The global burden of tuberculosis (tb)
The world is not on track to reach tuberculosis (TB) control goals
TB is the leading cause of death globally from a single infectious disease, killing more people than HIV
The END TB strategy aimed to reduce tuberculosis deaths by 35% by 2020 (and by
95% by 2053);
from 2015-2019, tuberculosis deaths were reduced by only 14%
>> far from WHO goals1.
In 2019 alone, 10 million people developed TB disease1
2019 TB cases
-
5.6 million men
-
3.2 million women
-
1.2 million children
Resulting in an estimated:
1,4 million deaths including
208,000 deaths in people living with HIV.1
Additional impact of COVID-19
Disruptions because of COVID-19 may result in additional TB cases and deaths:
The WHO estimates that there is a 50% reduction in TB cases detected and that TB deaths in 2020 will be ~1.85 million worldwide.
A modeling analysis by the Stop TB Partnership estimates that the disruption of TB control programs under a 3-month lockdown and a protracted 10-month restoration of services, the world could see an additional 6.3 million cases of TB between 2020 and 2025 and an additional 1.4 million TB deaths during that same period.
TB prevention needs more attention
Treatment of latent TB infection (LTBI) is the main intervention available to prevent development of active TB disease in those already infected with Mycobacterium tuberculosis, but current coverage rates are not optimal.1
We need do to more for TB prevention
Current coverage rates of latent TB treatment, the main intervention available to prevent development of active TB disease, are not optimal.1
Coverage rates of TB preventive treatment in people living with HIV1
Malawi:
26%
Indonesia:
12%
Gaps in TB prevention and TB detection for people who were newly enrolled in HIV care in 2019, selected countries1
-
Gap in TB detection and TB prevention
-
Detected and notified with active TB disease
-
Started on preventive treatment
What are the real costs of not accelerating efforts?
At the current rate, by 2030 failing to stop TB could cost nearly 1
TRILLION USD.
An estimated 28 million people will die from TB between 2015-2030, at a global cost 983 billion
USD.2
It’s more than the annual GDPs of Nigeria, South Africa and Egypt combined!
| India | 253 billion |
| South Africa | 132 billion |
| Indonesia | 124 billion |
| Nigeria | 79 billion |
| China | 60 billion |
| Russia | 32 billion |
| Bengladesh | 22 billion |
| Japan | 20 billion |
| Thailand | 18 billion |
| Pakistan | 14 billion |
| Worldwide | 956 billion |
Across healthcare settings, drug costs represent up to 12% of the overall cost for treating
drug-sensitive TB.
Hospitalisation cost is the major driver of costs to healthcare systems, and represents more than twice
the cost of drugs.4
-
Hospitalisation
-
Outpatient*
-
Drugs
-
Diagnostic and monitoring
-
Other
*Cost for the care that patients receive without being admitted or for a stay of less than 24 hours.
Preventing tb can offset direct and indirect societal costs
Both the direct and indirect costs of TB should be considered when measuring the impact on society and our healthcare systems.
Direct costs
- Out of pocket expenditure for patients due to their illness
- Costs of transportation to health facilities
- Expenditure for medication not covered by insurance or over the counter medications
Indirect costs
Cost of time lost due to illness, including:
- Scheduled visits to health facilities and unscheduled hospitalisation
- Time lost due to inability to work due to illness
Treating LTBI is not optional… it is the only way to avoid human and economic costs
How can we stop TB by treating LTBI?
People with latent TB infection represent a significant pool of individuals who could develop active TB
disease at some point in the future.
