What delays simultaneous screening for tuberculosis and COVID-19?

More than a year after the start of the coronavirus pandemic, countries have witnessed a drop in the number of people diagnosed and treated for tuberculosis. But public health experts and health organizations are now identifying efforts in countries to reverse this trend, including screening and screening patients with tuberculosis who test positive for COVID-19.

“I think one of the things we’re learning… is that there are real opportunities, not just to protect TB from diversion. [of COVID-19], the challenges of COVID, but to take advantage of opportunities to implement synergistic programs, so that when we reach … vulnerable communities, we test for both COVID and TB, ”said the executive director from the Global Fund, Peter Sands. week at a press conference organized by the Stop TB Partnership.

This is happening in India, which has the highest TB burden in the world, and which has seen daily TB notifications drop by 80% after a nationwide lockdown was imposed in March 2020. Provisional data released by the World Health Organization this week revealed a significant drop in tuberculosis cases. notifications in all countries. Compared with 2019, TB notification in 2020 fell by 42% in Indonesia, 41% in South Africa, 37% in the Philippines and 25% in India – some of the countries known to have high TB ​​burdens.

This coincides with data released last week by the Stop TB Partnership, which found that nine countries accounting for 60% of the global TB burden have experienced significant declines in TB diagnosis and treatment in 2020.

In August 2020, India’s Ministry of Health and Family Welfare released guidelines for two-way screening of patients for tuberculosis and COVID-19. This means that patients confirmed to have COVID-19 must be screened and then tested for tuberculosis, and vice versa.

Last week, about 44% of people with TB – or about 640,000 people – were tested for COVID-19, and more than 5,000 patients were diagnosed as having TB-COVID co-infection, according to the Stop TB partnership. .

Screening for tuberculosis is essential as countries increasingly see patients with symptoms similar to COVID-19, such as cough and fever, but end up testing negative for COVID-19.

Diagnosing tuberculosis amid COVID-19 has its challenges. Potential obstacles include the unavailability of the technology to test for both COVID and TB in a given area, the limited capacity of the health system to do both, the additional precautionary measures that health workers need to take, and mobility restrictions. In some cases, national guidelines for testing for both COVID-19 and tuberculosis are not available. Additionally, overwhelmed by COVID-19, some countries may not consider tuberculosis a priority.

WHO recommends screening for both diseases, especially for countries with a high tuberculosis burden. But not all countries follow her recommendation, said Tereza Kasaeva, director of the WHO’s global tuberculosis program.

“Why [are] other countries … do not do the same despite WHO recommendations? I will probably answer that it is a question of political will and of prioritization of the services to fight against tuberculosis, ”she said during a press briefing on March 22.

The limits of technology and health systems

One of the WHO recommendations is to step up routine screening for tuberculosis and simultaneous screening for COVID-19 and tuberculosis. But there may be technological and health system limitations to performing TB and COVID-19 testing in countries.

“There are only a limited number of platforms that can easily test both. And … a lot of clinics don’t have one, ”Emma Hannay, FIND access manager, told Devex.

The TrueNat and Xpert platforms are two of the point-of-care molecular tests that can be used to test for both tuberculosis and COVID-19. But the samples for each test are different, with COVID-19 requiring a nasopharyngeal swab and tuberculosis requiring a sputum sample. Their availability at the primary care level is also limited, Hannay said.

COVID-19 provides lessons on the need to diversify the manufacture of diagnostic tests for COVID-19 and tuberculosis, she added. Allowing local and regional manufacture of tests for diseases affecting the majority of low- and middle-income countries ensures a continuous supply and that the tests are applicable to local conditions.

“To illustrate with rapid diagnostic tests [for COVID-19], the first two tests that were [given emergency use listing] by WHO were both produced in the same country, literally in the same neighborhood [in South Korea]Hannay said.

