverage was relatively
high for TB, at 77.2% (range, 64.9–93.4%), but low for
TB/HIV co-infection (38.9%, range [29.6–53.6%]) and
MDR/RR-TB (27.2%, range [19.3–40.2%]). Major gaps
between the numbers of notified and confirmed MDR/
RR-TB cases and patients enrolled in second-line TB
treatment and in initiation of ART among HIV-positive
TB patients are of particular concern. The proportions
of estimated incident TB cases successfully treated for
TB, MDR/RR-TB and TB/HIV co-infection were 66.4%,
8.6% and 23.7%, respectively.

TB prevention

TPT coverage among PLHIV remained low, at 39%,
in 2018. This figure is based on reports from eight
countries, and coverage in non-reporting countries may
be even lower. TPT coverage of children under 5 years
who were household contacts of a bacteriologically

Fig. 8. TB treatment outcomes by patient category in the Western Pacific Region, 2018

XDR−TB

MDR/RR−TB

New and relapse HIV−positive TB

Retreatment, excluding relapse

New and relapse TB

0 25 50 75 100
Percentage (%)

Not evaluated

Lost to follow−up

Died

Failure

Treatment success

Data from 2016 were used for MDR/RR-TB and XDR-TB and from 2017 for the other types of TB.

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Epidemiology of tuberculosis in the Western Pacific RegionMorishita et al

from 1351 in 2015 to 1998 sites in 2018, based on
reports from 15 countries and areas.4 Increased case
notification rates were reported in several high-burden
countries (Lao People’s Democratic Republic, Papua
New Guinea and Philippines), which may reflect intensi-
fied case detection in these countries. Careful monitor-
ing will be necessary to ensure that the numbers do
not decrease over time. The same observation applies
to Pacific island nations, such as the Marshall Islands,
where active case finding projects may transiently in-
crease the case numbers; if the projects are successful,
they should be followed by drastic reductions in case
numbers.

Between 2015 and 2019, total funding, both
domestic and international, for TB in countries and
areas of the Region increased by 67%, from US$ 504
million to US$ 843 million, although the funding gap
remains large at US$ 249 million (23%).3,4 Indications
of increased resource allocation and service provision
are encouraging, as they may reflect increased political
commitment from governments in the Region.

Overall progress in reducing the TB burden in the
Western Pacific Region is slow, as little progress has

Despite a long-standing policy to test all TB patients for
HIV infection, the proportion of TB patients of known
HIV status remained low in many countries. The case
fatality ratios were high in Japan (16%), Lao People’s
Democratic Republic (22%), Papua New Guinea (13%)
and Vanuatu (17%). Contact investigation coverage
and treatment coverage for new drugs were among the
“top-10” TB indicators; however, data are not available.
The 2020 End TB Strategy milestones of reduced TB
incidence rate and deaths were achieved by 2018 by
only 19% (7/36) and 11% (4/36) of the countries in the
Region, respectively.

DISCUSSION

This epidemiological analysis shows regional progress
over time in certain programmatic areas, including sus-
tained, good treatment outcomes, improvements in TB/
HIV indicators and improved case detection and enrol-
ment of MDR/RR-TB cases. Programmes should continue
to extend diagnosis and case finding, enhance service
quality and increase resources for TB programmes.

The number of sites in the Region that provide TB
diagnoses with Xpert MTB/RIF® increased by 48%,

Fig. 9. Key gaps in the cascade of care for TB, MDR/RR-TB and TB/HIV co-infection in the Western Pacific
Region, 2018

Data for 2017 were used for successfully treated cases of TB and TB/HIV co-infection and data for 2016 for successfully treated cases of MDR/RR-TB.

