By Mary Hearty

New evidence from the World Health Organization (WHO) 2021 Global Health Report on Tuberculosis (TB) shows a tremendous decline in the number of people newly diagnosed with Tuberculosis (TB) in 2020, compared with 2019. This could be as a result of the disruption of essential TB services caused by the COVID-19 pandemic.

The diruption was in the form of 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 health care facilities during a pandemic, and stigma associated with similarities in the symptoms related to TB and COVID-19.

Furthermore, WHO’s global statistics show that the number of people newly diagnosed with TB fell from 7.1 million in 2019 to 5.8 million in 2020, an 18% decline back to the level of 2012 and far short of the approximately 10 million people who developed TB in 2020.

In Africa, the decline was much more modest at 2.5%. Among the leading countries were South Africa, Kenya, Angola, and Uganda.

Also, monthly and quarterly notifications of people newly diagnosed with TB in 2020 and in the first half of 2021 were substantially below the average for 2019 in most of the high TB burden countries, according to the WHO 2021 global TB report.

Dr Tereza Kasaeva, Director of WHO Global TB Programme during WHO ‘Science in 5’ interview on TB and COVID-19 restated that with the current disruption of the essential services, there is a significant drop in TB diagnosis notification meaning, access is limited so people are unable to get lifesaving treatment and transmission of the infection is continued.

African countries whose quarterly notifications were below the average for 2019 include: Angola, Lesotho, Ethiopia, South Africa, and Uganda.

Regarding new monthly notifications, only Namibia reported below average, according to the report.
Whereas, the largest relative reductions in annual notifications between 2019 and 2020 in Africa were seen in Gabon (80%) and Lesotho (35%).

The most immediate consequence of the large drop in the number of people newly diagnosed with TB in 2020 as mentioned in the report is an increase in the number of people who died from TB in 2020 globally, regionally and at the country level.

According to WHO, estimates for 2020 are 1.3 million TB deaths among HIV-negative people (up from 1.2 million in 2019) and an additional 214 000 among HIV-positive people (up from 209 000 in 2019).

The global number of deaths officially classified as caused by TB (1.3 million) in 2020 was almost double the number caused by HIV/AIDS (0.68 million), and TB mortality has been more severely impacted by the COVID-19 pandemic in 2020 than HIV/AIDS.

Of the deaths among HIV-negative people, 53% were men, 32% were women and 16% were children aged below 15 years. Of the deaths among HIV-positive people, 50% were men, 40% were women and 9.8% were children.

“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% since 2005 and the total number of deaths in 2020 returning to the level of 2017,” WHO stated in the 2021 report.

Moreover, the declines in TB incidence, that is, the number of people developing TB each year, achieved in previous years have slowed almost to a halt. These impacts are forecast to be much worse in 2021 and beyond.

“TB incidence is projected to be above the level of 2020 in most of them. This is consistent with earlier modelling projections published in 2020,” WHO highlighted.

The report also noted that the impact of disruptions to TB services on TB incidence in 2020 was more limited than the impact on TB mortality. One reason is that disruptions to diagnostic and treatment services affect those who already have TB disease first, resulting in an increase in the number of deaths.

Another reason is that the impact on incidence of the increased pool of prevalent cases that develops as more people with TB are not diagnosed and treated is slow due to the relatively long period of time between the acquisition of infection and the development of disease, which ranges from weeks to decades.

Furthermore, WHO argued that the highest burden of TB cases is in adult men, who accounted for 56% in 2020, whereas adult women accounted for 33% and children for 11%.

The higher share of TB cases among men was consistent with evidence from national TB prevalence surveys showing that TB disease affects men more than women, and that gap in case detection and reporting are higher among men.

In addition, WHO mentioned that drug-resistant TB continues to be a public health threat especially resistance to isoniazid and rifampicin – the two most effective first-line drugs. Resistance to both drugs, also defined as multidrug-resistant TB (MDR-TB) require treatment with second-line drugs.

“Globally, the burden of MDR-TB is considered stable. For more than 10 years, the best estimate of the proportion of people diagnosed with TB for the first time who had MDR-TB has remained at about 3–4% and the best estimate for those previously treated for TB has remained at about 18–21%,” WHO explained in the report.

Despite the limitations encountered, the End TB Strategy milestones for reductions in TB disease burden by 2020 were a 35% reduction in the number of TB deaths and a 20% reduction in the TB incidence rate, compared with levels in 2015.

The reduction in the number of TB deaths between 2015 and 2020 was only 9.2%, about one quarter of the way to the milestone. Progress achieved up to 2019- a 14% reduction from 2015 to 2019 and a 41% reduction from 2000 to 2019, was compromised by the increase in TB deaths in 2020 that resulted from disruptions to diagnosis and treatment caused by the COVID-19 pandemic.

WHO said that Africa made relatively good progress, with a reduction of 18%. Success stories reported at country level were in Kenya, Mozambique, Sierra Leone, Zimbabwe and Tanzania.

Globally, the WHO African Region came close to reaching the milestone, with a 19% reduction of TB incidents. This reflects impressive reductions of 4–10% per year in several countries in southern Africa, following a peak in the HIV epidemic and the expansion of TB and HIV prevention and care.

Aside from that, WHO noted 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 there was an 8.7% decline in spending between 2019 and 2020- from US$ 5.8 billion to US$ 5.3 billion, back to the level of 2016.

Therefore, WHO called for proactive planning and budgeting for both TB and COVID-19, procurement of supplies and risk management; maximizing remote care and support for people with TB by expanding the use of digital technologies; provision of simultaneous testing for TB and COVID-19 for individuals when indicated, including by leveraging TB laboratory networks and platforms, just to mention a few.

Dr Kasaeva advised those affected with TB to follow their doctor’s advice and ensure they maintain good hygiene and keep their places well ventilated.

She also cautioned people to stay vigilant as both diseases can have similar symptoms like coughing, high fever, difficulty in breathing, and encouraged people with TB history in the family to get tested for both COVID-19 and TB.