As South Africa nears Day 60 of its Covid-19 lockdown, a new modelling study by the Stop TB Partnership suggests the longer countries spend under lockdown the more tuberculosis (TB) cases and deaths the world could see.

That report is a modelling study, with all the uncertainties that entails, but there is now compelling evidence that South Africa’s TB response is already severely affected. Spotlight studied various new reports and asked a range of experts how the country’s TB response is holding up under lockdown.

TB testing

A recent report from the National Institute of Communicable Diseases (NICD) details a significant decline in TB testing since the beginning of the lockdown. In the weeks prior to the lockdown, the NICD conducted an average of 47,520 TB tests per week. This dropped to an average of 24,574 tests per week during the lockdown — a 48% reduction. The report concludes that the decrease is largely due to restrictions on movement and public transport, rather than the availability of healthcare services.

Dr Thandi Dlamini-Miti, senior medical technical advisor on TB and advanced clinical care at the organisation Right to Care, said that one region the organisation tracks registered 305 TB patients for April, which was nearly 200 less than the monthly average for the previous three months.

“This may be due to patients that are suspected of having TB not attending facilities during the lockdown, due to fears of catching Covid-19, or fear of the police,” she said.

For drug-resistant TB (DR-TB), Dr Norbert Ndjeka, director of HIV, TB and DR-TB at the National Department of Health, said there had been a huge decrease in case-finding and treatment initiation. 

“During quarter one of 2019, we registered 2,506 DR-TB patients on treatment. Quarter one of 2020 reflects 1,013 DR-TB patients. There could be a number of patients treated not yet recorded in the electronic register, but not many. Perhaps 10-15% of the 1,013,” he said.

There is currently no data outlining the impact on testing for paediatric TB. Dr James Seddon, a research clinician at the Desmond Tutu TB Centre (DTTC), said testing for TB in children was more complicated than with adults.  

“Testing young children for TB often involves taking respiratory samples because children, especially those under the age of five, don’t cough sputum [for a test] when asked. You actually have to get it by taking samples from their stomachs (to get swallowed sputum) or giving them nebulisers to stimulate coughing so you can then collect sputum that way,” he said.

“These are high-risk procedures for Covid-19, so the issues we’re having with testing children for TB at the moment might be more complicated.”

Screening for TB and Covid-19

Dlamini-Miti said she had hoped community screening for Covid-19 would improve TB case finding since some symptoms of the two diseases are similar. “But it does not look like that is happening. Teams are only screening for Covid-19,” she said.

Previously, the Department of Health told Spotlight community healthcare workers were still doing routine work in communities, rather than solely screening for Covid-19. Ndjeka said the department was working on integrating screening for TB with Covid-19. In clinics, Dr Anja Reuter, manager of Doctors Without Borders’ DR-TB medical activities in Khayelitsha, said it was critical to also screen for TB in patients who screen positive for Covid-19, given the overlap in symptoms.

“This is not routinely done at all health facilities at present,” she said. 

Treatment

Restriction on movement is not just a challenge for testing, but also has an effect on treatment. Dlamini-Miti said patients found to have TB may have delayed getting their results and starting treatment. “For DR-TB, the treatment gap may be higher due to closure of some of the DR-TB centres,” she said.

Dlamini-Miti said with patients missing appointments because of police and Covid-19 fears nurses had to inform them they should not have problems if they carry their TB treatment cards. “They should assure them that proper infection prevention and control measures are being taken at health facilities to minimise this.”

Agreeing with Dlamini-Miti, Reuter said the number of patients starting on treatment for TB and DR-TB had declined.

“This is very concerning as these undiagnosed cases can lead to undiagnosed patients dying and may predispose undiagnosed individuals to severe Covid-19 disease. TB and DR-TB, left untreated, can result in an increase in community transmission,” she said.

Seddon and his colleague Dr Megan Palmer, medical director at the DTTC’s Pharmacokinetics Unit, raised concerns over drug shortages, which could become worse.

“We do experience DR-TB drug shortages, but alternative drugs are used,” said Ndjeka. “We do not have patients who were sent home without medication. I agree that if the current status continues for the next two months we shall have a crisis at hand. Our pharmaceutical colleagues are working very hard to sort these issues.”

While patients were given two months’ worth of treatment, Ndjeka said the country would face problems with treatment should patients fail to return to clinics at the beginning of June.

