Coronavirus And Tuberculosis: We Need A Damage Control Plan

As the coronavirus COVID-19 pandemic sweeps the world, I and others working to fight TB have growing anxiety about what this pandemic will do to a much older infectious killer - tuberculosis (TB). We know from the Ebola experience that epidemics can disrupt even basic services such as routine immunization . No doubt, COVID-19 will adversely affect all routine health services everywhere. But TB services is might be one of the biggest casualties. Why?
Even before COVID-19, TB had a notorious track record as a ‘Captain of the Men of Death’. TB kills 4000 people each day, and 1.5 million people each year. TB is the leading killer of people living with HIV/AIDS. An estimated 10 million people developed TB in 2018, and nearly half a million people developed drug-resistant TB (DR-TB).
How COVID-19 impacted TB services in China & Korea
I was worried when COVID-19 emerged in China, because China has a large burden of TB. In 2018, an estimated 866,000 people fell
ill with TB in China, and 40,000 deaths were reported. As of mid-March, China has reported over 80,000 cases of COVID-19, with over 3000 deaths. How did the massive disruption due to COVID-19 impact TB services?
“Since long distance travel was prohibited in some areas of China, patients could not go out of their city for heath care. Also, in some cities with heavy burden of COVID-19, hospital systems collapsed because of the large number of patients. Because their priority was treating patients with COVID-19, they had no energy to treat other patients, including TB. Laboratory testing of TB was also interrupted,” said Hairong Huang , a TB laboratory expert and professor in China.
As South Korea battles COVID-19 (over 8000 cases so far), routine TB care has been disrupted. “Care for TB patients, particularly for those who need hospital-based care is being marginalized due to the COVID-19 epidemic”, said Dr. Jae-Joon Yim , a Professor at the Seoul National University Hospital. “South Korea requires at least two-week hospitalization for MDR-TB patients by law, but since the COVID-19 epidemic, we are not able to accommodate any MDR-TB patients who have been referred to our hospital,” he added.
DR-TB hospitals have negative air pressure wards, but these have been re-prioritized to deal with COVID-19 in Korea. “Georgia had to convert their pediatric DR-TB wards to a COVID-19 ward,” said Jennifer Furin , a TB physician and researcher. Children are already a neglected population in TB care.
If relatively affluent countries like China and Korea are struggling with TB, imagine what COVID-19 can do in low-income countries.
As the pandemic moves South...
The COVID-19 epidemic is now taking off in countries such as India and South Africa. Not only do these countries have large numbers of patients with TB, they also have massive numbers of people living in poverty, with immunosuppressive conditions such as HIV (South Africa) and malnutrition (India).
"As the Coronavirus moves to low-income countries, we're deeply concerned about the impact it could have among populations with high HIV prevalence or malnourished children. We’re calling on every country & individual to do everything they can to stop transmission"
Tedros Adhanom Ghebreyesus, Director General, World Health Organization
South Africa has declared COVID-19 a ‘national disaster’ while India has imposed sweeping travel restrictions. Both countries are currently testing very few people for COVID-19.
“Our president announced a lock down to protect South Africans. I think we all feel the burden as we realize that COVID-19 will affect those who are most vulnerable. As a former TB patient, I hope that our communities stand together and take the protective guidelines seriously as their social responsibility to one another. All of us have people whom we love who will be affected. Our health system needs our support,” said Ingrid Schoeman , a TB survivor and advocate with TB Proof in South Africa.
Keertan Dheda , a TB expert at the University of Cape Town, agrees that HIV is a major concern. “TB services will be impacted at various levels as resources are diverted to COVID-19 and the epidemic ramps up. Many healthcare workers are not happy to put themselves at risk. So, TB diagnosis will be delayed. I would predict a spike in TB incidence, given delayed diagnosis and higher transmission,” he said.
“India still hasn't gotten serious about the COVID-19 pandemic. We have so many untested TB patients. We, of course, have a lot of untested COVID-19 patients. This will blow up in time, and when it does - the health system will reallocate resources to COVID-19. TB will take a bad hit,” warned Saurabh Rane, a TB survivor and TB advocate in India. India has
struggled to scale-up newer TB drugs, and overall expenditure on health is low.
Anxiety among those affected with TB
“Many of us worry about our lung damage, if we will die if we get sick, and if we will be able to be tested,” said Kate O’Brien , a TB survivor in the US, and advocate with We Are TB . “Most people with TB in the USA aren’t in the position to stockpile food or miss work. We don’t have paid sick days, and many have no healthcare coverage,” she added. TB primarily affects foreign-born persons in the US.
Deepti Chavan, a TB advocate in India, survived XDR-TB, but lost a lung in the battle. Her doctor and her family are terrified of her going out. She was in isolation during her long battle with TB, and finds herself isolated again, because of COVID-19. “If I were to get COVID-19 despite taking precautions, will I survive?” she asks. “I have one lung left, and that is also ravaged by an aspergilloma (fungus). I will lose the battle against COVID-19 without even given a chance to fight it only because TB took away any chance that I had,” she added.
Saurabh Rane has similar concerns. “Due to my lung damage and history of TB, I am a 'high risk' person for this COVID-19 pandemic. I live in a densely populated area (Mumbai), which increases the chances of infection. I am nervous about the infection but I can afford to self-isolated myself. Many people in India cannot afford to stay home or isolate themselves in their own houses. What do they do?” he asked.