26% of the world’s population has latent TB infection (LTBI). The World Health
Organization’s END TB strategy aims to eliminate TB by 2050. The only way to achieve this objective is to
treat both TB and LTBI.7
High-risk LTBI populations are critically more vulnerable to disease progression:1
- Close contact with TB case
- Children
- People living with HIV
- Weakened immune system
Cost of treating each case of LTBI is significantly lower than active and MDR TB
Treating LTBI is essential to decrease the reservoir of latent TB infection, and the cost of its treatment is significantly lower compared to the cost of a treatment for active and multidrug resistant (MDR) TB.12,13
LTBI
≈ USD 422
Active TB
USD 8,241 - 9,214
MDR-TB
(including extensively drug resistant TB) USD 64,314 - or more 184, 349
Australian & EU-15 Health system 12,13
EU-15 - member countries of the EU prior to May 1, 2004.
Adapted from Diel R, et al (2014) and Chan EC, et al (2017)
LTBI & HIV/AIDS
TB is the leading cause of death among people living with HIV, causing more than one third of all
AIDS-related deaths.4
Adults and adolescents living with HIV should receive TB preventive treatment as part of a comprehensive
package of HIV care.5
People with HIV should ask their practitioner about TB preventative therapy as part of a comprehensive
package for HIV care.
Treat HIV. Treat LTBI
• HIV (human immunodeficiency virus) is a virus that damages the cells in your immune system and weakens your ability to fight everyday infections and disease.
• AIDS (acquired immune deficiency syndrome) is the name used to describe a number of potentially life-threatening infections and illnesses that happen when your immune system has been severely damaged by the HIV virus.
There are 2 major challenges when it comes to effective LTBI treatment
1 Insufficient coverage rates
Coverage rates of LTBI treatment are insufficient. Coverage is low among one of the most vulnerable patient groups - children aged under 5 years, reaching only 33%. 1
Among the 23 high TB/HIV burden countries with reported data, coverage of TB preventive treatment to people newly enrolled in HIV care ranged from ranged from less than 1% in Thailand to 89% in Zimbabwe, and there are still countries where the coverage cannot be calculated.1
The United Nation General Assembly Declaration Political declaration has for the first time in history specified a target for people to be put on LTBI treatment with focus on high burden countries - 30 million individuals over 2018-2022.14
2 Adherence and completion rates
Low adherence & completion rates lead to high lifelong risk of active TB.15,16
Completion of LTBI treatment is more likely with regimens of 3-4 months compared to those that require longer treatment duration (meta-analysis). 15
Overall completion rates worsen depending on treatment course duration. 16
Adapted from Goswami ND, et al (2012).
Cost effective LTBI treatment options
Shorter and cost effective LTBI treatments could be beneficial to tackle LTBI1
Why is cost-effectiveness important?
It indicates which interventions provide the highest "value for money" and helps in the choice of the interventions and programmes that maximise health for the available resources.
In this fight, we need to arm ourselves with the best tools available!
Over a 20-year period, treatment of LTBI with 3HP is predicted to result in 25 fewer lost QALYs and in 5.2 fewer cases of TB per 1000 individuals treated than with 9H.17
The quality-adjusted life year (QALY) is an outcome measure that expresses the duration and quality of life.
Adapted from Shepardson D, et al (2013).
Research done in 2020 showcases that the combination of:
• upscaling contact tracing for children
• treating both active TB and LTBI with short regimen
is modelled as cost effective among children in the 12 countries for which the strategy was modelled.20
- Shorter regimens could reduce the refusal rates and are associated with higher adherence but these were less known by HCPs than longer regimens.11
- Only 1 out of 5 HCPs in South Africa and only 1 out of 2 HCPs in the US, where it is included in national guidelines, knew of 3HP.11
Available LTBI treatments: Average pricing and number of intakes for WHO recommended regimens
| Regimen description | Price, US$* | Number of day dosing** | Treatment duration | Schedule |
|---|---|---|---|---|
| 6H 300mg of isoniazid | 3.18 | 180 | 6 months | daily |
| 9H 300mg of isoniazid | 4.77 | 270 | 9 months | daily |
|
3HP 900mg of isoniazid + 900mg of rifapentine |
16.39 | 12 | 3 months | weekly |
| 3R 600 mg of rifampicin | 24.79 | 90 | 3 months | daily |
|
3HR 600 mg of rifampicin + 300 mg of isoniazid |
26.37 | 90 | 3 months | daily |
|
1HP 600 mg of rifapentine + 300 mg of isoniazid |
26.78 | 30 | 1 month | daily |
| 4R 600 mg of rifampicin | 33.05 | 120 | 4 months | daily |
|
4HR 600 mg of rifampicin + 300 mg of isoniazid |
35.17 | 120 | 4 months | daily |
**1 month = 30days
Let’s make every dollar and cent count in the fight against TB!
