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Infectious Diseases

Updated 22 May 2020

Fighting TB in the time of Covid-19: how 1.4 million deaths can be prevented

Although the spotlight is currently on Covid-19, other potentially fatal diseases such as TB must not be neglected, experts warn.

The Covid-19 crisis is sweeping across the planet, becoming “the greatest disruptor the world has seen in generations”, according to a statement by the International Union Against Tuberculosis and Lung Disease (Union). But as the infection rate continues to surge, it should not result in other serious diseases, such as tuberculosis (TB), being neglected, a Union panel discussion on TB and Covid-19 on Wednesday concluded.

As of 21 May, South Africa has 369 confirmed Covid-19 deaths. Projections indicate that this figure could rise to more than 40 000 by November this year. However, according to the latest statistics by the World Health Organization (WHO), TB caused around 63 000 deaths in South Africa in 2018 (figures for 2019 are not yet available).

Following the recent release of modelling on the impacts of the initial Covid-19 response on TB – commissioned by the Stop TB Partnership in collaboration with the Imperial College, Avenir Health and Johns Hopkins University – key leaders in the Union panel discussed what the results of this modelling study mean, and how governments can all work together to prevent the potential 1.4 million TB deaths worldwide, caused by the Covid-19 pandemic.

A major factor indicated in the study was an estimation that, globally, a three-month lockdown and a protracted 10-month restoration could lead to an additional 6.3 million people falling ill with TB and an additional 1.4 million TB deaths over the next five years. As a result, the world would face a setback of around five to eight years in the fight against TB. Compared to 2013 and 2016, this will bring 2021 global TB incidence and deaths to much higher levels, due to the Covid-19 pandemic, the study reveals.

TB services should continue, and people should have access to them

One of the key areas of focus in countries should be to ensure that TB services continue and that people have access to them, Dr Lucica Ditiu, executive secretary of the Stop TB Partnership said. For Dr Tereza Kasaeva, director of the global TB programme, this access is particularly relevant in low- and middle-income countries.

“This crisis is ongoing and we can see a clear disruption of TB services in many low- and middle-income countries, but we have a chance to avoid dramatic disruption and additional deaths relating to this disruption.

“We are trying to advocate country officials to consider TB services as essential services as it’s a number one killer in the world,” she said, adding that governments should bear in mind the socio-economic background of TB, and should protect the most vulnerable: the poorest, the malnourished, and those losing their jobs, as they are the key drivers of TB, and testing for both TB and Covid-19 should, therefore, be considered essential services in this context.

However, although advocating for the continuation of testing, Kasaeva stressed that it should be done differently.

“Home-based treatment should be preferable with the use of digital technologies. We have WHO guidelines and we are recommending fully oral treatments for MDR-TB (multidrug-resistant) patients, and it should be in place urgently. TB preventive treatment is another critical factor. This treatment should be provided for at least 24 million people.”

According to Spotlight, South Africa has seen a significant drop in TB testing since the start of lockdown, a recent report from the National Institute of Communicable Diseases (NICD) shows. In the weeks before lockdown, an average of 47 520 TB tests per week was carried out by the NICD, which dropped to an average of 24 574 tests per week during lockdown. The report notes that this decrease was not due to a lack of availability of healthcare services, but rather the restriction on movement during lockdown. 

Supporting healthcare workers

While governments must ensure that TB services are continued, it is also imperative that healthcare workers are supported, Cheri Vincent, chief of the infectious diseases division at USAID said. 

“They [healthcare workers] are under tremendous stress right now. A lot of the TB platforms and services are being utilised to address Covid-19, so it’s really important that they’re not overburdened, not just with TB, but with Covid-19, and understanding the guidance and what are the best practices.”

Vincent further highlighted that while webinars and guidelines should be pushed out, it’s also about efficiency: “It’s not just doing what the evidence says. It’s about also doing it efficiently. It’s really challenging in these environments and people can’t just do how it is on paper. You really need to help them to figure out the ways to do it when you have limited supplies and staff, and you’re dealing with this crisis.”

Supply chain war

On the topic of access to tools for testing, in terms of diagnostics during this crisis, Catharina Boehme, CEO of FIND (Foundation for Innovative New Diagnostics), shed light on what’s been happening behind the scenes.

“What we see behind the scenes is a supply chain war that’s been going on, with a lot of pressures on companies and test producers to move production capacity to Covid-19 and away from malaria, TB and HIV.

“And I think working together as a community to make sure that that’s not happening, and also helping companies to make sure that there is a balance and that there are no stockouts going forward is very important.” 

Overcoming stigma

Some of the panellists, including Subrat Mohanty, project coordinator at the Union, and Vincent highlighted the social stigma associated with Covid-19, and that people are shying away from health facilities for TB during this time because they’re worried about being misdiagnosed with Covid-19, or being associated with the disease.

“We do have serious concerns with the overlap of the vulnerable populations between TB and Covid. The overlap of symptoms is really concerning, going back to Subrat’s point of the stigma and discrimination... so this is what we’re trying to do in this very difficult situation,” Vincent said.

To combat this issue, the panellists suggested that the essential information on Covid-19 needs to be carved out and be given to the right people, such as the community health workers, as well as survivors of the disease.

Spotlight reports that Dr Thandi Dlamini-Miti, senior medical technical advisor on TB and advanced clinical care at the organisation Right to Care, said she had hoped that community screening for Covid-19 would improve TB case finding, considering the symptoms overlap, but that it does not look like this is happening. This was after the Department of Health told Spotlight that community healthcare workers were continuing routine work in communities, rather than solely screening for Covid-19, and that the department was working on integrating screening for TB with Covid-19.