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This paper describes an action framework for countries with low tuberculosis (TB) incidence (<100 TB cases per million population) that are striving for TB elimination. The framework sets out priority interventions required for these countries to progress first towards “pre-elimination” (<10 cases per million) and eventually the elimination of TB as a public health problem (less than one case per million). TB epidemiology in most low-incidence countries is characterised by a low rate of transmission in the general population, occasional outbreaks, a majority of TB cases generated from progression of latent TB infection (LTBI) rather than local transmission, concentration to certain vulnerable and hard-to-reach risk groups, and challenges posed by cross-border migration. Common health system challenges are that political commitment, funding, clinical expertise and general awareness of TB diminishes as TB incidence falls. The framework presents a tailored response to these challenges, grouped into eight priority action areas: 1) ensure political commitment, funding and stewardship for planning and essential services; 2) address the most vulnerable and hard-to-reach groups; 3) address special needs of migrants and cross-border issues; 4) undertake screening for active TB and LTBI in TB contacts and selected high-risk groups, and provide appropriate treatment; 5) optimise the prevention and care of drug-resistant TB; 6) ensure continued surveillance, programme monitoring and evaluation and case-based data management; 7) invest in research and new tools; and 8) support global TB prevention, care and control. The overall approach needs to be multisectorial, focusing on equitable access to high-quality diagnosis and care, and on addressing the social determinants of TB. Because of increasing globalisation and population mobility, the response needs to have both national and global dimensions.

The target for TB elimination is to reduce annual incidence to less than one case per million population by 2050. Meeting that target requires a 1,000-fold reduction in incidence in little more than 35 years. This can be achieved only by combining the effective treatment of active TBearly case detection and high cure rates to interrupt transmissionwith methods to prevent new infections and to neutralize existing latent infections. Vigorous implementation of the WHO Stop TB Strategy is needed to achieve the former, facilitated by the effective supply of, and demand for, health services. The latter calls for new technology, including biomarkers of TB risk, diagnostics, drugs, and vaccines. An important milestone en route to elimination will be reached when there is less than 1 TB death per 100,000 population, marking entry into the elimination phase. This landmark can be reached by many countries within 1-2 decades.

Tuberculosis is the number one cause of death from infectious disease globally and drug-resistant forms of the disease are a major risk to global health security. On the occasion of World Tuberculosis Day (March 24, 2018), we provide an up-to-date review of the status of the tuberculosis epidemic, recommended diagnostics, drug treatments and vaccines, progress in delivery of care and prevention, progress in research and development, and actions needed to accelerate progress. This Review is presented in the context of the UN Sustainable Development Goals and WHO's End TB Strategy, which share the aim of ending the global tuberculosis epidemic. In 2016, globally there were an estimated 10·4 million new cases of tuberculosis, and 600 000 new cases with resistance to rifampicin (the most powerful first-line drug). All countries and age groups are affected by tuberculosis, but most cases (90%) in 2016 were in adults, and almost two-thirds were accounted for by seven countries: India, Indonesia, China, Philippines, Pakistan, South Africa, and Nigeria. The sex ratio (male to female) was 1·9 and 10% of patients with newly diagnosed tuberculosis were also HIV-positive. There were 1·7 million deaths from tuberculosis in 2016, including 0·4 million deaths among people co-infected with HIV (officially classified as deaths caused by HIV/AIDS). Progress in care and prevention means that the global mortality rate (deaths per 100 000 people per year) is decreasing by 3·4% per year and incidence (new cases per 100 000 people per year) is decreasing by 1·9% per year. From 2000 to 2016, the annual global number of tuberculosis deaths decreased by 24% and the mortality rate declined by 37%. Worldwide, an estimated 53 million deaths were averted through successful treatment. Nonetheless, major gaps in care and prevention remain. For example, the 6·3 million new cases of tuberculosis reported globally in 2016 represented only 61% of the estimated incidence; only one in five of the estimated number of people with drug-resistant tuberculosis was enrolled in treatment. Pipelines for new diagnostics, drugs, and vaccines are progressing, but slowly. Actions needed to accelerate progress towards global milestones and targets for reductions in the burden of tuberculosis disease set for 2020, 2025, 2030, and 2035 include closing coverage gaps in testing, reporting of cases, and overall access to health care, especially in countries that account for the largest share of the global gap; multisectoral efforts to reduce prevalence of major risk factors for infection and disease; and increased investment in research and development.