Another year, another WHO Global TB Report - and it’s really not looking good…

Three days ago we downloaded the new WHO Annual Global Report on TB and started workjing through it. It was a pretty horrible experience. As was anticipated in last year’s annual Report, most of the estimated global numbers relating to TB during 2021 year are up: estimated incident cases (up 4.5%), estimated mortalities (up 6.6%), estimated MDR-TB cases (up 3.4%) among others. Please note here that all these percentages reflect estimations so we shouldn't be 100% confident of their accuracy.

But at least there are a couple of definite year-on-year improvements, the most important being an increase in TB cases being found and treated compared to the last (terrible) year (this number up 5%), and thus a tiny resultant reduction in the huge percentage of cases estimated to being missed entirely (though still a terrible 40% of the estimated number of people with new disease missing treatment entirely). Yes - 40% of estimated case still aren't being found.

There’s another okay story, too, though – that, despite COVID, the treatment success rate for ‘all TB’ has been maintained at 86%, although we are not totally confident about this either since, according to the Report’s own data, a staggering 37% of all pulmonary cases were not diagnosed initially by bacteriological confirmation as is officially recommended. This means that the judgement of ‘treatment success’ for those who aren't bacteriologically confirmed is largely based on a wing and a prayer since it's mainly based simply on treatment completion. In support of this observation, it’s worth noting that the Report itself agrees, stating that this bacteriological aspect of diagnosis is “critical because it allows people to be correctly diagnosed”. It also, of course, allows them to be correctly assessed in respect of their treatment outcomes, though this isn't mentioned.

Welcome to the depressing reality of WHO Global TB Reports and reading between their lines.

Failing targets

The immediately depressing bottom line in this Report is that the current sets of END TB targets for both 2022 and 2025 in respect of general strategy, of treatments implemented, of preventative treatments made, and also of funding are (barring divine intervention) all now out of reach (all except for one – see the graphic immediately below). That they are now set for failure is bad enough, but what’s worse still is their abysmal current percentage scores in respect of their targets, ranging from a truly awful 5% of total target to the otherwise best of 66% (they should all be at least 80% at this point) - this apart from the one lone target for preventative TB treatment of HIV cases that is already surpassed. (But we’ve blogged about this one previously since it was actually achieved last year, and we awarded credit for its achievement not to global TB control or national TB programmes, but to the efforts of the global HIV program.)

What concerns us is that next year at the UN (assuming that another High Level Meeting is convened for reviewing these targets) these abject failures might well be spun by those politicians attending that COVID-19 is the primary cause. So let us be clear about this in case they do so: COVID-19 has definitely set things back, but it is a sorry but undeniable fact that things were already way off-track before the coronavirus first emerged in late 2019.

Here’s the evidence for our concern about the story being spun this way – it's in the opening paragraph of the section entitled ‘Top Findings and Messages from the Report’.

“The COVID-19 pandemic continues to have a damaging impact on access to 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.”

The truth is that it seems to us that, in many respects based on the actual evidence in the Report, the recent response at point of care has been valiant in these last three years. What’s been shameful is the lack of political will at both global and national level to support these efforts and so get a grip on these targets as they slipped beyond reach – but what is also important to appreciate is that this is not just since the COVID pandemic, and not even from just before the pandemic (when these same targets were all already ‘off track’. It’s been the same sorry story for the last two decades - and this is almost all down to a consistent lack of political will.

Take a look at the funding stream, for instance – something which is ENTIRELY under politicians’ control. The total sums that represent the sorry achievements in not reaching the UN HLM funding target so far are minuscule compared to the sort of sums used so profligately (and often wastefully) fighting the coronavirus pandemic – and we should also note that this relatively miniscule funding spent so far on TB in this period is less than half what all the leaders of the world unanimously COMMITTED to in 2018 at the UN (and this was already way off track BEFORE the pandemic just a year into the target period). What makes this even more appalling, though, is that the target itself (of US$15 billion a year) is itself so miniscule in comparison to the trillions that have been spent globally in response to the coronavirus. Some lives really do seem to be worth much more than others.

