Ending Tuberculosis (TB) in South-East (SE) Asia Region – WHO

Disclaimer: This post is for academic purposes only. Please read the original document if you intend to use them for clinical purposes.

South-East (SE) Asia Region of WHO, accounting for over 45% of the global TB burden in 2023, is at a critical juncture in its fight against the epidemic. The year 2025 serves as a milestone for the WHO End TB Strategy, yet the region is significantly off track to meet its targets. Between 2015 and 2023, TB incidence declined by a mere 6.7% against a 50% milestone, while TB deaths fell by only 11% against a 75% milestone. Furthermore, catastrophic costs continue to afflict 30% to 80% of TB-affected households, far from the goal of zero. The 2023 United Nations High-Level Meeting (UNHLM) on TB has injected new urgency, setting ambitious targets for 2023–2027, including treating 45 million people, providing TB preventive treatment (TPT) to 45 million high-risk individuals, and mobilizing US$ 22 billion in annual funding. However, achieving these goals is imperiled by persistent, systemic challenges.Key obstacles include suboptimal disease detection, Drug-resistant TB (DR-TB), Childhood TB, scale-up of TPT being critically low, insufficient social protection to shield families from financial ruin and funding crisis. To reverse this trajectory, a comprehensive, multisectoral approach is imperative to ensure that every person affected by TB receives quality care and support, making the vision of a TB-free region a reality.

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1. The Scale of the Tuberculosis Epidemic

TB, caused by Mycobacterium tuberculosis, remains a formidable global public health challenge. In 2023, an estimated 10.8 million people developed TB and 1.2 million died from the disease worldwide. The burden is disproportionately concentrated in the WHO South-East Asia Region, which, with roughly a quarter of the world’s population, accounted for nearly five million new TB cases in 2023. This high burden underscores the region’s critical role in achieving global TB elimination goals, as outlined in the UN Sustainable Development Goals and the WHO End TB Strategy.

The End TB Strategy provides a framework for ending the global epidemic, with targets for 2030 to achieve a 90% reduction in TB deaths and an 80% reduction in the TB incidence rate compared to 2015 levels, while eliminating catastrophic costs for affected families.

2. Performance Against End TB Strategy 2025 Milestones

Assessment of the SE Asia Region’s progress between 2015 and 2023 reveals a significant shortfall across all key indicators, placing the 2025 and 2030 targets in jeopardy.

Key Details of Performance:

• TB Incidence: The TB incidence rate in the region dropped from 251 per 100,000 population in 2015 to 234 per 100,000 in 2023. This 6.7% decline is far from the 50% reduction milestone.
• TB Deaths: The estimated number of TB deaths (including HIV-positive individuals) decreased from 679,000 in 2015 to 606,000 in 2023, an 11% reduction that falls dramatically short of the 75% milestone.
• Catastrophic Costs: Defined as total costs exceeding 20% of a household’s annual income, catastrophic expenditures remain a severe burden. Country-level estimates from 2023 show a wide range, with countries like Bangladesh (43%), India (38%), Indonesia (74%), and Myanmar (60%) reporting high proportions of affected families.

3. The 2023 UN High-Level Meeting: A Renewed Call to Action

The Political Declaration from the 2023 UN High-Level Meeting (UNHLM) on TB reaffirmed global commitment and established ambitious new targets for the period of 2023–2027, aiming to accelerate progress and recover from setbacks caused by the COVID-19 pandemic.

UNHLM Commitments & Targets (2023–2027):

These global targets have been apportioned to the SE Asia Region, creating specific yearly goals for diagnosis, treatment, and prevention.

4. Critical Challenges Hindering Progress

Despite high-level political commitments, a complex mix of systemic, socioeconomic, and operational challenges continues to impede the region’s TB response.

4.1 Suboptimal TB Detection and Diagnosis

A significant gap persists between the estimated number of new TB cases and those diagnosed and reported.

• Treatment Coverage: While treatment coverage improved to 78% in 2023, approximately 22% of people with TB remain missing, i.e. either undiagnosed or unreported.
• Diagnostic Gaps: In 2023, less than 40% of people with new and relapse TB received a WHO-recommended molecular rapid diagnostic test (mWRD) as their initial test, hindering early and accurate diagnosis, especially of drug-resistant strains.
• Persistent Determinants: The high TB burden is fueled by interconnected factors including poverty, undernutrition, overcrowded living conditions, and a substantial, often unregulated, private healthcare sector. Comorbidities like diabetes, HIV, smoking, and alcohol use also increase susceptibility.

4.2 The Threat of Drug-Resistant TB (DR-TB)

MDR/RR-TB poses a significant threat to TB control efforts in the region.

• Burden: An estimated 170,000 individuals developed MDR/RR-TB in the region in 2023. Nearly 90% of this burden is concentrated in India, Indonesia, and Myanmar.
• Detection Gap: Only 44% of the estimated MDR/RR-TB cases in the region were detected in 2023. Detection rates were particularly low in Myanmar (19%) and Nepal (18%).
• Treatment Access: There is an urgent need to scale up universal drug susceptibility testing and ensure access to newer, shorter, all-oral regimens like BPaL/M.

4.3 The Neglected Epidemic: Childhood TB

Children remain a vulnerable and underserved population in the regional TB response.

