Tuberculosis Notification and Incidence: Republic of Korea, 2023
Article information
Tuberculosis has likely regained its position as the world’s leading cause of death from a single infectious agent in 2023, after being surpassed by the coronavirus disease 2019 (COVID-19) pandemic for the past 3 years [1]. The global burden of tuberculosis remains substantial, with 10.8 million incident cases and 1.25 million deaths reported in 2023. Tuberculosis incidence declined from 2015 to 2019, but increased from 2020 to 2022 due to COVID-19, strained healthcare systems, reduced tuberculosis diagnosis and treatment access, and delayed case detection contributing to the rise in cases [2]. In 2023, the global number of tuberculosis cases rose slightly due to population growth, but the incidence rate remained stable, increasing only by 0.2% from 2022. While this suggests a slowing of the pandemic’s impact, drug-resistant tuberculosis, particularly multidrug-resistant/rifampicin-resistant tuberculosis (MDR/RR-TB), remains a major challenge. Although the Republic of Korea has also witnessed a continuous decline in overall tuberculosis incidence, MDR/RR-TB remains a persistent issue requiring targeted intervention and surveillance efforts.
In Korea, tuberculosis incidence has shown a consistent decline over the past decade (Figure 1). A total of 19,540 tuberculosis cases (38.2 per 100,000 population) were notified in 2023, reflecting a 4.1% decrease from 2022. This downward trend has been ongoing since 2011, with an average annual reduction of 7.6%, marking an overall 61.3% decrease, compared to 2011. Tuberculosis remains more prevalent among the elderly, with 65 years and older accounting for 11,309 cases (119.5 per 100,000 population), nearly 1.4 times higher than in younger age groups under 65 years old. Notably, while tuberculosis incidence among younger individuals decreased by 9.4%, among older adults it slightly increased (0.1%), highlighting the need for targeted tuberculosis control efforts in aging populations.
(A) Tuberculosis notification rates between 2001 and 2023, and (B) Number of notified cases of rifampicin-resistant tuberculosis (RR-TB, which is caused by strains resistant to rifampicin, while being either susceptible, or having an unknown susceptibility, to isoniazid) between 2022 and 2023 in the Republic of Korea. MDR-TB: multidrug-resistant tuberculosis (which is caused by strains resistant to at least both rifampicin and isoniazid).
Despite overall progress in tuberculosis prevention and control, MDR/RR-TB remains a critical issue in Korea. In 2023, 551 MDR/RR-TB cases were notified, constituting 2.8% of all tuberculosis cases, which is slightly higher than in 2022 (2.7%). Among new cases, the proportion of MDR/RR-TB was 1.8%, while among previously treated cases, it was 6.8%, a pattern consistent with global trends. The World Health Organization (WHO) estimates that 400,000 people developed MDR/RR-TB in 2023, with 150,000 deaths attributed to these resistant forms. Although the proportion of new tuberculosis cases with MDR/RR-TB has decreased globally from 4.1% in 2015 to 3.2% in 2023, previously treated cases still exhibit a high MDR/RR-TB burden, with an estimated 20% of such cases being drug-resistant. MDR/RR-TB incidence among new patients in Korea declined by 7.8% (308 in 2022, to 284 in 2023). However, unlike new patients, the number of cases among retreatment patients remained unchanged at 205 in both 2022 and 2023. This contrast highlights the need for enhanced drug-resistance surveillance and targeted strategies for previously treated patients.
MDR/RR-TB presents significant challenges, due to its long treatment duration, increased risk of adverse drug reactions, and lower medication compliance, making management more complex, compared to drug-susceptible tuberculosis. Korea implemented the public-private Mix (PPM) tuberculosis control project in 2011, which has proven to be an efficient patient management model [3]. Building on this success, the MDR-TB Consortium was established in 2020 to provide a more structured and comprehensive approach to MDR/RR-TB management [4]. The consortium adopts the existing PPM framework to strengthen people-centered care, focusing on individualized treatment, adherence support, and close monitoring to optimize outcomes.