Most healthcare systems are also not set up to offer a range of diagnostic tests to patients. Diagnostic testing does not feature strongly in countries’ health sector strategies, she said. WHO produced its first essential diagnostics list template in 2019, but only India has released its national essential diagnostics list so far, with a few countries working with WHO to develop theirs.

“Without this [list], you get kind of a somewhat eccentric approach in the country … Some places will have diagnostic tests widely available, others with large populations and a great need might not be. It’s not necessarily as strategic as it could be, ”Hannay said, adding that most countries don’t even have a director of diagnostics in the health ministry to drive diagnostic policy.

TB tests are more portable today and can be placed in clinics rather than in a centralized laboratory. But they’re still a far cry from the kind of rapid pregnancy test kits now available for COVID-19.

The challenge of mobilizing COVID-19 communities as a barrier

It is also difficult to get people in communities tested not only for COVID-19, but also for tuberculosis.

In Pakistan, which also saw a drop in tuberculosis cases in 2020, people tend to delay seeking care, said Hamidah Hussain, global technical manager of tuberculosis prevention programs for Interactive Research & Development, an institution. Singapore-based nonprofit supporting health programs in 17 countries. countries.

“People themselves don’t come for services. I think we’ve seen that, not only in tuberculosis, but I think even in other diseases, you see, people don’t come to the facilities as much as they used to for symptoms, ” Hussain told Devex.

The IRD, in collaboration with partners such as the Indus Health Network, has worked to integrate screening for TB and COVID-19, whether at the level of private clinics – where the majority of the population goes to first – or hospitals. The non-profit organization trained private general practitioners to identify and treat people with COVID-19, provided them with ambulances, and linked them to hospital networks.

The IRD and its partners also organize community camps, where they travel to communities in mobile x-ray vans to screen for both tuberculosis and COVID-19.

But the additional precautionary measures health workers need to take to perform screening in communities, such as wearing personal protective equipment and disinfecting the unit after each patient, add to the challenge.

“It reduced our throughput. So if a van before the pandemic was doing 100 x-rays a day, it was sort of, you know, down to … maybe 30% less or 40% less, ”Hussain said.

Getting the community tested in vans with people wearing hazmat suits was also a challenge.

“It’s not easy to come into the community wearing all the PPE clothing, and you know people wouldn’t come easily, so mobilizing the community to keep getting tested and all of that… was a little harder, ”she said.

Lockdowns, or when governments restrict movement during waves of COVID-19 infections, can disrupt some of these activities.

Changing traditional approaches

In places where two-way screening and screening guidelines for COVID-19 and TB are not in place, some organizations are continuing their traditional ways of working, while adjusting their approach to reduce the risk of COVID infection. 19.

In Cambodia, the local NGO KHANA operates in 10 health districts in four provinces of Cambodia, which includes the capital Phnom Penh, as part of a USAID-funded community mobilization project to end tuberculosis. The project started in October 2019, just three months before the COVID-19 outbreak.

But even in the midst of the pandemic, the NGO continued to actively search for cases. Its approach includes targeting specific age groups and vulnerable communities for TB screening and testing, including those working at manufacturing and construction sites. It also works through a ‘seed and recruit’ model, which involves TB survivors and those newly diagnosed with TB in finding other TB cases in the community. This helped Cambodia to keep the gap in TB notifications between 2019 and 2020 below 3%, although KHANA was only able to reach 70% of its target TB cases.

This is done while practicing social distancing and limiting crowds.

“So bidirectional [screening] can be applied which can be an option and a strategy [to identify more TB cases], but at our level, we will continue our efforts to find missing TB cases using one-to-one contact… for example rather than bringing together large and overcrowded populations for TB screening, ”said Choub Sok Chamreun, Director KHANA Executive, to Devex in an email.

It is not known when the pandemic will be over, but he said people with TB cannot wait for it to happen before accessing services.

“We cannot continue to see people with TB die and miss TB prevention and care services if we are to end TB by 2030. People with TB are prone to COVID-19 , the two services are therefore in need, ”he said.