Two clocks ticking down in the corners of an ancient plague
Is this because they weren’t getting sick? Or maybe it was because they were otherwise getting sick from COVID-19? No - it was simply because they were either too frightened to go to TB clinics, were physically locked down, or because the TB clinics had basically shut down because the staff had been switched to COVID control (or in many cases probably because of all three).
Sadly, this amounts to one more worrying example of “how the [coronavirus] pandemic is disproportionately affecting some of the world’s poorest people” as suggested by Dr Tedros, the WHO’s Director General in the report. Or as Richard Horton, editor of the Lancet, as recently identified how the pandemic as revealing a “truth [that is] so far barely acknowledged” in terms of the huge socio-economic discrepancies in both COVID deaths and consequences of lock-downs.
But this WHO report also amounts to a probable consequential death sentence from TB for a lot more people because the WHO also fears that at least half a million more people will have died from TB in 2020 than in 2019 (amounting to around a third more deaths). That’s bad enough but, given the sluggish but remorseless dynamics of this plague, this extra death toll will roll on for at least half a decade simply because this year will have also resulted in an increase in infections (averaging 10 million each year recently). This is now likely to climb towards the 12 million mark which is where it was peaking a decade ago and the consequences of this will haunt us for year.
But it also means more drug resistance. This is because long-term second-line drug therapies for MDR-TB have also been disrupted which has terrifying implications for TB control and, as is customary in most of these blogs, this is the focus of our concern.
Actually two clocks are ticking…
The official theme for this year’s World TB Day is ‘the clock is ticking...’. Our understanding is that this official metaphorical clock relates to what's ticking down on meeting the targets for ending TB (by 2030) and in particular reminding world leaders that the targets that they set in 2018 aren't being met. Particularly it's hoped that by identifying this these same world leaders will restore the efforts that were being made to meet their commitments before the corona-pandemic intervened.
It’s worth noting, though, that the targets set specifically for treating MDR-TB were already well off-track before we’d even heard of the coronavirus. What's more, in respect of drug-resistant TB we can hear a different ticking clock - one which is ticking down on an imminent resurgence of this drug-resistant pandemic that will inevitably now emerge in real numbers in the coming years and be potentially catastrophic. All the signs were actually already there in the WHO's last pre-COVID Global TB Report but the signs are much worse now in the WHO's most recent report on the impact of COVID-19.
Back last May the Stop TB Partnership released their own forecast[i] and in respect of what they were reporting of the effect of COVID-19 on MDR treatments, and we can usefully reconsider the most recent WHO estimates.
Tucked away at the end of their report Stop TB found that because of COVID-19 healthcare staff in three typical high burden countries were unable to properly monitor and support second-line drug treatment for MDR-TB as done previously. This collapse of care was reckoned to mean that the treatment completion rate had dropped to just 25% of those who started therapy. This has terrible implications not just for increased mortality but also for an amplified ongoing infectious cycle, but it should also be considered alongside the WHO estimate that in 2019 only 38% of those with MDR-TB were starting any treatment at all. Put these two percentages together and it means that LESS THAN 10% OF THOSE WHO HAVE MDR-TB ARE LIKELY NOW TO BE COMPLETING ANY TREATMENT (forget about whether this completion is successful or not).
Add to this the current success rate for treating MDR-TB (57%) and the picture is probably worse than it’s been for fifteen years: possibly NINETEEN OUT OF TWENTY PEOPLE WHO CONTRACT MDR-TB CANNOT CURRENTLY BE EXPECTED WITH ANY CONFIDENCE OF SUCCESSFULLY COMPLETING TREATMENT AND BEING CURED.
And bearing in mind that MDR-TB is still the only anti-microbial resistant infection that is spread by being airborne, if 95% of MDR-TB infectious cases remain sick with a lethal strain of disease then more and more will be infected with the same lethal strain.
If this isn’t a clock that is ticking down on a drug-resistant pandemic of real gravity we don’t know what is - and we hope that world leaders will hear the ticking of this clock as well this worrying World TB Day.
[i] THE POTENTIAL IMPACT OF THE COVID-19 RESPONSE ON TUBERCULOSIS IN HIGH-BURDEN COUNTRIES: A MODELLING ANALYSIS https://www.who.int/publications/m/item/impact-of-the-covid-19-pandemic-on-tb-detection-and-mortality-in-2020