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Tuberculosis is everywhere in the Eastern Mediterranean Region (figure 1). It is a very serious public health problem in the Region. The estimated regional incidence (number of cases) of tuberculosis is very high: around 560 000 people develop active tuberculosis every year. The estimated mortality (number of deaths) is also high: around 110 000 people die of tuberculosis every year; in other words 300 people die of tuberculosis every day. Tuberculosis is actually the leading cause of death from communicable disease in adults. Tuberculosis kills more people in the Region than other major communicable diseases such as HIV/AIDS and malaria, which result in estimated annual mortality of 48 000 and 59 000, respectively.

Tuberculosis is also an important developmental problem. The disease affects young adults: 70% to 80% of cases occur among the age group of 15 to 54 years. This is the most socially and economically productive age group in society, and patients are usually the breadwinners in their families. Suffering from tuberculosis means a long duration of illness, often for a period of several years, and a long period of treatment, at least 6 to 8 months. Illness obviously affects the patients’ social and economic productivity, and thus their income. Moreover, tuberculosis often affects the poorer segments of the community. Catastrophic health expenditure is not uncommon among those suffering from tuberculosis.

Among the 22 countries of the Region, low-income countries or countries with complex emergencies are affected most by tuberculosis. Pakistan has by far the highest incidence, around 290 000 tuberculosis patients a year, accounting for 51% of the tuberculosis cases in the Region. Other countries most affected by tuberculosis are Afghanistan, Egypt, Iraq, Islamic Republic of Iran, Morocco, Somalia, Sudan and Yemen. Together these nine countries account for 95% of the regional tuberculosis burden. Djibouti has by far the highest incidence rate, with 762 cases per 100 000 population. This is actually one of the highest tuberculosis incidence rates in the world. Other countries that have high incidence of tuberculosis (greater than 100 cases per 100 000 population) are Afghanistan, Pakistan, Somalia and Sudan.

Figure 1. Tuberculosis incidence in countries of the Region 2005

Drug-resistant tuberculosis was found everywhere at different levels in eight countries that conducted anti-tuberculosis drug resistance surveys[1]. Multidrug-resistant (MDR) tuberculosis was also found among new cases of tuberculosis in 7 out of the 8 countries. The level of MDR ranged from 0.8% in Qatar to 9.1% in Jordan among new cases and from 11.2% in Yemen and 30.3% in Jordan among previously treated. No concrete data are yet available in the Region concerning extreme drug resistance (XDR), which is resistance to second-line drugs; however, a study in the Islamic Republic of Iran indicated the presence of XDR in the country.

The HIV/AIDS epidemic has started having an impact on tuberculosis in the Region. HIV seroprevalence is increasing in countries that are affected by the HIV/AIDS epidemic. In Djibouti and Sudan, which are in the generalized epidemic stage, HIV seroprevalence among TB patients is estimated at 16% and 9%, respectively. In Somalia, which is on the edge of a generalized epidemic, it is 5%. The data are still limited in the Region, but around 7500 tuberculosis patients are probably infected with HIV in the Region.

Tuberculosis affects hundreds of thousands of people, causing considerable suffering in each individual affected. As noted previously, tuberculosis hits the poorer segments of society hardest. Stories of catastrophic health expenditure and suffering due to tuberculosis abound in the Region. One family lost all its income and went bankrupt because the mother suffered from tuberculosis for several years before she was able to get proper treatment and was cured. Another tragic story concerns a 13-year-old patient who lost both his parents due to tuberculosis. The child himself was a relapse case who was brought to the health facility by his only remaining relative, his grandfather.

All these real-life tragedies were preventable.