Service on Health Issues (Nov20/01)
Geneva, 2 Nov (Kanaga Raja) – The COVID-19 pandemic threatens to reverse recent progress made in reducing the global burden of tuberculosis (TB), the World Health Organization (WHO) has said.
In its Global Tuberculosis Report 2020 released recently, WHO said that the global number of TB deaths could increase by around 0.2-0.4 million in 2020 alone, if health services are disrupted to the extent that the number of people with TB who are detected and treated falls by 25-50% over a period of 3 months.
In India, Indonesia, the Philippines and South Africa, four countries that account for 44% of global TB cases, there were large drops in the reported number of people diagnosed with TB between January and June 2020, it added.
According to the report, the economic impact of the pandemic is predicted to worsen at least two of the key determinants of TB incidence: GDP per capita and under-nutrition.
Modelling has suggested that the number of people developing TB could increase by more than 1 million per year in the period 2020-2025.
“The impact on livelihoods resulting from lost income or unemployment could also increase the percentage of people with TB and their households facing catastrophic costs,” said WHO.
Negative impacts on essential TB services include the reallocation of human, financial and other resources from TB to the COVID-19 response, it added.
According to WHO, many countries have reported the use of GeneXpert machines for COVID-19 testing instead of diagnostic testing for TB (43 countries including 13 high TB burden countries), reassignment of staff in national TB programmes to COVID-19 related duties (85 countries including 20 high TB burden countries), and reallocation of budgets (52 countries including 14 high TB burden countries).
“In the face of the pandemic, countries, civil society and other partners have joined forces to ensure that essential services for both TB and COVID-19 are maintained for those in need,” said Dr Tereza Kaseva, Director of the Global TB Programme at WHO.
“These efforts are vital to strengthen health systems, ensure health for all, and save lives,” she added.
According to the WHO report, since the beginning of 2020, the COVID-19 pandemic has caused enormous health, social and economic impacts, which are likely to continue in 2021 and beyond.
Even after some of these impacts have been mitigated or contained, there will be medium- and longer-term consequences, including for the tuberculosis (TB) epidemic and response, it said.
“The pandemic threatens to reverse the progress made towards global TB targets by the end of 2019,” the report cautioned.
WHO said two modelling analyses have reached similar conclusions about the potential impact of the COVID-19 pandemic on global TB deaths, suggesting that the annual number could rise to the levels seen in 2015 or even 2012.
If the number of people with TB detected and treated were to fall by 25-50% over a period of 3 months – a range considered plausible based on data from several high TB burden countries – there could be between 200,000 and 400,000 excess TB deaths in 2020, bringing the total to about 1.6-1.8 million, said WHO.
An increase of 200,000 would take the world back to 2015 levels and an increase of 400,000 to 2012 levels, it added.
WHO also said that the COVID-19 pandemic is likely to have a medium-term impact on the number of people who develop TB each year.
Although physical distancing policies may help to reduce TB transmission, this effect could be offset by longer durations of infectiousness, increased household exposure to TB infection, worsening treatment outcomes and higher levels of poverty.
“In the absence of effective mitigation strategies, such as social protection and health insurance, severe economic contractions and loss of income (particularly among the most vulnerable populations) are likely to worsen some of the factors that determine TB epidemics, especially the prevalence of under-nutrition,” said WHO.
The report cited a study by The Stop TB Partnership that suggested that the COVID-19 pandemic could cause an additional 6.3 million TB cases globally between 2020 and 2025.
According to WHO, there is already evidence from several high TB burden countries of large reductions in the monthly number of people with TB being detected and officially reported in 2020, especially in India, Indonesia, the Philippines, Sierra Leone and South Africa.
PROGRESS TOWARDS GLOBAL TB TARGETS
The WHO report also provided an overview of progress made towards the global TB targets by the end of 2019.
According to WHO, the global TB targets for the period 2016-2035 have been set as part of the United Nations Sustainable Development Goals (SDGs), the World Health Organization (WHO) End TB Strategy and the political declaration of the UN high-level meeting on TB held in September 2018, which reaffirmed the SDG and End TB Strategy targets and established new targets for the numbers of people to be provided with TB treatment and TB preventive treatment during the period 2018-2022, as well as new targets for the funding to be mobilized between 2018 and 2022, based on the Stop TB Partnership’s Global Plan to End TB.
While progress towards TB targets has been made at global, regional and national levels, none of the targets is on track to be achieved worldwide, WHO said.
Of great concern is the fact that progress made by the end of 2019 could be reversed by the COVID-19 pandemic, it added.
According to WHO, globally, the TB incidence rate is falling, but not fast enough to reach the first milestone of the End TB Strategy, that is, a 20% reduction between 2015 and 2020.
Worldwide, the cumulative reduction from 2015 to 2019 was 9% (from 142 to 130 new cases per 100,000 population), including a reduction of 2.3% between 2018 and 2019.
More positively, the WHO European Region has almost reached the 2020 milestone, with a reduction of 19% between 2015 and 2019, and the African Region has made good progress, with a reduction of 16%.
Reductions in other WHO regions were 3.5% in the Eastern Mediterranean Region, 8.7% in the South-East Asia Region and 6.1% in the Western Pacific Region.
In the WHO Region of the Americas, incidence is slowly increasing, owing to an upward trend in Brazil.
