The ongoing Covid-19 pandemic has been a massive setback to nearly all areas of global health, from declining childhood vaccination coverage to worsening rates of extreme poverty. Progress in ending tuberculosis (TB) has been particularly hit hard. Last year’s Global TB Report by the World Health Organization (see my post) showed that the pandemic had reversed years of progress. For the first time in years, TB deaths had increased in 2020. The 2022 Global TB Report, released today, shows that both TB deaths and TB incidence increased during 2021. To make matters worse, the burden of drug-resistant TB (DR-TB) also increased by 3% between 2020 and 2021.
According to the WHO report, in 2021, an estimated 10.6 million people fell ill with TB. The incidence rate rose by 3.6% between 2020 and 2021, reversing declines of about 2% per year for most of the past 2 decades. Nearly 1.6 million people died from TB, making TB the second leading infectious killer after Covid-19.
Due to pandemic disruptions of essential health services in both 2020 and 2021, there have been huge and sustained drops in the number of people newly detected with TB. From a peak of 7.1 million in 2019, the number of people with newly diagnosed disease fell to 5.8 million in 2020, back to the level last seen in 2012. In 2021, there was a partial recovery, to 6.4 million, still lower than the pre-pandemic levels. This means, nearly 4.2 million people with TB were either not diagnosed, or not reported to National TB Programs during 2021. This, in turn, meant that people with undiagnosed TB were transmitting the infection to people in their communities. Interruptions in TB treatment, collapse of healthcare systems, worsening of social determinants like poverty, and co-infection with Covid-19 likely increased the number of deaths during the pandemic.
The WHO report notes a decline in global spending on TB services from US$6 billion in 2019 to US$5.4 billion in 2021, which is less than half of the global target of US$13 billion annually by 2022.
Path to recovery
The WHO report calls for intensified efforts along with increased funding to mitigate and reverse the negative impacts of the Covid-19 pandemic on TB. “The need for action has become even more pressing in the context of war in Ukraine, ongoing conflicts in other parts of the world, a global energy crisis and associated risks to food security, which are likely to worsen some of the broader determinants of TB,” the report notes.
“WHO’s Global TB Report makes a strong case on the need to join forces and urgently redouble efforts to get the TB response back-on-track to reach TB targets and save lives,” said Tereza Kasaeva, Director, Global TB Programme, WHO. “We cannot falter in our commitment till we reach and save every person, family and community impacted by this deadly disease. No more excuses and delays – in prioritizing and investing to end one of the top infectious killers,” she added.
It is critical for countries to restore essential health services that include routine TB care and DR-TB care. Ensuring widespread access to Covid-19 tests, vaccines and therapeutics in low-income countries is critical, even as immune-evasive Omicron subvariants are causing new waves.
Improving TB case detection is especially urgent. All countries have scaled up PCR-testing and genetic sequencing capacity for Covid-19, and this expanded capacity could be used for TB testing. Better integration of TB and Covid-19 testing may be helpful during Covid-19 waves. During the pandemic, huge advances have been made (see my post) in digital health tools (e.g. mobile apps), tele-health, use of digital adherence technologies, and home delivery of medicines. All of these could help with the recovery of TB services.
“To reverse the negative impact of Covid-19 pandemic on TB, we must increase funding for TB programs, involve community health workers and TB survivors in framing effective policies, and support patients in every way possible,” said Keyuri Bhanushali, a tuberculosis survivor and advocate in India. Although shorter regimes are now in place, they are not available everywhere, she noted.
Increased funding is also urgently needed to identify new TB drugs and shorter drug regimens, novel vaccines, and true point-of-care tests that can take TB testing closer to people’s homes and communities. Even as efforts are underway to develop such tools, it is critical to scale-up existing WHO-recommended rapid diagnostics and shorter drug regimens.
Dismayed by the continued global backslide in progress against TB, a number of TB and global health organizations, experts and activists have launched a campaign to urge countries to implement new, shorter, stronger, safer, evidence-based TB prevention and treatment regimens, as part of a comprehensive package of patient-centered care.
Inspired by the legacy of Paul Farmer, the 1/4/6×24 Campaign calls for the “staff, stuff, space, systems and support” necessary to make groundbreaking short-course TB prevention and treatment regimens accessible to all who need them as a human right by the end of 2024.
These safer, shorter cures recommended by the WHO for nearly all forms of TB are: one month or once-weekly regimens for TB prevention, four-month regimens for drug-sensitive TB, and six-month regimens for drug-resistant TB – by the end of 2024.
“This campaign is a remedy proposed by a coalition of TB community groups, civil society organizations, survivor networks and their allies to the second year of setbacks felt across all aspects of TB programs since Covid-19,” said Lindsay McKenna, TB Project Co-Director at Treatment Action Group (TAG), one of the organizations involved in coordinating the campaign. “It acknowledges that despite the pandemic, we’re actually sitting in a place of great opportunity. Scientific advances have given us shorter regimens for treating and preventing nearly all forms of TB. WHO has acted quickly to put these regimens into guidelines. Now it’s our responsibility as a global TB community to ensure that people with and at risk of TB can benefit from access to them. Universalizing access to the highest standard of treatment is necessary not only to build back but to go farther than where we were before Covid-19,” she explained.
“The 1/4/6×24 Campaign expands Paul Farmer’s vision of prioritizing care for the most impoverished and vulnerable, which given the startling numbers in the WHO report must include reinvigorating the fight against TB,” said Patrick Ulysse, Chief Operating Officer of Partners in Health.
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