It took many years of hard work before the tuberculosis “community” could say in 2015 that there was hope in overcoming the disease. Now Covid-19 threatens to set back the world eight years in its fight against TB, said Lucicia Ditiu, executive director of the Stop TB Partnership, this week.

Modelling by the partnership — in collaboration with Avenir Health, John Hopkins University and Imperial College London — predicts that up to 6.3 million more people will develop TB and 1.4 million more people will die of TB by 2025. TB is the world’s most fatal infectious disease and kills 1.5 million people a year. It is most prevalent and devastating in lower-income countries. In many ways, TB overlaps Covid-19. The symptoms are similar, both diseases affect the lungs and infection by both can be prevented in similar ways.

“We are a bunch of idiots,” Ditiu declared — for freezing access to TB services, depleting resources and moving staff to the Covid-19 response. “We are unable as human beings to think properly,” she said of the world’s inability to fight more than one disease at a time.

Ditiu was speaking at a webinar organised by science-sharing platform The Union, entitled “How to Prevent 1.4-million Deaths: Advancing TB care and prevention in the time of Covid-19”. Moderated by Victoria MacDonald from Channel 4 News, the panel discussion highlighted the severe consequences and opportunities that Covid-19 holds for the world’s TB response.

Disruptions to basic TB response

Dr Tereza Kasaeva, director of the World Health Organisation’s Global TB Programme, said her organisation recognised disruptions to the basic TB response and was discussing the issue with country officials, highlighting the challenges and opportunities. The TB community had unique experience, said Kasaeva, which should be used to fight Covid-19. Past investments to deal with TB have equipped health systems to tackle Covid-19. But TB should not be neglected in the process.

The socio-economic structure of the TB situation had to be borne in mind, said Kasaeva, to make sure the most vulnerable, impoverished and malnourished people were protected. Cheri Vincent, chief of the Infectious Diseases Division at USAID, said her organisation had started to shift towards building the capacity of local partners. USAID has more than 50 advisers embedded in ministries of health and continues to advise people on the ground to respond better to the crises, she explained.

“It’s not about what TB should learn from Covid,” said Ditiu, but what Covid-19 had to learn from TB. Over the years, the Stop TB Partnership had ensured staff were trained to treat lung disease and hospital buildings had specialised infection control. Mask wearing, contact tracing and active case-finding have been promoted by the TB community for years, Ditiu revealed.

Case-finding for TB and Covid-19 simultaneously

The experts emphasised the need to ensure active case-finding for TB was not only continued during the Covid-19 pandemic, but intensified.

Testing and screening for TB and Covid-19 at the same time was relatively simple and would be most effective, said Kasaeva. However, many countries, including South Africa, have rolled out mass screening and testing only for Covid-19.

A decrease in TB testing and diagnosis across the world is concerning the experts, as it indicates that TB patients are unable to access TB services and active case-finding has been affected by Covid-19. In South Africa, TB testing has declined by nearly 50% since the start of the lockdown. Vincent noted the overlap of vulnerable populations, and symptoms, and said co-morbidity of TB and Covid-19 should be monitored. There is not much data on how dual-disease of TB and Covid-19 manifests, but it is known that people with lung-diseases such as TB are particularly vulnerable to complications from Covid-19.

Treatment

Kasaeva argued that treatment should be continued, but differently. A shift to home-based and oral treatments for TB patients was critical to ensure the lowest possible risk of transmission. In addition, she advocated the provision of preventative treatment for households around the world. More than 20 million people needed this treatment. Ditiu explained that Stop TB had developed adherence technologies to monitor and observe the treatment of patients remotely. These included digital and artificial intelligence tools, which should be rolled out to vulnerable communities. 

Many hospitals are seeing their TB wards converted to Covid-19 wards. Many TB wards have specialised circulation control to prevent infection, making them ideal for Covid-19 patients, but capacity to treat TB patients is severely affected.

Kasaeva called for personal protection equipment (PPE) for all TB care staff.

Jose Luis Castro, executive director of The Union, noted that a global shortage of healthcare workers had been severely exacerbated by the pandemic. Those in situ had to be protected at all costs. Subrat Mohanty from The Union highlighted that confusion and stigma caused by similarities between Covid-19 and TB were concerning. Messaging was important, he added, with community members and health workers being made aware of access treatment and how the two diseases should be treated. De-stigmatisation had to be part of this communication.

Opportunities

“In every crisis lies an opportunity,” said Catharina Boehme, CEO of FIND, suggesting that opportunities arising from Covid-19 for the TB response might outweigh disadvantages. While research is on hold and companies are under pressure to develop Covid-19 tests rather than TB tests, these services are now starting to resume in new, innovative ways.

Boehme acknowledged economic devastation would mean less funding for TB, but she highlighted that “we’ve never worked in this way before”. 

Due to the Covid-19 crisis, the TB community had seen end-to-end partnerships and new ways of data and IP sharing. Boehme noted with concern a “supply chain war”. Pressure was being applied to pharmaceutical companies to move production capacity to Covid-19 “and away from malaria, HIV and TB”. She urged the TB community to make sure this did not happen. Expanded manufacturing lines and the development of production capacity in Africa and Asia was already being seen and could drive affordability and access in the future, she said. MC