WHO TB Report 2020 – so much fresh cause for concern yet no real alarm call! Is anybody out there?
A week ago the WHO published its latest annual report on the global state of tuberculosis. This one reports on the year 2019 – in other words there's no data record yet about the impact that COVID-19 is currently having on the constant global tuberculosis pandemic that so far this year is still killing more than the coronavirus. The report does award the coronavirus a chapter however - quite rightly so given the possible impact it is having on TB treatment, diagnosis of new cases, mortalities, disruption of services and also on drug-resistance. Notwithstanding the implications of this chapter for next year's report, this latest one makes for a very depressing read indeed because, reading between its lines, we tragically conclude that almost all of the current interim targets set for ending TB by 2030 are already out of reach and that's really serious.
Each year we critically review these reports as carefully as we can, and we always find aspects which concern us. This year is no exception but in many ways our concerns are worse than usual. We always put them on record privately hoping they are unjustified because of misunderstandings on our part. As usual, we also welcome any corrections if mistakes on our part are obvious. (For the record, to date we have never received any).
First the ‘good news’
These reports (perhaps understandably) invariably frame their more depressing contents within presentations of whatever data that can reasonably be described as ‘progress’. (In this instance such progress focuses on two sets of TB-specific targets: one is a set of interim targets for 2020 set by the Stop TB partnership and agreed by the World Health Assembly back in 2015; and the other is a set targets set for 2022 by the UN at its high level meeting on TB in 2018).
Dr Tedros, the WHO Director General, introduces the new WHO report as follows:
“This year’s World Health Organization (WHO) global TB report comes at a critical time. The report provides an opportunity to reflect on progress made in the fight against TB, but also to highlight the risks that threaten to erode the gains we have made. There is good news. The number of people treated for TB has grown since the UN high level meeting, with over 14 million people reached with TB care in 2018 and 2019. The number of people provided with TB preventive treatment has [also] quadrupled since 2015, from 1 million in 2015 to over 4 million in 2019.” [we have emboldened the key text and review it below]
Note how he focuses on ‘good news’ and 'progress' and then specifically describes these two achievements as "impressive" Sadly we have to disagree with him because given the severity of this rolling global emergency we consider all progress made in both of them to be not just modest but also insufficient to meet the targets associated with them. We will explain why along with exposing some of our most serious causes for concern.
‘The number of people treated for TB has grown since the UN high level meeting’
We suspect that Dr Tedros knows as well as we do that this cumulative target (which was set at 40 million TB cases to be treated over five years up till 2022) could never have been described as ambitious. In fact it was embarrassingly conservative, aiming for only 80% case finding when it should surely have been higher, and averaging only 8 million new cases being treated each year (amounting to a modest increase of 2 million a year at a time when nearly 4 million cases were known to be being missed).
For several years now the constant call has been to ‘find and treat’ these ‘missing millions’ (i.e. those millions who are reckoned to never get notified to national TB programmes each year), but meeting this 40 million target will still mean that millions will be being missed. Meanwhile, so far in the first two years of the five year target programme, too few extra cases have been found each year anyway so this most modest of targets looks to already be at real risk – and if this is the case then this insufficient growth in treatment numbers isn’t a cause for celebration at all. It’s actually a cause for alarm.
Dr Tedros is correct, of course: 14.1 million have indeed been treated in the first two years of the programme (7 million were treated in 2018 and 7.1 million in 2019) but that still doesn’t put us on track to meet this modest target.
Two paras later and Dr Tedros acknowledges that these numbers will have now been rocked by the coronavirus anyway. He notes that WHO’s own modelling has reckoned that a 50% drop in notifications over three months could easily result in 400,000 extra TB deaths this year alone which could rise to an extra million a year over the next five years. This means that they are already expecting at least half a million more cases this current year to be missed (so this current year’s notifications may well get knocked back from 7.1 million to around 6.5 million in next year’s report or this current year's number of incident cases could rise for the first time since 2005). This would then make for an even bigger gap of maybe 20 million cases needed to be found and treated in 2021 and 2022 to hit this target – meaning that almost ALL TB cases in 2021 and 2022 would need to be found and treated (when the current case detection rate is languishing at 71% and has probably already fallen back this year).