A total of 78 countries are on track to reach the 2020 milestone, including seven high TB burden countries that have already reached it (Cambodia, Ethiopia, Kenya, Namibia, the Russian Federation, South Africa and the United Republic of Tanzania) and three others that are on track (Lesotho, Myanmar and Zimbabwe), said WHO.
In 2019, 54 countries had a low incidence of TB (less than 10 cases per 100,000 population per year), mostly in the WHO Region of the Americas and European Region, plus a few countries in the Eastern Mediterranean and Western Pacific regions.
These countries are well placed to target TB elimination, said WHO.
WHO also said that in absolute numbers, about 10.0 million people fell ill with TB in 2019. Of these, 56% were men, 32% were women and 12% were children (aged less than 15). Overall, 8.2% of people with TB were living with HIV.
Worldwide, TB is the leading infectious disease killer and one of the top 10 causes of death overall, it noted.
In 2019, it caused 1.4 million deaths, including 208,000 among HIV-positive people.
The annual number of TB deaths is falling globally, but not fast enough to reach the first milestone of the End TB Strategy, that is, a 35% reduction between 2015 and 2020, said WHO.
The cumulative reduction between 2015 and 2019 was only 14%, less than halfway towards the milestone.
The WHO European Region is on track to reach the 2020 milestone, with a 31% reduction from 2015 to 2019, and the African Region has made good progress, achieving a reduction of 19%.
Reductions in other WHO regions were 6.1% in the Americas, 11% in the Eastern Mediterranean, 10% in South- East Asia and 17% in the Western Pacific.
A total of 46 countries are on track to reach the 2020 milestone. This includes seven high TB burden countries that have already reached it (Bangladesh, Kenya, Mozambique, Myanmar, the Russian Federation, Sierra Leone and the United Republic of Tanzania) and one other that is on track (Viet Nam).
According to WHO, globally, the annual number of people reported to have been provided with treatment for TB disease has grown in recent years, from about 6 million in 2015 to 7.0 million in 2018 and 7.1 million in 2019.
The annual number of people reported to have been provided with treatment for multi-drug- or rifampicin-resistant TB (MDR/RR-TB) disease has also grown, from a global total of 122,726 in 2015 to 156,205 in 2018 and 177,099 in 2019.
The cumulative total of 14.1 million people treated for TB in 2018 and 2019 was 35% of the cumulative 5-year (2018-2022) target of 40 million.
For children, the combined total was 1.04 million (about 0.5 million in each year), 30% of the way towards the cumulative 5-year target of 3.5 million.
A total of 42 countries, including 13 of the 30 high TB burden countries, reported that the number of people treated for TB increased by 10% or more between 2017 and 2019, while TB incidence in these countries was estimated to have slowly declined.
WHO said that increases in absolute terms were particularly large in two high TB burden countries, India and Indonesia, at 513,000 people (+31%) and 120,000 people (+27%), respectively.
The total number of people treated for MDR/RR-TB in 2018-2019, at 333,304, was 22% of the way towards the 5-year target of 1.5 million. For children, the total was 8,986, less than 10% of the 5-year target of 115,000.
In 70 countries, the number of people reported to have been enrolled in treatment for MDR/RR-TB increased by 10% or more between 2017 and 2019.
The five countries with the biggest increases in absolute numbers were (in descending order) India, China, the Russian Federation, Indonesia and Angola.
WHO also said that the number of people provided with TB preventive treatment has increased in recent years, from 1.0 million in 2015 to 2.2 million in 2018 and 4.1 million in 2019.
Most of those provided with TB preventive treatment were people living with HIV: 1.8 million in 2018 and 3.5 million in 2019.
India and South Africa accounted for 25% and 18% of the combined total for 2018-2019, respectively.
The 6.3 million people started on TB preventive treatment in 2018 and 2019 was 21% of the way towards the 5-year target of 30 million, with progress for household contacts lagging far behind, said WHO.
For people living with HIV, the sub-target of 6 million is on track to be met in 2020, it added.
Funding for TB prevention, diagnosis, treatment and care in 121 low- and middle-income countries has reached US$6.5 billion in 2020, up from US$6.1 billion in 2017 and US$5.6 billion in 2015.
WHO said even allowing for the fact that there will have been additional funding in the remaining 14 low- and middle- income countries, and in high-income countries, funding falls far short of the UN high-level meeting target of at least US$13 billion per year by 2022, adding that to reach the target, funding needs to approximately double.
Overall, most funding (85%) comes from domestic sources. However, aggregate figures are strongly influenced by the BRICS group of countries (Brazil, Russian Federation, India, China and South Africa), said WHO.
The BRICS countries account for 57% of available funding in 2020, 97% of which is from domestic sources.
In other low- and middle-income countries, international donor funding remains crucial, said the report.
In 2020, such funding accounted for 44% of the funding available in the 25 high TB burden countries outside BRICS and 57% of funding in low-income countries.
Funding for TB research has grown in recent years, said WHO, adding that it reached US$906 million in 2018, up from US$772 million in 2017.
However, this amount was less than half of the UN high-level meeting target of US$2 billion per year, it added.
Meanwhile, in response to WHO’s Global TB Report 2020, Sharonann Lynch, Senior HIV/TB Policy Advisor at Medecins Sans Frontieres (MSF) Access Campaign, said: “Two years after global leaders agreed to give TB the attention the world’s deadliest infectious disease deserves, it’s disheartening to see that governments are not on track to reach testing and treatment goals.”
“TB has remained a burden throughout the course of human history, so isn’t it about time that governments got more serious about tackling this killer disease?,” she added.