PHWR Public Health Weekly Report

Tuberculosis (TB) is an infectious disease caused by Mycobacterium tuberculosis. It is both preventable and curable infectious disease [1]. In the Republic of Korea (ROK), TB is designated as a Class 2 national notifiable infectious disease, and is managed through a surveillance system. The total number of TB patients in ROK was 19,540 in 2023, reflecting a 4.1% decrease (n=843) compared to 2022 (n=20,383), marking the 12th consecutive year of decline since 2011 [2]. The appendix of the “2023 Annual Report on the Notified Tuberculosis” published every year by the Korea Disease Control and Prevention Agency (KDCA), provides the number of TB-related deaths and mortality rates excerpted from the “Cause-of-Death Statistics” published by Statistics Korea. The KDCA monitors TB-related deaths using these statistics. This article examines the current status of TB-related deaths in ROK based on the “2023 Cause-of-Death Statistics” published by Statistics Korea and presents future plans for the national TB control policy.

1. Subjects

The subjects analyzed in this article are individuals whose cause of death was TB, classified under the 8th Korean Standard Classification of Diseases and Causes of Death (codes: A15–A19), as reported in the “Cause-of-Death Statistics” published by Statistics Korea. Specifically, this included individuals who died from respiratory TB (codes: A15–A16) and other TB (codes: A17–A19) [3]. Statistics Korea compiles causes of deaths from registered deaths in ROK, in accordance with the Korean Standard Classification of Diseases and Causes of Death. The agency supplements data for omitted death reports, inaccurate causes of death, or deaths due to external factors (e.g., accidents) using administrative data to ensure accuracy. In addition, the KDCA provides Statistics Korea with report and registry data on TB patients as administrative data to enable more accurate classification of TB-related deaths.

2. Analysis

The TB mortality rate represents the number of TB-related deaths in a given year divided by the resident registration mid-year population, expressed per 100,000 people. The age-standardized mortality rate accounts for the effects of population age structure, allowing for comparisons across groups with different population compositions. It was calculated using the 2005 resident registration mid-year population as the standard population [3]. The ranking of mortality rates by cause of death was calculated by consolidating respiratory TB (A15–A16) and other TB (A17–A19) under the broad category of TB (A15–A19) among the 57 causes of death listed in the general classification table provided by the Cause-of-Death Statistics [3,4].

For data analysis, statistical tables detailing the number of death and mortality rate by cause from 2003 and 2014–2023 were downloaded from the Korean Statistical Information Service [4]. Statistical analyses were performed using the Microsoft Excel.

The number of TB-related deaths in 2023 was 1,331, reflecting a 0.7% increase (n=9) compared to 2022 (n=1,322). However, the TB mortality rate remained the same at 2.6 per 100,000 people in both 2023 and 2022 (Table 1, Figure 1). Of the 1,331 TB deaths (A15–A19) in 2023, 1,227 (2.4 per 100,000 people) were related to respiratory TB (A15–A16), while 104 (0.2 per 100,000 people) were related to other TB (A17–A19), indicating that respiratory TB accounted for 92.2% of cases. Respiratory TB deaths decreased slightly from 1,324 (2.6 per 100,000 people) in 2021 to 1,223 (2.4 per 100,000 people) in 2022, and increased minimally by 4 cases (0.3%) to 1,227 (2.4 per 100,000 people) in 2023. In contrast, deaths from other TB decreased from 106 (0.2 per 100,000 people) in 2021 to 99 (0.2 per 100,000 people) in 2022, but increased by 5 cases (5.1%) to 104 in 2023 (Table 1).