●●

100% 77.2% 66.4%
0

500K

1.5M

Estimated
incidence

Notified Successfully
treated

●●

100% 27.2% 20% 8.6%
0

25K

50K

75K

100K

125K

Estimated
incidence

Lab−
confirmed

Enrolled in
treatment

Successfully
treated

MDR/RR−TB

●●

100% 38.9% 32.4% 23.7%
0

10K

20K

30K

40K

50K

Estimated
incidence

Notified Enrolled in
ART

Successfully
treated

TB/HIV

WPSAR Vol 11, No 4, 2020 | doi: 10.5365/wpsar.2020.11.3.002 https://ojs.wpro.who.int/10

Morishita et alEpidemiology of tuberculosis in the Western Pacific Region

Our analyses signal several challenges for the
Region: (1) wide variation among countries in the
geographical distribution and incidence of TB, including
the fact that TB continues to largely affect younger age
groups in several countries; (2) a sizeable proportion of
TB cases remain unreached, undiagnosed or unreported;
(3) insufficient coverage of DST and use of WHO-
recommended rapid diagnostic tests; (4) suboptimal
TB treatment success rates in some countries and poor

been made in some countries. In 2018, the TB inci-
dence rate was 96 per 100 000 population, whereas
the 2020 milestone is 79 per 100 000 population, and
an estimated 97 000 deaths from TB occurred, whereas
the 2020 milestone is 70 200. In view of the current
annual reductions in the TB incidence rate (1.0%) and
the number of deaths (3.4%), the Region is unlikely to
achieve the 2020 milestones and other targets of the
End TB Strategy.

Table 1. Proposed scorecard for assessing the “top-10” indicators for monitoring implementation of the End TB
Strategy in the Western Pacific Region

Treatment
coverage

Treatment
success rate

TB‐affected
households with
catastrophic costs

due to TB

TB patients
tested using
WRD at
diagnosis

LTBI
treatment
coverage
(PLHIV)

LTBI treatment
coverage

(Child contact)

DST coverage
for TB
patients

Documentation
of HIV status

Case fatality
ratio

Estimated
incidence

rate

Estimated
deaths

Recommendeed Target† ≥90% ≥90% 0% ≥90% ≥90% ≥90% 100% 100% ≤5% ‐20% ‐35%

American Samoa* 80 100
Australia 87 82 93 88 3 10 ‐3
Brunei Darussalam* 87 75 0 0 100 100 6 15 ‐4
China 92 93 15 63 60 5 ‐6 ‐5
Cook Islands*
Fiji* 80 81 40 95 100 109 89 9 4 11
Micronesia (Federated States of)* 80 88 86 0 11 ‐10 ‐7
Guam* 87 89 69 100 96 8 ‐9 ‐7
China, Hong Kong SAR 87 65 32 11 91 78 3 ‐7 ‐13
Japan 87 68 62 74 8.3 16 ‐14 ‐8
Cambodia 58 94 0 94 7 ‐18 ‐9
Kiribati* 80 89 50 100 51 11 ‐38 1
Republic of Korea 94 83 26 60 84 7 ‐17 ‐9
Lao People's Democratic Republic 57 89 63 63 18 52 81 22 ‐11 ‐33
China, Macao SAR* 87 82 68 20 99 92 8 ‐16 ‐12
Marshall Islands* 170 83 77 100 22 11 45 47
Mongolia 29 91 70 39 0 7.4 79 70 3 0 ‐1
Northern Mariana Islands (Commonwealth of the)* 87 98 32 100 100 8 65 64
Malaysia 87 81 38 88 78 82 5 3 1
New Caledonia* 87 35 5.4 100 30 8 ‐36 ‐34
Niue* 87 0 8
Nauru* 87 78 0 0 8 ‐51 ‐50
New Zealand* 87 82 100 0 0.3 4 1 3
Philippines 63 91 35 36 52 9.4 4 27 5 1 ‐8
Palau* 87 80 88 100 94 8 20 21
Papua New Guinea 75 68 54 21 27 0 55 13 0 12
French Polynesia* 87 81 63 100 85 8 15 17
Singapore 87 79 60 0 100 98 89 2 5 ‐11
Solomon Islands* 80 92 27 0 28 11 ‐14 ‐7
Tokelau* 11 ‐85 ‐84
Tonga* 87 82 89 100 100 8 ‐37 ‐36
Tuvalu* 87 68 74 89 100 8 30 35
Viet Nam 57 92 63 20 39 22 84 85 8 ‐9 ‐24
Vanuatu* 67 96 46 100 69 17 ‐27 17
Wallis and Futuna*
Samoa* 87 57 0 0 100 8 ‐43 ‐42
Cutoff values for colour code
Green ≥85 ≥85 ≤29 ≥80 ≥70 ≥70 ≥80 ≥85 ≤5 < 0 < 0
Yellow 60‐84 75‐84 30‐59 60‐79 50‐69 50‐69 60‐79 75‐84 6‐9 0‐5 0‐5
Red ≤59 ≤74 ≥60 ≤59 ≤49 ≤49 ≤59 ≤74 ≥10 ≥6 ≥6