Why is this so appalling? We must be immediately clear about something: humanity’s number 1 infectious killer is currently not COVID-19. It is tuberculosis, and because of the inclinations of politicians it is not getting a fraction of the political attention it demands.

We’re becoming increasingly angry about this neglect - and we hope you will share this anger when you read the sorry list of evidence of what is a long-term betrayal of a vulnerable slice of humanity – those millions at most risk from TB (who are most specifically the poor in TB endemic countries) who have been, and still are, being continuously treated with such disdain and contempt by global and national authorities entrusted with their welfare. You can make your own mind up about this. We hope that you will read on and decide for yourself.

The Tale of Neglect

TB was officially called out as a Global Emergency almost 30 years ago now, so there has been plenty of time to bring the numbers down to a level where this would no longer be the case and 1.6 million (at least in our opinion) are still dying each year. But this still hasn’t happened while other diseases have garnered much more successful attention.

HIV deaths are now half that of TB, for instance. For a decade HIV was holding the unholy crown of being the most lethal infection, so this flip surely tells us a lot about the relative political commitment to responding appropriately to each disease.

This has meant that, while the HIV crisis is significantly reduced, the TB pandemic runs on and on litle changed except for a growing component that is drug-resistant. But what makes this so sad is that this is not happening without targets being set – because they have been set again and again, and serially missed, with nothing really changing, and each time a new set of targets miraculously welcomed as if it were the first.

The Report sells things a little differently we should add, not just glossing over this catalogue of failure completely, but also by promoting this idea that COVID-19 is the factor that’s tripped things up (and that otherwise things wouldn’t be quite that bad). We identified an example of disingenuous dissemination, for instance, in the words of Dr Tereza Kasaeva, the Director of the WHO Global TB Programme in her introduction: “The report provides important new evidence and makes a strong case for the need to join forces and urgently redouble efforts to get the TB response back on track to reach TB targets and save lives.”

In response, we can point out two things to Dr Kasaeva: one is that the TB response was actually far from ‘on track’ before COVID as is implied in her statement. (In fact, it has never been on track, period.) And secondly, neither is there much 'new' in respect of evidence to show how off-track things are, and we will substantiate this statement with a set of important older 'evidence' that supports the case that it is politicians who need to more than redouble their efforts.

Of course, Dr Kasaeva must know full well that TB target failures aren’t fresh or new at all because they are in the literature, and are both historic and appalling. What's more, as we will see, they are principally caused by shameful political lack of commitment and willful neglect. Here's a list of some of the worst items of evidence in chronological order.

Twenty-two years ago, in March 2000 (a sluggish seven years after TB was declared a Global Emergency, incidentally), the Stop TB Initiative called for action on TB and endorsed two goals for 2005: one was to diagnose 75% of global cases and the other to cure 85% of this diagnosed cohort. That first goal has never been reached (the best reported percentage was 71% in 2019, nearly two decades after that target was first set).

Soon after this, the WHO set its own Global Plan for TB and added its own target: by 2010 it intended to see the global burden of TB disease reduced by 50%. Nothing near that reduction has ever been reported.

In 2006, with rates of disease still rising, the newly convened Stop TB Partnership launched a second Global Plan: by 2015 to reduce the global burden of prevalence and death by 50% relative to what it had been in 1990. There was an implicit problem here, something which has been casually and continuously glossed over ever since. This is that no-one actually had an accurate estimate of what the disease burden was either in 1990 nor (unfortunately it turned out) even in 2015. Estimates have been continuously revised retrospectively right up to the present as belated population surveillance programmes have serially revealed more and more undiagnosed TB.

