Covid-19 has set back alarmingly the fight against TB, says WHO

The year 2020 has become synonymous with Covid-19, as the pandemic swept throughout the globe. But a new report by the World Health Organisation (WHO) has painted a bleak picture about the affect that the pandemic has had on tuberculosis control efforts.

The affect was particularly severe in high-burden countries such as SA, where TB testing alone had dropped by almost 50%.

According to preliminary data released to coincide with World TB Day on Wednesday, SA was among the worst-affected countries, with a decline in TB care and monthly notifications measuring 41%. This was the biggest reduction after Indonesia, which recorded a drop of about 42%. Among the 80 countries, surveyed Philippines is the third worst-affected nation with a shrink of about 37%, and India at 25%.

The report estimated that 1.4 million fewer people received care last year compared to 2019 — a reduction of 21% from 2019 — and half a million excess TB deaths could set the world back a decade to the level of TB mortality in 2010.

“The effects of Covid-19 go far beyond the death and disease caused by the virus itself. The disruption to essential services for people with TB is just one tragic example of the ways the pandemic is disproportionately affecting some of the world’s poorest people, who were already at higher risk for TB,” said Dr Tedros Adhanom Ghebreyesus, WHO director-general.

“These sobering data point to the need for countries to make universal health coverage a priority as they respond to and recover from the pandemic, to ensure access to essential services for TB and all diseases.”

Public health expert and UCT professor of pulmonology Keertan Dheda said the latest findings were sobering, but not surprising, given the affect of Covid-19 on other medical conditions.

He said a combination of factors, such as health-care workers falling ill, diverting of human resources to Covid-19 services, clinic closures and fear of Covid-19 all affected TB services negatively. But all is not lost.

“To gain lost ground we need to actively go out and find the missing and undiagnosed cases. We cannot rely on patients self-reporting to medical services during the Covid-19 era.

“Measures that require rapid implementation comprise a combination of interventions including the use of TB screening Apps such as those that worked successfully for Covid-19, operationalising public facing dashboards for TB, like we have for Covid-19, so we can monitor the disease and sending health-care workers into the community to screen those at risk for TB,” said Dheda.

Prof Harry Hausler, head of HIV/TB Care, said that while the gaps in TB care were not surprising given the interruption caused by Covid-19 lockdown on movement of people and people’s reluctance in accessing health facilities, various initiatives could turn the tide. These included political and multisectoral will to address both Covid-19 and TB.

“Lessons learnt in contact-tracing for Covid-19 can be applied to contact-tracing for TB. New technologies such as digital chest X-rays, which on its own found about 58% of the people with TB in 2019, needs to be scaled up and applied strategically in hotspots. TB screening should be integrated into Covid-19 screening and referral pathways for TB testing made known,” he said.

The WHO report noted that more than half a million more people may have died from TB in 2020 “simply because they were unable to obtain a diagnosis”.

It said building up health systems so everyone can get the services they need is key. The world body said some countries had already taken steps to mitigate the affect of Covid-19 on service delivery, by strengthening infection control, expanding use of digital technologies to provide remote advice and support, and providing home-based TB prevention and care.

“But many people who have TB are unable to get the care they need. This is not a new problem. Before Covid-19 struck, the gap between the estimated number of people developing TB each year and the annual number of people officially reported as diagnosed with TB was about three million. The pandemic has greatly worsened the situation.”

The report said, critically, it would be vital to reduce health inequities.

“For centuries, people with TB have been among the most marginalised and vulnerable. Covid-19 has intensified the disparities in living conditions and ability to access services both within and between countries,” said Dr Tereza Kasaeva, director of WHO’s Global TB Programme.

“We must now make a renewed effort to work together to ensure that TB programmes are strong enough to deliver during any future emergency — and look for innovative ways to do this.”

Prof Heather Zar, head of paediatrics at Red Cross Children's Hospital, said though a decline in TB services was expected he was surprised by the extent,  particularly in SA.

“I think some decline was expected as services closed through the lockdown and were more difficult to access after, and people kept away from health facilities for fear of getting Covid-19. But this is a huge decline,” Zar said.

She added that while some of the public health measures during Covid-19, such as wearing of masks and social distancing might have reduced TB transmission to an extent, the reality was that TB became less of a concern after health resources were diverted to fighting the pandemic.

Western Cape Premier Alan Winde said the TB positivity rate had increased over the past year, hitting a high of 21% in September 2020.

“This indicates that we were not testing enough people to pick up new TB cases.  The reality is that the Covid-19 pandemic was a hammer blow to our efforts to respond to TB, and we must now step up the fight drastically,” he said.

Winde announced that there is a common resolve to “step up the fight” against TB in the Western Cape. One of the initiatives was to develop a detailed implementation plan for TB, which will be presented to the provincial Aids council within a month.

The Western Cape health department and the city of Cape Town would in the next three years provide a programme, using the Melinda Gates Foundation's R80m funding, to “magnify focus on TB by rapidly identifying people with TB, linking them to care and ensuring that patients are effectively treated”.

This data-led approach to fighting TB will include: 

• Introducing TB screening in men’s health programmes, which are more infected by TB than women. 
• Using technology in the fight against TB, including social media messaging and the introduction of a TB self-screening app similar to the Covid-19 self-screening questionnaire. 
• Systematic screening for all HIV-negative people accessing health services.  
• Introducing a publicly accessible TB dashboard to drive behaviour change in communities. 

TimesLIVE