Trends in pulmonary tuberculosis mortality between 1985 and 2018: an observational analysis
Authors: Singh Harpreet , Rupal Arashdeep , Omari Omar Al , Jani Chinmay , Ahmed Alaaeldin , Walker Alexander , Shalhoub Joseph , Thomson Carey , Marshall Dominic C , Salciccioli Justin D 
Published: September 2022

Introduction
Pulmonary tuberculosis (TB) is a major source of global mortality and morbidity, particularly in the developing world. Latent infection has enabled it to spread to approximately a quarter of the world's population. The late 1980s and early 1990s saw an increase in the number of reported TB cases related to the HIV epidemic and immigration, as well as the spread of multidrug-resistant TB (MDR TB). Few studies have reported pulmonary TB mortality trends. Our study reports and compares trends in pulmonary TB mortality between 1985 and 2018 in countries throughout the world.
Methods
We utilized the World Health Organization (WHO) mortality database to extract TB mortality data based on the International Classification of Diseases (ICD) 10 system. Based on the availability and quality of data, we included Canada and the United States (US) from the Americas; Austria, Belgium, Bulgaria, Croatia, Czech Republic, Denmark, Estonia, Finland, France, Germany, Greece, Hungary, Ireland, Israel, Italy, Latvia, Lithuania, Netherlands, Poland, Portugal, Republic of Moldova, Romania, Slovakia, Slovenia, Spain, Sweden, Switzerland, and United Kingdom from Europe; Australia, New Zealand, and Japan from the Western Pacific region. Crude mortality rates were dichotomized by sex and reported by year. We computed age standardized death rates (ASRDs) per 100,000 population using the world standard population. Pulmonary TB mortality trends were examined using Joinpoint regression analysis and reported using estimated annual percentage changes (EAPCs).
Results
We observed a decrease in mortality in males and females in all countries except the Republic of Moldova, which showed an increase in female mortality (+0.12%). Among all countries, Lithuania had the greatest reduction in male mortality (-12.01%) between 1993-2018, and Hungary had the greatest reduction in female mortality (-1.57%) between 1985-2017. Male mortality declined at a steady rate across the study period. Slovenia had the most rapid recent declining trend for males with an EAPC of -47% (2003-2016), followed by Australia (-33.6%, 2014-2017), whereas Croatia and Austria showed an increase in EAPC of +25.0% (2015-2017) and +17.8% (2010-2014), respectively. For females, New Zealand had the most rapid recent declining trend (-47.2%, 1985-2015), followed by Hungary (-35.1%, 2004-2007), whereas Croatia showed an increase in EAPC (+24.9%, 2014-2017).
Conclusion
Pulmonary TB mortality is disproportionately higher among Central and Eastern European countries. This communicable disease cannot be eliminated from any one region without a global approach. Priority action areas include ensuring early diagnosis and appropriate treatment to the most vulnerable groups. In low- and middle-income countries with high TB incidence, attenuation of socioeconomic determinants including extreme poverty, inadequate living conditions, and malnutrition remains crucial.