Maverick Citizen Op-ed

Prevention has to be a priority for all diseases, not just the pandemic of the moment

By Gavin Churchyard 30 October 2020

File Photo: Patients with HIV and tuberculosis (TB) wear masks while awaiting consultation at a clinic in Cape Town's Khayelitsha township, February 23, 2010. In South Africa, 5.5 million people live with HIV/AIDS ? more than in any other country - while 33 million people live with the disease worldwide. In Khayelitsha there is a saying, ?Living with HIV, dying from TB?. The weakened immune system leaves those infected vulnerable to infectious diseases like TB, which spreads easily in Khayelitsha?s poor living conditions and dense population. The TB incidence there is among the highest in the world. REUTERS/Finbarr O'Reilly

Covid-19 has dominated the news since the beginning of the year, but scant attention has been paid to tuberculosis (TB), which each year kills more than one million people, while an estimated 10-million people fall ill from the disease. Covid-19, a new infectious disease in humans, and TB, a disease that has been in existence for thousands of years, are strangely intertwined, yet not intertwined enough.

Patients that have TB are at greater risk of developing severe Covid-19, and in turn Covid-19 may worsen TB treatment outcomes. As much of the world waits with bated breath for an effective Covid-19 vaccine, bacille Calmette-Guerin (BCG), a vaccine that’s been used since 1921 to prevent TB, is now being tested to help alter the course of the Covid-19 pandemic.

Why do people still fall ill with TB when there is a vaccine? One of the main reasons is that the BCG vaccine given after birth provides poor protection against TB disease in adolescents and adults. BCG is now being tested in a clinical trial to see whether giving it will prevent TB infection in those age groups. As a physician and researcher who’s devoted most of my life to the prevention and treatment of TB, I am looking on with interest at this renewed enthusiasm towards the only vaccine currently available for TB. As this year’s Covid-19 pandemic has brought to the fore, prevention is key when it comes to a disease that easily spreads from one person to another.

Although the development of new TB vaccines has been identified as a priority by the World Health Organisation (WHO), the reality is that we are years away from newer, more effective vaccines. In the meantime, though, we have other tools we can deploy to prevent TB disease from occurring or to treat it when it does occur.

Very exciting news was reported at the 51st Conference on Lung Health, which took place last week and centered on the theme of advancing prevention. Researchers reported that combining one of the antibiotics (rifapentine) used in the three-month TB preventive therapy regimen with three other antibiotics can reduce the duration of treatment for TB disease from six to four months. These results highlight that use of rifapentine is a game-changer for both treatment and prevention of TB disease.

Up until now, a long course regimen of a single antibiotic (isoniazid) for six months has been used to treat TB infection. New, short-course TB preventive therapy regimens, using a combination of isoniazid and rifapentine, given weekly for three months, are becoming available globally. By giving anti-TB drugs to people with dormant TB infections, we can prevent them from developing active TB disease in the first place, and the shorter regimen is associated with better treatment completion and fewer side effects.  

Unfortunately, lockdowns implemented to contain the spread of Covid-19 have inadvertently introduced barriers to accessing health services, limiting TB diagnosis, treatment and prevention services. A modelling study released by the Stop TB Partnership in March this year found that the response to the Covid-19 pandemic could lead to 6,3 million more people becoming ill with TB by 2025, and 1,4 million more deaths from the disease over the same period. At least five years of hard-won progress in our TB response are expected to be lost.

The onslaught of Covid-19 has been compared to being in a war. We know from World Wars I and II that TB rates spiked as healthcare services were disrupted and resources were diverted to other sectors. Already, we’ve seen reductions in TB case notification during Covid-19, leading to ongoing disease transmission as undetected cases cannot be identified and treated. It is possible to end the TB epidemic, but it will take herculean effort, and as soon as we relax our efforts, the situation will worsen. We can’t drop our guard, we must push to implement effective TB interventions, particularly TB preventive therapy that shields those most at risk of developing TB disease.

It shouldn’t be a question of prioritising resources for either TB or Covid-19 – we must find a way to deal with both. Already, we are seeing some countries starting to integrate screening and testing for TB with Covid-19 contact tracing and testing.

