The Good, the Bad … and the Significantly Absent A review of the 2019 Global TB Report
This year’s Global Report on TB was published last week by the WHO. It’s become a custom for us to comment on it on each occasion.
First of all, we immediately recognise that in the 26 years since TB was first declared a Global Emergency (and indeed in each of the years since when we have been commenting on them) these reports have improved immeasurably. Now, for instance, they appear replete with data with which they were appallingly deficient in their earlier editions. But just like with the TB emergency itself, there’s been an awful lot of catching up to do, and it’s self-evident that much more is still needed in these reports - not least to enable accountability.
This report is the first to be published since last year’s High Level Meeting (HLM) on TB at the UN. Because it was such a milestone this report emerges as one of special interest, not least because of a bunch of targets which were unanimously committed to by all member states in the HLM's political declaration. These targets were for the following five years (2018-2022) and there was a lot of talk around at the time about ‘accountability’ (or how to make see these targets met). So this report gives the TB community our first window on the progress towards in meeting them given that it reports data on 2018, the forst of the five years.
Of course, we fully accept that a political declaration is not legally bindings but nevertheless these weren’t just aspirational targets – they were COMMITMENTS signed up to by all member state,( both TB endemic ones with limited resources and also states with little TB but with the capacity to support high burden countries in meeting these goals - all with collective committed responsibilities to drive this disease down).
As usual, there’s both good and bad in the report, but this time both come with real cause for alarm because there’s precious little sign that most countries are paying any real attention to what they signed up to. Treatment provision is still appalling (especially for MDR-TB and for preventative therapy) and international support is desperately deficient. What’s also alarming, however, is that some of what we expected to be visible in the report relating to accountability is actually absent.
Let’s first take a quick look at what’s the good news. First of all, the rate of incidence of disease (new cases per 100,000 population) is continuing to reduce (though it’s doing so terribly slowly at 2% a year – too slow to meet the immediate crucial 2020 milestone that is fundamental to meeting the Global Strategy to End TB). Mortality is estimated to be dropping too (by nearly 10% this year) but, despite this, the case fatality ratio still festers at 15% (reduced by 2% in the last three years when it needs to drop by another 5% in the next two). The numbers of TB cases being notified (i.e. being found), meanwhile, is rising more encouragingly (to 7 million a year with treatment outcomes improving by 4 points as well). MDR-TB treatment is improving a little (not just in terms of numbers on treatment and associated outcome rates, but also in terms of estimated global burden of disease - as improbable as this last may be given the continuing poor success rates and treatment coverage). Preventative TB treatment of HIV co-infections is also well on target (which is great news, though this is may well be as much a reflection of the efforts made by HIV programmes as it is of TB programmes given that the other two targets for preventative therapy are so terrifyingly far off track as will be seen below). And finally (and tantalisingly) a post-exposure vaccine has been showing promising results, with a report of it providing a 54% protection against reactivated disease over two years in existing latent infections (though it’s so far only been tested at limited scale and has not yet been tested at all on children or HIV coinfections).
The not-so-good (or Bad)
Unfortunately pretty much the same amount of new disease is still reckoned to be occurring year-on-year despite so much effort (estimated to be anywhere between 9 and 11.1 million new cases each year, but rounded off to 10 million) and so most of the world is basically not on track to meet the 2020 milestones. What’s more, too few pulmonary cases are being bacteriologically confirmed as they should be (only 55% overall globally, compared to 80% in richer countries). Treatment of children remains abysmal, as does preventative treatment of close contacts of infectious cases. When it comes to financial provision it’s also a familiar story, wth funding for the provision of TB prevention, diagnosis and treatment short by a third of what’s reckoned to be needed; international donor funding amounting to only a third of what’s necessary (including money for TB from the Global Fund which is still desperately disproportionately under-provided in comparison to the disease burdens of malaria and HIV); and finally funding for research and development of new drugs and vaccines which is also only a third of what’s needed.
And the significantly absent?
