More than a year into the coronavirus pandemic, countries have witnessed a decline in the number of people diagnosed and treated for tuberculosis. But public health experts and health organizations are now identifying efforts being made in countries to reverse this trend, including screening and testing patients for TB who test positive for COVID-19.
“I think one of the things we're learning … is that there are real opportunities, not just to in a sense protect TB from the diversion [of COVID-19], the challenges of COVID, but to leverage the opportunities to run programs that are synergistic, so that when we reach out into ... vulnerable communities, we test for both COVID and for TB,” The Global Fund Executive Director Peter Sands said last week during a media briefing hosted by the Stop TB Partnership.
This is happening in India, which has the highest TB burden globally, and which saw daily TB notifications decline 80% after the imposition of a national lockdown in March 2020. Provisional data published by the World Health Organization this week revealed significant declines in TB case notifications across countries. Compared to 2019, TB notification in 2020 fell 42% in Indonesia, 41% in South Africa, 37% in the Philippines, and 25% in India — some of the known high-TB burden countries.
This coincides with data released last week by the Stop TB Partnership, which found nine countries representing 60% of the global TB burden suffered significant declines in TB diagnosis and treatment in 2020.
In August 2020, the Indian Ministry of Health and Family Welfare issued guidance for bidirectional screening of patients for TB and COVID-19. This means patients confirmed to have COVID-19 should be screened and then tested for TB, and vice versa.
“People with TB are prone to COVID-19, thus both services are in need.”— Choub Sok Chamreun, executive director, KHANA
As of last week, around 44% of people with TB — approximately 640,000 people — were tested for COVID-19, and more than 5,000 patients were diagnosed to have TB-COVID co-infection, according to the Stop TB Partnership.
Testing for TB is critical as countries see more and more patients presenting with symptoms similar to COVID-19, such as cough and fever, but end up testing negative for COVID-19.
Diagnosing TB amid COVID-19 has its challenges. Potential barriers include the unavailability of technology to test for both COVID and TB in a given area, the limited capacity of the health system to do both, the additional precautionary measures health workers need to carry out, and mobility restrictions. In some instances, in-country guidance to test for both COVID-19 and TB is not available. In addition, overwhelmed with COVID-19, some countries may not see TB as a priority.
WHO recommends screening for both diseases, particularly for high TB burden countries. But not all countries are following its recommendation, said Tereza Kasaeva, director of WHO’s global TB program.
“Why [are] other countries ... not doing the same despite WHO recommendations? I will respond probably it's the matter of political will and prioritization of the TB services,” she said during a March 22 press briefing.
The limits of technology and health systems
Among WHO’s recommendations is to scale up systematic screening for TB, and simultaneous testing for COVID-19 and TB. But there can be technological and health system limitations to carry out testing for TB and COVID-19 in countries.
“There's only a finite number of platforms that can easily sort of test for both. And ... a lot of clinics don't have them,” Emma Hannay, chief access officer at FIND, told Devex.
The TrueNat and Xpert platforms are two of the point-of-care molecular tests that can be used to test for both TB and COVID-19. But the samples for each test are different, with COVID-19 requiring a nasopharyngeal swab and TB requiring a sputum sample. Their availability at the primary care level is also limited, Hannay said.
COVID-19 provides lessons on the need to diversify the manufacturing of diagnostic tests for both COVID-19 and TB, she added. Allowing tests for diseases afflicting the majority of low- and middle-income countries to be manufactured locally and regionally ensures continued supply as well as that tests are applicable to local conditions.
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“To illustrate with rapid diagnostic tests [for COVID-19], the first two tests that were [given emergency use listing] by WHO were both produced in the same country, literally in the same neighborhood [in South Korea]”, Hannay said.
Most health systems are also not set up to offer a range of diagnostic tests to patients. Diagnostic testing doesn’t feature strongly in countries’ health sector strategies, she said. WHO produced its first model essential diagnostics list in 2019, but only India has so far published its national essential diagnostics list, with a few countries working with WHO to develop their own.
“Without that [list], you get a sort of somewhat eccentric approach in-country ... Some places will have diagnostic testing widely available, others with big populations and a big need might not. It's not necessarily as strategic as it could be,” Hannay said, adding that most countries don’t even have a chief diagnostics officer sitting in the health ministry to drive diagnostics policy.
TB tests today are more portable and can be placed in clinics as opposed to a centralized laboratory. But they’re still far off from the kind of rapid pregnancy-like test kits now available for COVID-19.
The challenge of mobilizing communities COVID-19 as a barrier
There are also challenges in getting people in communities to be tested not just for COVID-19, but also for TB.
In Pakistan, which also saw a decline in TB cases in 2020, people tend to delay seeking care, said Hamidah Hussain, global technical lead on TB preventative programs for Interactive Research & Development, a nonprofit institution based in Singapore and supporting health programs in 17 countries.
“People themselves are not coming in for services. I think we have seen that, not only in TB, but I think even in other diseases as well, right, that people are not coming to the facilities as much as they used to for any symptoms,” Hussain told Devex.
IRD together with partners such as the Indus Health Network has been working to integrate TB and COVID-19 screening, whether at the level of private clinics — which is where the majority of the population first go to — or hospitals. The nonprofit trained private general practitioners to identify and treat people with COVID-19, provided them ambulances, and linked them to hospital networks.
IRD and partners also hold community camps, where they go to communities in mobile X-Ray vans to screen for both TB and COVID-19.
But the additional precautionary measures health workers need to take to carry out screening in communities, such as donning personal protective equipment and sanitizing the unit after every patient, add to the challenge.
“It decreased our throughput. So if a van prior to the pandemic would conduct 100 X-Rays in a day, it kind of, you know, decreased to ... maybe 30% less or 40% less,” Hussain said.
Getting the community to get screened in vans with people wearing hazmat suits was also a challenge.
“It's not easy to go into the community wearing the entire PPE garb, and you know people would not come by easily so mobilizing the community to still come in and get tested and all that … was a little harder,” she said.
Lockdowns, or when governments limit movement during waves of COVID-19 infections, can pause some of these activities.
Modifying traditional approaches
In places where bidirectional screening and testing guidelines for COVID-19 and TB are not in place, some organizations continue with their traditional ways of working, while adjusting their approach to reduce risks of COVID-19 infection.
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In Cambodia, local NGO KHANA operates in 10 health districts in four provinces in Cambodia, which includes the capital Phnom Penh, under a USAID-funded community mobilization project to end TB. The project started in October 2019, just three months before the COVID-19 outbreak.
But even in the middle of the pandemic, the NGO continued with active case finding. Its approach includes targeting particular age groups and vulnerable communities for TB screening and testing, including those working in manufacturing and construction sites. It also works through a “seed-and-recruit” model, which involves TB survivors and those newly diagnosed with TB in finding other TB cases in the community. This helped Cambodia keep the gap on TB notifications between 2019 and 2020 to less than 3%, although KHANA was only able to achieve 70% of its target TB cases.
This is done while practicing social distancing as well as limiting crowds.
“If bi-directional [screening] can be applied that can be one option and strategy [to identify more TB cases], but at our level we will continue our efforts in finding the TB missing cases using one to one contact … for example rather than to gathering big and crowded populations for TB screening,” Choub Sok Chamreun, executive director of KHANA, told Devex in an email.
It’s unclear when the pandemic will be over, but he said people with TB cannot wait for that to happen before accessing services.
“We cannot continue to see people with TB dying and missing the TB prevention and care services if we are wishing to end TB by 2030. People with TB are prone to COVID-19, thus both services are in need,” he said.