Figure 1. Based on cause-of-death statistics in Statistics Korea, the number of tuberculosis (TB) deaths and TB mortality rate by year, the number and proportion of TB deaths aged 65 and older (2014–2023)

Table 1 Based on cause-of-death statistics in Statistics Korea, status of tuberculosis deaths (2014–2023)

		2014	2015	2016	2017	2018	2019	2020	2021	2022	2023
Tuberculosis (A15–A19)	Number	2,305	2,209	2,186	1,816	1,800	1,610	1,356	1,430	1,322	1,331
	Mortality rate	4.5	4.3	4.3	3.5	3.5	3.1	2.6	2.8	2.6	2.6
	% Changea)	3.4	△4.2	△1.0	△16.9	△0.9	△10.6	△15.8	5.5	△7.6	0.7
Tuberculosis deaths
Respiratory tuberculosis (A15–A16)	Number	2,136	2,019	2,020	1,678	1,658	1,492	1,223	1,324	1,223	1,227
	Mortality rate	4.2	4.0	4.0	3.3	3.2	2.9	2.4	2.6	2.4	2.4
	% Changea)	3.9	△5.5	0.0	△16.9	△1.2	△10.0	△18.0	8.3	△7.6	0.3
Other tuberculosis (A17–A19)	Number	169	190	166	138	142	118	133	106	99	104
	Mortality rate	0.3	0.4	0.3	0.3	0.3	0.2	0.3	0.2	0.2	0.2
	% Changea)	△3.4	12.4	△12.6	△16.9	2.9	△16.9	12.7	△20.3	△6.6	5.1
Gender
Men	Number	1,480	1,390	1,349	1,107	1,120	977	842	854	791	830
	Mortality rate	5.8	5.5	5.3	4.3	4.4	3.8	3.3	3.3	3.1	3.3
	% Changea)	1.7	△6.1	△2.9	△17.9	1.2	△12.8	△13.8	1.4	△7.4	4.9
Women	Number	775	825	819	837	709	680	633	514	576	531
	Mortality rate	3.1	3.2	3.2	3.3	2.8	2.6	2.5	2.0	2.2	2.1
	% Changea)	6.5	△0.7	2.2	△15.3	△4.1	△6.9	△18.8	12.1	△7.8	△5.6
Age (yr)
0–4	Number	0	0	0	0	0	0	0	0	0	0
	Mortality rate	-	-	-	-	-	-	-	-	-	-
5–9	Number	0	0	0	0	0	0	0	0	0	0
	Mortality rate	-	-	-	-	-	-	-	-	-	-
10–14	Number	0	0	0	0	0	0	0	0	0	0
	Mortality rate	-	-	-	-	-	-	-	-	-	-
15–19	Number	2	0	0	0	0	0	0	0	0	0
	Mortality rate	0.1	-	-	-	-	-	-	-	-	-
20–24	Number	2	0	5	2	0	1	2	2	0	0
	Mortality rate	0.1	-	0.1	0.1	-	0	0.1	0.1	-	-
25–29	Number	5	8	3	4	4	2	3	3	0	2
	Mortality rate	0.2	0.3	0.1	0.1	0.1	0.1	0.1	0.1	-	0.1
30–34	Number	12	18	6	2	6	4	1	1	5	2
	Mortality rate	0.3	0.5	0.2	0.1	0.2	0.1	0.0	0.0	0.2	0.1
35–39	Number	24	15	16	10	4	6	14	5	1	3
	Mortality rate	0.6	0.4	0.4	0.3	0.1	0.2	0.4	0.1	0.0	0.1
40–44	Number	40	37	27	21	13	11	18	14	15	10
	Mortality rate	0.9	0.8	0.6	0.5	0.3	0.3	0.5	0.4	0.4	0.2
45–49	Number	69	66	64	47	47	35	32	24	21	21
	Mortality rate	1.6	1.5	1.4	1.0	1.0	0.8	0.7	0.6	0.5	0.5
50–54	Number	117	113	87	65	58	50	44	52	40	40
	Mortality rate	2.7	2.6	2.1	1.6	1.4	1.2	1.0	1.2	0.9	0.9
55–59	Number	110	117	95	81	109	78	54	59	42	37
	Mortality rate	3.0	3.0	2.3	1.9	2.6	1.8	1.3	1.4	1.0	0.9
60–64	Number	104	98	97	88	76	88	68	91	67	56
	Mortality rate	4.1	3.6	3.3	2.8	2.3	2.4	1.8	2.3	1.6	1.3
65–69	Number	144	141	120	84	77	67	71	74	72	76
	Mortality rate	7.2	6.7	5.5	3.7	3.3	2.7	2.7	2.6	2.3	2.3
70–74	Number	293	201	177	146	132	121	90	96	87	82
	Mortality rate	16.4	11.3	10.0	8.3	7.3	6.4	4.5	4.6	4.0	3.7
75–79	Number	385	371	369	290	313	224	206	191	154	175
	Mortality rate	29.7	27.4	26.2	19.3	19.7	14.0	12.9	12.0	9.6	10.6
≥80	Number	998	1,023	1,120	976	960	923	752	818	818	827
	Mortality rate	82.7	78.0	78.8	63.7	58.4	52.2	39.7	40.4	37.7	36.0
	Proportion	43.3	46.3	51.2	53.7	53.3	57.3	55.5	57.2	61.9	62.1
Unknown	Number	0	1	0	0	1	0	1	0	0	0
<65	Number	485	472	400	320	317	275	236	251	191	171
	Mortality rate	1.1	1.1	0.9	0.7	0.7	0.6	0.5	0.6	0.5	0.4
≥65	Number	1,820	1,736	1,786	1,496	1,482	1,335	1,119	1,179	1,131	1,160
	Mortality rate	28.9	26.5	26.3	21.2	20.1	17.3	13.8	13.7	12.6	12.3
	Proportion	79.0	78.6	81.7	82.4	82.3	82.9	82.5	82.4	85.6	87.2