Top Indicators (%) % Change from 2015

† The target levels are for 2025 for the “Top indicators” and for 2020 for “% change from 2015” of estimated incidence and deaths. Targets for contact investigation
coverage and treatment coverage for new TB drugs, which are included in the top 10 indicators, are not available in the WHO Global TB database. Detailed defini-
tions of each indicator are provided in the Global TB Report 2019, p. 15.1

* Countries estimated to have fewer than 1000 cases, where the percentage change in estimated incidence and deaths may not reflect true trends because of pos-
sible large fluctuations.

Pitcairn Islands is excluded from annual collection of data on TB.

DST: drug susceptibility testing; LTBI: latent tuberculosis infection; PLHIV: people living with HIV;

TB: tuberculosis; WRD: WHO-recommended rapid diagnostic test.

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Epidemiology of tuberculosis in the Western Pacific RegionMorishita et al

including Cambodia, China, the Lao People’s Democratic
Republic, Mongolia and Papua New Guinea.14 In the
Philippines, over-reliance on chest X-ray for diagnosis
resulted in increased case notifications of clinically diag-
nosed TB in the 2010s. Subsequently, the introduction
of a mandatory TB notification policy increased reporting
from the private sector, resulting in a sharp rise in case
notifications in 2018, although a national survey demon-
strated many unidentified cases. (Epidemiological review
for tuberculosis in the Philippines. 2019, unpublished).
The recent increase in TB case notifications in the Lao
People’s Democratic Republic can be attributed to intensi-
fied case-finding among high-risk populations (Epidemio-
logical review for tuberculosis in Lao People’s Democratic
Republic. 2019, unpublished), and a decrease in case
notifications in Cambodia is probably attributable to re-
duced community-based case-finding activities because
of reduced external funding (Epidemiological review for
tuberculosis in Cambodia. 2019, unpublished). Trends in
case notification should therefore be considered carefully
in relation to any major programmatic changes. In most
instances, an emphasis on “finding missing cases” is
appropriate. Furthermore, given the geographical varia-
tion in TB epidemiology within a country, monitoring and
evaluation should be strengthened at subnational level
to ensure better-targeted interventions guided by data.15

Accurate diagnosis is a fundamental component
of TB care. Rapid molecular diagnostics ensure early
detection and prompt treatment, while testing for drug
resistance is essential to ensure appropriate treatment.1
As part of TB laboratory-strengthening in the End TB
Strategy, countries are encouraged to adopt a policy to
use a WHO-recommended rapid diagnostic test as the
initial test for all people with presumptive TB and to
provide universal access to DST for patients with bac-
teriologically confirmed TB.1 In the Region in 2018, only
25% of countries and areas (n = 9/36) had a policy to
use a WHO-recommended rapid test at diagnosis, and
only 39% (n = 14/36) had a policy of universal access
to DST.4 This explains the insufficient DST coverage
and use of WHO-recommended rapid diagnostic tests
that we observed. Adoption and implementation of such
policies requires substantial investment, with sustainable
financing for TB laboratory services. This remains a major
challenge, but successful examples exist in other parts of
the world16 to guide implementation. In-depth analysis
of national networks for TB diagnosis and specimen
transport to understand the levels of underutilization or

treatment outcomes for PLHIV and patients with DR-TB;
(5) limited TPT coverage of PLHIV and child contacts;
and (6) a substantial proportion of TB-affected families
facing catastrophic costs.

