The shifting of resources and disruption of healthcare caused by the COVID-19 pandemic is being blamed for an increase in deaths due to tuberculosis, the first in over a decade, according to a recent global report from the World Health Organization (WHO).
It's estimated that 1.5 million people died of TB in 2020, including 214,000 HIV-positive people; in 2019, an estimated 1.4 million people died, according to the Global Tuberculosis Report, released October 14. Experts fear that the pandemic-related challenges of diagnosing and treating the disease are causing many cases of TB to go undetected and undiagnosed; the number of newly diagnosed cases and government-reported cases fell from 7.1 million in 2019 to 5.8 million in 2020.
TB has been killing millions of people for thousands of years, says Jeff Starke, MD, the director of the Children's Tuberculosis Clinic at Texas Children's Hospital in Houston and a member of the WHO Childhood Tuberculosis Roadmap Committee. "It's the pandemic that's hiding in plain sight. Every year in the world about 10 million people get sick with TB, and between 1 and 1.5 million people die — that's every year, year after year," says Dr. Starke.
What Is Tuberculosis (TB)?
Both COVID-19 and tuberculosis primarily affect the lungs, but COVID-19 is caused by a virus and TB is caused by bacteria known as Mycobacterium tuberculosis. The TB bacteria usually attack the lungs, but they can invade any part of the body, including the kidneys, spine, and brain, according to the Centers for Disease Control and Prevention (CDC).
TB is contagious, but it's not easily spread from person to person, and not everyone infected with TB bacteria gets ill. There are two kinds of TB conditions: latent (or silent) TB and TB disease. It's suspected that about 1.8 billion people, or a quarter of the world's population, has latent TB, according to the American Lung Association. Active TB can almost always be treated and cured if it is diagnosed and the medicine is taken as directed.
TB is everywhere and can affect anyone — the disease doesn't know borders and nations, although there are a group of high TB burden countries where the risk of contracting tuberculosis is much higher, says the TB expert Tereza Kasaeva, MD, in a World Health Organization video. "Every single day, tuberculosis claims more than 4,100 lives," said Dr. Kasaeva.
Fewer Resources Mean Few People Diagnosed or Reported to Have TB
The WHO estimates that 4.1 million people currently have TB but are either undiagnosed or have not reported their condition to national authorities, a jump from 2.9 million in 2019. According to the organization, far fewer people were diagnosed, treated, or provided with TB preventive treatment in 2020 compared with the previous year.
Experts point to a diversion of human and financial resources as a major driver of the current TB crisis. "TB control programs in the United States and around the world have been decimated because the people who work in those programs have been pulled away to work on the COVID-19 pandemic," says Starke. That's because people who work in TB are experts in contact tracing, which is a major weapon in preventing active TB, he adds.
Individuals identified as high risk, which can include people with HIV infection or close contacts of people who are newly diagnosed with TB, are considered candidates for preventive treatment, which can keep someone from ever developing active TB.
The reduced number of people working on TB in health departments and other organizations has also caused issues with people getting the proper care or medications, says Starke.
It's worrisome that even though the number of cases reported to the WHO is down substantially, the number of deaths is actually up, he says. "That means the mortality rate due to TB has had a significant increase over the past year."
The TB situation is further exacerbated by the difficulty of accessing healthcare during the pandemic, the WHO report notes. Lockdowns and people's fears of getting COVID-19 at hospitals and clinics are primary factors in the increase of deaths and undiagnosed cases, states the organization.
"Although the pandemic has caused the disruption of diagnosis and care for many diseases, the impact on TB has been especially severe," says Sundari Mase, MD, MPH, the former India Country TB Medical Officer for WHO and current chair of Stop TB USA.
More undiagnosed and unreported cases could continue to cause a rise in TB cases and deaths, because there will be more people who are infectious and spreading the disease to others than there have been in the past, says Dr. Mase.
"This report confirms our fears that the disruption of essential health services due to the pandemic could start to unravel years of progress against tuberculosis," said Tedros Adhanom Ghebreyesus, MD, the WHO's director-general, in a statement. "This is alarming news that must serve as a global wake-up call to the urgent need for investments and innovation to close the gaps in diagnosis, treatment, and care for the millions of people affected by this ancient but preventable and treatable disease," he said.
More Research Is Needed to Determine if COVID-19 Worsens TB
Researchers are still learning about TB's impact on COVID-19. "We don't know if getting COVID-19 makes TB worse — it certainly could, but we don't know that yet," says Starke.
Further complicating the issue is the fact that TB and COVID-19 can have overlapping symptoms, which include cough, fever, and difficulty breathing, according to WHO. TB diagnoses are being missed because some providers are attributing what are actually TB symptoms to COVID-19, says Starke.
Globalization Means That if TB Is Anywhere, TB Is Everywhere
TB is a leading infectious disease killer in the world, says Mase. "Although here in the United States we have lower case numbers compared with other countries, TB anywhere is TB everywhere because of globalization — that's why it's really important that we tackle TB, especially in the highest burden countries," she says.
It's frightening that there's been a 41 percent decrease in TB notifications from India, the country with the highest TB burden in the world, she says. "We already estimated there were one million unreported/undiagnosed cases in India pre-pandemic, and to see that huge drop is really worrisome," says Mase. It's estimated that two out of five people in India have latent TB, and there are 2.8 million cases of active TB each year, according to USAID.
Even though we have only about 8,000 cases of TB in the United States, we too have seen a decrease in the number of reported or diagnosed cases, suggesting that the same phenomenon that's going on globally is going on here, she says. "That means that we could see more transmission and outbreaks here in the U.S."
More Resources Are Needed to Fight TB
Funding is a really big part of the equation, says Mase. "Funding has dropped for TB globally, and the U.S. is one of the main funders. We need to refocus attention and resources on building TB infrastructure, both globally and in the U.S.," she says. More money is needed for training, education, treatment, and building infrastructure, she adds.
Starke agrees — more funding is needed in the fight against TB. "We're all marveling at how fast we were able to develop a vaccine for coronavirus," says Starke. "Tuberculosis has been around for 6,000 years and we still don't have an effective vaccine. The amount of money put into TB vaccine research has been dwarfed by the amount of money that has been put into vaccines for the coronavirus, HIV, malaria, and many other diseases," he says.
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