TB research on hold

Previously, Spotlight reported on important research being done by the DTTC, particularly on paediatric TB. However, because of the pandemic, most of the DTTC’s paediatric clinical trials and research were put on hold.

“The clinical trials that are interventional, where we are testing different drugs, we have stopped recruitment for, though we are continuing follow-up. But everything is on almost a skeleton service and all the observational studies we have paused over this period,” said Seddon.

“I think there’s a real danger that, as everyone focuses on coronavirus, everything else gets neglected and diseases like TB, HIV and malaria are likely to affect many more children globally in the next year to five years.”

Seddon warned that, by suspending research into other diseases, progress made in those areas could suffer. 

Impact on DR-TB centres

For DR-TB patients, the department issued a directive in late April detailing clinical management of DR-TB patients during the lockdown period. The directive states, where possible, patients’ time in clinics must be reduced to prevent the possibility and spread of infection. Depending on status, patients should be seen every two, four or eight weeks, monthly or every two months.

At Brooklyn Chest TB Hospital in Cape Town, Palmer said efforts were being made to discharge clinically stable patients to free up space for Covid-19.

“One of the XDR wards was emptied and has been set up as a Covid-19 ward. Occupancy was also reduced in other adult and paediatric wards,” she said.

“Those patients are normally in hospital because they are sick and vulnerable, with concern over adherence and their ability to complete treatment,” said Palmer.

Ndjeka said several provinces had taken the same approach with DR-TB patients, with patients being sent home with two months’ worth of treatment and educated on how to take the medication and what to do if there were challenges. “Very sick patients were not sent home, to the best of my knowledge,” he said.

Before the lockdown, the bed occupancy rate in DR-TB sites across the country was 50%, Ndjeka said, adding that a decentralisation policy seemed to be successful.

Keeping TB in the picture

Although South Africa’s lockdown measures have resulted in some health benefits, such as a decrease in hospital trauma cases, current indications are that the TB response has suffered — although the dynamics at play are complex and hard to predict. While social distancing may decrease community exposure to TB, the risk of transmission will remain high in places where people with TB are living in close contact with others. Similarly, although cloth masks help to prevent the spread of Covid-19, they do little to protect against TB.

“In terms of hygiene, we know that anything less than an N95 [respirator mask] cannot entirely protect against TB because the [airborne] particles are much smaller,” said Palmer.

“The [cloth] masks are unlikely to add a substantial benefit to TB. TB is entirely airborne, so it’s not transmitted through contact like Covid-19. The hand washing won’t directly impact TB transmission. Improved respiratory hygiene practises [such as] cough etiquette is a good thing for TB.”

Reuter commented on socio-economic pressures and food insecurity faced by patients during the lockdown.

“People with DR-TB or severe TB may be incapacitated by illness, unable to work and therefore particularly affected. Yet Sassa (the South African Social Security Agency) has suspended all new applications for temporary disability grants. This may affect patients’ ability to drink tablets (especially DR-TB where up to 20 tablets need to be taken daily); and it may affect patients’ ability to access transport to get to the clinic,” she said.

Seddon agreed. “If you’re hungry your TB becomes irrelevant, everything becomes less important so [TB] becomes a lower priority for people.”

“We have to make sure we do not drop the ball on TB at this time,” Dlamini-Miti declared. “TB kills over 160 people daily in this country, and over 1.4 million per year globally. If we do not act, we will see an increase in TB transmission, an increase in TB cases in later months, and more deaths.”

Dlamini-Miti said there should be increased health promotion focusing on the symptoms of TB, the importance of testing and treatment and the implications of Covid-19 on untreated active TB. The Stop TB Partnership modelling report states: “To recover the gains made over the last years through increased efforts and investments in TB, it is important to have supplementary measures and resources to reduce the accumulated pool of undetected people with TB.”

This could include ramping up active case-finding with intensified community engagement and contact tracing. The Stop TB Partnership also recommends an “uninterrupted” supply of quality-assured treatment for all persons with TB. Looking at the bigger picture, the report estimates that, globally, a three-month lockdown and a 10-month restoration period could cause an additional 6.3 million TB cases and an additional 1.4 million TB deaths between 2020 and 2025.

“Every evening I look at the Covid-19 statistics, and I recently had a look at the TB mortality in South Africa, where about 175 people die from TB every day. I think these numbers must keep us all focused that there are other health conditions that are killing people,” said Palmer. MC/DM

This article was produced by Spotlight – health journalism in the public interest.

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