Unit: person, person per 100,000 population, %. △=decrease; –=not available. ^a)% change from previous year..

Regarding the ranking of mortality rates by 56 causes of death, TB’s ranking has been gradually decreasing from 11th in 2003 (6.9 per 100,000 people), to 13th in 2013 (4.4 per 100,000 people), and the 15th in both 2022 and 2023 (2.6 per 100,000 people). From 1983 to 2020, TB had the highest mortality rate among infectious diseases. However, during the coronavirus disease 2019 (COVID-19) pandemic, the ranking changed, with TB falling to second place behind COVID-19 in 2022 and 2023 (Table 2).

Table 2 Based on cause-of-death statistics in Statistics Korea, cause of death and mortality rate (2003, 2013, 2022, 2023)

Ranka)	2003			2013			2022			2023
	Cause of death	Mortality rate		Cause of death	Mortality rate		Cause of death	Mortality rate		Cause of death	Mortality rate
1	Malignant neoplasm	131.9		Malignant neoplasm	149.0		Malignant neoplasm	162.7		Malignant neoplasm	166.7
2	Cerebrovascular disease	75.9		Cerebrovascular disease	50.3		Cardiovascular disease	65.8		Cardiovascular disease	64.8
3	Cardiovascular disease	35.7		Cardiovascular disease	50.2		COVID-19	61.0		Pneumonia	57.5
4	Diabetes	25.2		Intentional self-harm	28.5		Pneumonia	52.1		Cerebrovascular disease	47.3
5	Intentional self-harm	22.7		Diabetes	21.5		Cerebrovascular disease	49.6		Intentional self-harm	27.3
6	Liver disease	20.6		Pneumonia	21.4		Intentional self-harm	25.2		Alzheimer’s disease	21.7
7	Transport accidents	19.2		Chronic lower respiratory disease	14.0		Alzheimer’s disease	22.7		Diabetes	21.6
8	Chronic lower respiratory disease	19.1		Liver disease	13.2		Diabetes	21.8		Hypertensive disease	15.6
9	Hypertensive disease	10.7		Transport accidents	11.9		Hypertensive disease	15.1		Sepsis	15.3
10	Falls	7.3		Hypertensive disease	9.4		Liver disease	14.7		COVID-19	14.6
11	Tuberculosisa)	6.9		Alzheimer’s disease	8.5		Sepsis	13.5		Liver disease	14.2
12				Falls	4.6		Chronic lower respiratory disease	11.7		Chronic lower respiratory disease	12.3
13				Tuberculosisa)	4.4		Transport accidents	6.8		Transport accidents	6.4
14							Falls	5.3		Falls	4.9
15							Tuberculosisa)	2.6		Tuberculosisa)	2.6

Unit: person per 100,000 popoulation. COVID-19=coronavirus disease 2019. ^a)The rank is to be list of mortality rate by cause-death by processing ‘tuberculosis (A15–A19)’ to add respiratory tuberculosis (A15–A16) and other tuberculosis (A17–A19) in 57 classification tables..