Advancing TB prevention needs to become our motto. The world is on track to meet the United Nations targets of starting 30 million people on TB preventive therapy. Until now, the long, six-month course of TB preventive therapy has been used to reach those targets. By using short-course preventive therapy regimens, we can prevent TB in even more people as they are more likely to complete the treatment. Encouragingly, high TB burden countries, such as Pakistan, Zimbabwe, Kenya and Ethiopia, have already ordered or started scaling up short-course TB preventive therapy regimens, and more countries, such as South Africa, Uganda, Lesotho and Zambia are poised to start national roll-outs.

While Covid-19 is front page news, now is not the time to be complacent about TB. We must renew our efforts to prevent this long-standing disease if we want to save lives. And we must re-energise ourselves to meet the commitments made at the 2018 United Nations General Assembly to scale up TB preventive therapy to help end the TB epidemic. DM/MC

Prof Gavin Churchyard is a specialist physician, internationally renowned for his contributions in tuberculosis (TB). He is the founder and CEO of The Aurum Institute, which focuses on TB and HIV service delivery, management and research.

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  • TB is South Africa’s leading cause of death. Between 63,000 and 89,000 people die from it every year; that’s over TEN people every hour.
    A total of 1.5 million people died from TB in 2018 (including 251 000 people with HIV) and we did not shut down our economies and restrict our citizens. Worldwide, TB is one of the top 10 causes of death and the leading cause of a single infectious agent (above HIV/AIDS).
    In 2018, an estimated 10 million people fell ill with tuberculosis(TB) worldwide. But TB is curable and preventable.
    In 2018, 1.1 million children fell ill with TB globally, and there were 205 000 child deaths due to TB (including among children with HIV).
    Globally], due to the Covid-19 pandemic, there has been a 25% to 50% reduction in the number of people with TB who are detected and treated over a period of three months in 2020. Because of this, it’s estimated that the number of TB deaths in 2020 could increase by between 200,000 and 400,000 people.
    Why have we reacted so strongly and I believe disproportionately compared to our response to TB to deaths of our young from this plaque of mostly the elderly and those with underlying conditions which make them susceptible to SARS-CoV-2 virus attack?
    Due to some deeply evolved responses to disease, fears of contagion lead us to become more conformist and tribalistic, and our leaders have been driven to a misplaced ‘better safe than sorry logic’ and reactions.
    Apparently, any signs of free-thinking become less valued when there is the risk of contagion.
    Trying to understand the value of different containment policies, we might question whether our thoughts are really the result of rational reasoning, or whether they might have been shaped by an ancient response that evolved millennia ago.

  • Mr Kirschner fails to acknowledge that the lockdown has essentially worked for COVID-19, while the economic consequences have been large it has prevented huge numbers of cases, just look a Brazil to see this.
    I don’t buy the argument that TB cases will definitely go up due to covid-19, despite the modelling. Influenza was wiped out by the lockdown, there may well have been significant impact on reducing TB cases, which is why notifications are down.

  • Concerning Tom Boyles’s comment, I am not sure why he mentioned Brazil where its president resisted locking down the country. Brazil’s Covid-19 mortality was high, at 762 per million, but the mortality of neighbouring Peru, which had strong military enforced lock-downs was 1052 per million.
    As to the expected rising future deaths from TB and other diseases, unless Tom Boyle wants to deny the concept of preventative medicine and that fewer people have been seeking medical attention due to Covid-19, there will be more deaths due indirectly to our responses to Covid19 in the future. How many more would be conjecture, but more there will be.
    Reduced movement and mixing, social distancing, and masks reduce flu transmission. The highest flu mortality is those under 4 and the aged, and unfortunately, many of the aged who might have succumbed to flu have succumbed to Covid-19.
    The rising infections in the Northern hemisphere would be influenced by the now colder climate keeping people indoors. In contrast, the falling infections in the Southern countries are almost certainly influenced by the warmer weather allowing fresher air.
    It would appear that Covis-19 will be with us for some time, while the vaccine has become contentious. Countries are facing choices of stronger restrictions to hopefully reduce SARS-CoV-2 infection as against increases in other diseases, economic and social destruction.

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