The story of implementing LTBI treatment in real-life practice
For more in depth information on LTBI
Prevent Tuberculosis
Management of TB infection Continuing Medical Education (CME) opportunity available at:
Union e-learning
Go to e-learning website- Module 1. Introduction to TB
- Module 2. Pathogenesis of TB
- Module 3. At risk populations
- Module 4. Identifying TB infection
- Module 5. TB Prevention Treatment (TPT)
- Module 6. Implementation of TB prevention
This eCME material has been developed with finacial support from Sanofi.
You can find more information on LTBI at the following websites
- World Health Organization Guidelines on LTBI
- World Health Organization Global TB Report
- The End TB strategy is a WHO initiative
- The CDC (US Centers for Disease Control and Prevention) LTBI guide for primary health care providers
- The European Centre for Disease Prevention and Control (ECDC) management of LTBI in Europe
- The Union website with in-depth information on TB prevention and guide to national TB guidelines around the world
- Stop TB Partnership information on developments in LTBI
- Australian Government Department of Health Position Statement on LTBI management
- TB FACTS information on LTBI from around the world, including South Africa and India
- The global fund
- The Treatment Action Group
References:
- World Health Organization. Global tuberculosis report and fact sheet, 2020, available at https://www.who.int/tb/publications/global_report/en, last accessed October 2020.
- Global TB Caucus. The price of a pandemic, 2017; available at https://www.globaltbcaucus.org/research, last accessed January 2020.
- Stop TB Partnership in collaboration with Imperial College, Avenir Health, Johns Hopkins University and USAIDon T. Modeling Report of the impact of COVID-19 B, 1 May 2020.
- Laurence YV, et al. Pharmacoeconomics. 2015;33:939-55.
- Kik S, et al. BMC Public Health. 2009;9:283-90.
- Castro KG, et al. Int J Tuberc Lung Dis. 2016;20:926-33.
- Dye C, et al. Annu Rev Public Health. 2013;34:271-86.
- UNAIDS Global HIV & AIDS statistics — 2020 fact sheet
- Fox GJ et al. Preventive therapy for latent tuberculosis infection — the promise and the challenges. Int. Journal of Infectious Dis. 2017 Mar;56:68–76
- WHO consolidated guidelines on tuberculosis. Module 1: prevention. Tuberculosis preventive treatment, 24.03.2020
- World Health Organization. The END TB STRATEGY, 2015 // WHO - world health organization, UNGA- United Nations General Assembly.
- Diel R, et al. Eur Respir J. 2014;43:554-65.
- Chan EC, et al. Communicable Dis Intel. 2017;41:E191-4.
- United Nations 73rd session of the General Assembly; resolution on the fight against tuberculosis (adopted 10 October 2018).
- Pease C, et al. BMC Infectious Diseases. 2017;17:265.
- Goswami ND, et al. BMC Public Health. 2012;12:468.
- Shepardson D, et al. Int J Tuberc Lung Dis. 2013;17:1531-7.
- January 2021 medicines catalog, GDF.
- Research conducted in 5 countries by the agency Axess Research for sanofi, August and September 2019.
- Y. Jo et al., Cost-effectiveness of scaling up short course preventive therapy for tuberculosis among children across 12 countries, EClinicalMedicine (2020) https://doi.org/10.1016/j.eclinm.2020.100707
- Research conducted in 5 countries by the agency Axess Research for sanofi, August and September 2019.