Tuberculosis control: getting back on track in the era of COVID-19
A new report by WHO has laid bare the worrying extent to which the COVID-19 pandemic has disrupted efforts to combat tuberculosis. At the centre of the 2022 Global Tuberculosis Report are the statistics on case notifications. In 2019, the year before the COVID-19 pandemic was declared, 7·1 million new cases of tuberculosis were reported worldwide. In 2020, this number dropped to 5·8 million, before recovering somewhat to 6·4 million in 2021. WHO is confident that the reduced number of reported cases of tuberculosis does not represent a genuine drop in the disease burden. The most likely explanation is, instead, that the first 2 years of the pandemic saw dramatically reduced access to health care and diagnostic services.
WHO reckons that about 3 million new cases of tuberculosis were missed in 2019, making a total of just over 10 million cases for the year. More than 4 million cases are thought to have been missed in both 2020 and 2021, leaving the estimated total number of new cases at 10·1 million for 2020 and 10·6 million for 2021. The upward trend stands in stark contrast to the slowly declining incidence of tuberculosis in the years leading up to 2019. “It is a bleak picture”, said Tereza Kasaeva, Director of the WHO Global Tuberculosis Programme. “We have had large numbers of people with undiagnosed and untreated tuberculosis in the community.”
The data on mortality reflect the seriousness of the situation. Having fallen every year from 2005 to 2019, the number of estimated deaths from tuberculosis increased from 1·4 million in 2019 to 1·5 million in 2020 and 1·6 million in 2021. The number of new cases of drug-resistant tuberculosis gradually fell from 2015 to 2020. The trend was reversed in 2021, with an estimated 450 000 new cases, up from 437 000 in the previous year. Moreover, the number of individuals who received treatment for drug-resistant tuberculosis fell from 181 533 in 2019 to 150 469 in 2020. It rose to 161 746 in 2021, but this still represents only around a third of those who require treatment.
“We have seen de-prioritisation of tuberculosis services and care, and the needs of the poorest people”, Kasaeva told The Lancet Respiratory Medicine. “We were already struggling with funding, and during the pandemic there was repurposing of the limited funds”. Spending on tuberculosis in low-income and middle-income countries stood at US$6 billion in 2019. It dropped to $5·4 billion in 2021. Yet at the 2018 UN high-level meeting on tuberculosis, member states agreed to the release of US$13 billion annually for prevention and treatment activities by 2022, and to $2 billion for research and development in each year from 2018 to 2022. In 2020, spending on tuberculosis research was just $915 million.
There was further bad news from the Seventh Replenishment Conference of the Global Fund to fight AIDS, Tuberculosis and Malaria, which was held on Sept 18–21, 2022. The Global Fund has requested a minimum of $18 billion to finance its activities from 2023 to 2025. By the end of the conference, it had received pledges totalling $14·25 billion. The Global Fund dominates international donor funding for tuberculosis. Such funding represents half of the available resources to tackle tuberculosis in 26 of the 30 high-burden countries. However, the Global Fund reserves no more than a quarter of its resources for tuberculosis, despite the fact that the disease kills more people than HIV/AIDS and malaria combined.
“The cost of ending tuberculosis has gone up, because of the setbacks that happened as a result of the COVID-19 pandemic”, commented Suvanand Sahu, Deputy Director of the Stop TB Partnership. “Countries are going to have to spend a lot of money on aggressive case detection, treatment, and prevention activities.” He noted that the consequences of the missed cases are likely to linger. “When you have a period in which tuberculosis is uncontrolled, there is a lag before the increases in infections and mortality are fully apparent”, said Sahu. Unpublished modelling work from WHO indicated that 2022 could see a peak in deaths from tuberculosis.
The WHO report also notes that the COVID-19 pandemic is likely to have stalled or reversed progress in achieving not only global tuberculosis targets, but also universal health coverage, which will in turn affect prevention and control of tuberculosis. The ongoing armed conflicts, energy crisis, and rampant inflation that have beset countries across the world will compound the problem. “Undernutrition is one of the key drivers of tuberculosis”, said Kasaeva. “We are seeing rising poverty and food insecurity, and that will certainly have an impact on tuberculosis.”
Much depends on the speed at which high-burden countries are able to get back on track. “We need to see urgent efforts and rapid success in catching up on diagnosing people with tuberculosis to mitigate the effects of the pandemic”, said Katherine Floyd, who led the team that produced the Global Tuberculosis Report 2022. “Unless that happens, we will be continually adding to the number of undiagnosed people in the community, leaving them at high risk of dying from tuberculosis and infecting others.”
Source: The Lancet Respiratory Medicine