The wide variation in TB epidemiology and con-
textual factors among countries poses a challenge for
mounting a coordinated regional TB response. In coun-
tries with a low TB burden, such as Australia and New
Zealand, >80% of the cases notified are in foreign-born
individuals, and TB is essentially an imported disease.4
In countries and areas with ageing populations, such
as Japan and the Republic of Korea, TB occurs mainly
in the elderly, people aged ≥65 years accounting for
66.7% of total case notifications in Japan, 45.4% in
the Republic of Korea and 43.7% in Hong Kong SAR
(China) in 2018.4 In lower-income high-burden coun-
tries, undernutrition is considered a major risk factor for
TB,1 and high rates of cigarette smoking may contribute
to over-representation of TB in men.9 In Pacific island
countries, diabetes is highly prevalent and considered a
major driver of the TB epidemic.10,11 Understanding of
population-level risk factors for TB by analysis of routine
surveillance data, survey results and facility records is
important in order to design targeted interventions. The
Western Pacific Region therefore requires a tailored
regional strategy to guide the response in various
epidemiological and contextual settings, including for
small Pacific island countries with unique geographical
challenges and high TB incidence rates per capita, such
as Kiribati, Marshall Islands and Tuvalu.

TB case notifications are affected by many factors,
and careful analysis and interpretation are required to
understand the strengths and weaknesses of national TB
programmes. Interventions such as community-based
active case finding, facility-based systematic screening,
increased use of sensitive screening and diagnostic tools
and algorithms, improved referral mechanisms and speci-
men transport, engagement of private and other health
sectors and mandatory notification policies can increase
case notifications.12,13 Although decreasing numbers of
case notifications may represent a true decrease in TB
incidence, they may be due to decreased case finding or
reduced TB programme funding and functioning.12 In the
Region, significant funding for TB is provided by the Global
Fund to Fight AIDS, Tuberculosis and Malaria. Over time,
such funding has supported expansion of TB services and
improved TB surveillance in many high-burden countries,

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Morishita et alEpidemiology of tuberculosis in the Western Pacific Region

4 million children under 5 years who are household
contacts of people affected by TB and 20 million other
household contacts of TB cases.1 At the current rate
of treatment enrolment, the world will not reach the
target for household contacts, and, in May 2020, global
TB partners released a joint call to action to scale up
access to TPT.22 In view of the low coverage of TPT
in the Region, rapid adoption and implementation of
the recently published TPT guidelines23 is critical. In
particular, a systems approach is necessary to make
contact investigation and TPT integral parts of primary
health care services as an essential public health func-
tion.24

TB patients continue to bear a heavy financial
burden, despite the provision of free TB services in
most countries in the Region. National surveys of the
cost of TB patients have provided solid evidence that
TB-affected families face severe financial hardship,
non-medical costs and income loss due to TB are major
components, poor households get poorer due to TB and
loss of jobs, and households of patients with DR-TB and
TB/HIV co-infection face significantly higher costs.1,25
These results are powerful arguments for initiating policy
dialogue with other programmes and sectors and as a
basis for policies and strategies to optimize health care
delivery and financing and increase social protection for
TB patients.1

