Detection of cases, diagnostics, treatment go for complete toss; deaths increase for first time
The world suffered huge reverses in progress towards tuberculosis (TB) elimination in 2020, thanks to the novel coronavirus disease (COVID-19) pandemic. And, India has been the worst-hit.
These are major findings of the Global TB report released by the World Health Organization (WHO) October 14, 2021. The Philippines and Indonesia were also severely impacted.
The biggest impact was felt in terms of detection of new cases. This means a large number of cases went undetected due to highly curtailed access to diagnostics and restrictions imposed to contain the pandemic. From 2016-2019, the number of new cases rose continuously, but fell dramatically to 20 per cent in 2020.
The big global drop in notifications of TB cases in 2020, as compared with 2019, means that the gap between the number of people who actually got the disease and the new people who got diagnosed “widened substantially” in 2020. The report estimated that gap to be around 4.1 million cases.
“This was a major reversal of previous progress in closing the gap between 2012 and 2019,” the report noted, adding that the world has now gone back to the levels of 2012.
India contributed the biggest drop in detection of new cases. Some 41 per cent of the total number of cases that dropped in 2020, as compared to 2019, came from India. Thus, a large chunk of TB cases went missing in the country.
Besides, Indonesia (14 per cent), the Philippines (12 per cent) and China (8 per cent) and 12 other countries accounted for 93 per cent of the total global drop of 1.3 million cases.
This fact can be looked at from another perspective. When the world was making strides in closing the gap between people who actually got sickened and diagnosed with TB from 2013-19, India and Indonesia were the biggest contributors to this achievement. Now, these very countries are the two biggest laggards.
The general reasons cited in the report include both supply- and demand-side disruptions to TB diagnostic and treatment services. The report noted:
Examples of such disruptions include reduced health system capacity to continue to provide services, less willingness and ability to seek care in the context of lockdowns and associated restrictions on movement, concerns about the risks of going to healthcare facilities during a pandemic, and stigma associated with similarities in the symptoms related to TB and COVID-19.
Diagnosis decreases, death increases
The biggest fallout of the decline in notification of new cases is that it has resulted in an increase in TB deaths. The report estimated that people dying with TB, who did not have an HIV co-infection, went up by 0.1 million in 2020 as compared to the previous year. Those who suffered with HIV co-infection registered an additional 5,000 deaths in 2020. Overall, the deaths have gone back to the level of 2017.
“The COVID-19 pandemic has reversed years of global progress in reducing the number of people who die from TB, with the first year-on-year increase (of 5.6 per cent) since 2005 and the total number of deaths in 2020 returning to the level of 2017,” the report said.
TB was ranked the 13th leading cause of death globally till 2019. Thanks to huge setbacks, it is now estimated to be the second leading cause, only after COVID-19.
The report said the number of people suffering from drug-resistant TB who were provided treatment, went down by 15 per cent in 2020, as compared to the previous year. However, the burden of multi-drug resistant TB (MDR-TB) and extensively drug-resistant TB (XDR-TB) remain stable.
Major milestones missed
The ‘End TB Strategy’ milestones for reductions in TB disease burden by 2020 were a 35 per cent reduction in the number of TB deaths. Instead, the global reduction in the corresponding time period has only been 9.2 per cent. However, 33 countries, including Kenya, Mozambique, Tanzania, Vietnam and Russia, proved to be outliers of an otherwise worrying trend.
The same Strategy aimed to reduce the TB incidence rate to 20 per cent by 2020, as compared with the levels in 2015. But the target achieved till 2020 was only 11 per cent.
However, six high-burden countries, including, Ethiopia, Kenya, Myanmar, Namibia, South Africa and the United Republic of Tanzania came out as success stories along with 27 other countries who did manage to achieve these targets.
People suffering from conditions that make them vulnerable to TB, particularly an HIV infection, are also provided preventive treatment. Even this segment saw a decline.
The global number of people who were provided with TB preventive treatment increased to 3.6 million in 2019, from 1.0 million in 2015. However, in 2020, only 2.8 million people (21 per cent reduction) could avail this service.
Way forward
If these results give an impression that 2020 was the worst year for TB elimination, the worst may actually be yet to come in 2021 and 2022 thanks to the spillover effect, the report said.
Modelling studies suggest that TB mortality in 2021 is projected to be much higher than in 2020 in all of the 16 countries that accounted for almost all of the global drop in TB notifications. TB incidence is projected to be above the level of 2020 in most of them.
To improve the diagnosis, the report said countries need to increase the proportion of cases that are confirmed bacteriologically either through bacteria culture or rapid tests. The share of rapid tests especially needs to go up as only 33 per cent of total cases were diagnosed through it.
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