New survey finds millions of people affected by TB still diagnosed, treated with outdated tools

Data on 37 countries reveals widespread failure to follow latest international recommendations for policies on prevention, diagnosis, and treatment

Step Up for TB 2020 examines the national policies of 37 countries with a high burden of TB, assessing the extent to which they align with World Health Organization (WHO) guidelines and international recommendations. With an estimated 7.7 million people developing TB each year, these 37 surveyed countries represent 77% of the global TB burden and 74% of the estimated burden of drug-resistant TB.

“Earlier this year, the COVID-19 pandemic hit the world with devastating impact, and governments around the world quickly adopted new policies and laws in response,” said Dr. Lucica Ditiu, STBP Executive Director. “Meanwhile, TB remains the top infectious disease killer, even though it is preventable and curable. To make matters worse, most countries still use outdated policies, practices, tools and treatment regimens. Our survey, which is conducted regularly, shows improvements every year, but we have a long way to go. We all must ensure that every single person affected by TB is diagnosed and treated using the latest available international guidelines and tools.”

Previously known as Out of Step, this fourth edition in the series covers a larger set of countries and additional policies and practices related to four key areas: diagnosis, treatment, prevention and medicines procurement.

Diagnosis
On diagnosis, the report finds that many of the surveyed countries still have outdated testing policies that may lead to inadequate TB prevention and care. Around 347,000 people who develop TB each year in the 37 surveyed countries have a form of the disease that is resistant to existing treatments. Of them, only 1% can hope to access comprehensive universal drug sensitivity tests, as just six of the 37 countries (18%) have introduced the necessary policies.

TB is the most common cause of death among people living with HIV, more than 28 million of whom live in the 37 surveyed countries. But a mere 14% of those countries have put policies in place that allow for the use of lateral flow urine lipoarabinomannan assay (LAM) testing for TB, which has been internationally recommended since 2015. This leaves more than 17 million people living with HIV without access to a rapid, affordable and life-saving TB diagnostic tool.

There is, however, some positive news on diagnostics policies. Countries made progress on certain key indicators since 2017 when the last report in this series was published. For example, 80% of surveyed countries—with more than 1.5 billion inhabitants—indicate that they are now able to use rapid molecular TB tests as the initial test for people with symptoms of TB, finally moving away microscopy. However, most countries do not seem to have implemented this policy at scale; this should be a priority.

Treatment
Alarmingly, when it comes to treatment, nearly 39% of countries are likely to still use injectable medicines to treat drug-resistant TB (DR-TB) among adults, having failed to update the relevant policies in line with the latest international guidance. STBP calls for an immediate halt to the use of TB treatment involving injectables; oral medicines should be used instead, as recommended by WHO since 2018.

Progress was noted on the treatment of DR-TB in children, with 72% of countries introducing injectable-free treatment regimens, benefitting 5,000 children in 2019. However, children with TB are often left without proper treatment because of the lack of adapted tools to diagnose TB in children. An estimated 30,000 children become ill with DR-TB every year but, in 2019, only 5,586 were diagnosed, treated and notified to the WHO.

The report finds considerable gaps in the use of decentralized models of DR-TB care, covering only 21% of people affected by DR-TB in eight countries. By failing to remove barriers that prevent people affected by DR-TB from accessing care outside of specialized clinical settings, countries limit access to and increase the cost of accessing TB services. In addition, unnecessary in-patient treatment models dramatically increase the risk of further transmission of the infection within the clinical setting.

Prevention
After decades of neglect, TB prevention has finally been recognized as a priority area in the fight against TB. Systematic screening for active TB, testing for latent TB infection among household contacts and provision of TB preventive treatment are now included in the national policies of all surveyed countries. Additionally, 81% of the surveyed countries, with a total population of more than 2.8 billion people, have policies in place that provide for a shorter TB preventive therapy regimen. Of concern is the finding that nearly half of the countries did not have policies on the provision of TB preventive treatment to household contacts of all age groups, even though they have committed to a specific UN target on this to be achieved by 2022.

Procurement
Findings on procurement policies are a further cause for concern. A vast majority of surveyed countries do not require the approval of a stringent regulatory authority or WHO prequalification for imported or locally manufactured TB medicines. As a result, people living with TB are at risk of being treated with medicines of sub-standard or unknown quality that may worsen the TB disease and make it more challenging to treat. Countries should urgently work to remove barriers to effective, sustainable procurement. The way to this is often through policy and legislative change.

“The World Health Organization has been rapidly reviewing new evidence and updating policies and guidelines to ensure that people with TB access quality prevention and care as soon as possible. This includes guidance during the COVID-19 pandemic promoting home-based care and digital innovations,” said Dr. Tereza Kasaeva, Director of WHO’s Global TB Programme. “We urge all countries to urgently step up implementation and roll out of WHO guidance, especially in high TB burden countries, as this is vital for better outcomes for people affected by TB and to save lives.”

With just two years until the 2022 deadline for the UN TB targets, urgent investment is required to get global efforts back on track and accelerate them further. The Stop TB Partnership and MSF call on the leadership of all countries to update and implement their TB policies in line with the latest WHO and internationally recognized guidelines in time for the next World TB Day on 24 March 2021.