But what really concerns us is the lack of clear reporting on most of the targets that were set at the UN HLM. These were commitments (or ‘promises’ as Dr Tedros, the WHO Director General calls them) made by all member countries. These were unanimously agreed to be necessary to keep things on track to meet the Global Strategy (which again all member states signed up to back in 2014). So we were particularly looking for updates relating to the specific numbers that had been committed to regarding find-and-treat targets for several different categories of TB cases in paragraphs 24 and 25 of the HLM’s final political declaration.
Here’s what all member countries are on record as committing to last year:
providing diagnosis and treatment with the aim of successfully treating 40 million people with tuberculosis from 2018 to 2022
including from within this number, 3.5 million children,
and also including 1.5 million people with drug-resistant tuberculosis,
including from within this 1.5 million 115,000 children with MDR-TB
preventing tuberculosis for those most at risk of falling ill with TB by providing preventative treatment with a particular focus on high burden countries for at least 30 million people by 2022, including:
4 million children under 5 years of age who are household contacts,
20 million other household contacts of people affected by tuberculosis,
and 6 million people living with HIV.
So there were basically eight numerical targets signed up to.
Well our concern is that we can find too little monitoring data on these targets within the pages of the report – in fact we could only find four targets formally referred to as HLM targets at all and only two of these were find-and-treat ones (‘TB treatment’ and ‘TB preventative treatment’). The other two related to budgets and funding.
In other words, out of an original total of eight find-to-treat HLM targets, only two are being reported on in this report in a way that can be readily monitored by those concerned.
So we’re worried, and as a result we set to picking the report apart to find out how each of these other targets may be progressing.
What follows is an analysis which we hope will awake others’ interests in this issue. We also hope that it also stakes out the territory in some sort of fashion that resembles how we think it should be done (so that stakeholders can track progress).
Please don’t think this is some sort of semantic exercise, or indeed that it is the final word on the matter, because we hope it can be better followed up by fellow activists. Dr Tedros, the WHO director general himself, identified in his foreword to the report that “civil society, partners and affected communities are important drivers of progress against this top killer”, while Dr Tereza Kasaeva, the WHO’s director of its Global Tuberculosis Porgramme says in her Message that the WHO TB report is “essential … for high-level advocacy, increasing awareness and fundraising. Knowledge and data are powerful weapons in the fight against TB”. We agree with both of them, but if a set of targets are committed to but then progress towards them can’t be easily monitored by global authorities, donors, civil society, and partners of those in the line of fire of this disease, then we’re not sure how useful the content of this report really is. In fact, it seems to us that an essential section is absent from the report and that it may be failing those it serves as a result.
So let’s review the targets one by one as best we can.
Target 1: providing diagnosis and treatment with the aim of successfully treating 40 million people with tuberculosis from 2018 to 2022.
This target thankfully looks to be on track and should be easily exceeded. Notifications have risen this year by 9% to 7 million which looks like being exactly as per target. In the next four years till 2022 this current rate should see this target easily met especially since the target for adult drug-susceptible TB is actually a lesser 35 million cases (allowing for excluding the numbers in targets 2 & 3).
It should be added very briefly, however, that this target is also by far the most unambitious of all eight and achieving it should not be seen as any sort of significant achievement. In fact it's even a questionable one because it’s fundamentally not congruent with the Global Plan’s target for incidence rate reduction (which itself is a questionable target as well as we will discuss in a blog in the near future).
It should perhaps also be noted that (in all instances in the report) when it comes to general treatment provision it is ‘notifications’ only which are identified whilst it was 'treatments with the aim of curing' which were actually targeted (and the report doesn’t actually enumerate numbers who were actually started on treatment). As such, it is quite possible that the actual number that were started on treatment during 2018 was really less than 7 million – in fact, if we apply the same proportion between those on record as having been notified in 2017 (6.4 million) and the number in the same 2017cohort that were recorded as having started on treatment and whose treatment outcomes were measured (6.143 million), it may actually be 6.7 million. In other words the world may not actually be quite as on track to meet this target as suggested (though the target is still eminently achievable).