By gender, TB-related deaths among men increased by 39 cases (4.9%) from 791 (3.1 per 100,000 people) in 2022 to 830 (3.3 per 100,000 people) in 2023. The number of TB-related deaths in women decreased by 30 cases (5.6%) to 501 (2.0 per 100,000 people) in 2023 from the previous year (n=531, 2.1 per 100,000 people) (Table 1). In addition, among the number of TB-related deaths in 2023, the numbers of TB-related deaths in men and women accounted for 62.4% (n=830), and 37.6% (n=501), respectively, indicating deaths among men being approximately 1.7 times higher than among women (Table 1).

By age group, TB-related deaths increased in 2023 among individuals aged 25–29 years old (0→2), 35–39 years old (1→3), 65–69 years old (72→76), 75–79 years old (154→175), and 80 years old or older (818→827) compared to the previous year (Table 1). The mortality rate among individuals aged 80 years or older was 36.0 per 100,000 people in 2023, a decrease from the previous year (37.7 per 100,000 people), this age group accounted for highest proportion of TB-related deaths at 62.1% (n=827). This percentage has been gradually increasing over the years: 41.9% in 2014 to 53.7% in 2018, 61.9% in 2022, and 62.1% in 2023 (Table 1).

The number of TB-related deaths in 2023 by region was the highest in Gyeonggi-do (1.9 per 100,000 people) and Seoul (197 per 100,000 people), with these two regions together accounting for 34.0% (n=452) of all TB-related deaths (n=1,331). In addition, the highest TB mortality rate were reported in Gyeongsangbuk-do and Jeollanam-do (5.0 per 100,000 people), while the lowest rate was observed in Ulsan Metropolitan City (0.9 per 100,000 people) (Table 3, Figure 2).

Figure 2. Based on cause-of-death statistics in Statistics Korea, the number of tuberculosis (TB) deaths, TB mortality rates, and age-standardized TB mortality rates by province (2023)
Age-standardized mortality rate is counted on standards population in 2005 in the Republic of Korea.

Table 3 Based on cause-of-death statistics in Statistics Korea, statistics of tuberculosis deaths by province (2014–2023)

Province		2014	2015	2016	2017	2018	2019	2020	2021	2022	2023
Total	Number	2,305	2,209	2,186	1,816	1,800	1,610	1,356	1,430	1,322	1,331
	Mortality rate	4.5	4.3	4.3	3.5	3.5	3.1	2.6	2.8	2.6	2.6
	Age-standardized mortality ratea)	3.0	2.7	2.5	1.9	1.8	1.5	1.2	1.2	1.1	1.0
Seoul	Number	388	347	358	270	351	329	230	245	217	197
	Mortality rate	3.9	3.5	3.6	2.8	3.6	3.4	2.4	2.6	2.3	2.1
Busan	Number	140	150	136	102	116	105	76	94	72	69
	Mortality rate	4.0	4.3	3.9	3.0	3.4	3.1	2.3	2.8	2.2	2.1
Daegu	Number	131	118	119	111	107	81	83	65	65	82
	Mortality rate	5.3	4.8	4.8	4.5	4.4	3.3	3.4	2.7	2.7	3.5
Incheon	Number	129	106	91	81	83	83	80	66	67	79
	Mortality rate	4.5	3.7	3.1	2.8	2.8	2.8	2.7	2.3	2.3	2.7
Gwangju	Number	73	60	62	47	33	42	31	23	40	17
	Mortality rate	5.0	4.1	4.2	3.2	2.3	2.9	2.1	1.6	2.8	1.2
Daejeon	Number	45	44	36	46	41	35	31	22	26	22
	Mortality rate	3.0	2.9	2.4	3.1	2.8	2.4	2.1	1.5	1.8	1.5
Ulsan	Number	29	29	35	25	25	27	25	31	18	10
	Mortality rate	2.5	2.5	3.0	2.2	2.2	2.4	2.2	2.8	1.6	0.9
Sejong	Number	9	3	3	8	7	6	2	5	1	8
	Mortality rate	6.5	1.6	1.3	3.1	2.4	1.8	0.6	1.4	0.3	2.1
Gyeonggi	Number	391	422	396	327	298	292	245	292	257	255
	Mortality rate	3.2	3.4	3.2	2.6	2.3	2.2	1.9	2.2	1.9	1.9
Gangwon	Number	124	99	92	98	87	76	58	68	75	55
	Mortality rate	8.1	6.5	6.0	6.4	5.7	5.0	3.8	4.4	4.9	3.6
Chungbuk	Number	77	67	68	78	73	54	57	37	45	49
	Mortality rate	4.9	4.3	4.3	4.9	4.6	3.4	3.6	2.3	2.8	3.1
Chungnam	Number	114	125	119	135	112	74	68	70	77	69
	Mortality rate	5.6	6.1	5.7	6.5	5.3	3.5	3.2	3.3	3.6	3.3
Jeonbuk	Number	107	90	130	78	86	54	46	54	44	52
	Mortality rate	5.8	4.8	7.0	4.2	4.7	3.0	2.6	3.0	2.5	3.0
Jeonnam	Number	176	181	140	112	94	125	109	102	86	90
	Mortality rate	9.3	9.6	7.4	5.9	5.0	6.7	5.9	5.6	4.7	5.0
Gyeongbuk	Number	191	183	244	182	134	126	115	112	102	129
	Mortality rate	7.1	6.8	9.1	6.8	5.0	4.7	4.4	4.3	3.9	5.0
Gyeongnam	Number	164	166	142	102	144	87	79	127	115	128
	Mortality rate	4.9	5.0	4.2	3.0	4.3	2.6	2.4	3.8	3.5	3.9
Jeju	Number	17	19	15	14	9	14	21	17	15	20
	Mortality rate	2.9	3.1	2.4	2.2	1.4	2.1	3.1	2.5	2.2	3.0

