The 2024 Global TB Report – much the same story, but with one startling addition

The WHO’s annual TB Report was published earlier this month, but this year’s has had little fanfare and almost no media attention. Curiously, even doughty MSF appears to have ignored it completely this year (the first time we can recall) even though the disease has been highlighted via press release as having ‘resurged’ to once more be mankind’s most lethal infectious killer. (Readers of these blogs may remember that we reported that this had happened over two years ago, by the way, but hey…).

Despite it being much the same story, there are still some noteworthy observations to make.

Other agencies' comments on this 2024 TB Report

The Treatment Action Group in New York (TAG), for instance, weighed in by stressing how domestic funding for treating TB has declined (last year matching in 2018 only 26% of the budget target agreed at the last UN TB summit that was agreed the same year…) while international aid for TB has plateaued. Not reassuring to consider, since each of the significant annual shortfalls since the first UN summit in 2018 adds up to a cumulative disaster in respect of the total target that was originally set for 2025 and now been shuffled to 2027. Not only is there now no realistic chance of budgetary recovery in this timescale, but TAG also point out that TB endemic countries are revealing new and growing sovereign debts which will inevitably further threaten the future of ongoing TB response and domestic funding.

Peter Sand (the Executive Director of The Global Fund) remains publicly upbeat, meanwhile. “If we act decisively, we can [still] end tuberculosis” he announced, though he’s not that specific when that might be, nor (in truth) about what those decisive actions really are beyond the ones that are already being missed.

The Stop TB Partnership, meanwhile, classifies the progress such as it is recorded in this Report as being either ‘Amazing!’, ‘Good!’, ‘Bad!’, ‘Very Bad!’ or requiring fresh ‘Attention’.

‘Amazing!’ is categorised by the fact that 8.2 million people were diagnosed and put on treatment in 2023 (out of an estimated 10.8 million cases), an all-time record. This is certainly encouraging progress in both number and proportion of cases being treated, but there is still enormous work to do if the 2027 target is to be met.

‘Good!’ (for Stop TB) is that there was another all-time high, this one of people being given TB Preventative Treatment (high-risk individuals being treated for latent infection). This is also true, and is also progress, particularly if compared to the four abysmal years (2018-2022) when these same targets were being abjectly missed by health ministries of countries who had themselves agreed to them back in 2018 at the UN.

Stop TB’s ‘Bad!’, meanwhile, relates to the number of people being diagnosed with rapid molecular tests (agreed by everyone as being a vitally important part of TB diagnosis). This number was "flat-lining" in 2023 when it should have been rising. Stop TB specifically identify that “less than half (48%) of people with TB diagnosed in 2023 had a rapid molecular [bacteriological] test at the time of diagnosis” (which is bad...).  

What they don’t add to this, however, is that a staggering 38% of notified TB cases (i.e. 4 out of every 10) still start drug treatment without any bacteriological confirmation of disease at all! This is something that is way beyond bad considering that we are 31 years into an officially declared global emergency. By now not a single patient enrolled on a TB programme anywhere should be starting multi-drug treatment of six months or longer without any bacteriological diagnosis at all (rapid molecular or otherwise). This isn’t an extreme viewpoint, incidentally, because the very countries who are failing to implement this target agree with this just last year set a target that by 2027 100% of TB cases put on treatment will have been bacteriologically tested.

‘Very bad!’, meanwhile relates to funding, both domestic and international which we have already touched on above, courtesy of TAG.

Dr Cassandra Kelly-Cirino, the Executive Director of The Union (more prosaically known as ‘the International Union Against Tuberculosis and Lung Disease’), amplifies these sentiments in a statement of her own concerning this last Report: “We must confront a harsh reality” she states. “Despite our efforts, we are merely treading water, failing to make significant strides toward our goal of ending TB … This is unacceptable ... There are no more excuses … It’s time for us to be bold and acknowledge that our current strategy is not yielding the results we need - this is a profound injustice.”

These are strong words which, in our opinion, are entirely justified.

It should also be noted, however, that the estimated death toll is reported to have reduced slightly again this year (by 5%) – we suggest that this seems a little miraculous because it was formerly expected to rise for several year after the impact that COVID-19 had on TB programmes with massive reductions in therapeutic take up for two years. The net reduction in the global number of estimated deaths caused by TB between 2015 and 2023 has been 23%, incidentally, almost one-third of the way to the WHO End TB Strategy milestone of a 75% reduction by 2025. We are way off target in other words. The fact that none of the sources quoted above particularly home in on this positive estimated 5% reduction in deaths suggests that we may not be the only ones scratching our head at this part of the Report though superficially, at least, it’s good news.

There may or may not be inaccuracy of estimations or even misrepresentation revealed in this apparent reduction- we can't tell. It’s certainly obvious, though, that the quality of reporting nation-by-nation in these Global Reports is highly variable. What’s more, some of these variabilities may not just reflect struggling under-resourced national TB programmes – sometimes they point more to political interference.

Such nation-by-nation variability makes it effectively impossible to really pick out trends one way or the other that might be genuinely useful and informative which is something that must be desperately frustrating for policy makers. In Mozambique, for instance, the proportion of estimated new cases that are getting enrolled on treatment has nearly doubled in the last 10 years (an unquestionable success story), and yet the estimated incidence rate of newly emerging disease remains almost static (it should have significantly reduced). In India, meanwhile, where there was significant alarm about both potentially emerging numbers of cases and levels of drug-resistance, treatment rates have only been rising in the last two years – and yet estimated incident rates have been being reported as coming down for a decade. In the DPRK, meanwhile (where, because of geopolitical actions and international lack of support, the numbers of cases being started on treatment has fluctuated wildly during the last 10 years), the estimated incident rates remains almost static. In Indonesia (following its prevalence survey that revealed much more TB than was previously being estimated) the rates of patients put on treatment has risen by nearly 100% since 2015. Things do come through slowly with TB, but the rate of new incident disease in Indonesia has only reduced by 25% in this same period.

The thing requiring 'attention'?

Finally, if you are a perceptive reader, you will have noticed that we have failed to comment on the aspect of the Report that Stop TB identified as needing fresh ‘Attention!’. Well, we found it to be the most astonishing and unexpected part of the Report of all because it concerns a previously undiscussed aspect of TB. This is ‘asymptomatic TB disease’ and, because it has a whole set of implications and complexities associated with it, we want to discuss this in some detail in a separate blog to be published shortly.