3.4 Drug-resistant TB treatment
Treatment for people diagnosed with rifampicin-resistant TB (RR-TB), isoniazid-resistant TB and multidrug-resistant TB (MDR-TB, defined as resistance to isoniazid and rifampicin) requires regimens that include second-line drugs, such as bedaquiline and fluoroquinolones; these regimens are more expensive (≥US$ 1000 per person) and cause more side-effects than first-line treatments for drug-susceptible TB (1). Pre-extensively drug-resistant TB (pre-XDR-TB, defined as TB that is resistant to rifampicin and any fluoroquinolone) and XDR-TB (resistance to rifampicin, any fluoroquinolone and at least one of bedaquiline or linezolid) are even harder to treat.
Globally in 2021, 161 746 people were enrolled on treatment for MDR/RR-TB, a small increase of 7.5% from 150 469 in 2020 but still below 181 533 in 2019. Most of those enrolled on treatment were adults (Fig. 3.4.1).
Fig. 3.4.1 The global number of people reported to have been enrolled on treatment for MDR/RR-TB, 2015–2021
Trends in treatment enrolment between 2009 (the first year for which WHO collected data from all countries) and 2021 vary considerably by country (Fig.
3.4.2).
Fig. 3.4.2 Number of people diagnosed with MDR/RR-TB (blue) and enrolled on MDR-TB treatment (red), 2010–2021, 30 high MDR-TB burden countries
The cumulative total number of people reported as enrolled on treatment for MDR/RR-TB from 2018 to 2021 was 648 953, only 43% of the 5-year target (2018-2022) of 1.5 million that was set at the UN high-level meeting on TB in 2018. For children
specifically, the cumulative number was 17 715, only 15% of the 5-year target of 115 000.
Fig. 3.4.3 Global progress in the number of people treated for MDR/RR-TB between 2018 and 2021, compared with cumulative targets set for 2018–2022 at the UN high-level meeting on TB
The numbers of people being detected with MDR/RR-TB and enrolled on treatment fall far short of the estimated number of people developing MDR/RR-TB (incident cases) each year (Fig. 3.4.4).
Closing the gap requires improvements in overall detection of people with TB (Section 3.3), improvements in the percentage of those diagnosed with TB who were bacteriologically confirmed
(necessary to test for drug resistance) and improvements in the coverage of testing for RR-TB (Section 3.2).
Fig. 3.4.4 Number of people diagnosed with MDR/RR-TB (blue) and number enrolled on MDR/RR-TB treatment (red), compared with estimates of the number of incident cases of MDR/RR-TB (95% uncertainty interval shown in green), 2015–2021, globally and for WHO regions
Estimated levels of treatment coverage in 2021 i.e. the number of people enrolled on treatment for MDR-TB in 2021 as a percentage of the estimated number of people who developed MDR/RR-TB (incident cases) remain low (Fig.
3.4.5). The WHO regions with the best treatment coverage are the European Region and the Region of the Americas .Among the 30 high MDR/RR-TB burden countries, those with the best treatment coverage are 2021:Azerbaijan, Kazakhstan, the Russian
Federation, Peru, the Republic of Moldova, Uzbekistan, Belarus, Ukraine and India. Those with worrying low levels include Mongolia and Pakistan.
Fig. 3.4.5 Estimated treatment coverage for MDR/RR-TBa in 2021, 30 high MDR-TB burden countries,b WHO regions and globally
b Incidence estimates for India are interim and subject to finalization, in consultation with the Health Ministry & Family Welfare, India.
There are 10 countries that account for 72% of the global gap between the estimated number of people who developed MDR/RR-TB in 2021 and the number of people enrolled on treatment for MDR/RR-TB (Fig. 3.4.6).
Fig. 3.4.6 The ten countries with the largest gaps between the number of people started on treatment for MDR-TB and the best estimates of MDR/RR-TB incidence, a 2021
Globally in 2019 (the latest patient cohort for which data are available), the treatment success rate for people treated for MDR/RR-TB with second-line regimens was 60%; a further improvement from 59% and up from 50% in 2012 (Fig.
3.4.7).
Fig. 3.4.7 Treatment outcomes for people diagnosed with MDR/RR-TB globally, 2012–2019
Among WHO regions, the treatment success rate in 2019 was lowest in the European Region and highest in the Eastern Mediterranean Region (Fig.
3.4.8).
Fig. 3.4.8 Treatment outcomes for people diagnosed with MDR/RR-TB who were started on treatment in 2019, WHO regions and globally
By the end of 2021, 124 countries were using bedaquiline as part of treatment for drug-resistant TB (Fig. 3.4.9), up from 110 in 2020 and 22 in 2013.
Fig. 3.4.9 Countries that used bedaquiline for the treatment of MDR, pre-XDR-TB, and XDR-TB as part of expanded access, compassionate use or under normal programmatic conditions by the end of 2021
By the end of 2021, 109 countries were using all-oral longer regimens for the treatment of MDR/RR-TB (Fig. 3.4.10). This was an increase from 92 in 2020 and 86 in 2019.
Fig. 3.4.10 Countries that used all-oral longer MDR-TB treatment regimens by the end of 2021
By the end of 2021, 92 countries were using shorter regimens for the treatment of MDR/RR-TB (Fig. 3.4.11), up from 65 in 2020.
Fig. 3.4.11 Countries that used all-oral shorter MDR-TB treatment regimens by the end of 2021
In 2021, at least some people diagnosed with DR-TB were being monitored for adverse events in most countries (Fig. 3.4.12).
Fig. 3.4.12 Number of patients with active follow up of adverse events as a proportion of patients enrolled on treatment for drug-resistant TB, 2021
Country-specific details about treatment for drug-resistant TB are available in the Global tuberculosis report app and country profiles.
Data shown on this webpage are as of 29 August 2022 (see Annex 2 of the main report for more details).
Note: Figure 3.4.6 was updated (Philippines and Viet Nam replaced Afghanistan and Ukraine) on 8 December 2022 after fixing a data source error.
References
WHO consolidated guidelines on tuberculosis, Module 4: Treatment - drug-resistant tuberculosis treatment. Geneva: World Health Organization; 2020 (https://covid.comesa.int/publications/i/item/9789240007048).