Unit: person, person per 100,000 population. ^a)Calculate the age-standardized tuberculosis mortality rate, 2005 resident registration mid-year population was used as the standard population..

When analyzing TB-related deaths in elderly individuals aged 65 years or older who accounted for more than 80% of TB-related deaths, the number of TB-related deaths by year was 1,482 in 2018, 1,119 in 2020, and 1,131 in 2022, a 4.1% decrease in 2022 compared to 2021, but increased to 1,160 in 2023 by 2.6% compared to the previous year (Table 1, Figure 1). In addition, this figure is a 13.1% decrease from 2019 or before the COVID-19 pandemic (Table 1, Figure 1). The percentage of TB-related deaths among individuals aged 65 years and older has been increasing annually (Table 1, Figure 1). It was 82.4% in 2021, 85.6% in 2022, and 87.2% in 2023 over the past three years, and increased by 8.2% from 2014 or 10 years ago (Table 1, Figure 1). The TB mortality rates among individuals aged 65 and older has also shown a declining trend from 20.1 per 100,000 people in 2018 to 13.8 per 100,000 people in 2020, and 12.6 per 100,000 people in 2022. In 2023 TB-related mortality rate further decreased slightly to 12.3 per 100,000 people (Table 1).

The KDCA is actively implementing TB eradication projects by establishing the National Strategic Plan for TB Control every five years in accordance with the ‘Tuberculosis Prevention Act’ [5]. Since the peak number of TB cases in 2011 (n=50,491), the number of TB patients has decreased by an annual average of 7.6% until 2023 (n=19,540), continuing the downward trend for 12 consecutive years with a total decrease of 61.3% [2,6]. In addition, TB-related deaths in 2023 was 1,331, which was a 5.9% annual average decrease since 2014 (n=2,305), with a 42.3% decrease compared to 10 years ago. Since 2011, the nationwide expansion of the TB control program under the public-private mix project has been accompanied by a gradual increase in national subsidies for out-of-pocket medical expenses for TB treatment [5,7]. Especially since the implementation of the special copayment decreasing policy for TB in 2017, the out-of-pocket medical expenses required for TB treatment have been fully supported, which greatly enhanced healthcare accessibility and coverage for TB patients. In addition, the KDCA established the National Strategic Plan for TB Control every five years since 2013, and continues to implement related policies covering the entire TB control cycle (prevention–diagnosis–treatment) through the 1st National Strategic Plan for TB Control (2013–2017), the 2nd National Strategic Plan for TB Control (2018–2022), the Strengthening Measures for TB Prevention and Control (2019), and the 3rd National Strategic Plan for TB Control (2023–2027) [8].

