1.3 Drug-resistant TB
Since 1994, the World Health Organization (WHO) has systematically collected and analysed data on levels of resistance to anti-TB drugs from countries and areas (1). For about 2 decades, most attention was given to the proportion of people diagnosed with TB who had rifampicin-resistant TB (RR-TB) and multidrug-resistant TB (MDR-TB, defined as resistance to both rifampicin and isoniazid). Following the availability of rapid tests that simultaneously test for TB and RR-TB (since 2010) and subsequent updates to WHO recommendations for the treatment of drug-resistant TB, the focus of global surveillance has been on the proportion of people diagnosed with TB who have RR-TB (for data sources and availability, see Box 1.3.1).
Since 2022, new methods have been used to produce time series of estimates of the number of people developing RR-TB each year (incident cases), covering the period from 2015 up to the most recent complete calendar year (2, 3). Data on resistance to other anti-TB drugs (fluoroquinolones, isoniazid, bedaquiline and linezolid) are collected as well, but the country coverage of such data is much more limited.
Globally, the estimated annual number of people who developed RR-TB has been falling since 2015 (Fig. 1.3.1). The estimated number in 2025 was 370 000 (95% uncertainty interval [UI]: 330 000–400 000).
Fig. 1.3.1 Global trend in the estimated number of people who developed RR-TB (incident cases), 2015–2025
Globally, an estimated 140 000 people (95% UI: 85 000–190 000) died from RR-TB in 2025.
The reason why the number of people developing RR-TB is not estimated to have increased from 2020–2023, in contrast to the number of people developing TB overall (Section 1.1), is that increases in the overall number of people developing TB have been offset by an estimated downward trend since 2015 in the proportion of people with TB who have RR-TB (Fig. 1.3.2).
Globally, the estimated proportion of new TB cases with RR-TB fell from 4.4% (95% UI: 3.5–5.3%) in 2015 to 3.1% (95% UI: 2.5–3.6%) in 2025; the estimated proportion of previously treated cases with RR-TB fell from 20% (95% UI: 14–26%) in 2015 to 15% (95% UI: 11–19%) in 2025.
Fig. 1.3.2 Global trend in the estimated percentage of people with TB who had RR-TB, 2015–2025
Trends at regional level vary (Fig. 1.3.3). Between 2020 and 2025, there were estimated increases in the number of people who developed RR-TB in the WHO Region of the Americas and the WHO South-East Asia Region. In contrast, the estimated number of people developing RR-TB each year has been declining since 2015 in both the African and Eastern Mediterranean regions. Numbers are also estimated to have been falling for most of the period 2015–2025 in the European Region. After a persistent decline from 2015–2021 and a stable trend from 2021–2022, there was a year-on-year decline in the Western Pacific Region between 2023 and 2025.
Fig. 1.3.3 Regional trends in the estimated number of people who developed RR-TB (incident cases), 2015–2025
Trends in the 30 high RR-TB burden countries also vary (Fig. 1.3.4).
Fig. 1.3.4 Trends in the estimated number of people who developed RR-TB (incident cases), 30 high RR-TB burden countries, 2015–2025a
The estimated number of people who developed RR-TB decreased substantially in the 4 countries that are part of the global RR-TB watchlist for 2026–2030 (Fig. 1.3.5).
Fig. 1.3.5 Trends in the estimated number of people who developed RR-TB (incident cases), 4 global RR-TB watchlist countries, 2015–2025a
Four countries accounted for over half of the global number of people estimated to have developed RR-TB (incident cases) in 2025: China, India, the Philippines and the Russian Federation (Fig. 1.3.6 below and Fig. 1.3.7).
Fig. 1.3.6 Estimated number of people who developed RR-TB (incident cases) in 2025, for countries with at least 1000 incident cases
The proportion of people with TB who had RR-TB varies considerably among regions and countries (Fig. 1.3.8 below and Fig. 1.3.9). For people with no previous history of TB treatment (new cases), best estimates were 2.0% in the WHO African and Eastern Mediterranean regions, 3.1% in the Western Pacific Region, 3.5% in the Region of the Americas and 3.6% in the South-East Asia Region. In contrast, this proportion was 21% in the European Region. For people previously treated for TB, best estimates ranged from 4.7% in the Eastern Mediterranean Region to 48% in the European Region. At country level, the highest proportions are found in the Russian Federation and in several countries in eastern Europe and Central Asia.
Fig. 1.3.8 Percentage of people with TB who had RR-TB, for those with no previous history of TB treatment, 2025
Other patterns of drug resistance
There were an estimated 1.0 million incident cases (95% UI: 0.32–1.7 million) of isoniazid-resistant TB in 2025, including people with both rifampicin-susceptible TB and RR-TB.
Globally in 2025, the estimated proportion of RR-TB cases with pre-extensively drug-resistant TB (pre-XDR-TB, defined as resistance to rifampicin and any fluoroquinolone) was 23% (95% UI: 15–30%).
Box 1.3.1: Anti-TB drug resistance: data sources and availability
There are two main sources of data about levels of anti-TB drug resistance: national surveys and continuous surveillance (i.e. routine diagnostic testing for drug resistance among people diagnosed with bacteriologically confirmed TB) (4).
By the end of 2025, 93 countries and areas had representative data about levels of resistance to rifampicin from continuous surveillance systems, 17 had nationally representative survey data dating from 2000 or later and 70 had data from both continuous surveillance and surveys (Fig. 1.3.10). This total of 180 countries and areas worldwide collectively accounted for 99% of the world’s population and 99% of incident cases of TB in 2025.
Of the 43 countries that are in one or both lists of high TB burden and high RR-TB burden countries being used by WHO in the period 2026–2030, 41 had survey or surveillance data on levels of drug resistance.
Fig. 1.3.10 Sources of data for rifampicin resistance among people diagnosed with TB, for those with no previous history of TB treatment, 2000–2025
References
Dean AS, Tosas Auguet O, Glaziou P, Zignol M, Ismail N, Kasaeva T et al (2022). 25 years of surveillance of drug-resistant tuberculosis: achievements, challenges, and way forward. Lancet Infect Dis 22(7):E191-E196 ( https://doi.org/10.1016/S1473-3099(21)00808-2).
WHO Global Task Force on TB Impact Measurement: report of a subgroup meeting on methods used by WHO to estimate TB disease burden, 11–12 May 2022, Geneva, Switzerland. Geneva: World Health Organization; 2022 ( https://iris.who.int/handle/10665/363428).
Background document 2. Methods for estimating the incidence of drug-resistant TB. In: WHO/Global Task Force on TB Impact Measurement [website]. Geneva: World Health Organization; 2022 ( https://cdn.who.int/media/docs/default-source/hq-tuberculosis/global-task-force-on-tb-impact-measurement/meetings/2022-05/tf-2022-05-2-background--document-2--dr-tb.pdf?sfvrsn=a8757cfa_3).
Guidance for the surveillance of drug resistance in tuberculosis: Sixth edition. Geneva: World Health Organization; 2020 ( https://iris.who.int/handle/10665/339760). Licence: CC BY-NC-SA 3.0 IGO.
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