Speed is not enough, accelerating progress is key to end TB: new WHO report

Bobby Ramakant *

Global fight against tuberculosis (TB) is making modest gains, although largely not yet on track to end TB. 2019 Global TB Report of the World Health Organization (WHO) launched on 17 October 2019 gives hope, not despair, because sustained efforts have yielded some significant results.

Only European region is on track to meet 2020 targets of 20% reduction in new TB cases, and 35% reduction in TB deaths (compared to 2015). 7 high TB burden countries are also on track to meet these 2020 targets: Kenya, Lesotho, Myanmar, Russia, South Africa, Tanzania, and Zimbabwe. Rest of the world is lagging behind.

10 million people fell ill with TB as per estimates in 2018 (same as in 2017). TB rates in children though went up by 100,000 in 2018, with 1.1 million TB cases estimated in children in 2018 (compared to 1 million in 2017). The data was reported by 202 countries and territories that account for more than 99% of the world’s population and estimated TB cases.

UNHLM sub-target of treating 7 million in 2018 met

At the UN High Level Meeting (UNHLM) on TB in 2018, one of the commitments was to treat 40 million people with TB during 2018-2022: 7 million in 2018 and 8 million new cases every year till 2022. 7 million new people were notified with TB in 2018 and received lifesaving therapy (in 2017, 6.4 million new TB cases were notified). India’s notification rate went up from 1.2 million (2013) to 2 million (2018) – an increase of over 60%.

Out of 10 million estimated new TB cases, 7 million were notified in 2018. India shares a major part (25%) of the gap of 3 million.

100,000 less TB deaths in 2018

Compared to 2017, there were 100,000 fewer deaths due to TB in 2018. 1.5 million people died of TB in 2018, out of which 251,000 were among TB coinfected people living with HIV. In 2017 there were 1.6 million TB deaths out of which 300,000 were among TB coinfected people living with HIV.

Compared to TB deaths among HIV negative people in 2000 (1.7 million), there is a 27% decline in 2018 (1.2 million). TB deaths among coinfected people living with HIV came down by 60% in 2018 (251,000) compared to 2000 (620,000).

Southeast Asia (44%) and Western Pacific (18%) regions of the WHO together shouldered the lion’s share of the TB global burden in 2018. India has the highest TB burden in the world: 27% (same as that in 2017).

Drug resistance levels hover around half a million a year

In 2018, half a million rifampicin-resistant TB cases were estimated (similar levels as in 2017). Out of these, 78% were of multidrug-resistant TB (MDR-TB) in 2018 (compared to 82% in 2017).

In 2018, 186,772 cases of MDR-TB were notified and 156,071 put on treatment (compared to 160,684 MDR-TB notifications in 2017 and 139,114 put on treatment).

India accounts for 27% of drug-resistant TB burden followed by 14% in China and 9% in Russia (in 2017, India accounted for 24% MDR-TB global burden, China 13% and Russia 10%).

3.4% of all new TB cases and 18% of previously treated TB cases had MDR-TB or rifampicin-resistant TB in 2018 (in 2017, 3.5% of new cases and 18% of previously treated TB cases had MDR-TB or rifampicin resistant TB).

“But more alarming is that over 50% of previously treated cases of the former Soviet Union region had these drug-resistant forms of TB in 2018” said Shobha Shukla, Executive Director of CNS (Citizen News Service).

This is indeed a grim reminder that a lot more needs to be done to eliminate drug resistance as only 1 in 3 MDR-TB patients were enrolled on treatment in 2018. India is home to 43% of number of people who are estimated to have MDR-TB but not yet on treatment. Four key actions to bridge this gap includes, increase in: TB detection, bacteriologically confirmed TB cases, coverage of drug-resistant TB testing and provision of treatment for drug-resistant TB.

Global treatment success rate for MDR-TB and rifampicin resistant TB was 56% in 2018. High MDR burden countries with better treatment success rate are Bangladesh, Ethiopia, Kazakhstan, and Myanmar.