Meanwhile, since 2014, the TB-related deaths had been decreasing, but shows a stagnant pattern with a 0.7% increase in 2023 compared to the previous year. Analysis shows that age rather than gender, plays a more significant role in TB mortality.Regions with a higher proportion of elderly populations reported a greater burden of TB-related deaths [9]. While TB-related deaths among individuals aged 65 or older in 2023 decreased by 13.1% compared to 2019 or before the COVID-19 pandemic, this age group accounted for an increasing proportion of TB deaths, reaching 87.2% in 2023. As ROK is expected to enter a super-aging society in 2025, where individuals aged 65 or older will exceed 20% of the total population [10], this percentage is expected to rise further.

Therefore, it is necessary to actively promote and implement programs for the prevention and early detection of TB in elderly individuals aged 65 years or older who are more vulnerable due to multiple comorbidities and challenges in treatment adherence. The KDCA is actively conducting various public awareness campaigns to promote TB prevention behaviors and increase TB screening rates among elderly individuals.

Furthermore, contacts aged 65 years or older of TB patients have been included as targets in evaluations of latent TB infection screening rates for local governments. Additionally, in the case of the ‘Mobile TB Screening Project’ that has been implemented nationwide since 2020, TB screening is being conducted more actively in the form of mobile screening for those with relatively low medical accessibility among elderly individuals aged 65 years or older, such as medical aid beneficiaries and community-dwelling bedridden patients [11]. Furthermore, to improve treatment success rates based on the experience and outcomes of patient medication management obtained through TB management personnel, the ‘customized and integrated TB patient management’ policy is being implemented from June 2024 [12,13]. This policy is intended to link medication management with social welfare services for all TB patients during the entire treatment period, rather than the medication management program that was conducted for only active TB patients for about two weeks by separate TB management personnel. This article presents the results of a descriptive statistical analysis using TB-related death statistics tables excerpted from the Cause-of-Death Statistics published by Statistics Korea. Detailed characteristics of TB-related deaths not included in the statistical tables could not be analyzed.

To enhance the accuracy of TB-related death surveillance data, beginning from January 1, 2025, death certificates will be required when reporting a death as a TB treatment outcome, as per the revised Enforcement Decree of the Tuberculosis Prevention Act. In addition, the KDCA will aim to improve consistency between the two data sources through a comparative evaluation with the Cause-of-Death Statistics published by Statistics Korea. In order to achieve the goal of the ‘3rd Strategic Plan for TB Control’ to reduce TB incidence to less than 20 cases per 100,000 people by 2027, the KDCA will continue to pursue comprehensive policies and initiatives spanning the entire TB control cycle including prevention, early detection, and treatment.

Ethics Statement: Not applicable.

Funding Source: None.

Acknowledgments: We thank to the Vital Statistics Division in Statistics Korea, Divisions of Infectious Disease Response in Regional Centers for Disease Control and Prevention, Departments of TB management in local governments by province and district, Departments related to TB in Health and Environment and Centers for Infectious Diseases Control and Prevention by province, the Masan National Tuberculosis Hospital, the Mokpo National Tuberculosis Hospital for planning and managing projects for the TB screening, TB epidemiological investigation, TB patient management, diagnosis test etc. according to the third national strategic plan for TB control. Also, we are grateful to the relevant organizations in the Korean National Tuberculosis Association and medical institutions participating in the nationwide Public-Private Mix TB program and the TB socio-economic support program, etc. cooperated in relation to TB management and research development project.

Conflict of Interest: Young-joon Park is an editorial board member of the journal, but was not involved in the review process of this manuscript. Otherwise, there is no conflict of interest to declare.

Author Contributions: Conceptualization: HWL, JSK. Data curation: HWL, JSK. Formal analysis: HWL, JSK. Investigation: HWL, JSK. Visualization: HWL, JSK. Supervision: JEK, YJP. Writing – original draft: HWL, JSK. Writing – review & editing: JEK, YJP.