Impact of the TB response in Taiwan

Taiwan’s demographic and public health infrastructure has been central to shaping its TB control efforts. The island has experienced rapid demographic transitions, with fertility rates dropping from 7 births per woman in 1951 to 1.09 in 2023, one of the lowest globally. By 2023, only 135,571 newborns were registered, marking the lowest in history, while 18% of the population was aged 65 years or older—a figure projected to reach 20% by 2025, classifying Taiwan as a super-aged society. Despite these demographic pressures, Taiwan has achieved substantial progress in TB control, reducing incidence from 73 per 100,000 in 2005 to 28 in 2023, with mortality dropping from 4.3 to 1.9 per 100,000 over the same period.

These achievements reflect long-standing investments and political commitment. The Taiwan CDC, established in 1999, integrated TB control under a centralized framework, with funding fully covered by the central government. The National TB Program (NTP) introduced milestone initiatives, including the “Ten-Year Halving Tuberculosis Plan” (2006–2015), followed by the “End TB by 2035 Project” (Phase I: 2016–2020; Phase II: 2021–2025), with preparations for Phase III underway. Mandatory case reporting under the Communicable Disease Control Act is strictly enforced, with penalties for physicians and institutions failing to report, while surveillance systems such as the Notifiable Infectious Disease Reporting System (NIDRS), Laboratory Automated Reporting System (LARS), and the National TB Management System ensure comprehensive monitoring and timely data integration.

Taiwan’s National Health Insurance (NHI) plays a crucial role by ensuring universal coverage for 99% of residents. Since 1997, the “No Reporting, No Reimbursement” policy has tied reimbursement of TB services to mandatory notification, incentivizing complete case reporting. Patients can access TB diagnosis and treatment through all hospitals and nearly 90% of private clinics contracted with NHI. To encourage timely diagnosis and treatment, copayments for TB and latent TB infection (LTBI) patients are fully reimbursed by Taiwan CDC, and care for uninsured individuals is also covered. This financial safety net has minimized both patient delays and health system delays in seeking TB care.

A comprehensive patient support structure strengthens these systems. Around 700 TB case managers under a Pay-for-Performance (P4P) scheme coordinate care between clinics and public health services, while 2,500 public health nurses at 374 centers provide education, monitor adherence, and conduct contact tracing. Since 2006, Taiwan has adopted a people-centered Directly Observed Therapy (DOT) program, with government-employed DOT workers assigned to each patient. This model has significantly reduced treatment interruption, loss to follow-up, and TB-specific mortality, maintaining recurrence rates below 1% since 2008. In 2015, Taiwan introduced electronic DOT (eDOT) to enhance accessibility and privacy, which gained renewed traction after the launch of eDOT 2.0 in late 2023.

Special attention has also been given to foreign-born populations, particularly migrant workers, who exceeded 700,000 in 2023 and now account for over 9% of TB cases. Health examinations are mandated shortly after arrival and at regular intervals. Previously, workers diagnosed with TB were repatriated, but regulatory changes since 2014 have allowed them to stay for treatment under DOT. Further amendments in 2015 and 2022 shifted the decision-making power to workers themselves, dramatically increasing the proportion remaining for treatment from 10.6% in 2014 to nearly 89% in 2022. These reforms have improved TB notification among foreign patients, raising timely reporting rates to over 96%.

To alleviate the economic burden of TB, Taiwan provides targeted financial support. The Taiwan Anti-Tuberculosis Association offers an annual grant of USD 31,000 to support low-income patients lacking social welfare resources. A 2018 National TB Patient Catastrophic Cost Survey revealed that 22% of non-MDR-TB and 45% of MDR-TB households experienced catastrophic costs, primarily due to income loss and non-medical expenses rather than direct medical fees. Low household income, stigma, and inpatient care were identified as key risk factors for financial hardship. Taiwan’s system of subsidies, reimbursement of copayments, and dedicated grants reflects its commitment to reducing financial barriers and ensuring equitable access to TB treatment.

Source: Chan, P.C., Chiang, C.Y., Lee, P.H., Lo, H.Y., Chu, P.W., Chen, J.J., Kato, S. and Raviglione, M.C.B., 2025. Assessing the impact of the TB response in Taiwan–the journey towards ending TB. IJTLD open, 2(5), pp.251-259.

Tuberculosis in Patients With Chronic Mental Illness

Patients with mental illness were found to have a significantly higher risk of developing tuberculosis (TB). To investigate this association, this study utilized the National Health Insurance Research Database (NHIRD), a nationally representative dataset in Taiwan, to assess TB incidence among patients with chronic psychiatric disorders—including schizophrenia, bipolar disorder, schizoaffective disorder, and major depressive disorder—compared to the general population. Patients diagnosed between 2002 and 2013 were identified through the Catastrophic Illness Registry, which ensures strict clinical verification and captures only severe and persistent mental illness cases. After excluding individuals with conditions such as type 1 diabetes, cirrhosis, cancer, dialysis, HIV, past TB, and amended diagnoses, a total of 162,377 subjects were included in the analysis. TB cases were defined using the Tuberculosis Database, which requires positive culture results, radiographic abnormalities, and diagnostic confirmation.

The study population consisted of 162,161 mental illness patients and 810,805 matched controls, with no significant baseline differences in sex, age, income, urbanization level, comorbidity index, or major comorbidities, confirming effective propensity score matching. Results showed consistently higher TB incidence in mental illness patients overall (87 vs. 71 per 100,000 person-years), across both sexes, and most age groups. The difference was particularly pronounced in those aged 65 years or older (278 vs. 195). TB incidence was also higher across nearly all income levels and urbanization strata, except for rural towns where rates were slightly lower in patients with mental illness. Importantly, the elevated TB incidence was observed regardless of the presence of type 2 diabetes mellitus or chronic kidney disease.

After adjusting for confounding variables, the conditional Cox proportional hazards model confirmed a 1.48-fold increased risk of TB among patients with mental illness (95% CI: 1.38–1.59). Additional risk factors included older age, which showed a steep increase in hazard ratios (HRs ranging from 1.86 for ages 20–34 to 21.82 for ≥65 relative to <20), and lower income, which was inversely associated with TB risk. Comorbidities such as type 2 diabetes (HR: 1.22) and chronic kidney disease (HR: 1.24) further heightened susceptibility. Cumulative incidence curves demonstrated a persistently higher rate of TB in the mental illness group compared with the general population, underscoring the need for targeted TB screening and preventive strategies for this vulnerable population.

Source: Hung, L.C., Kung, P.T., Tsai, T.H., Tsai, W.C. and Huang, K.H., 2025. Risk Assessment of Tuberculosis in Patients With Chronic Mental Illness and Related Factors: A Population‐Based Cohort Study in Taiwan. The Clinical Respiratory Journal, 19(6), p.e70088.