How does COVID-19 affect patients with tuberculosis?

I N just one year, COVID-19 has undone more than a decade’s progress in the fight against tuberculosis (TB). 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.

While COVID-19 fatality numbers are decreasing worldwide, TB-related deaths remain steady at 4,000 cases a day – an occurrence partly due to limited access to TB treatment services during COVID lockdown periods and TB funds being diverted to fight the virus.

Also, Professor Gregory Erhabor, a chest physician at the Obafemi Awolowo University Teaching Hospital, Ile-Ife, added “the fear of contracting COVID-19 from the health centres or being diagnosed with having COVID-19 resulted in treatment default, poor drug adherence, development of drug resistance and increasing community spread of TB.”

He added, “more worrisome is the fact that TB and COVID-19 share a number of similarities which could result in diagnostic delay and mismanagement. To be diagnosed with COVID-19 does not exclude underlying TB in a TB endemic setting.”

The STOP TB Partnership shared new data on last Thursday showing that nine of the countries with the most TB cases, including Nigeria – representing 60 per cent of the global TB burden – saw a drastic decline in diagnosis and treatment of TB infections in 2020, ranging from 16 to 41 per cent. The drop brought the overall number of people diagnosed and treated for TB in those countries to 2008 levels.

Nigeria, like most African countries, is still battling the age-long disease of TB. It has the highest burden of TB in Africa and the sixth globally. Case detection for TB is abysmally low, accounting for more than two-thirds of undetected cases worldwide.

Worryingly, Professor Olanisun Adewole, a TB expert, in the review of the number of presumptive cases, the number detected and treatment outcomes, such as death and loss to follow-up (LTFU) rates, at a TB Clinic (Obafemi Awolowo University Teaching Hospitals Complex, Ile Ife, Nigeria) between January and 28 May 2019 and January and 28 May 2020, reported a reduction of 35 per cent and 34 per cent in the number of presumptive TB and active TB cases detected respectively compared with the same period in 2019.

However, the period between April and May 2020 has so far accounted for only 7 per cent and 13.6 per cent of the number of presumptive cases and TB cases detected respectively. This is quite low compared with the figures of 46 per cent and 50.7 per cent obtained over the same period in 2019. No deaths were recorded during the period. However, there were two cases of LTFU between April and 28 May 2020.

The TB presumptive register is an indication of the number of individuals screened for TB and contains the lists of those with symptoms and signs of TB who are being evaluated using sputum testing. The treatment register details those with a confirmed diagnosis of TB who have commenced treatment at the centre.

Professor Adewole, in the International Journal of Tuberculosis and Lung Disease said, “COVID-19 has restricted access to diagnostic assessment, as indicated by the declining number of presumptive cases, and to uninterrupted treatment. The greater the number of symptomatic individuals tested, the greater the number of TB cases that would likely be detected. This reduction could be a result of the lockdown.

“Reduced access to transport during lockdown could limit accessibility to the test and treatment centre. Again, because of the associated stigma with COVID-19, patients may be averse to visiting health care facilities unless absolutely necessary.”

Moreover, findings in the 2020 edition of the Public Health Action on TB Surge and the Wellness on Wheels (WoW) campaigns, both Active TB case finding (ACF)’s interventions that were rolled out in January 2020, showed COVID-19 epidemic has impacted negatively on TB services in Nigeria.

TB Surge was implemented across 61 high-volume facilities in nine Nigerian states (Lagos, Ogun, Akwa-Ibom, Cross River, Rivers, Nasarawa, Kano, Benue and Katsina). It was conducted over eight weeks in March and April 2020.  The WoW campaign, which employs a mobile diagnostic unit to deliver care to the doorstep of people at risk of a TB was implemented in Kano State for four weeks (March 2020).

There was a progressive decrease of respectively 63 per cent, 64 per cent, 73 per cent and 72 per cent in clinic attendance, presumptive TB identification, TB cases detected and treatment initiation for the TB Surge ACF intervention since the emergence of coronavirus; a similar decrease was noted for the WoW intervention.

Nigeria, which has the highest TB burden in Africa, and ranks among 30 high TB burden countries worldwide, has recently diverted some of the 300 GeneXpert machines in the country for COVID-19 use as part of its strategy to scale-up diagnosis. This will have a severe negative impact on TB control efforts by limiting access to these diagnostic platforms for TB services.

Even more worrying, Executive Director, Stop TB Partnership, Dr Lucica Ditiu, says at least 1.0 million fewer people received necessary care for TB during 2020 compared with the previous year, even as case notification for TB dropped by 16 to 21 per cent and diagnosis and treatment for TB by 23 per cent.

Ditiu said “We did a modelling study a year ago and made predictions on how COVID-19 would impact the TB epidemic. What we see now that has really happened is the impact has been much worse than predicted.”

However, she said that pushing the TB agenda and not allowing COVID-19 mitigation measures and COVID-19 disease and pandemic to impact TB is very important since individuals with TB and COVID-19 are three times more likely to die than those infected with TB alone.

Executive Director, Global Fund to Fight AIDS, Tuberculosis and Malaria, Peter Sands, during a press briefing declared TB as a global pandemic that also killed lots of people all over the world in the past although the investment in TB is not as substantial as the investment in COVID-19.

According to him, “COVID-19 claimed 1.8 million lives in 2020 but the numbers of people who died from TB in 2020 may have been around 1.7 million, 90 per cent of the number of COVID deaths.

“We haven’t finished the fight against TB, as an older pandemic. Should we not use the forced rethinking of our approaches to global health that COVID has catalysed? Let’s really step up our fight against TB, and get rid of it. If we don’t, we are again creating another future risk for humanity in the form of multidrug-resistant (MDR) TB.”

Professor Adewole suggested the TB programme leverage resources used to combat the pandemic such as digital health technology and funds, and work towards strengthening a patient-centred approach to care to limit the challenges that COVID-19 presents to TB control.

“A complete overhaul of Nigeria’s emergency response to infectious diseases, Professor Erhabor said, is important to combat emerging and re-emerging diseases globally.

“This is very important moreso in Africa where our healthcare system cannot withstand any undue disease burden,” he added.

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