A 3-month long lockdown could lead to an additional 1.4 million TB deaths and an additional 6.3 million cases over the next five years – if existing tuberculosis services are put on a prolonged hold, reports a new study by the Stop TB Partnership, which estimated the global impact of COVID-19 lockdowns on TB. The study has important implications for policymakers as they struggle to balance the length of lockdowns with other impacts, including on health systems. 

However, if TB services are rapidly restored, the long-lasting impacts of the COVID-19 lockdown on TB could be minimized, concludes the study, released on Wednesday. In the best case scenario of a 2-month lockdown and an ‘enhanced’ 2-month long recovery period, there would be a 4% increase in TB deaths (342,500) and 3% increase in TB cases (1,826,400) over the next 5 years, predicted the researchers.

Existing TB services thus need to be restored as quickly as possible; otherwise COVID-imposed lockdowns could set back the fight against tuberculosis by 5-8 years, warned the Stop TB Partnership’s Executive Director, Lucica Ditiu, in an interview with Health Policy Watch:

“In the agitation of COVID, it appears people forgot that there are other diseases…all existing financial efforts and tools have been disrupted or diverted, and all the efforts you have made for the past 5-8 years may be gone.

“By disrupting existing services, we will pay this price later and it will cost us much more,” said Ditiu.

TB is the biggest infectious disease killer worldwide, leading to 1.5 million deaths and 10 million cases every year.  The mortality rate from TB is about 3% – equal or even greater to that of COVID-19, depending on the estimates. It is estimated that about a quarter of the world’s population has at some time in their lives been infected by TB – although many infections also remain latent and are eventually overcome by the body’s own defenses. 

The USAID-supported study, carried out by Imperial College, Avenir Health, and Johns Hopkins University examined two scenarios for how the pandemic might impact TB prevention, treatment and control.  

In the study, a number of scenarios were modelled, including 2-3 month lockdowns and 3-10 month recovery periods. The study finds that on average, for every month of lockdown, there would be an excess of 130 000 deaths and 600 000 cases of TB per month. 

In the worst case scenario,  a 3-month long lockdown and a slow 10-month long recovery period could lead to an additional 1,367,300 deaths in the next five years, increasing total TB deaths by 16%. In this scenario, TB cases would increase by 10% to 6,331,100 cases over the next 5 years. 

The “worst-case scenario” reported by the study is probably an underestimate, said Ditiu.

“The restoration period is likely to be more than 10 months because it looks like lockdowns are going to continue. I think that we will see a much bigger mortality than the modelling study suggests.”

The study’s authors contend that these are probably underestimates of true TB infection and death trends, mainly because they did not include underlying comorbidities like direct interactions between the Tuberculosis bacterium and the SARS-CoV-2 virus. There is already some evidence that people with TB history or existing TB are more vulnerable to the SARS-CoV-2 virus, just like any other patient with an underlying illness, said Deputy Executive Director of the Stop TB Partnership Suvanand Sahu, in a webinar Tuesday launching the report.

Increased poverty due to COVID-19 lockdowns can further increase TB burden over the next few months because TB disproportionately affects people living in poverty. Poverty was not included in the study’s model, however.

However, COVID-19 will increase poverty for the first time in 22 years, according to a recent report by the World Bank, which predicts that over 8% of the world’s population will sink below the poverty line as a result of COVID-19.

Rapidly Restoring Existing Tuberculosis Services Can Minimize Negative Impact Of COVID-19 Lockdowns

The lockdown has already led to a worrying drop in TB diagnosis in the two countries with the highest TB burden in the world – Indonesia and India. Identification of cases has dropped by 80% in India and by 70% in Indonesia, said Ditiu.

Lockdowns can have a profound effect on TB burden because people are often unable to visit health clinics for more routine care, and this leads to missed opportunities to diagnose and treat undetected TB cases.

“Rapid restoration of TB services is critical for minimising these adverse impacts [of COVID-19 lockdowns]…Long term outcomes can be strongly influenced by the pace of short-term recovery,” said the study.

As the pandemic drags on, a range of supplementary measures and resources can be used to recover pre-pandemic TB detection rates, the study highlights:

“Such measures may include ramped-up active case-finding, alongside intensive community engagement and contact tracing…[as well as ensuring an]…uninterrupted supply of quality assured treatment and care for every single person with TB.” 

It’s Not Rocket Science To Address Both COVID-19 & TB; Romania’s Timis County Tests and Treats Both Simultaneously

It is not difficult to address both COVID-19 and existing diseases, and it is not necessary to disrupt existing services. “The solution is not rocket science”, said Ditiu, in an interview with Health Policy Watch.

“There is no need to disrupt existing services for which treatments are available such as immunization programs or malaria, especially for diseases that cause millions of deaths. 

“Furthermore, we can address TB and COVID-19 simultaneously because we already have the infrastructure to do both in parallel,” said Ditiu.  The Geneva-based, UN-hosted organization, includes   more than 2,000 partners worldwide.

‘There are many intersection points between TB and COVID-19, that’s absolutely clear. Firstly, healthcare staff working for TB programs know a lot about diagnosis, treatment and infection control measures for COVID-19. Secondly, we can also use the GeneXpert machines [to diagnose both TB and COVID-19] as well as other putting other measures that are already in place like contact tracing [to work].”

In March, Cepheid, the manufacturers of GeneXpert, a widely-used TB diagnostic, received emergency US Food and Drug Administration approval for a COVID-19 test on the platform.

In Western Romania’s Timis County, the TB situation is “very good” because it is protocol to maintain existing TB services during the emergency period, said Adriana Socaci, TB Coordinator for the Timis County, in an interview with Health Policy Watch. 

Timis County has thus maintained ambulatory TB diagnosis and treatment services in the region, administering some 400 tests in the past two months. So far, ambulatory TB services have identified 2 patients with both TB and COVID-19, said Socaci. However, TB hospital visits are being spaced further apart snce the lockdown to respect COVID-19 social distance guidelines, and that has led to an overall reduction in the number of patients that can be seen. 

During routine COVID-19 testing in Timis County, healthcare workers also collect sputum samples to test patients for TB when lung X-rays are suggestive of the bacterial disease. 

Sputum samples, which are analyzed for TB using a combination of already-existing smear testing and the higher-throughput GeneXpert tests, were used to identify 8 patients with TB that did not have COVID-19, said Socaci. In the past two months, almost 125 suspected COVID-19 cases have also been tested for TB.

National Policies Must Adjust To Regional And Local Conditions; Funding Must Triple

As countries try to address COVID-19 and TB, Ditiu warns that policies need to adjust based on each country’s conditions and the location of available services.

“There is no one solution that can be generalized across countries, as every country is different. Policies need to adjust based on the country’s conditions and the location of available services.We will have to be mindful of whether these services are centralized or not.”

Funding will also be a big question, said Ditiu. We will need to triple current spending to get back to where we were with respect to TB. 

We will also need to find ways to ensure that money currently earmarked and available for TB gets used, he stressed.

“While Africa’s funding for TB has not been suspended, Africa’s capacity to spend the money for TB right now is 0.”

Image Credits: Socios en Salud, Svĕt Lustig Vijay, PLOS Medicine.