COVID-19 casts a shadow over progress on TB

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Efforts to contain the COVID-19 pandemic have inadvertently affected tuberculosis (TB) programmes and other aspects of non-COVID healthcare, according to two recent commentaries, published in Annals of Clinical Microbiology and Antimicrobials and Tropical Medicine and Health. The linkages between COVID-19, TB and HIV are most pronounced in sub-Saharan Africa, where TB is the leading cause of death for people with HIV. Nonetheless, the impact has also been felt in the high income setting of the United Kingdom (UK).

As COVID-19 took centre-stage in the UK, TB healthcare workers were reassigned roles in COVID-19 management and up to 30% of healthcare staff were either sick or in self-isolation. Patients also minimised visits to healthcare facilities to reduce the risk of acquiring coronavirus. This may adversely affect TB diagnosis, adherence to treatment, the management of side effects and treatment outcomes. Intensive care bed units have been reserved for those requiring COVID-19 care.

Treatment of active TB disease has taken priority over other important components of TB prevention and care, such as management of latent TB infection (every case of active TB disease comes from this latent TB pool) and non-transmissible extrapulmonary TB infection (which is common in people with HIV). People with HIV – as well as young children – are at greater risk of progressing from latent TB to active disease, underlining the importance of not neglecting TB preventive therapy even during COVID-19.

Glossary

latent TB

A form of TB that is not active. Persons with latent TB are infected with M. tuberculosis but do not have any symptoms and they cannot spread TB infection to others. Only specific tests will tell if anyone has latent TB. Treatment for latent TB is recommended in people living with HIV. 

stigma

Social attitudes that suggest that having a particular illness or being in a particular situation is something to be ashamed of. Stigma can be questioned and challenged.

active TB

Active disease caused by Mycobacterium tuberculosis, as evidenced by a confirmatory culture, or, in the absence of culture, suggestive clinical symptoms.

malaria

A serious disease caused by a parasite that commonly infects a certain type of mosquito which feeds on humans. People who get malaria are typically very sick with high fevers, shaking chills, and flu-like illness. 

capacity

In discussions of consent for medical treatment, the ability of a person to make a decision for themselves and understand its implications. Young children, people who are unconscious and some people with mental health problems may lack capacity. In the context of health services, the staff and resources that are available for patient care.

Social distancing is one of the COVID-19 prevention and containment measures. But this is not an option for homeless people or for those who are socio-economically disadvantaged and live in overcrowded dwellings, who have an elevated risk of both COVID-19 and TB. Forcing people to stay indoors may increase the risk of transmission of COVID-19 and TB in such communities.

The review notes that even before COVID-19 and Brexit in the UK, there were regular anti-TB therapy stock-outs. With supply chain disruptions during COVID-19, this could lead to situations where people get TB regimens consisting of drugs available in the stock (instead of those they are sensitive to), leading to more adverse effects and treatment failures. There is also a risk of substandard doses or medicines, compromising drug efficacy and worsening health inequalities.

African nations have largely relied on overseas development aid and revenue from extractive industries. With the threat of global economic recession due to the pandemic looming large, the economies of those African nations which were already either in borderline or full economic recession prior to the pandemic, will be further affected. In addition to this economic crunch, health funds have been diverted to COVID-19. Under such circumstances, increasing domestic health funding will be even more challenging for them than before and may further increase their dependence on international donors.

In Africa, where quality of TB care was suboptimal even before COVID-19, the pandemic has only worsened patient care and TB control. With restrictions on movement due to the pandemic and shrinking disposable income to support transportation costs and other direct and indirect medical costs, people with HIV, TB and malaria, are likely to face even more difficulties than before in accessing health services.

Weak health systems result in diagnostic challenges. Fever is a common symptom of TB and COVID-19 (and also malaria). Cough and breathlessness are common to those with TB and COVID-19. Some high burden TB nations like Nigeria are deploying TB molecular diagnostic machines (Gene Xpert) to test for COVID-19 too. While such steps may scale up diagnosis of COVID-19, they will negatively impact early and accurate diagnosis of TB. Reduced access to effective anti-TB therapy might increase infectiousness of the disease which will worsen health inequalities and “result in reversal of global health gains in key indicators,” say the authors.

There are very few data on co-infection with COVID-19 and TB, or on COVID-19 in people who have had TB in the past. It is possible that people with damaged lungs and/or reduced lung capacity (caused by TB) may have worse COVID-19 outcomes.

The report also reminds that Africa has earlier learnt its lessons from Ebola where “institutional mistrust and misinformation” became barriers to seeking care and preventing infection. The COVID-19 response has often compromised rights-based approaches to health. Putting the blame of acquiring or transmitting TB or COVID-19 infection on the person, or stigmatising those who are infected, are likely to be big deterrents for those with symptoms to voluntarily seeking care.

For instance, a person with persistent cough (which could be because of TB or COVID-19 or some other reason) may feel hesitant to go to health services due to the fear and stigma associated with COVID-19. The review authors rightly call for de-stigmatising all infectious diseases (and not just TB, HIV or COVID-19). Lessons from TB and HIV programmes show the pivotal role of community engagement at every level in reducing stigma, discrimination and shaping a rights-based health response which should not take a backseat.

Dr Florian Amimo and colleagues rightly summarise that “populations need protection not only from the pandemic but also from the consequences of its control measures.”

References

Togun T et al. Anticipating the impact of the COVID-19 pandemic on TB patients and TB control programmes. Annals of Clinical Microbiology and Antimicrobials, 19: 21,  23 May 2020 (open access).

https://doi.org/10.1186/s12941-020-00363-1

Amimo F et al. What does the COVID-19 pandemic mean for HIV, tuberculosis, and malaria control? Tropical Medicine and Health, 48: 32, 13 May 2020 (open access).

https://doi.org/10.1186/s41182-020-00219-6