TWN Info Service on Health Issues (Oct22/03)
31 October 2022
Third World Network

UN: TB cases, deaths rise during COVID-19 pandemic, says WHO
Published in SUNS #9678 dated 31 October 2022

Geneva, 28 Oct (Kanaga Raja) — An estimated 10.6 million people fell ill with tuberculosis in 2021, an increase of 4.5% from 10.1 million in 2020, according to the World Health Organization (WHO).

In its Global Tuberculosis Report 2022, WHO said the COVID-19 pandemic continues to have a damaging impact on access to tuberculosis (TB) diagnosis and treatment and the burden of TB disease.

Progress made in the years up to 2019 has slowed, stalled or reversed, and global TB targets are off track, it said.

The most obvious and immediate impact was a large global drop in the reported number of people newly diagnosed with TB, it added.

“From a peak of 7.1 million in 2019, this fell to 5.8 million in 2020 (-18%), back to the level last seen in 2012.”

The WHO said that the TB incidence rate (new cases per 100,000 population per year) rose by 3.6% between 2020 and 2021, reversing declines of about 2% per year for most of the previous two decades.

“Globally, the estimated number of deaths from TB increased between 2019 and 2021, reversing years of decline between 2005 and 2019. In 2021, there were an estimated 1.4 million deaths among HIV-negative people and 187, 000 deaths among HIV-positive people, for a combined total of 1.6 million,” the WHO report said.

This was up from best estimates of 1.5 million in 2020 and 1.4 million in 2019, and back to the level of 2017, it added.

The WHO said the burden of drug-resistant TB (DR-TB) is also estimated to have increased between 2020 and 2021, with 450,000 new cases of rifampicin-resistant TB (RR-TB) in 2021.

On a positive note, the report highlighted some success stories. For example, it said globally, the success rate for people treated for TB in 2020 was 86%, the same level as 2019, suggesting that the quality of care was maintained in the first year of the COVID-19 pandemic.

In addition, it said the global number of people provided with TB preventive treatment recovered in 2021, to close to 2019 levels, and the global target for provision of treatment to people living with HIV was surpassed.

Intensified efforts backed by increased funding are urgently required to mitigate and reverse the negative impacts of the pandemic on TB, said the WHO.

“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 further worsen some of the broader determinants of TB,” it cautioned.

According to the report, the most obvious and immediate impact on TB of disruptions caused by the COVID-19 pandemic was a large global fall in the number of people newly diagnosed with TB and reported (i.e. officially notified) in 2020, compared with 2019.

Following large increases between 2017 and 2019, there was a reduction of 18% between 2019 and 2020, from 7.1 million to 5.8 million, while there was a partial recovery in 2021, to 6.4 million, it said.

A similar pattern of increases in notifications of people newly diagnosed with TB up to 2019 followed by a sharp fall in 2020 and some recovery in 2021 is evident in two of the six WHO regions: the Americas and South-East Asia, it added. It said the WHO Eastern Mediterranean Region saw a marked reduction in notifications between 2019 and 2020, followed by an almost complete recovery in 2021.

In the WHO European Region, there was a clear negative impact in 2020, but the reduction from 2020-2021 was consistent with the pre-2020 trend.

The report said that in the WHO Western Pacific Region, there was no recovery in 2021, while the WHO African Region stood out as experiencing only a modest negative impact in 2020 (-2.3%), and notifications in 2021 were above the 2019 level.

It said the WHO regions of South-East Asia and the Western Pacific accounted for most of the global reductions (compared with 2019): 84% of the total in 2020, and 99% in 2021.

Most (90%) of the global reduction in the reported number of people newly diagnosed with TB between 2019 and 2020 was accounted for by 10 countries, with the top three (India, Indonesia and the Philippines) accounting for 67%. In 2021, 90% of the reduction compared with 2019 was accounted for by only five countries, it added.