But this wouldn’t allow for what is a probable surge in estimated cases as a result of the coronavirus anyway.
So the WHO’s own writing-on-the-wall suggests that this most modest of targets is actually already out of reach, two years before the target period expires and yet this isn't being flagged up as it should be. But as we will discuss later on in this blog, these numbers disguise something more worrying still which suggests that almost all of the world leaders have done little or nothing to respond to their own call-to-arms.
‘The number of people provided with TB preventive treatment has quadrupled since 2015, from 1 million in 2015 to over 4 million in 2019’
This certainly sounds pretty impressive, doesn’t it? In reality, however, we find it to be a frighteningly disingenuous statement because of what it doesn’t mention in relation to this target. We should still acknowledge nevertheless that, like the first one we've looked at, this statement is also essentially true (because the numbers have indeed quadrupled) – but they are going to need to do far more than that for this target to be met, and this target is much more complex than is presented by Dr Tedros anyway.
First of all, we can state that stating that the quadrupling to 4 million is impressive is fundamentally misleading because the target for 2022 was actually a very ambitious 30 million. The significant gulf between what has been achieved numerically so far and the actual gross target is casually ignored in the Director General’s introduction which is surely regrettable.
But there’s far worse hidden away behind this statement, because this 30 million target was originally broken down into three sub-groups, all of whom were intended to be preventatively treated because of their being close contacts of known infectious case and who are known to be especially high risk or a contributory factor for ongoing infections and deaths. These three close-contact sub-groups were: HIV positive people; children (both of these first two groups being at special risk); and all other adults.
So let’s look at how these sub-groups were broken down in terms of the original target (see the bottom line in this table) and then let’s take another look at Dr Tedros’s statement and the progress made so far in meeting the targets (all numbers are in millions).
What is immediately obvious is that the target for treating HIV positive close contact cases was always likely to be met with ease (and most probably exceeded). This is good, for sure, but what is equally obvious is that there is now something dreadfully wrong with the other two targets. This discrepancy was actually already obvious a year ago (in fact we took some pains to identify this) yet nothing appears to have been done about it and no progress made – and for most of the more recent months of 2020, we've had COVID-19 on the loose so catch up is sadly now improbable. So it looks very likely indeed that two of these three targets are already well beyond reasonable reach. In fact they look like becoming catastrophes.
The overarching message of both this report from the WHO and that of the UN Secretary-General’s 2020 progress report on TB belies this, however. Both reckon that ‘high-level commitments’ have ‘galvanized global, regional and national progress towards ending TB’, although they recognise that ‘urgent and more ambitious investments and actions are required to put the world on track to reach targets, especially in the context of the COVID-19 pandemic’. Are these reasonable conclusions to have drawn? And are they even possible? How truly galvanised the current reported progress actually has been remains a matter of debate, but one key word is definitely missing: urgent and ambitious investments and actions are required to put the world back on track to reach these target, because already most are now well off-track and COVID-19 is making everything a lot more challenging.
But there’s actually something even more revealing about the sub-group of this target that does look like it should be hit which perhaps tells us more about how much more galvanised the response to HIV has been compared to that for TB. We suggest this because we’re not sure whether the unquestionable success with the preventative programme being implemented for PLWH who are in close contact with notified TB cases should be being credited as progress made by national TB programmes at all. We suspect that the disproportionate success of this single sub-group in relation to the other two targets set for preventative therapy may be more revealing about the more galvanized efforts being made by HIV programmes and by HIV activists than by national TB programmes.