(There is something very relevant to add here in this respect that relates to this current 2022 Report, incidentally - that in 2021, the first-ever Indian national survey was completed. It was one of the largest surveys ever completed with a sample size of about 320,000 people but was furthermore anticipated by some experts to possibly/probably reveal that previous estimates of TB in India may have been significantly underestimated. Given that India is already reckoned to have more TB cases than any other country, this would then provoke yet another upwards re-estimation of global burden of incidence, case detection and mortality, quite probably significantly, and in turn this would again demand retrospective re-estimations as well. This current 2022 WHO Report does mention this Survey, but it's unclear how much it was taken into asccount in respect of its setiames. The Report states that the Surveyt was “started in 2019 but was interrupted for several months in 2020 due to the COVID-19 pandemic and then completed in 2021”. It further adds that this same survey has “informed interim estimates of TB incidence published as part of this report” but it doesn’t explain the extent or nature of this ‘informing’. Given that elsewhere the WHO states that this Survey’s results “are currently under discussion between WHO and the National TB Elimination Programme of the Ministry of Health & Family Welfare, India”, we wonder not just what this implies, but also what these discussions may consist of. We strongly suspect, based on previous expert opinion, that the Survey's numbers are considered suspect, and so the world may be faced next year with yet another retrospective upwards re-estimation of some of the baselines with the WHO Targets for 2025 needing to be carefully reconsidered because next year will be the year in which the 2022 targets will be properly analysed.)

But back to 2006: that year the Partnership also extended the Stop TB Initiative’s goals (that had been well missed in 2005) extending them a whole ten years to 2015.

It’s important to add here that it was also already being identified back in 2006 that there was a significant funding gap that was putting everything at risk of failure – reckoned to amount to US$30 billion of the US$56 billion that was being budgetted for the entirety of Stop TB’s programme through to 2015. This therefore amounted to a projected deficit of over 50% - so not much has changed in respect of funding reticence since it would seem, since much the same percentage deficit is reported in this latest Report 16 years later.

What’s more, the 2006 Plan for 2015 introduced strategies relating specifically to MDR-TB which was now being identified as a serious unaddressed threat to progress. This 2006 strategy aimed to reduce the estimated prevalent number of MDR-TB cases of 533,000 to a more manageable 193,000 by 2015 (i.e. a reduction of 64%). Sadly, prevalence estimates for MDR-TB (which it should be added are incredibly significant in terms of epidemiological modelling for tuberculosis because of the normal duration of infection) were dropped from WHO Reports several years ago for unidentified reasons, but we can at least be certain that they amount to a lot more today than half a million.

Curiously more recently, the annual estimates of MDR-TB incidence (of new cases occurring each year) have more recently been re-estimated considerably downwards to be regularly reported as being "essentially unchanged" (or similar) - this despite both the poor success rates and the abysmal case detection. In other words, we can’t really now make much of this target for 2015 beyond suggesting it was not just missed – it may even have been basically meaningless.

At the subsequent 62nd World Health Assembly in 2009, meanwhile, the Global Plan for 2006-15 was redrafted to become the Global Plan for 2011-2015. Much remained the same as before, but the goal of the number of MDR cases that should now be being treated annually by 2015 was significantly hiked (from an earlier set 110,000 to 270,000). In line with this, the previous plan of so significantly reducing the prevalence rates of MDR-TB by 64% was diluted to simply to “reduce the global burden of drug-resistant TB” – in other words this goal, following a more realistic re-appraisal of the scale of the challenge, was now that the incidence and prevalence of MDR-TB should simply be “declining by 2015”. But even this goal was missed!