Among the 30 high TB burden and three global TB watch-list countries, the largest relative reductions in annual TB case notifications between 2019 and 2020 (ordered according to the size of the relative reduction) were in the Philippines, Lesotho, Indonesia, Zimbabwe, India, Myanmar and Bangladesh (all above 20%).

The substantial disruptions to TB case detection and reporting in 2020 and 2021 probably reflect both supply-side and demand-side influences on TB diagnostic and treatment services, said the report.

Examples include reduced health system capacity to continue to provide services; reduced ability to seek care in the context of lockdowns, and associated restrictions on movement; concerns about the risks of going to health care facilities during a pandemic; and stigma associated with similarities in the symptoms related to TB and COVID-19.

Globally, the annual estimated number of deaths from TB fell between 2005 and 2019, but the estimates for 2020 and 2021 suggest that this trend has been reversed, said the report.

There were an estimated 1.4 million deaths among HIV-negative people and 187,000 deaths among HIV-positive people in 2021, for a combined total of 1.6 million, representing an increase from best estimates of 1.5 million in 2020 and 1.4 million in 2019, and a return to the level of 2017, it added.

The WHO said most of the estimated increase in TB deaths globally was accounted for by four countries: India, Indonesia, Myanmar and the Philippines.

The global number of deaths officially classified as caused by TB in 2021 (1.4 million) was more than double the number caused by HIV/AIDS (0.65 million), and TB mortality has been much more severely impacted by the COVID-19 pandemic than HIV/AIDS, said the report.

In contrast to TB, deaths from HIV/AIDS continued to decline between 2019 and 2021, it added.

The latest year for which WHO has published estimates of global deaths by cause is 2019, it said, adding that in that year, TB was the 13th leading cause of death worldwide and the top cause from a single infectious agent.

In 2020 and 2021, it is anticipated that TB will rank as the second leading cause of death from a single infectious agent, after COVID-19, said WHO.

In 2021, 82% of global TB deaths among HIV-negative people occurred in the WHO African and South-East Asia regions; India alone accounted for 36% of such deaths. The WHO African and South-East Asia regions accounted for 82% of the combined total of TB deaths in HIV-negative and HIV-positive people; India accounted for 32% of such deaths.

Of the global TB deaths among HIV-negative people, 54% were in men, 32% were in women and 14% were in children (aged below 15 years), said the WHO, adding that of the global TB deaths among HIV-positive people, 51% were in men, 38% were in women and 11% were in children.

An estimated 10.6 million people fell ill with TB worldwide in 2021, an increase of 4.5% from 10.1 million in 2020, reversing many years of slow decline, said the report.

Similarly, the TB incidence rate (new cases per 100,000 population per year) is estimated to have increased by 3.6% between 2020 and 2021, following declines of about 2% per year for most of the past two decades.

These sharp reversals of progress are consistent with previous projections  and reflect the estimated impact of disruptions to essential TB services during the COVID-19 pandemic, said the report.

At regional level, the TB incidence rate increased between 2020 and 2021 in five of the six WHO regions. The exception was the WHO African Region, where disruptions related to COVID-19 have had little impact on the number of people diagnosed and officially notified with TB.

WHO said that geographically, in 2021, most people who developed TB were in the WHO regions of South-East Asia (45%), Africa (23%) and the Western Pacific (18%), with smaller proportions in the Eastern Mediterranean (8.1%), the Americas (2.9%) and Europe (2.2%).

The 30 high TB burden countries accounted for 87% of all estimated incident cases worldwide, and eight of these countries accounted for more than two thirds of the global total: India (28%), Indonesia (9.2%), China (7.4%), the Philippines (7.0%), Pakistan (5.8%), Nigeria (4.4%), Bangladesh (3.6%) and the Democratic Republic of the Congo (2.9%).

While TB can affect anyone, regardless of age or sex, the WHO said that the highest burden is in adult men, who accounted for 56.5% of all TB cases in 2021; by comparison, adult women accounted for 32.5% and children for 11% of cases.