The truth is that this should not be that surprising anyway given that the Global Fund to Fight AIDS, TB and Malaria (the Global Fund) still only designates a sixth of its total budget for TB rather than a logical third or more (given that TB is responsible for more deaths than both of the other two diseases combined). This is not just a persistent imbalance - it's an injustice which surely is reflective of one more failure in respect of TB control. What is really shameful, however is that this iniquity has persisted in spite of the 2018 HLM at the UN and the relative death tolls of these three diseases.
Dr Tereza Kasaeva Director, WHO’s Global TB Programme Director, offers her own introduction to this report immediately behind Dr Tedros’s, incidentally, and her tone is a little more muted. In fact, while she doesn’t really reveal how depressing this report really is, she seems to struggle more than Dr Tedros to find any good news to focus on, The only one she identifies is as follows: “The good news is that the WHO European Region is on track to reach the 2020 milestones of the End TB Strategy, and the African Region is making good progress towards these milestones”. As we will see as we look into this further, there is little to be in any way complacent about even with these milestones.
So exactly where are our own major concerns?
Estimates of incidence
One of the targets set for ending TB has been to see the incident rate reduce to 20% in 2022 compared to what it was in 2015 (which was 142/100,00).
So exactly what does this mean?
This ‘incidence rate’ comprises the sum total of all new or relapse cases of TB who are estimated to occur in any given year proportional to every 100.000 global population. In other words, this target number is not an absolute number of cases (either notified or estimated); it’s actually a proportion of the global population at the time. This rate of new incident infections is derived from the estimated number of new cases believed to have occurred during the year in question (including those reckoned to be missed) which is then computed against the total contemporary global population and then reduced down to the estimated number of new infections occurring in every 100,000 global citizens.
There is plenty of room for confusion here – not least because the number of new and relapse cases being estimated each year has been remaining almost exactly the same for the last few years at ‘about 10 million’ whilst the rate of them occurring has been reported as reducing. And it’s this ‘rate’, of course, that is the object of the target (not the number).
So how exactly can the rate be reducing while the number has been staying the same? The answer is simple: it’s because the global population has been increasing over the same period. As such, even if the estimated incidence number remains the same, its proportion in relation to the increasing global population reduces accordingly.
Here are the numbers to explain this (all taken from WHO and UN numbers):
One concern is that this target (the ‘rate’) is essentially uncertain anyway because it’s based on estimates of missed cases who (by definition) remain uncountable. We do know, at least, what the target set for 2022 was (see bottom right of table), and we can equally anticipate the global population for that year with some confidence based on current trends (see the bottom line on the table). So using these two numbers we can also calculate the necessary estimate of new and relapse cases that might be needed to meet this target. Using the table above above we can see that a 20% drop from the 2015 estimated incidence rate (from 140/100,00 to 114/100,000) in a global population of 8 billion would mean that an estimate of 9.12 million new TB cases that year would be needed to meet the target.
This numerical target was certainly possible in a pre-COVID world, but unfortunately that world no longer exists. Now it rally should be recognised that, on the WHO’s own preliminary modelled projections of increased TB infections because of this novel virus, meeting this target is highly improbable without a huge change in trends in the next two years.
In fact, it may well already be impossible without massing increases in funding. The Stop TB Partnership’s independent study has already suggested that the COVID-19 pandemic could cause an additional 6.3 million TB cases globally between 2020 and 2025. Finding and treating them will require a proportionate increase in annual resource of perhaps around 15%, but the current budgetary targets for finding and treating TB patients are already being reported by the WHO in this same report to be being missed by 50% - a gap that has been ironically growing in the two years since the High Level Meeting.
What’s also worth noting is that meeting this key target reduction of 20% wouldn’t actually mean mean that the estimated number of TB cases would have dropped by 20% as well - it would mean that the number of incident cases would have dropped by only just under 9%! Suddenly this target doesn't sound so ambitious either... and yet because of COVID it is almost certainly going to be missed.
But the biggest problem of all is that this number was set knowing that it was inevitably dependant on rigorous estimates and so (given the ongoing deficiency of surveillance) its final outcome will remain uncertain anyway (Please keep a lookout for the forthcoming blog concerning the Indian Prevalence Survey to see more of what we mean by this).