In January 2024, the fifth edition of Korean Guidelines Tuberculosis was introduced, incorporating shorter-course treatment regimens for MDR/RR-TB for the first time. Among these, the MDR-existing and new drugs (END) regimen [5], developed through Korean tuberculosis researchers, and the bedaquiline, pretomanid, linezolid and moxifloxacin (BPaLM) regimen [6], recommended by the WHO, have been newly introduced as effective treatment options. Furthermore, as of April 1, 2024, reimbursement coverage has been expanded to include shorter treatment regimens. This policy change, based on the revised Korean guidelines, aims to enhance treatment adherence, reduce the economic burden on patients, and improve overall treatment outcomes. These changes mark a significant advancement in MDR/RR-TB management in Korea.
Korea has been one of the first countries globally to introduce novel anti-tuberculosis drugs, bedaquiline and delamanid, to treat MDR-TB. To ensure their appropriate use and management, the Korea Disease Control and Prevention Agency in September 2016 implemented a pre-approval system for novel drugs in MDR-TB Treatment. Under this system, patients requiring these new drugs must undergo a pre-approval review process conducted by the National Tuberculosis Expert Review Committee, which assesses the appropriateness of the drug’s use, and recommends accompanying medications. Only approved cases receive reimbursement coverage under the national health insurance system. Between September 2016 and December 2019, among 754 patients approved for bedaquiline or delamanid, the treatment success rate was 80.2% [7], while a separate study analyzing 7,226 MDR/RR-TB patients diagnosed between 2011 and 2017 notified a 73.5% success rate [8]. These findings highlight the impact of new drug introduction and structured pre-approval processes in enhancing MDR-TB treatment outcomes in Korea.
Despite these advances, further efforts are required to effectively control and manage MDR/RR-TB in Korea. First, early diagnosis through molecular-based drug susceptibility testing is crucial to prevent resistance amplification. Second, ensuring access to novel drugs and individualized treatment approaches will improve outcomes for difficult-to-treat MDR/RR-TB cases. Third, targeted interventions for high-risk groups, particularly the elderly and previously treated patients, must be reinforced to sustain the declining MDR/RR-TB incidence trend [9]. Fourth, the recent WHO guideline recommends preventive treatment for contacts of people with MDR/RR-TB. Korea should proactively consider its inclusion in future policies with strong governmental commitment and support [10]. Continued commitment to tuberculosis control and innovation in MDR/RR-TB treatment will be essential to achieve the long-term goal of tuberculosis elimination in Korea.
MDR/RR-TB remains a significant barrier to tuberculosis control in Korea. While efforts such as shorter treatment regimens, expanded reimbursement policies, and the MDR-TB Consortium have improved management, further action is needed. Continued policy development, financial support, and enhanced access to innovative treatments are crucial, which were also highlighted in the recent United Nation High-Level Meeting on antimicrobial resistance [11]. Strengthening early detection, people-centered care, and surveillance systems will be essential to overcoming MDR/RR-TB challenges, and eliminating tuberculosis long-term.
Ethics approval was waived because it involved anonymized data sets that exist in the public domain, and did not contain any individual human data.
Notes
Authors’ Contributions
Conceptualization: all authors. Formal analysis: Min J, Jeong Y. Data curation: Min J, Jeong Y. Funding acquisition: Min J. Writing - original draft preparation: all authors. Writing - review and editing: all authors. Approval of final manuscript: all authors.
Conflicts of Interest
Jinsoo Min is an editor of the journal, but he was not involved in the peer reviewer selection, evaluation, or decision process of this article. No other potential conf licts of interest relevant to this article were reported.
Funding
This work was supported by the Research Program, funded by the Korea National Institute of Health (grant number 2022E200100). The funder had no role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript.