The Impact of war and siege on Tigray's Tuberculosis Program

Background 

Health is a human right, not a luxury.  Tuberculosis (TB) is a major global public health problem and drug resistant TB continues to be a global public health threat. Though it is a curable and preventable communicable disease, TB is the leading cause of death from a single infectious agent ranking above HIV/AIDS and the leading cause of morbidity & mortality among people living with HIV.  The struggle to end TB is not just a struggle against a single disease. It’s also the struggle to end poverty, inequity, unsafe housing, discrimination and stigma, and to extend social protection and universal health coverage. This article examines the impact of two-year old war and siege on Tigray's Tuberculosis Program.

Pre-war: TB situation in Tigray 

270 Public Health facilities (health centers and hospitals) were drug sensitive (DS) TB treatment sites and 11 of these hospitals were Drug resistant (DR) TB treatment initiation centers. 70% health facilities (HFs) were also Microscopic diagnostic sites, 17 HFs were GeneXpert testing (First line DST) sites, and the regional reference laboratory was used as culture/Drug susceptibility testing/DST/ site for the region, and all other HFs were networked through sputum specimen collection and transportation and result communication by postal service with these testing sites to ensure universal access for DST.  

Adult and pediatric first line (FL) anti-TB medicine for DS TB, second line (SL) anti-TB drugs for DR TB patients and all types of TB laboratory commodities were supplied to the region every two months through vertical health system within the Federal Ministry of Health (FMOH) through Ethiopian Pharmaceutical supply Agency (EPSA central) delivery system from Addis Ababa to the two sub-regional hubs (Mekelle EPSA hub and Shire EPSA hub).  

There were 7,000 drug susceptible (DS) TB cases on care and receiving treatment in Tigray a year before the war started in Nov. 2020. The TB incidence per 100,000 population reduced from 192 in 2015 to 140 in 2020 and the mortality rate per 100,000 population has reduced from 26 in 2015 to 19 in a report done 2020.

During the two-year war and  siege Period: Nov 2020 till present

Because of the war, total siege, and blockade to Tigray:

• 90% of the public health facilities reported to be fully or partially damaged or looted including Microscope, GeneXpert, X-ray and other TB laboratory equipment that led 90% of TB diagnosis . Now diagnosis solely relies  on clinical criterias. 80% of the health facilities were unable to report and only an average of 62 HFs (20%) were able to send TB case detection report on the WHO weekly reporting in 2022 through health cluster partners.
• Both Mekelle and Shire hubs were consistently out of  stock of all FL and SL anti-TB medicine and TB laboratory commodities
• HFs kept on short-term main stay by re-distributing and sharing of what remained in their stores for months, but this option already waned off
• Direct supply of all types of anti-TB medicine and TB laboratory commodities from FMOH to Tigray interrupted with total siege and blockade superimposed the impact war and especially after July 2021 and after wards:
• On Feb 2022, Through ICRC 538 first line anti-TB adult kits delivered to Tigray _ covered only 7% adult TB patients on treatment and consumed within days
• On 25 July 2022, through WHO 1,800 Adult first line anti-TB delivered and consumed within 3 months and SL adult and pediatric anti-TB medicines for longer regimen options adequate only for days.
• There were not any TB laboratory commodities, pediatric first line anti-TB drugs, second line anti-TB medicines essential for short regime (9-11months duration) and other ancillary drugs supply.

1. Impact of the war and siege on TB program

• The negative impact of the siege on the key TB determinants such as poverty, undernutrition, HIV infection and diabetes increases the number of people acquiring infection and developing disease (and thus the number of deaths caused by TB and drug-resistant TB).
• TB is affecting the economically and culturally disadvantaged segment of the population who are hard hit by the ongoing conflict and siege specially at this critical time. High number of congregated settings due to the conflict like over-crowded and poorly ventilated camps of IDPs, and homeless shelters are contributing to higher transmission risk and susceptibility to TB that leads TB to concentrate in such key affected population.
• In general, Tigray lost its gains and its health system collapsed and returned to decades back which is badly impacting the progress towards the global TB treatment targets set at the UN high-level meeting. The disrupted TB diagnostic and treatment services left the Global TB targets off-track and unchecked resulting in:

• Patients denied of or put on suboptimal treatment: 
• Become exposed to develop next level resistant strain (Rifampicin- Resistance/Multi-drug resistance/Pre-XDR and X-DR TB) and is contributing to alarmingly accumulate the number of drug-resistant TB which is also a risk to the other areas of the country and other parts of the world.
• created a fertile ground for TB and drug resistant TB transmission
• Hindered diagnosis of TB and drug resistant TB, and it also become impossible to differentiate drug resistant strain from susceptible TB.
• large drop in the number of people newly diagnosed with TB and drug resistant TB. The Tigray regional health bureau become able monitor only 28 DR TB patient on care in Mekelle hospital by Oct 2022 though there were 120 drug resistant (DR) TB patients on care and receiving treatment in Tigray in the year before the war start on Nov 2020. It became impossible to trace the where about or monitor their treatment progress of the other DR TB patients.
• If undiagnosed and not treated, those individuals can die or become chronically ill and continue to transmit TB and resistant TB, allowing for the TB epidemic to continue.
• Increasing defaulters and other unfavorable treatment outcomes. e.g., Treatment success rate for DR TB patients reduced from 73% in 2019 to 48% in 2022 and Cure rate for bacteriologically confirmed DS TB patients reduced from 77% in 2019 to 60% in 2022 in Mekelle hospital.
• finally, resulted in an increase in TB deaths to unacceptable level among both HIV negative and HIV Positive people, returning to the level of decades ago.
• These impacts will be much worse in the coming years

What will happen if the current war, siege, and blockage to medicine and TB Lab commodities prolonged

Unless quick action taken to deliver TB drugs and TB lab commodities, the whole population of Tigray forced to be left vulnerable to TB and drug resistant TB.

What should be done

Actions to mitigate and reverse these impacts are urgently required. The immediate priority is to restore access to TB medicine, provision of essential TB lab services  and support the TB program to ensure the levels of TB treatment and case detection can recover to at least the pre-war level. 

Otherwise, the world will witness a severe crisis of drug resistant TB in Tigray if the international communities remain in deep non-response.