Around 7.5m people were diagnosed with TB in 2022, the highest number ever, but this is positive as it shows countries’ ability to detect the disease is recovering after the Covid-19 pandemic, according to the World Health Organisation (WHO) 2023 Global tuberculosis (TB) Report released recently.
The report revealed that contributing most to the global rebound in new diagnoses were India and Indonesia, accounting for 56% of the increase between 2021 and 2022, followed by Philippines (11% of the global increase) and Pakistan (8.4%).
On the upside, however, treatment coverage has returned to the pre-pandemic level of 70%, up from 62% in 2021, reports Health Policy Watch.
The disease was the second leading cause of death last year, beaten only by Covid-19, despite being “completely preventable and curable”, said Dr Tereza Kasaeva, WHO’s Global TB Programme director, at the report’s launch.
“What’s missing? Prioritisation and enough investment, as we have much better tools for successful treatment, even for the most severe forms of drug-resistant TB,” she said
Deaths from the disease were down to an estimated 1.3m, compared with 1.4m for 2020 and 2021, according to the report, but the net reduction in deaths between 2015 to 2022 was only 19% – nowhere near the WHO End TB Strategy milestone of a 75% reduction by 2025.
The WHO African and European regions have made the best progress in cutting deaths since 2015, while 47 countries have achieved reductions of at least 35%.
Mandatory screening
At Kaneshie Polyclinic, a health centre in Accra, Ghana’s capital, there is a rule. Every patient who walks through the door – a woman in labour, a construction worker with an injury, a child with malaria – is screened for TB.
This national policy is meant to address a tragic problem; two-thirds of the people in this country with TB don’t know they have it.
Worldwide, 40% of people with TB are untreated and undiagnosed, said the WHO report, even though currently, there is great hope in the fight against TB.
Significant innovations in diagnosing and treatment have started to reach developing countries, and clinical trial results show promise for a new vaccine.
The New York Times reports that infectious disease experts who have battled TB for decades express renewed conviction that, with enough money and a commitment to bring those tools to neglected communities, TB could be nearly vanquished.
A recent visit to the Kaneshie clinic revealed both the progress and the remaining barriers. Despite the clinic’s policy of screening everyone for TB by asking a few questions about coughs and other symptoms, patients streamed into the building and were sent for care without any such queries.
A member of the TB team, it turned out, was on holiday, another was on maternity leave and a third was off sick. That left just two, who were busy processing tests and doling out drugs.
So no one was screened, not that day or any other day in the previous week.
When the screening policy is working, new medications, the first to come to market since the 1970s, can be taken as just a couple of pills daily, rather than as handfuls of tablets and painful injections, the way TB treatments were delivered in the past.
Those diagnosed with drug-resistant TB receive medication to take for six months, a far shorter time than previously required.
For decades, the standard treatment for drug-resistant TB was to take drugs daily for a year and a half, sometimes two years. Inevitably, many patients stopped taking the medicines before they were cured and ended up with more severe disease.
The new drugs have far fewer onerous side effects than older medications, which could cause permanent deafness and psychiatric disorders. Such improvements help more people to continue taking the drugs, which is good for patients, and eases the strain on a fragile health system.
In Ghana and most other countries with a high prevalence of TB, the drugs are paid for by the Global Fund to Fight Aids, TB and Malaria, an international partnership that raises money to help countries fight the diseases.
The sustainability of those programmes depends on donor largess. Currently, the treatment for adults recommended by the WHO costs at least $150 per patient in low- and middle-income countries.
Still, there has been progress in recent months in making the medicines more affordable, and prices may soon drop further.
Johnson & Johnson has lowered the price of a key TB drug in some developing countries after pressure from patient advocacy groups, the United Nations and others. The company also agreed in September not to enforce a patent, meaning generic drug companies in India and elsewhere will be able to make a significantly cheaper version of the medication.
And for the first time in more than 100 years, there is real hope for an effective vaccine: a promising candidate called M72, developed by GSK with financial backing from the Gates Foundation and other philanthropies, is now in the last stage of clinical trials.
‘MDR-TB a public health crisis’
However, despite optimism about these milestones, “Multidrug-resistant TB remains a public health crisis”, said Kasaeva, with only two out of five people with multidrug-resistant or rifampicin-resistant TB (MDR/RR-TB) receiving treatment last year.
With around 410 000 people developing drug-resistant TB in 2022, Kasaeva described the condition as “stable”.
“The cumulative reduction in the TB incidence rate from 2015 to 2022 was only 8.7%, far from the WHO and TB strategy milestone over 50% reduction by 2025.”
Some 42% of the global burden of people with drug-resistant TB comes from just three countries – India (27%), the Philippines (7.5%) and Russia (7.5%).
On the positive side, almost three-quarters (73%) of people diagnosed with pulmonary TB were tested for rifampicin resistance, up from 69% in 2021. Some 4.4% were diagnosed with MDR/RR-TB.
The cumulative number of people with MDR/RR-TB on treatment from 2018 to 2022 was 825 000 – 55% of the 5-year target of 1.5m. For children, the cumulative number was 21 600 – a dismal 19% of the 5-year target of 115 000.
But the report notes that there have been “steady improvements in the treatment success rate for people diagnosed with MDR/ RR-TB”.
On the horizon
Better technology to diagnose TB is slowly reaching clinics in developing countries. Clinics across South Asia and sub-Saharan Africa, including the one in Ghana, now have machinery to use rapid molecular diagnostic tests – equipment that was donated as part of the Covid response.
That means many health centres have finally stopped using an unreliable diagnostic method, developed in the 1800s, of viewing sputum smears under microscopes.
Still, last year, less than half of people diagnosed with TB were first given a molecular test, according to the TB report. The rest were diagnosed with a microscope, or, in many cases, by their clinical symptoms.
The molecular diagnosis can also spot drug-resistant TB right away. (The old method involved starting a person on a course of the most common drugs and waiting to see whether the treatment worked; if patients had the drug-resistant form of the disease, they just got sicker.)
Clinic staff in Ghana, however, say that while preventive therapy works well, people who are newly diagnosed don’t want anyone to know they have the disease, which is associated with poverty and suffering, so they don’t volunteer information about other people who may have been infected.
And the understaffed health system struggles to track them.
Only 169 health centres across Ghana have the capacity to use the new testing method. Usually, samples must be sent away – up to a three-hour drive in some rural areas. By the time results come in, it can be hard to track down those who were tested.
“The equation is simple. If we were putting more resources into testing for TB, we would be finding more TB,” said Dr Yaw Adusi-Poku, who heads Ghana’s national TB control programme.
That would require more molecular testing sites, more staff trained to spot the disease, more people to ask questions at the clinic door, and more nurses.
Molecular diagnosis is considerably more expensive than the old method.
Cepheid, the company that makes cartridges for the testing machines, recently agreed to cut the price of each one to $8 from $10, which the company says is at cost. An analysis commissioned by Doctors Without Borders found that the cartridges could be made for under $5; the company says this is inaccurate.
Cepheid continues to charge $15 per test for the diagnosis of extremely drug-resistant TB, the most lethal form of the disease.
Funding for TB services in low- and middle-income countries fell to $5.8bn in 2022 from $6.4bn in 2018, which is just half of what the WHO says is needed. About $1bn is available each year for TB research, half the amount the UN says is required.
At a special meeting on TB at the United Nations in September, governments committed to spending at least $22bn a year on TB by 2027. But at a similar meeting in 2018, the same donors promised to spend $13bn by 2022, less than half of which materialised.
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