Target 2: including from within these 40 million treated cases 3.5 million children
Unfortunately, this is a harder number to unpack from the report which only discloses that 8% of all notifications of TB occurred children less than 15 years of age. This percentage computes to around 560,000 childhood cases being notified in 2018, although again it isn’t clear how many of them were actually put on treatment (it could quite possibly be less given that stock-outs of paediatric dosages of TB drugs are more common than adult ones). If all the notified children were indeed treated, however, this now requires that almost 3 million childhood cases must be found and treated over the next 4 years of the target period (i.e. 735,000 annually on average). This amounts to an immediate scale up of at least 31%.
We’d suggest that this improvement in provision of treatment for children is also certainly achievable, though it should be noted that it will require focused effort to do so - something which is not being specifically or visibly identified anywhere in this report. In other words, will national TB programs focus their precious resources on these kids unless they’re encouraged to do so? History and current evidence suggests a simple and very sad answer to this.
Target 3: including from within the 40 million, finding and treating 1.5 million people with drug-resistant tuberculosis
Globally, 156,071 MDR cases were recorded as being put on treatment in 2018 (this time we do have an number for this) and this was an encouraging 17% rise on 2017. However, the report also records that the number of notified enrolments actually fell in eight counrries with high MDR-TB burdens, suggesting that the overall spread of treatment of MDR is seriously variable and some of the most vulnerable cases are being neglected.
Nevertheless, if this global increase were to continue for the remaining four years until 2022, then the cumulative total will still only amount to less than 1.1 million over the whole target period. This will end up being well short of the target committed to, so a serious scale up is needed over the next four years for this target to be hit or even nearly hit.
Adjusting treatment provision to meet the target by ‘only’ 400,000 over four years may seem something that is relatively easily achievable by switching resources, but it actually amounts to extra cumulative increases of 7% in each of the next four years (i.e. a 24% increase in 2019, increasing to an annual 45% increase by 2022, or a three-and-a quarter fold hike that year on the 2018 number). This is now required for us to have a chance of the world reaching the 1.5 million target.
Looked at another way: if this incremental increase is actually achieved then the anticipatable global treatment load for MDR-TB in 2022 will be over half a million cases – or more than three times the current annual treatment total who were started on treatment in 2018. How much will this cost? Well, the average cost of treating an MDR cases is reckoned to be US$6,430, so the global budget for the year 2022 for MDR-TB for providing treatment should be expected to be an eye watering US£3.26 billion dollars. Who exactly is going to pay for this? The money MUST come from richer nations. (The total budget – which wasn’t met - for treating MDR-TB in 2018 in the 30 high burden countries where most MDR is believed to exist was just half of this total).
It seems that no-one is taking any appropriate steps to properly anticipate how this huge increased load is going to be supported in the coming years by middle- and low-income countries, particularly since the number of existing notifications of MDR-TB is already significantly outstripping the global capacity to provide treatment (only 84% of notified MDR cases were started on treatment in 2018). Without any question, this target is going to demand immense additional resource.
Target 4: including from within these 1.5 million MDR cases, 115,000 children with MDR-TB are to be found and treated
We are unable to identify any data at all relating to the treatment of MDR-TB in childhood cases.
This is obviously a serious omission. We have previously asked the WHO several months ago if these data would be included in this report. They never responded to us.
Target 5: preventing tuberculosis for those most at risk of falling ill by providing preventative treatment with a particular focus on high burden countries for at least 3 million people, including:
a) including 4 million children under 5 years of age
Globally in 2018, 1.3 million children aged under 5 years were estimated to be household contacts of bacteriologically confirmed pulmonary TB cases and so were at particularly risk because of their vulnerable immunity. Relevant data (which was reported to the WHO by only 109 member countries when it should have been all of them) showed that a total of only 349,487 children aged under 5 years were actually initiated on TB preventive treatment in 2018.
