The WHO's new WHO Global Tuberculosis Report - what one disease has been doing to another...

On 14th October the WHO released its annual Global Tuberculosis Report. Its contents make for grim reading. We review its alarming contents below, contextualized from the outset by the Report’s own conclusions which included the following devastating understatement:

‘This report shows that progress towards TB milestones and targets has been hit hard by the COVID-19 pandemic … Global TB targets are mostly off-track.’

What follows reviews through the Report topic-by-topic, reviewing just how ‘off-track’ these targets are and exposing why the Report's conclusions so devastatingly understate the situation.

1. Deaths from TB in 2020

TB deaths have increased for the first time in a decade, though intriguingly, the estimated increase that has been reported is actually not that dramatic (rising from 1.4 million to 1.5 million). We've suggested in several previous blogs that the annual estimates may be a little under-pegged anyway because they don’t appear to appropriately allow for the growing prevalent number of MDR-TB cases but, be that as it may, the headline in the respect of deaths in this Report shouldn't be about those occurring in the year under review (2020) but for those to come:

‘TB mortality is projected to be much higher {in 2021] than in 2020.’

Note – not just 'higher' but ‘much higher’.

In this year’s Report the extra deaths were most probably caused by drug stock-outs, lack of diagnostics, and the switching of human resource from TB programmes to COVID programmes etc. They comprise the first casualties of the current disruptions but do so because they were already being treated and so were in the immediate firing line from a disruption to services.

The slower effects are yet to show but existing estimates already predict a far more significant rise which will totally reverse the End TB target for reduction of deaths. We'll have to wait and see by how much.

2. Numbers of people infected with TB

These have basically neither risen nor fallen. With deaths estimated to have risen, it may seem curious that incident cases appear not to have done the same, stalling at around 10 million, but with TB things typically come through slowly. In the absence of preventative therapy (which we’ll come to later) there logically has to be more infectious TB circulating in the community for more cases to emerge. Given the relative slow cyclical emergence of active infectious TB from initial infection, this takes time to come through, so there is every reason to predict a significant rise in incident numbers in the next years.

In fact this is appropriately identified:

‘These impacts are forecast to be much worse in 2021 and 2022.’

Here again in respect of case numbers we see that ominous words ‘much’.

Meanwhile here’s a world map of where most TB cases are believed to have occurred in 2020:

Its shadings are very much the same as previous years. So what should we expect? Basically the shadings are likely to get darker in the coming years. The Report itself reckons that infections will peak in the Report after next year. Much as we'd rather that cases didn't rise at all, we hope they're right in this (and we fear they may not be). We discuss this probability in the next section.

Here's the sentence on this from the Report:

‘The biggest impact on TB incidence is forecast to be in 2022.’

And our conclusion? In relation to the incidence target for incidence, we are now way off track.

3. The number actually treated in 2020

This number dropped substantially during 2020 (which incidentally makes the estimates of incidence that bit more uncertain than it is already, so is an additional worry).

‘This fell from 7.1 million in 2019 to 5.8 million in 2020, an 18% decline back to the level of 2012 and far short of the approximately 10 million people who developed TB in 2020 [amounting to] 4.1 million [or 41% of] people not diagnosed with the disease, or not officially reported to national authorities in 2020, up from 2.9 million in 2019.’

It's not just that this 41% weren't treated, of course. Reality predicts that these extra 1.2 million untreated people will infect a significant number of other extra individuals, creating a further cyclical increase of untreated cases unless significant steps are made to find and treat them. This means that the forecast that the rise in incidence will peak in 2022 is fundamentally dependent on the capacity to reinstate the infrastructures available that failed to adequately treat TB and do this in this current year of 2021.

There is no evidence in the Report or anywhere else that this is currently happening.

Regarding the target set at the UN in 2018, we actually considered this target to be shamefully modest and easily reached (identifying this previously). Sadly, it looks like even this target may now be missed.

4. The numbers of drug-resistant (MDR-TB cases put on treatment during 2020

Drug-resistant TB remains our most acute concern, largely because we remain convinced that this aspect of global health is under-addressed, under-reported and still massively undiagnosed. What this Report contains on the subject is unfortunately anything but reassuring.