You may well think we’re exaggerating and/or cherry picking (which of course we accept that we are), but here are some examples of those old targets that were set in 2009 for 2015 which tell the story clear as day for anyone willing to read them:

1. That by 2015 at least 75% of MDR-TB patients would be being treated successfully. Currently in the latest Report this patient success rate is 60% (which curiously was lauded in the Report as a success while in fact this same 60% success rate was actually reported back in 2009, the year when this target was set, before subsequently collapsing). But with a little extra effort using the current case detatction rate and success rate, we can also develop a fuller picture of the current situation; which is that these 60% fortunate recovered souls in 2021 actually comprise (at best) only 24% of the current estimated incident global incident burden of MDR-TB cases (in other words 3 out of every 4 new MDR cases were still either failing treatment or having no access to it in 2021). And if we then consider what might be the current prevalent burden given the normal life expectancy of a TB case being 3-5 years, this number of cases who remain infectious amount to something very worrying indeed. For any infectious disease with a lifetime of anything greater than 1, such a poor case treatment rate would be an implicit recipe for an ever-increasing incidence of infection, pure and simple (and untreated TB is reckoned to have an R0 number of 3.4-4.5).

2. That by 2015 the proportion of detected MDR-TB patients should comprise 56% of the global estimated cases (in other words the case detection rate (CDR) should be 56%). In 2021 this percentage is still estimated not to have climbed above 33%.

3. That by 2015, 270,000 confirmed cases of MDR-TB cases would be enrolled on treatment according to international guidelines. In 2021, 150,469 are reported as being enrolled on treatment, an achievement that amounts to just 55% of the target set for six years previous.

4. That by 2015 at least one new safe and effective vaccine would be available. In the 2022 Report, no new vaccine is reckoned to be on the immediate horizon (elsewhere it’s recently anticipated probably not to happen before, at best, 2028). The contrast with the development and manufacture of vaccines for COVID-19 is invidious.

5. That by 2015 a Case Detection Rate of 84% for ‘all’ TB would be achieved. In the 2022 Report, this is reported as being only 60%.

Then in 2015, with the previous targets drifting by unmet, yet another initiative was launched by the Stop TB Partnership – ‘the Paradigm Shift 2016-2020’. In it a set of targets were identified, with milestones set for both 2020 and 2025. By 2020 they demanded a 35% reduction in deaths compared with 2015 and a 20% reduction in incidence rate. Neither were achieved, unsurprisingly. And they introduced a new important goal too: that by 2020 no families affected by TB would be facing catastrophic costs in order to survive. This last goal was also picked up at the UN HLM in 2018, and so slipped back top 2022 – and tragically this also is self-evidently going by the board as well.

Failure after failure after failure…

One very important thing is worth adding here. The original Working Group who developed the 2006-15 Plan identified four major risk areas, all of which it sought to address. One of them was ‘a lack of political will’; and a second was ‘a lack of global co-ordination’. On both counts these risk areas still persist today and in our opinion account, broadly speaking, for this totality of historic and ongoing failure.

These are people, not numbers and they are affected by determinants of disease

In this review we have been mainly discussing numbers, but it’s important to remember that these numbers represent individual people, fellow members of our human family, who each deserves much, much better from the global community and from their elected politicians – and indeed from all of us.

Unfortunately, however, almost certainly things are going to get a lot worse – and the Report is explicit about this (although oddly it doesn’t mention Climate Change as a factor when it obviously already is).

“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 worsen some of the broader determinants of TB.”

The 2022 Report estimates that around 2.2 million TB cases (or around a fifth) arose in 2021 primarily because of ‘under-nourishment’. With startling increases in numbers of people reckoned by Oxfam to be being thrown into extreme poverty, the number of people affected by this key determinant of under-nourishment is unfortunately sure to rise unless the global situation changes for the better. In other words, the numbers are certain to rise further unless serious new efforts are made.

The Report amplifies this, adding “that there could be further increases in TB deaths and TB incidence. The faster that TB case detection can be restored (not only back to 2019 levels but also to address backlogs from 2020 and 2021), the more these potential increases can be moderated.”

Moderated? Surely these people need much, much more than moderation! What they need as much as anything is evidence of political will and commitment to finally meeting some targets