• Case Estimates: An estimated 650,000 children (0–14 years) developed TB in the region in 2023.
• Detection Failure: Only 49% of these children (315,990) were diagnosed and treated. Detection rates were alarmingly low in countries like Thailand (17%) and Sri Lanka (30%).
• Diagnostic Challenges: Diagnosis is hampered by non-specific symptoms, difficulty in obtaining sputum samples, and a lack of child-friendly diagnostic tools and trained personnel.

4.4 Underutilization of TB Preventive Treatment (TPT)

TPT is a highly effective intervention to prevent the progression from TB infection to active disease, yet its implementation remains critically low.

• Household Contacts: TPT coverage among household contacts of TB patients remains suboptimal across the region.
• People Living with HIV (PLHIV): Among PLHIV newly enrolled in antiretroviral therapy in 2023, TPT coverage was extremely low in reporting countries, including Nepal (0.21%), Thailand (2.90%), and Bangladesh (8%).

4.5 Socio-economic Burdens and Support Gaps

• Social Protection: Though TB services are often free in the public sector, indirect costs (transport, income loss) impose catastrophic burdens. Social protection schemes like cash transfers and nutritional support are essential but often have limited coverage, are poorly integrated with TB programs, and face bureaucratic hurdles.
• Psychosocial Care: Mental health support is a neglected component of TB services, despite the high burden of stigma, isolation, and stress experienced by patients.
• Community Engagement: Community involvement is often limited to passive awareness campaigns rather than meaningful participation in program design, implementation, and monitoring.

4.6 The Fundamental Constraint: Insufficient and Unstable Funding

Funding remains a primary obstacle to scaling up TB control efforts.

• Funding Gaps: In 2024, significant unfunded gaps were projected for the national TB budgets of Bangladesh (81%), Indonesia (56%), Myanmar (55%), and Nepal (54%).
• Donor Dependency: Many countries, including Bangladesh, Indonesia, Myanmar, and Timor-Leste, remain heavily dependent on international funding, raising concerns about sustainability.

5. Strategic Priorities and Innovations for Acceleration

To overcome these challenges and meet the UNHLM targets, countries must urgently scale up proven interventions and embrace innovative approaches.

• Improving TB Detection:
  • Technology: Scale up mWRDs (e.g., GeneXpert®, TrueNAT®) and deploy digital chest X-rays with AI-enabled computer-aided detection (CAD) software, especially in remote areas.
  • Active Case-Finding (ACF): Conduct systematic screening among high-risk and vulnerable groups such as prisoners, migrants, urban poor, and contacts of TB patients.
  • Integration: Embed TB screening into broader health services, including primary care, HIV clinics, diabetes clinics, and maternal and child health programs.
  • Public-Private Mix (PPM): Engage the private sector through digital notification platforms, referral networks, and social franchising models.
• Improving DR-TB Diagnosis and Treatment:
  • Expand access to rapid molecular tests and next-generation sequencing for early resistance detection.
  • Ensure universal access to and availability of shorter, safer, all-oral regimens such as BPaLM and BPaL, which have shown high success rates (up to 89% in Thailand).
• Strengthening Childhood TB Management:
  • Improve diagnostic capabilities by using child-friendly samples like stool for molecular testing.
  • Implement child-friendly diagnostic algorithms and provide FDCs (fixed-dose combinations) to simplify treatment.
  • Build the capacity of healthcare workers and paediatricians in childhood TB management.
• Scaling Up TPT and Social Protection:
  • Integrate TPT delivery into HIV services and use shorter regimens (e.g., 3HP) to improve uptake and completion.
  • Expand comprehensive social protection measures, including conditional cash transfers (e.g., India’s Ni-kshay Poshan Yojana), nutritional support, and transport vouchers, ensuring they reach all patients, including those in the private sector.
• Enhancing Research and Innovation:
  • Invest in the development of new point-of-care diagnostics, safer and shorter treatment regimens, and more effective TB vaccines.
  • Conduct operational research to identify optimal delivery models and address implementation barriers.
  • Strengthen research on the links between TB and mental health, social determinants, and effective community engagement models.
• Securing Sustainable Financing:
  • Increase domestic investment to ensure national ownership and sustainability.
  • Explore innovative financing mechanisms, such as sin taxes (on tobacco and alcohol), results-based financing, social impact bonds (SIBs), Debt2Health swaps, and blended finance models.

6. Conclusion

Ending the TB epidemic in the WHO South-East Asia Region is a critical developmental and public health imperative. The region’s success is indispensable for achieving global End TB targets. The current trajectory, however, is insufficient to meet the ambitious goals set forth by the End TB Strategy and the 2023 UN High-Level Meeting. Overcoming the substantial challenges of under-detection, drug resistance, funding shortfalls, and socioeconomic barriers requires a paradigm shift from incremental progress to accelerated, comprehensive action. This necessitates unwavering political leadership, significantly increased domestic and innovative financing, the rapid deployment of new technologies, and a people-centered approach that empowers communities and ensures no one is left behind. Only through a concerted, multipronged, and collaborative effort can the aspirational vision of a TB-free South-East Asia be realized.

_{Citation: Ending tuberculosis in the WHO South-East Asia Region: reflections and the road ahead in the milestone year of 2025. New Delhi: World Health Organization, Regional Office for South-East Asia; 2024. Licence: CC BY-NC-SA 3.0 IGO.}