The target for TB mortality for 2020 is for a numerical reduction and so this time isn’t influenced by population trends. It aims for a 35% reduction in estimated deaths for 2020 from the baseline of 2015 but, while we may be dealing with simpler numbers, yet again we should recognise that we are once again ultimately dealing with estimates. This is because the total mortality numbers reported are fundamentally dependant on three things: the absolute numbers of TB deaths being recorded by national TB programmes; the estimated numbers of missed cases (both drug-susceptible and drug-resistant); and their relative case fatality ratios which are variable. So once again this target is essentially dependant on an indirect estimate of incidence which is largely dependent on surveillance which (while it may be slowly improving) is still far from up to speed with the slow rolling bow wave of tuberculosis. So if this estimate is wrong, then both targets (for both incidence and mortality) are meaningless. This is also something we will discuss further in our forthcoming blog on the Indian Prevalence survey (or rather the absence of the Indian prevalence survey in this current report).
With this in mind, even meeting this target may not necessarily be totally reassuring, but so far the world is well off-track anyway. So far (in 2019 which is most of the way through the 2015-20 period) a drop of 14% is estimated - roughly two-fifths of the 35% target when we should want to see it rather see it at four-fifths (or 28%). So we’re currently seeing just half of what’s needed to see this target met – and this was reported BEFORE the coronavirus impacted in what is this target's current final year. So once again we have to conclude that meeting this target is not just highly unlikely: given that COVID will have inevitably caused more TB deaths this current year it's almost certainly impossible.
But again we sadly find ourselves wondering once again whether at least part of what has been achieved here reflects more on the efforts of the HIV programmes anyway because living with HIV is known to add such a significant risk of death from a TB infection. This trend difference between HIV negative and positive deaths isn't new - the report actually identifies that us mortality rate fell by 45% in HIV negative TB cases between 2000 and 2019, but fell by a much higher 76% in HIV positive cases in the same period.
So what is noted as ‘good news’ in the Report by Dr Kasaeva (that the European region is ‘on track’ and the African region is making ‘good progress’ in respect of mortalities from TB) may just be a reflection of better efforts made with HIV treatment because both of these regions are where better efforts have been made by HIV programmes in controlling HIV deaths and a significant proportion of these deaths of PLWH have been finally caused by tuberculosis. And, if so, that's hardly good news.
People with TB facing catastrophic costs
The aspirational target set in 2015 was that none (i.e. 0%) of those infected with TB would suffer from incurring catastrophic costs (defined as total costs equivalent to 20% or more of annual household income) as a result of their infection by 2020.
This was a target set back in 2015 for 2020. It was certainly always an ambitious one and we doubt was was ever seriously expected to me met. But nevertheless the financial costs for those suffering from TB infections were hoped to be massively less catastrophic by now, but the pathetic numbers now being reported turn out to be catastrophic in themselves.
First of all, it turns out that in 2019 (at a way point four years into this five year target period) only 17 of the 193 UN member countries countries have even bothered completing a national survey of costs faced by their TB patients and their households at all.
Meanwhile from this paltry reported data, it’s reckoned that 49% of people with TB still face catastrophic costs. For people with drug-resistant TB, the figure was higher still, at 80%.
From any perspective, this record is shameful and should surely be called out as such, but the report disappoints by failing to do so. Sadly this situation will be made even worse for those affected by the anticipated economic impact of the coronavirus which the report appropriately recognises: “The impact on livelihoods resulting from lost income or unemployment could also increase the percentage of people with TB and their households facing catastrophic costs” it says.
So if only 8% of the world’s countries can even bother to file a report on a global target set by themselves, how on earth are the struggling stake holders in this fight against this ancient killer expected to have any confidence in how this target will be finally reported – which is due to happen this time next year? And what, meanwhile, should they expect and fear from an infection by it?
Tragically, it looks like more of the same impoverishment.