First of all there was a fall of 22% of MDR-TB cases detected – which was not in any way due to reductions in incidence. In fact it was almost certainly caused by supply problems with diagnostics and also because in some countries existing precious diagnostics were switched from TB to detecting SARS-CoV-2 infections.

The fact that this 22% reduction of those detected is not that far adrift from the reduction in the total number of new diagnoses with normal TB (18%) is at least a little reassuring because it suggests that MDR-TB services in 2020 were only marginally more affected by COVID than TB services generally were. But that’s where the good news ends because there was also a reduction in those enrolled on treatment:

‘Worldwide, with 150,359 people with MDR/RR-TB were enrolled on treatment in 2020, down 15% from the total of 177 100 in 2019 … (about 1 in 3 of those in need).’

This ‘1 in 3’ estimate really troubles us.

We note that the Report records that only ‘about 1 in 3 of those in need’ of MDR-TB treatment were put on treatment in 2020, and suggest that this is a revealing misrepresentation because the true number of those ‘in need’ (as the WHO know as well as anybody) do not only comprise annual incident cases who developed DR disease during 2020. They also include all those prevalent cases who have survived from previous years and, given that a typical TB case can frequently survive three years or more before succumbing to their infection, the number of those who are really ‘in need’ of treatment must more probably be nearly 2 million. This would mean that as few as 1 in 10 of ‘those in need’ of treatment for MDR-TB were provided with treatment during 2020, and (given the poor success rate of those in treatment of 60%) meaning that only 1 in 17 cases in 2020 can expect be come back to health cured. And this, of course, is nowhere close to 1 in 3. The failure to identify this properly is, in our view, a misleading aspect on the part of the Report.

Notwithstanding this, the Report is nevertheless unequivocal about immediate prospects for targets for MDR-TB - that as a component of this current crisis it remains extremely serious and inadequately addressed:

‘Reversals in progress in the number of people enrolled on treatment mean that the global targets set at the UN high-level meeting appear increasingly out of reach.’

We hate to say that this, but the targets for MDR-TB aren't 'increasingly out of reach': they were actually always out of reach because there were never the appropriate funding targets set to resource a proper response to this part of TB in lower income countries (where national targets that were set were impossibly high from the outset without them).

5. Preventative Treatment

Preventative treatment, broadly speaking, means picking up the close contacts of known infectious cases and putting them on a course of preventative treatment that can be expected to reduce their chances of developing active TB disease themselves (and therefore also infecting others). This is a critically important aspect of TB control because it can effectively break the cycle of infection. The news in respect of the targets set at the UN in 2018 in respect of this was already bad in last year’s Report. In this one they go from bad to really serious but we need to pick the numbers apart to really understand why.

‘Other impacts include … TB preventive treatment (-21%, from 3.6 million to 2.8 million).’

‘This probably reflected disruptions to health services caused by the COVID-19 pandemic. The combined total of 8.7 million in 2018–2020 is only 29% of the target of 30 million for the 5-year period 2018–2022. Most of those provided with TB preventive treatment to date have been people living with HIV.’

This last sentence is the important one because it indicates the only reason that this overall shortfall isn’t much worse still. It reveals how HIV cases were being picked up for preventative TB treatment in 2020 by HIV programmes (not TB programmes). This discrepancy isn't new – we identified it this time last year in fact. TB programmes in high burden countries were simply not addressing this issue despite those targets agreed at the UN.

What’s now made this so much worse, of course, is COVID-19, but the current numbers strongly suggests that HIV services have fared much better than TB ones in this troubled year, and we should be urgently asking why this is. For us, it's one more example of how relatively neglected TB remains in the field of global health in spite of its rolling appalling death toll (far higher than that from HIV, incidentally).

This discrepancy is far from insignificant as we can see when we review the numbers. While the 2022 target for preventative therapy provision for people living with HIV (as agreed by all members states at the UN in 2019) has not just been met but is already exceeded by 20% (two years ahead of target), the target for household contacts of TB cases currently currently lurks shamefully in the shadows of the achievements in HIV at a truly appalling 94% deficit (in other words it has barely even been touched).