It also said drug-resistant TB (DR-TB) continues to be a public health threat. Resistance to rifampicin – the most effective first-line drug – is of greatest concern.

Explaining that resistance to rifampicin and isoniazid is defined as multi-drug- resistant TB (MDR-TB), the WHO said both MDR-TB and rifampicin-resistant TB (RR-TB) require treatment with second-line drugs.

“Globally, the estimated number of people who developed MDR-TB or RR-TB (MDR/RR-TB) each year was relatively stable between 2015 and 2020, but it grew in 2021.”

There were an estimated 450,000 incident cases in 2021, up 3.1% from 437,000 in 2020, said the report.

The main explanation for the increase is the overall increase in TB incidence between 2020 and 2021, which is estimated to have been caused by the impact of the COVID-19 pandemic on TB detection, it added.

It said three countries accounted for 42% of global cases in 2021: India (26%), the Russian Federation (8.5%) and Pakistan (7.9%).

The report said the highest proportions (above 50% of previously treated cases with MDR/RR-TB) are found in the Russian Federation and in several countries in Eastern Europe and Central Asia.

It also said the gap between the estimated number of people who fell ill with TB (incident cases) and the number of people newly diagnosed and reported widened in both 2020 and 2021 compared with 2019, to best estimates of over 4 million in each year.

This was a reversal of previous progress in closing the gap between 2012 and 2019, when the global number of people newly diagnosed with TB and reported rose from 5.7-5.8 million annually in the years 2009-2012 to 6.4 million in 2017 and 7.1 million in 2019, while TB incidence fell slowly, said the report.

The reported number of people newly diagnosed with TB in 2020, at 5.8 million, took the world back to the level of 2012; the partial recovery to 6.4 million in 2021 is similar to the level of 2017, it added.

The report said that of the 30 high TB burden countries, those with the highest levels of treatment coverage in 2021 included Bangladesh, Brazil, China, Uganda and Zambia.

“Ten high TB burden countries had worryingly low levels of treatment coverage in 2021, with best estimates of below 50%: the Central African Republic, Gabon, Indonesia, Lesotho, Liberia, Mongolia, Myanmar, Nigeria, the Philippines and Viet Nam.”

The WHO said the global number of people provided with TB preventive treatment in 2021 was 3.5 million – still slightly below the level of 3.6 million that was reached in 2019 but a good recovery from 3.2 million in 2020 and much higher than 1.0 million in 2015.

The combined total of 12.5 million in 2018-2021 is only 42% of the target of 30 million for the 5-year period 2018-2022, it added.

It said that progress in reducing the burden of TB disease requires adequate funding for TB diagnostic, treatment and prevention services, sustained over many years.

However, funding in low- and middle-income countries (LMICs) that account for 98% of reported TB cases falls far short of what is needed, and it fell between 2019 and 2021, the report added.

In 2021, estimated spending on TB diagnostic, treatment and prevention services in LMICs was US$5.4 billion, it said. This was slightly less than the total of US$5.5 billion in 2020 and down 10% from US$6.0 billion in 2019.

The total of US$5.4 billion is only 42% of the global target of US$13 billion annually by 2022 and only 35% of the US$15.6 billion estimated to be required in 2021 in the Stop TB Partnership’s Global Plan to End TB, 2018-2022, said the WHO.

As in the previous 10 years, WHO said, most of the funding used in 2021 (US$4.3 billion from a total of US$5.4 billion; i.e. 79%) was from domestic sources, with the aggregate figure strongly influenced by Brazil, the Russian Federation, India, China and South Africa (BRICS).

It said together, these five countries accounted for US$2.7 billion (64%) of the total of US$4.3 billion that was provided from domestic sources in 2021.

Overall, domestic sources accounted for 93% of the funding for TB diagnostic, treatment and prevention services in BRICS and all of the funding used in Brazil, China and the Russian Federation, said the WHO. +