New cases being put on treatment (revisited with some real concerns)
“Globally, 7.1 million people with TB were reported to have been newly diagnosed and notified in 2019, up from 7.0 million in 2018 and a large increase from 6.4 million in 2017 and 5.7–5.8 million annually in the period 2009–2012”.
We’ve already seen that the number of cases actually only rose by 0.1 million from 2018 to 2019 – an insufficient hike to stay on track for the UN target of 40 million cumulative cases by 2022. But is there some amount of clutching at straws here in including those earlier numbers? (The period 2009-12 referred to above was one in which pretty much every other TB case was reckoned to be being missed after all, and it is this last year that the report was supposedly focused on).
But it was this focus on the last two years (the first two of the current five year target) that drew our attention to these numbers. Unpacking what amounts to only an increase of 700,000 (6.4-7.1 million) annually being put on treatment between 2017 and 2019 has thrown up an even more serious concern, because the report adds that two countries in particular (India and Indonesia) have accounted for this increase. Superficially this may sound encouraging given that both of these countries have immense TB epidemics, but that’s what's drawn out attention. Our concern arose when we deducted these two national increases from the difference in global totals between 2017 and 2019 - something the report chose not to do although it surely must have been something those in Geneva noticed while preparing it.
When we did this, we recognised that there’s actually only been a terrifyingly insufficient increase in new cases being treated in all the other countries of the world in the last two years - in all countries of the world, that is, except India and Indonesia, when supposedly the response has been being galvanized and during which the number of estimated new cases has not dropped.
We deducted half of the recorded two year increases in India and Indonesia (a creditable 633,000 extra cases treated averaging out at 316,500 each year) from the difference in sum global totals between 2017 (6.4 million) and 2019 (7.1 million in 2019) which amounts to 700,000. Our calculation this runs at 700,000 - 316,500 = 383,500. The net increase with these Indian and Indonesian increases omitted then amounts only to a total of less than 0.4 million over these two years.
Let us repeat this because it is so appallingly shocking: the net global increase in global TB treated cases since 2017 with India and Indonesia omitted amounts to only just under 0.4 million a year and this paltry increase occurred in a period that was coincident with the UN high level meeting when so-called ‘galvanised’ world leaders unanimously demanded that something very different should happen.*
Is this possible? Have we got something wrong? And if we haven’t (and we don’t think we have done) then shouldn’t this shamefully poor response to the UNHLM have been identified and highlighted in this latest report because of what it implies (because it means that we were already abjectly failing to control tuberculosis before COVID intervened)?
(And please note, furthermore, that this abject failure showed itself in 2019 before any impact from the coronavirus.)
A summary concludes the second chapter of the report as follows:
“The overarching message of this report and that of the UN Secretary-General’s 2020 progress report on TB is the same. High-level commitments have galvanized global, regional and national progress towards ending TB, but urgent and more ambitious investments and actions are required to put the world on track to reach targets, especially in the context of the COVID-19 pandemic.”
Does what we have identified above in any way confirm any sort of galvanising? Sadly we don’t think so. Even more tragically (due to the coronavirus) the rolling tragedy that is 21st century TB is almost certainly going to roll on remorselessly taking more millions of vulnerable lives with it, quite possibly now pushing us back up to over 2 million lives lost a year because of the coronavirus. Meanwhile, almost certainly all of the interim targets are going to be missed.
At least we can agree that urgent and more ambitious actions than ever are now required to put the world back on track but, given the poor progress that self-evidently preceded the COVID-19 pandemic, we are really struggling to see how fortunes can possibly change before the next report that will be published this time next year, nor how any of these targets will now be met.
Perhaps more importantly of all, we believe that this should have been properly identified in the report.
Meanwhile in a follow-up blog to this review, we want to ask another uncomfortable question:
What exactly has been happening to the Indian Prevalence Survey?
* This section was originally calculated incorrectly, and was corrected on 25/10/20. The error was identified by ourselves.