New Delhi: The headline finding of the WHO’s Global Tuberculosis Report 2022, released on October 27, continued to be the same as it was for 2021 – COVID-19 has reversed years of progress towards the goal of eliminating TB by 2030. As such, the global health body has advised all high TB burden countries to launch campaigns to make up for the loss.
During 2020 and 2021, things seem to have gone bad for India, which has the highest TB burden in the world. Incidentally, India aims to eliminate TB by 2025, five years before the global deadline. Health experts, however, consider this goal dubious given the realities of the country’s TB landscape.
The 2022 WHO report maps the developments of 2021. It says the TB deaths in India increased by 6.6% as compared to 2015. The interim global target, on the other hand, was to achieve a 35% reduction in TB deaths by 2020, as compared to 2015, to be on track to achieve the final 2030 targets.
Even compared to 2020, TB deaths in India rose in 2021, going from 4.8 lakh-5.06 lakh – an increase of 5.1%. India is among the four countries where, according to the report, most of the estimated increase in deaths took place. The other three countries are Indonesia, Myanmar and the Philippines.
Another major worry was the significant reduction in notification (put simply, reporting) of TB cases. India reported the highest reduction in reporting from 2019 to 2020, across the globe. In 2021, this reduction was arrested to some extent, but still left a lot to be desired.
“Reductions in the reported number of people diagnosed with TB in 2020 and 2021 suggest that the number of people with undiagnosed and untreated TB has grown, resulting first in an increased number of TB deaths and more community transmission of the infection, and then, with some lag-time, increased numbers of people developing TB,” the report read.
TB is a notifiable disease; that is, every TB case is required by law to be reported to the government, whether it is registered at a private or public hospital. For every country, an incidence rate (number of cases per 100,000 population) is estimated. The difference between the number of cases actually reported and the estimate as per the incidence rate is reckoned as gap in notification or reporting.
The three countries that contributed the most from the drop in reporting from 2019 to 2020 were India, Indonesia and the Philippines – accounting for 67% of the global total reduction. These countries made partial recoveries in 2021, but still accounted for 60% of the global reduction from 2019, the report said.
Insofar as India’s individual performance is concerned, a 29% decline in case reporting happened in 2021 vis-a-vis 2019 (the corresponding figure was 41% in 2020) – still the highest gap in terms of notification, globally. In other words, 41% and 29% TB cases went unreported in 2020 and 2021, respectively, in the country.
What’s more, India’s performance on this front directly affects global performance. “India and Indonesia, had previously been the main contributors to the large global increase [in TB notification] that occurred between 2013 and 2019,” the report stated.
The incidence of TB in India has gone up too. The WHO, in collaboration with Imperial College, London (the latter developed ‘methods to estimate the TB incidence and mortality’) estimated that TB incidence in India went up from 204 cases per 100,000 population to 210 per 100,000 in 2021 – an increase of 2.8%
Another major cause for concern is drug failure or drug resistance among TB patients. This happens mostly due to missed doses of drugs, which form the first line of TB treatment, either due to a lack of access or a voluntary gap in treatment.
Drug-resistance is hard to treat and also makes treatment costlier. As per the WHO report, the number of people diagnosed with drug-resistant TB rose by 18% in India in 2021 compared to 2019 levels. On the other hand, a lot more TB patients (25% more) were put on a drug-resistant TB treatment regimen because the first line of treatment drugs failed. India also has the highest number of drug-resistant TB cases in the world – 26% of all global cases.
The WHO report mapped the five major causes of TB infections in all countries. For India and also the world, undernutrition was the biggest contributing factor in 2021. A lack of nutrients blunts the natural and innate immune response to the disease, once an individual is exposed to TB-causing bacteria. Hence, undernourished people who do not have access to sufficient nutritious food are more susceptible to the disease.
Alcohol use, diabetes, HIV and smoking were identified, in descending order, as other factors responsible for causing TB.
For people who suffer form HIV or are contacts of confirmed TB cases, preventive TB treatment is prescribed. The rates of preventive TB treatment declined by 3.1% in India from 2020 to 2021.
Amidst declining TB achievements, India also cut funding for TB by nearly half in 2021 compared to 2020. According to the WHO report, the domestic funding for TB decreased from $326 million in 2020 to $183 million in 2021. It should be noted that India ranks second among 30-high burden countries which cut domestic expenditure on TB.
International funding to India, however, nearly doubled in this period.
Globally, the obvious key takeaway was the downslide in many TB elimination achievements in 2021 – thanks to disruptions caused due to the COVID-19 pandemic. This has thrown the world off track in the TB endgame which was supposed to be completed by 2030. The most obvious impact was felt on the notification of TB cases.
The second most pronounced effect was an increase in TB deaths and now they have gone back to 2017 levels. TB was second only to COVID-19 as a cause of death from a single pathogen in 2021. Deaths from TB in 2021 were more than double those from HIV/AIDS, which continued to fall. What’s more, the incidence rate, which has declined by 2% every year in the last two decades, increased by 3.6% between 2020 and 2021.
The WHO has called upon countries to increase funding and launch dedicated surveillance and catch-up programmes to combat the losses in TB eradication achievements.