This analysis has several limitations. First, data for
several indicators, such as TPT and DST coverage, were
not complete, and therefore the regional averages are
not always from all countries. Second, regional averages
of the indicators and estimated burden are driven largely
by the numbers recorded in China and the Philippines,
where the numbers of cases are relatively large; there-
fore, the findings must be interpreted carefully. Third,
the number and proportion of successfully treated
patients used in the analysis of the care cascade were
for patient cohorts in previous years (2017 for TB and
TB/HIV, 2016 for DR-TB); therefore, the gaps calculated
for 2018 may not be accurate, although we believe
them to be very close approximations of the complete
data set. Finally, in countries and areas with few cases,
the percentage changes in estimated incidence and
mortality shown on the scorecard may not reflect true
trends because of possible large fluctuations. Despite
these limitations, our analysis provides comprehensive,
useful insights into the regional TB situation based on

access to existing diagnostic tools and investigation of
opportunities for collaboration with other public health
programmes and the private sector could pave the way
for a massive roll-out of WHO-recommended rapid diag-
nostic tests and expanded DST. This will be essential to
close the gap in case detection and improve treatment
outcomes for patients with MDR/RR-TB. It could also re-
duce MDR/RR-TB transmission by prompt initiation of ef-
fective treatment. Estimating longer-term population-level
benefits of such policies could convince policy-makers to
take action.

Treatment outcomes remain a challenge in many
countries in the Region, particularly for patients with DR-
TB and TB/HIV co-infection. WHO recommends a wide
range of interventions to facilitate early diagnosis and
optimal treatment, including screening of PLHIV for TB,
early initiation of ART, better infection control, provision
of TPT, wider use of more effective MDR-TB treatment
regimens, active TB drug-safety monitoring and manage-
ment and more patient-centred models of care.1 Digital
technologies to support adherence to TB medication are
becoming increasingly available.17 Assessing and ad-
dressing gaps in such interventions and promoting the
uptake of new tools and innovations should help to im-
prove treatment outcomes. Furthermore, risk groups and
geographical areas in which poor treatment outcomes are
reported should be identified to guide the most appropri-
ate targeted responses. Generally, treatment outcomes
vary by geographical areas according to the local TB
epidemiology and response.18 (Epidemiological review
for tuberculosis in the Philippines. 2019, unpublished;
Epidemiological review for tuberculosis in Lao People’s
Democratic Republic. 2019, unpublished). In Japan, the
overall treatment success rate is low mainly because of a
high mortality rate among the elderly, the population most
affected by TB.19 Other countries in which the population
is ageing rapidly and the proportion of TB cases among
the elderly is increasing may face a similar challenge in
the future.20 Global and regional TB programmes should
be ready to address the issue of TB among the elderly
on the basis of evidence-based guidance and effective
interventions.21

TPT is an essential intervention for achieving the
goals of the End TB Strategy. The first United Nations
high-level meeting on TB, held in 2018, set a new global
target, to provide TPT to at least 30 million people in
the period 2018–2022, comprising 6 million PLHIV,

WPSAR Vol 11, No 4, 2020 | doi: 10.5365/wpsar.2020.11.3.002https://ojs.wpro.who.int/ 13

Epidemiology of tuberculosis in the Western Pacific RegionMorishita et al

4. Global tuberculosis database. Geneva: World Health Organization;
2020. Available from: https://www.who.int/tb/country/data/down-
load/en/.

5. Glaziou P. Predicted impact of the COVID-19 pandemic on global
tuberculosis deaths in 2020. medRxiv. doi:10.1101/2020.04.28.
20079582.

6. Regional framework for action on implementation of the End
TB Strategy in the Western Pacific, 2016–2020. Manila: World
Health Organization Regional Office for the Western Pacific;
2016. Available from: https://iris.wpro.who.int/bitstream/han-
dle/10665.1/13131/9789290617556_eng.pdf.

7. Rahevar K, Fujiwara PI, Ahmadova S, Morishita F, Reichman LB.
Implementing the End TB Strategy in the Western Pacific Region:
Translating vision into reality. Respirology. 2018;23(8):735–
42.