Accurate TB diagnosis is a critical cog in the end-TB wheel

Bacteriologically confirmed TB diagnosis of all cases is scientifically based approach which is supported by WHO and national TB programmes' guidelines. But in 2018, only 55% of pulmonary TB cases were bacteriologically diagnosed (compared to 56% in 2017).

Globally 51% of people who had bacteriologically confirmed TB, were also tested for rifampicin resistance (up from 41% in 2017). This rifampicin resistance testing coverage was 46% in new and 83% in previously treated TB cases.

64% notified TB cases had a documented HIV test result in 2018 (compared to 60% in 2017). TB-HIV coinfection is highest in Africa where 87% of notified TB cases had a documented HIV test result.

Out of estimated 862,000 of TB coinfected people living with HIV, 56% (477,461) were detected of TB. Out of those detected, 86% were on antiretroviral therapy in 2018.

Prevent TB to end TB

WHO guidance issued in 2018 recommends TB preventive treatment (TPT) for people living with HIV, household contacts of bacteriologically confirmed pulmonary TB cases and clinical risk groups (e.g. those receiving dialysis).

The UNHLM on TB had set the target of providing TPT to 30 million people during 2018-2022, out of which, 6 million will be people living with HIV, and 24 million will be household contacts (4 million children aged under 5 years, and 20 million other household contacts).

Globally in 2018, 65 countries reported initiating TB preventive treatment for 1.8 million people living with HIV, up from just under 1 million in 2017. South Africa accounted for 61% of the total number of people living with HIV enrolled in TB preventive treatment in 2018.

Of the 38 high TB or TB-HIV burden countries, 16 reported providing treatment to people newly enrolled in HIV care in 2018. Among these, coverage ranged from 10% of PLHIV newly enrolled in care in Indonesia to 97% in Russia. Overall, in 66 countries for which it could be calculated, coverage was 49%.

In India, 17% of new cases of people living with HIV notified in 2018 (175,361) were put on TPT (29,214).

Globally in 2018, an estimated 1.3 million children aged under 5 years were household contacts of bacteriologically confirmed pulmonary TB cases. The number of household contacts initiated on TB preventive treatment in 2018 was much smaller: data reported by 109 countries show 349,487 children aged under 5 years (a 20% increase from 292,182 in 2017), equivalent to 27% of the 1.3 million children estimated to be eligible; and 79,195 people in other age groups (a 30% decrease from 103,344 in 2017) received TPT.

Among estimated number of eligible children under 5 years of age in India (322,000), 26% were put on TPT (83,109). In 2018, 153 countries reported providing BCG vaccination as a standard part of childhood immunization programmes, of which 113 reported coverage of at least 90%.

TPT also is listed among top 10 indicators for monitoring implementation of the WHO End TB Strategy.

TB rates for healthcare workers

The ratio of the TB notification rate among healthcare workers to the TB notification rate in the general adult population is a good indicator of the impact of TB infection prevention and control in health facilities and should be around one. In 2018, a total of 22,819 healthcare workers from 74 countries were reported with TB; India accounted for 56% of these cases and China for 16%.

In eight countries (Algeria, Burkina Faso, Colombia, Dominican Republic, Honduras, India, Lesotho and the United Republic of Tanzania), the number of TB cases per 100,000 healthcare workers was more than double the notification rate in the general adult population.

Writing is on the wall: #StepUpTheFight

Lot more action is required to ensure not just speed but velocity picks up rapidly to bring the world on track to end TB. Let's set our eyes on key targets as we push the pedal towards them: The WHO End TB Strategy milestones and four global targets set in the political declaration at the UNHLM on TB are:

o TB incidence: 20% reduction by 2020 compared with 2015
o TB deaths: 35% reduction by 2020 compared with 2015
o TB patients not facing catastrophic costs (100% of TB patients by 2020)
o TB treatment to 40 million people, 2018-2022 (7 million in 2018 and 8 million every year thereon)
o TB Preventive Treatment (TPT): at least 30 million people to get TPT 2018-2022
o Funding for TB prevention and care: US$ 13 billion, annually by 2022
o Funding for TB research: US$ 2 billion annually 2018-2022