Anticipating and mitigating the damage
The TB community has the opportunity to anticipate and mitigate the disruption of COVID-19 on TB services. The first step would be to make an inventory of all the likely pathways by which COVID-19 can affect TB.
One, TB patients and survivors often have lung damage. Although there are no data yet, I suspect lung damage might make TB patients more prone to COVID-19 and its negative outcomes.
Two, TB patients also tend to have comorbid or living conditions that increase their
vulnerability. These include conditions such as malnutrition, HIV, silicosis, diabetes, homelessness and smoking. It is unclear how COVID-19 might worsen food security, adversely affect HIV care, diabetes care, and so on at this time. But these should be anticipated.
So, high TB burden countries must do everything they can do protect TB patients and survivors from COVID-19 exposure. If TB patients and survivors develop COVID-19 symptoms, they must be tested immediately and hospitalized, if indicated.
Three, the global COVID-19 response will likely result in diversion of healthcare workforce and resources away from routine TB services, or reduction in the number of health workers because of illness and self-isolation. TB wards could become COVID wards.
Such diversion of resources or workforce could result in poor quality of TB care (which is not great to begin with ), treatment interruptions and inadequate follow-up. DR-TB care is likely to suffer the most. Interventions such as TB contact investigation and preventive therapy are likely to be completely de-prioritized.
To mitigate this, interventions such as task-shifting could be tried. In addition, volunteers could be called in and trained to help. Where possible, services could be offered via phone (Call Centers), Whatspp, Zoom, and other digital tools (e.g. video observed therapy , smart pill boxes).
Four, diversion of TB funding towards COVID-19 is a real concern. Every effort should be made to minimize this. The bigger concern, in the longer term, is that countries will cut expenditure on TB, because of the massive economic loss due to COVID-19. TB is already under-funded by about $3 billion/year. Donor support (e.g. via Global Fund, PEPFAR, Unitaid), therefore, might be critical to tide over this looming crisis.
Five, COVID-19 is already depleting and disrupting the global supply chain for all drugs, including TB medicines , and other products (e.g. N95 respirators). The Global Drug Facility could play a key role here and ensure optimal distribution of existing TB drugs. Public sector companies could be tapped during health emergencies to meet demand.
Six, diagnostic laboratories are already being prioritized for COVID-19 testing instead of TB testing. This can result in substantial delays in TB diagnosis, with increased community transmission of TB. TB programs must enlist additional staff to continue TB testing services, or out-source testing to private or academic/research laboratories.
Seven, the COVID-19 pandemic could result in serious disruptions of payments (e.g. cash transfers) and social benefits to persons with TB. This, in turn, could reduce treatment completion rates. This is one area where automated payment and artificial intelligence systems could be deployed.
Eight, COVID-19 is already impacting all research activities, and scientific conferences. All TB events for next week’s World TB Day are cancelled. Virtual and long-distance events will have to become the new normal.
Delays of TB drug, diagnostic and vaccine trials can have a big impact on when new tools can be introduced. Updates to TB guidelines & policies will likely also be delayed. Normative agencies such as WHO could lean on various WHO Collaborating Centers related to TB, and enlist their support for guideline updates.
Nine, the COVID-19 chaos could weaken the quality of TB data that high-burden countries are able to collect and analyze. As it is, 3 of 10 million TB patients are deemed ‘missing’ because they are either not detected, or not reported to health systems. To mitigate this, TB programs could tap students and researchers working in TB, to conduct surveys.
Ten, as massive efforts are being made to develop new COVID-19 tests, drugs and vaccines, this could have a chilling effect on R&D for new TB technologies. R&D for TB is already under-funded by about $1 billion/year. Mitigating this would require advocating for countries to meet their “fair share” targets by spending at least 0.1% of their overall R&D expenditures on TB research.
Proactive, not reactive
Everyone working in TB has the window of opportunity to be proactive about mitigating the damage. Otherwise, we will end up seeing huge increases in TB mortality in the coming months.
Agencies such as the WHO and Stop TB Partnership could set up a special COVID-TB damage control unit to mitigate COVID-related challenges in the highest TB burden countries.
“Focusing solely on COVID-19 can damage the very fragile gains we have in TB. So, we must ensure programs and care for people is not interrupted or affected.” said Lucica Ditiu , Director of the Stop TB Partnership.
“The control of COVID-19 can benefit from the work TB programs have done over the years in areas such as infection control, diagnosis, contact tracing, and isolation,” she added. The reverse might also work - any investments made in COVID-19 control should be leveraged for TB care, after the pandemic subsides.
The COVID-19 pandemic has exposed the need for all countries (including rich countries such as the United States) to invest in universal health coverage and social benefits. As Amy Kapczyski and Gregg Gonsalves put it, “COVID-19 is a crisis of social solidarity and social investment .” This applies to TB as well.
Lastly, advocacy is critical to make sure TB does not become completely invisible during the pandemic. As Deepti Chavan put it, “People are leaving no stone unturned to stop the coronavirus pandemic. If we show even half of this dedication towards ending TB, we can stop millions from dying from a preventable and curable disease.”
Acknowledgements: I am grateful to all those who provided input, despite the ongoing pandemic. In particular, I thank Dr Hojoon Sohn, Johns Hopkins Bloomberg School of Public Health, for his support.
Madhukar Pai

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