8. Definitions and reporting framework for tuberculosis – 2013 revi-
sion (updated December 2014 and January 2020). Geneva: World
Health Organization; 2013. Available from: https://apps.who.int/
iris/bitstream/handle/10665/79199/9789241505345_eng.
pdf?sequence=1.

9. Marais BJ, Lönnroth K, Lawn SD, Migliori GB, Mwaba P, Glaziou
P, et al. Tuberculosis comorbidity with communicable and non-
communicable diseases: integrating health services and control
efforts. Lancet Infect Dis. 2013;13(5):436–48.

10. Trinidad RM, Brostrom R, Morello MI, Montgomery D, Thein CC,
Gajitos ML, et al. Tuberculosis screening at a diabetes clinic in the
Republic of the Marshall Islands. J Clin Tuberc Other Mycobact
Dis. 2016;5:4–7.

11. Viney K, Cavanaugh J, Kienene T, Harley D, Kelly PM, Sleigh A,
et al. Tuberculosis and diabetes mellitus in the Republic of
Kiribati: a case–control study. Trop Med Int Health.
2015;20(5):650–7.

12. Understanding and using tuberculosis data. Geneva: World Health
Organization; 2014. Available from: https://apps.who.int/iris/bit-
stream/handle/10665/129942/9789241548786_eng.pdf;jse
ssionid=A3E2F29EE3F8C50C70DC7D24AC58A7BD?sequen
ce=1.

13. Systematic screening for active tuberculosis; principles
and recommendations. Geneva: World Health Organiza-
tion; 2013. Available from: https://apps.who.int/iris/bit-
s t r e a m / h a n d l e / 10 6 6 5 / 8 4 9 71 / 9 7 8 9 2415 4 8 6 01 _ e n g .
pdf?sequence=1.

14. TheGlobalFund data explorer. Geneva: Global Fund to Fight AIDS,
Tuberculosis and Malaria; 2020. Available from: https://data.the-
globalfund.org/investments/home.

15. Nishikiori N, Morishita F. Using tuberculosis surveillance data for
informed programmatic decision-making. West Pac Surveill Re-
sponse. 2013;4(1):1–3.

16. Rehm M, de Melo Freitas M, van der Land J. Optimizing and un-
derstanding the use of Xpert MTB/RIF® testing (Challenge TB
Technical Brief). Washington, DC: United States Agency for In-
ternational Development; 2019. Available from: https://www.chal-
lengetb.org/publications/tools/briefs/CTB_Technical_Brief_GeneX-
pert.pdf.

17. Handbook for the use of digital technologies to support tuber-
culosis medication adherence [Internet]. Geneva: World Health
Organization; 2017. Available from: https://apps.who.int/iris/
bit stre am / handle /10665/2598 32 /9789241513456 - eng.
pdf?sequence=1.

several years of data reported according to adopted,
well-established case definitions from nearly all the
countries in the Region.

If the Region is to achieve the End TB Strategy targets
beyond the interim 2020 milestones, it must overcome
several challenges. Some of these challenges lie outside
national TB programmes and even the health sector, requir-
ing a multisectoral response.3 In addition, the COVID-19
pandemic has disrupted health services worldwide and
poses a considerable challenge for TB programmes and
for TB patients; however, it also provides an opportunity to
increase investment in health and to promote multisectoral
responses to health system transformation, from which the
TB programme can benefit and to which it can contribute.
The WHO Regional Office for the Western Pacific will
continue to provide data-driven, evidence-based regional
guidance and will support Member States on their journey
towards ending TB.

Acknowledgements

The authors wish to thank the national TB programmes
in the countries and areas of the Western Pacific Region.
They are grateful to everyone involved in collecting and
validating data and estimating burden, particularly WHO
staff in the TB Monitoring and Evaluation team of the
Global TB Programme at WHO headquarters and WHO
country offices in the Western Pacific Region.

Conflicts of interests

The authors have no conflict of interests.

Funding

None.

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