What COVID has been doing to tuberculosis control...

This unfortunately is a really bad news story relating to the current world of tuberculosis control….

…which emerged for us last week out of what seemed to be otherwise a generally innocent and positive Global Fund for HIV TB and Malaria’s annual report for 2022. It provided information on the current annual state of play with the fight against these three scourges.

’50 million lives saved’ the Report trumpets as its headline, which certainly sounds like something to reasonably be triumphant about. Further on, however, it identifies more details of‘the State of the Fight’ in relation to each of these three diseases. Although the report is far from explicit about the awful state of TB control, when contextualised its contents are frankly terrifying and represent nothing remotely resembling a triumph, in fact it looks more like a car crash.

Before discussing this further, it’s worth identifying that the annual estimated global death toll from TB is more than the sum of the other two diseases the Global Fund 'fights' (HIV and Malaria) combined, but bafflingly year-on year TB only gets a sixth of the total Global Fund budget instead of maybe a half. It is worth keeping this extraordinary anomaly in mind while reading on.

The Global Fund’s Report’s current TB numbers appear to come from the impending WHO Global TB Report which is due to be published next month. In other words, the Global Fund has afforded us a sneak preview of this. Here are the numbers just published.

So let’s identify three of their quoted numbers and then put them into a considerably less triumphant and more proper context.

5.3 million were treated for TB in 2021

That’s a hefty number for sure, but (since the annual incident number of cases will almost certainly have risen because of COVID from the stagnating 10 million new cases per year that has been being regularly estimated for the last decade or so) it actually probably represents only 50% of new cases (we’ll wait for what the WHO have to say on this because this isn’t declared by the Global Fund). We need to remember that TB has been an officially declared ‘Global Emergency’ for almost 30 years now, so this would amount to a truly appalling percentage of cases treated, COVID or no COVID. 5.3 million is also the lowest number treated for around 15 years.

In 2018 a UN target was set for 2022 of treating 40 million in the 5 years running up to this (2018-22) – i.e. averaging 8 million cases treated each year. We have repeatedly pointed out that this was never an appropriately ambitious target because it was asking only to ramp up treatment by around 30% in this crucial period and would still be missing 2 million cases each year. Sadly, last year this number fell from its high point of 7.1 million in 2019 back to 5.8 million (amounting to an 18% decline on pre-pandemic levels). So with only 5.3 million we are now seeing a 25% decline on the high point of 2019.

The Global Fund’s Report, incidentally, sounds rather bizarrely vaguely upbeat about the number it is reporting. As you can see in the image above: “TB programs began to recover in 2021 from the impact of the COVID-19 pandemic, with gains in the number of people on treatment for TB”.

Gains in number of people on treatment? We simply can’t make such a claim compute with their numbers. In fact, 2021 saw a drop of half a million against the previous year.

If we put another way, it looks even worse. If we use the number being treated to estimate how many cases are being missed (which is critical because they are the ones who are going to feed the ongoing cycle of disease) then an even more worrying picture emerges. In 2019 it was reckoned that 2.9 million cases were missed. Now it looks like it’s probably twice that number (again we will have to wait and see what the WHO’s report reckons on this).

110,000 on treatment for MDR-TB

This report gives us no idea what the new estimate for annual incident MDR-TB cases for 2021 will be in next month’s WHO Report, but what we can be sure of is that it simply cannot possibly have reduced. In fact we’ll be surprised (and concerned as well) if it’s not risen significantly because logically it should have done.

Our concern arises because, in our opinion, this incident number has been being serially anyway for years for reasons of expediency (because there has been no appetite to do otherwise because of lack of resource to treat MDR cases).

All we can say is with certainty, however, is that this number of MDR cases being treated (110,000) is 37% lower than the number treated in 2019 (177,000). The five year cumulative target for 2018-22, moreover, was to treat 1.5 million, but at current rates it will take, not 5, but 13 years to hit this target. This is a catastrophe because MDR cases that aren’t treated inevitably infect others and create more drug-resistance.

395,000 were put on preventative treatment

This number, as innocent as it sounds, is unbelievably awful if it’s true (and we hope it’s a mistake). This is because the preventative treatment roll-out for the previous year (2020) was 2.8 million (so the current number amounts to an 86% collapse) and that itself was down from 3.6 million from the year before.

In light of this, this new total that amounts to a car crash.

So exactly what is the idea behind preventative treatment is? Of course, it’s to prevent more active TB emerging; it’s to strangle the cycle of ongoing infection. So with over 10 million new infections (and rising) does anyone seriously expect the incidence of new infectious cases to be dropping any time soon with this paltry number of treatment prevention? It looks like no National TB Program (or indeed anyone in Geneva) is taking this target seriously any more.

But this target for the 5 years 2018-20 was set by ALL of the countries of the world back in 2018 at the UN, and the running total three pre-pandemic was already totalling only 29% of the cumulative target. Now (with this slump in treatment) this running total has barely been raised by a single further percentage point.

According to these three numbers that the Global Fund seem to be projecting positively as a recovery, there is something dreadfully wrong in the world of TB.

We will watch out for the annual WHO Report, as we do every year, but we do so this year now with real trepidation.