Disruption to diagnostic & treatment services across the globe meant that the number of deaths due to TB increased for the first time in 2020. On the other hand, the diagnosis of new cases has been reduced highlighting the impact of the pandemic on diagnostic & treatment services. The trend in India was also similar.
Tuberculosis (TB) is a potentially serious infectious disease caused by bacteria (Mycobacterium tuberculosis) that mainly affects the lungs. Though a quarter of the world’s population is infected with tuberculosis bacteria, only a small proportion of those infected become sick with TB. Those with weakened immune systems such as people living with HIV, malnutrition or diabetes, or people who use tobacco, consume alcohol, etc. are at a higher risk of falling ill from TB.
Though the disease is curable and preventable, millions fall ill globally every year across countries and age groups. Over the years, multiple initiatives have been taken at the global level to tackle the disease. However, the COVID-19 pandemic has resulted in the reversal of decades of progress in TB elimination. For the first time in over a decade, the number of deaths due to TB has increased due to reduced access to TB diagnosis and treatment in the face of the pandemic.
Recently, the World Health Organization (WHO) published the Global Tuberculosis Report 2021 which is an annual publication being published since 1997. The report provides a comprehensive and up-to-date assessment of the TB epidemic and is based primarily on data gathered by WHO in annual rounds of data collection. In 2021, data reported by 197 countries and territories which account for more than 99% of the world’s population and TB cases have been considered.
The global incidence of TB cases per lakh population continues to decline
It is estimated that the global incidence of TB cases per lakh population has dropped to 127, the lowest since the year 2000. The was as high as 174 cases per lakh population at the beginning of the millennium and since then, there has been a gradual drop in the incidence of TB over the years. An estimated 9.9 million people fell ill with TB in 2020.
Fewer new cases of TB diagnosed in 2020 compared to 2019
The number of new cases of TB diagnosed annually was 6.4 million cases in 2016 which increased to 7.1 million in 2019. However, in 2020, the number dropped to 5.8 million cases, a drop of 18% compared to 2019. A similar pattern, an increase in new cases up to 2019 and a subsequent sharp drop in cases in 2020 has been observed in 5 out of 6 WHO regions. About 1.3 million fewer cases of TB were detected in 2020 compared to 2019 and about 84% of this global drop in new cases was reported from the regions of South-East Asia and the Western Pacific. India (41%), Indonesia (14%), the Philippines (12%), China (8%) and 12 other countries accounted for 93% of the total global drop of 1.3 million in 2020.
This reduction is largely due to the pandemic which resulted in reduced access to disease diagnosis, treatment, and spending. While healthcare systems were put to test during this period, people were also hesitant to go to hospitals due to lockdowns and movement restrictions, risks of catching an infection, and stigma associated with similarities in the symptoms related to TB and COVID-19. Furthermore, an 8.7% decline in spending on TB between 2019 and 2020 (from US$ 5.8 billion to US$ 5.3 billion) has been reported. The 2020 spending on TB back to the 2016 level of funding.
Though the number of new cases of TB has reduced, the number of deaths due to the disease has increased in 2020. A total of 1.5 million people died from TB in 2020 (including 2.14 lakh people with HIV). Globally, TB is the 13th leading cause of death and the second leading infectious killer after COVID-19. Compared to the over 1.4 million deaths (including 2.09 lakh people with HIV) in 2019, the number of deaths has increased in 2020. This is for the first time since 2005 that the total number of deaths due to TB has increased year on year. The same trend has been reflected in the global TB mortality per lakh population. The years of progress made in reducing TB deaths globally has suffered a setback by the pandemic. In fact, the increase in deaths confirms that the reduction in the diagnosis of new cases is due to the pandemic and not due to the incidence of disease.
The trend in India is similar to the Global trend
Just like the global trend, the incidence of TB cases in India has reduced in the last two decades. In the year 2000, the incidence was as high as 289 cases per lakh population which have now reduced to 188 cases per lakh population. This is the lowest incidence since the year 2000.
COVID-19 has affected TB diagnosis and treatment in India
Similar to the global trend, the number of new cases of TB reported in India in 2020 is less than in 2019. The number of new cases of TB dropped from 2.64 million in 2019 to 2.57 million in 2020, a reduction of 3%. In other words, India reported about 70,000 fewer cases in 2020 compared to 2019 which may be attributed to the effect of the pandemic.
The number of deaths due to TB, including those with HIV, has increased from around 0.45 million persons in 2019 to 0.5 million persons in 2020, an increase of 10%. This trend is on par with the global trend, indicating that India, just like most other countries, has been hit significantly by COVID-19 in providing diagnosis, treatment, and spending.
Country-specific models suggest that in the 16 top countries contributing to a higher number of TB cases including India, greater negative impacts in terms of deaths and cases are expected in 2021. The greatest impact on TB deaths is expected in 2021 and on TB incidence is forecast for 2022.
Progress towards TB milestones and targets has been hit hard by the COVID-19 pandemic
The ‘End TB’ Strategy of WHO serves as a blueprint for countries to reduce TB incidence by 80%, TB deaths by 90%, and to eliminate catastrophic costs for TB-affected households, by 2030. The Strategy is not a ‘one size fits all’ approach and its success depends on adaptation for diverse country settings.
The ‘End TB’ Strategy’s targets for reduction 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 to the 2015 levels. These milestones were not achieved globally or in most WHO regions and countries. The reduction in the number of TB deaths between 2015 and 2020 was only 9.2% globally, a quarter of the milestone. The progress up to 2019 (14% reduction from 2015 to 2019) and a 41% reduction in TB deaths from 2000 to 2019 in was disrupted by the pandemic.
In India, the government stated that under the National TB Elimination Programme (NTEP), multiple steps have been taken to mitigate the impact of COVID-19 on TB Services. Among the steps listed by the government are provision for free TB drugs for an extended duration and door-step delivery, provision of guidance on ensuring the functionality of TB diagnostic labs, issuance of multiple advisories to States and districts to ensure uninterrupted services during COVID-19, and guidance to states/UTs for Bi-directional TB-COVID screening and screening of TB among ILI/SARI cases.
WHO calls for urgent action to mitigate and reverse the impact of COVID-19
The WHO has called for urgent action to mitigate and reverse the impact of the COVID-19 pandemic on TB. The immediate priority is to restore access to and provision of essential TB services such that levels of TB case detection and treatment are brought back to 2019 levels. Ending the TB epidemic by 2030 is also among the health targets of the United Nations Sustainable Development Goals (SDGs). While this target looks like a long shot at this moment, restoring normalcy in diagnostic & treatment services would be the first step in that journey.
Featured Image: Global Deaths due to TB