News In the first update on tuberculosis since the UN General Assembly High Level meeting on Sep 26, 2018, in which All UN Member States committed to end the global tuberculosis epidemic by 2030, WHO published the Global Tuberculosis Report on Oct 17, 2019. The report details data from 202 countries and territories that account for more than 99% of the world’s population and estimated the number of tuberculosis cases. Ahead of the first 2020 mile­ stone, tuberculosis still accounts for the highest mortality from any infectious diseases world­ w ide, even surpassing HIV/AIDs, causing 1·5 million deaths in 2018. According to WHO’s report, the current pace of change is not enough: the global cumulative rate of reduction for tuberculosis incidence was only 6·3% between 2015 and 2018, which is much less than that of the 2020 milestone of 20%. Enormous intercountry variation exists, with only eight countries accounting for two thirds of the global total of tuberculosis cases. The report notes a concerning trend in the rise of notifications of new and relapsed cases: 7·0 million new cases of tuberculosis in 2018, an increase from 0·6 million in 2017, and 1·2 million since 2012. Most new cases between 2013 and 2018 are from India and Indonesia, with new cases increasing 60% and 70%, respectively. India has the highest number of cases in one country (27%) and has ambitiously set an earlier goal of 2025 to end the tuberculosis epidemic; progress of which would affect tuberculosis goals worldwide. However, in a press release from the Scientific Director of The Union in response to this report, Paula Fujiwara says that although India is making some progress in treatment, “progress is still too slow to meet the targets—and if we don´t www.thelancet.com/respiratory Vol 8 January 2020 end TB in India we can’t hope to end tuberculosis globally”. Small improvements in the coverage of testing, detection, and treatment of multidrug- and rifampicin-resistant tuberculosis were noted with an increase of bacteriologically confirmed tuberculosis rising 10% from 2017. Nevertheless, people with drugresist­­ant tuberculosis accounted for more than half a million new cases in 2018 and only one in three of these were enrolled in treatment; albeit an improvement on the one in four reported in 2017. A vast proportion (75%) of the gap between treatment and new cases of drug-resistant tuberculosis is in only ten countries. The report attributes one of the main reasons for the delay in progress to the shortage in needed invest­ ment into tuberculosis prevention. Christina Yoon, an Assistant Professor at the School of Medicine, University of California, San Francisco, agrees that preventive measures and treatment are where the underperformance is greatest. “Scaling-up preventive therapy and reaching the ‘missing’ 3 million active tuberculosis cases are still our biggest challenges, particularly among children.” Other funding gaps remain, such as that in tuberculosis research in the USA, which fell short of the UN high-level meeting commitment by $1·2 billion in 2017, and a huge annual funding gap overall of $3·3 billion in 2019. Additionally, international donor funding is far below what is needed annually with almost $1·4 billion less than estimated in the initial Global Plan. 65 countries have initiated tuberculosis prevention in people living with HIV, of whom account for almost 9% of all cases and 1·8 million people with tuberculosis. The overall coverage in 66 countries was 49%, which looks promising to achieve the target of 6 million people over 2018–22. Yet, the number of household contacts had a much smaller coverage, for example, only 27% of all the estimated 1·3 million eligible children younger than 5 years. As suggested in the report, Yoon supports the idea that future research can help to improve tuberculosis care and the burden of new cases: “This year’s report describes uptake of the regimen 3HP in tuberculosis endemic countries for the first time. Although few tuberculosis endemic countries reported using 3HP outside of research settings, as routine use of 3HP increases over time, it will be very interesting to see the impact of shorter course preventive therapy regimens on preventive therapy scale-up and TB epidemiology.” On a positive note, the overall number of tuberculosis cases and deaths are reducing year on year. One WHO region (WHO Europe) and seven high burden countries (Kenya, Lesotho, Myanmar, Russia, South Africa, Tanzania, and Zimbabwe) are on track for the 2020 milestone; incidence and related deaths also reducing relatively fast in the WHO African Region. Although progress is being made, investment into prevention, care, and research needs to double each year for the next 3 years. Financial provisions need expanding for the substantial costs of tuberculosis on patients and their contacts, and a focus on access to care and preventive treatment, with a movement towards increasing use of molecular tests to bio­log­ ically confirm the disease. Overall a multisectoral approach is essential to reaching the 2020 milestones. The next evaluation of these goals will be at the UN Secretary-General’s Assembly, which is expected to be held in September, 2020. TEK Image/Science Photo Library WHO global progress report on tuberculosis elimination Published Online November 6, 2019 https://doi.org/10.1016/ S2213-2600(19)30418-7 This online publication has been corrected. The corrected version first appeared at thelancet.com/ respiratory on November 15, 2019 For the WHO Global Tuberculosis Report 2019 see https://www.who.int/tb/ publications/global_report/en/ For the Union response see https://www.theunion.org/ news-centre/news/unionresponse-to-the-who-2019global-tuberculosis-report Emilia Harding 19