This is equivalent to a coverage of just 27% of last year’s estimated demand – and so leaves a requirement of incremental increases of nearly 50% year-on-year until 2022 for this target to be met.
Worryingly, the number being put on treatment does not even appear to be currently increasing. In fact, the number of countries which actually reported implementing any childhood preventative therapy at all reduced in 2018 compared to 2017 (with 12 % fewer countries reporting data on this aspect of the pandemic despite it being an HLM target). This is really serious.
b) 20 million other household contacts of people affected by tuberculosis
The number of household contacts placed on TB preventive treatment in 2018 basically fell massivley short of the numbers required to meet the targets set at the UN high-level meeting on TB in 2018. Only 79,195 household contacts aged 5 years or older were reported to have been initiated on TB preventive treatment in 2018.
To make this worse, this was actually down 30% from 103,344 in 2017, but these data are made even worse still by the fact that the numbers reported for this category by 47 member countries (i.e. a quarter of all member states) was actually identical to the numbers of reported contacts who were aged under 5 years. As incredible as this may seem, this suggests that the importance of this target is being widely ignored and also that the current reporting systems are being fundamentally misunderstood by NTPs. The total number of household contacts who were over five years of age may actually be over-reported by these same numbers since they have been probably counted twice.
Optimistically (assuming that this was not the case, and that the annual number does not drop further) the ominous picture emerges that the number of household contacts who need to be put on treatment each year needs to nearly quadruple year-on-year for the target of 20 million to be met.
c) 6 million people living with HIV (PLHIV) should receive preventive treatment by 2022
This one at least is more encouraging. In 2018, 65 countries reported initiating TB preventive treatment for a total of 1.8 million PLHIV, a number which was up from just under 1 million in 2017 (i.e. it nearly doubled). This 2018 number suggests that the target of 6 million in the period 2018–2022 can be easily achieved but this should still be carefully considered against further data recording that only 16 of the 38 high TB and TB/HIV burden countries reported any provision at all of TB preventive treatment to PLHIV who were newly enrolled in HIV care in 2018 further suggesting that the spread of treatment provision is erratic. This variable provision is further confirmed by the fact that the numbers reported by 22 countries of the 65 countries were actually down on those fthey reported in 2017.
Everyone agreed that last year’s HLM was a milestone event, particularly because it included world leaders committing to a set of targets which were described by many as ‘amazing’. It’s never fun being a party pooper, especially when popping the balloons could have negative impact on the very charity whose name this blog is written under, but a long time ago a fearsome Ugandan TB nurse called Magdalene Ichumar told us about the tragic reality she regularly experienced sending patients who had failed treatment back into their communities to reinfect others because of lack of resource. “The truth will set me free” she told us.
So here is our truth: we know that the WHO employs good people and we know that they are doing all they can; we also know that NTPs employ good people and we know that they are doing all they can. But we also now see that these targets risk becoming a sham. The first of them (finding and treating 40 million by 2022) isn’t even 'amazing' (because it’s not coherent with the Global Plan to end TB); and the others aren’t even beginning to be properly reported and monitored.
Monitoring and reporting the progress of commitments really isn’t rocket science - in fact, the report defines exactly what it means: “commitments should be followed by the actions needed to keep or achieve them. Monitoring and reporting are then used to track progress related to commitments and actions”.
But how can progress be tracked if the necessary evidence of it isn’t appropriately available in the Global Reports?
Dr Paula Fujiwara, the scientific director of the International Union Against Tuberculosis and Lung Disease (The Union) has reviewed the report and says that the “well-meaning goal [of ending TB] will remain a fantasy unless there is a dramatic shift in the way we do business”. It is not rocket science, she adds, saying “making serious gains against TB in a short time frame is possible even in the world’s largest and most geographically diverse countries if political leaders prioritise the disease”. She’s absolutely right of course, but (as WHO’s own graphic shows) as a global community we need appropriate access to the evidence of these shifts in political priority in relation to those commitments made last year, and right now we don’t have them.