These are the two targets that make up this truly appalling deficit - household contacts both older than 5 years of age and lyounger, both of whom had targets set for them by the UN.

6. Funding shortfalls

Funding issues lie behind everything, of course. If programmes are not adequately resourced those relevant countries will never succeed in meeting their targets. And sadly funding for TB during 2020 fared badly, both in terms of general treatment provision and research.

Firstly for general treatment provision.

‘Other impacts include … a fall in global spending on TB diagnostic, treatment and prevention services (from US$ 5.8 billion to US$ 5.3 billion, less than half of what is needed).’

The Report records that the vast proportion of funding for TB services never comes from international donors, but mainly comes from domestic resources. This vital domestic resource reduced by more than 10% during 2020 (no doubt because of pressures on health budgets because of COVID) - but this year’s reduction follows in the wake of a trail of annual reports recording similar funding shortfalls, each one logged at less than half of the targeted annual need. In fact 2020's US$5.3 billion is worrying closer to a third of the annual target than a half - the sort of levels at which no progress with TB control can be anticipated.

But let us insert some necessary realism in here as well. The true shortfall towards the target isn’t merely annual – it’s obviously cumulative – and so, as of 2021, it is no longer ‘less than half what’s needed’ at all. In respect of the final target it's considerably less than this and needs to be reported that way. If viewed cumulatively as it should be (not annually) the necessary hike that is now required is not a bit over 100% for the next two years – it now requires an annual hike for both 2021 and 2022 of around 400% for the target to be met!

And the same thing applies to funding for TB research (with the annual target unanimously set at the UN in 2018 of US$2 billion annually, but current research expenditure similarly less than half this). So again, a hike of around 400% is required to see this target met as it should be.

And we can't help but identify the relality that the total gross cost of these two hikes over the next two years is actually nothing if compared to the monumental expenditure being lavished on researching diagnostic, treatment and vaccine technologies for COVID-19.

Conclusions

Drawing a conclusion is simple: this year’s Report is troubling in the extreme. So what to do?

The Report’s own conclusion at least suggests where to start:

‘The immediate priority is to restore access to and provision of essential TB services such that levels of TB case detection and treatment can recover to at least 2019 levels, especially in the most badly-affected countries.’

This still won't see most of the targets near met, but at least it will see an appropriate focus on recovery. We suspect that in fact there is MUCH more needed to getting back to 2019 levels than is identified in the Report. With that achieved, there is then the second fundamental requirement of getting thing back on to a downward trajectory (targets or no targets). It's a shame, we think, that the Report fails to really highlight how much is needed

We feel it best, however, to leave the final words to two major global players (both of whom we massively respect). Firstly, to Lucia Ditiu, Executive Director of the Stop TB Partnership, who has been responsible for so much of the progress that was being made before COVID-19 hit. She particularly identifies that it's not just COVID-19 that has done the damage - it's the ongoing shamefully deficient political response to this emergency and the consistently deficient funding levels that lie at the root of the mountainous problem that now exists:

"Unfortunately, today's report confirms what we all feared—that more and more people are dying from TB. … it is a reality. The COVID-19 pandemic combined with low political will and appallingly low levels of funding have reversed hard-fought gains in the fight against this age-old disease. People are dying because we are failing to empower and support them and failing to ensure they have access to the preventive therapy, diagnostic tools, and treatments they need … It's time to move beyond empty promises, roll up our sleeves, and put our money where our mouth is. I am afraid we are running out of time, and we need speed, money, and commitment today if we want to make a dent in the TB epidemic."

And secondly to to Dr Tedros, Director General of the WHO, quoting from the introduction to the Report itself, where he identifies that, lying behind the devastation caused by this plague (even more so than COVID-19), is basic inequality.

‘I want to remind you that the struggle to end TB is not just a struggle against a single disease. It’s also the struggle to end poverty, inequity, unsafe housing, discrimination and stigma, and to extend social protection and universal health coverage .... with the same solidarity, determination and equitable use of tools [that we're using to defeat COVID-19], we can end TB.’