International Coronavirus 'Lockdown' Encroaches on Tuberculosis Epidemic Control

Though it may be associated with the past in popular culture, tuberculosis (TB) is still the world’s most fatal infectious disease, killing an estimated 1.5 million people each year.

Substantial disruptions in tuberculosis care have taken place during the coronavirus pandemic and are increasing mortality from the disease, according to a report published by civil society organizations involved in global tuberculosis mitigation.

The Impact of COVID-19 on the TB Epidemic: A Community Perspective was compiled by a coalition of TB stakeholder groups such as The Global TB Caucus, Stop TB Partnership, TB People, McGill University, and more.

The report is a detailed survey of communities affected by TB around the world. Results paint a bleak and troubling picture:

• More than 70% of healthcare workers and advocates surveyed reported a decrease in the number of people coming to health facilities for TB testing.
• Program officers surveyed reported significant drops in tuberculosis notification: 88% in Global Fund supported countries, 68% in the USA.
• In Kenya, 50% of people with TB reported having trouble finding transport to care and in India, 36% of people with TB reported health facilities they normally visit closed.
• In Kenya, 70% of respondents reported not receiving enough support amid the pandemic.

“For TB, COVID-19 related lockdowns came in very handy, leaving people with no food, no work, no money, no health care. The various barriers we faced to access TB services were compounded. What a gift for TB ­­— and what a disaster for people affected by TB,” wrote human rights lawyer and public health consultant Timur Abdullaev.

Abdullaev speaks from personal experience, as he was drawn into advocacy and consulting after having contracted tuberculosis himself.

Many within TB advocacy and research are deeply concerned by the reversal of progress brought on in recent months.

“If we were climbing a mountain before COVID-19, that mountain has now become Mount

Everest. This means we need to work extra hard to mitigate the damage and stay focused on TB for the long haul,” wrote Madhukar Pai, MD, PhD, Director of the McGill International TB Centre.

Yet according to an anonymous health care worker from Morocco quoted in the report, “if we had used a quarter of the resources allocated to COVID... we would have eliminated TB a long time ago.”

Even the impact of public health messaging against COVID-19 in areas with high tuberculosis prevalence appears problematic, given comparative risks. About half of the population in Kenya is under 35 and thus at low risk for more than mild SARS-CoV-2 infection, but many people avoided care due to fear of COVID-19.

“For instance, more than half of people with TB in Kenya and India reported fear of contracting COVID-19 at a health facility, and more than half of people with TB in Kenya indicated experiencing feelings of shame because of the similar symptoms of both respiratory diseases,” Blessina Kumar, a member of the World Health Organization Civil Society Task Force on TB, said.

The survey included 159 people with TB from Kenya and 58 from India who reported significant challenges in accessing TB services during the pandemic and associated lockdowns.

Key barriers included difficulty finding transport to access TB care, changes in TB services, and fear of contracting COVID-19 during a healthcare visit. People also reported increased stigma due to newfound fear stoked among the public of coughing and other respiratory symptoms.

The patients surveyed expressed feelings of abandonment as well as urgent need of nutritional, economic and psychosocial support.

“[I am] sometimes rejected by family members because they think [I have the] same signs of COVID-19. [I’m] even thinking of moving from the family,” remarked one person with TB in Kenya.

A team of 73 TB researchers also expressed issues directly related to the so-called ‘lockdown’ policies.

Issues included “diversion of personnel, equipment, and funding of COVID-19 over TB” to the point that it appeared tuberculosis infrastructure was being repurposed to suit political demands for a laser-focus on COVID-19.

“Survey participants repeatedly noted existing lab space and infrastructure being closed during lockdowns or repurposed for COVID-19. Similarly, respondents experienced reduced access to research participants due to immobility during lockdowns. There is unified demand from TB researchers for additional and continued resources for TB, and for research investments in COVID-19 to be leveraged for TB. TB research and infrastructure are currently being leveraged for COVID-19-related research,” authors of the report wrote.

Once the initial few weeks of “flattening the curve” were over, some researchers were surprised that the work they were doing on TB was suddenly gone.

“Our team dropped our TB projects to work on COVID and it has been hard to resuscitate the projects now…it was nice to contribute to COVID while our TB projects were on hold, but it is clear that our TB projects have suffered,” a Canadian researcher remarked.

Other community reports validated and deepened these complaints:

• Around Global Fund supported countries, 59% of advocates reported seeing resources for people with TB diverted to respond to COVID-19.
• In the US, 87% of TB policy and program officers reported being reassigned to COVID-19.
• Over half of health care workers globally reported reductions in TB services where they worked.

Health care workers and advocates also pointed to the need for a more serious human rights perspective when it comes to mass quarantine.

An advocate from Kenya was particularly salient on the matter:

“From conversations with community health workers, there is a lot of stigma around COVID. 'You can not cough in peace,' one said related as any cough is mistaken as COVID, and when you become a suspected case, you are forcefully quarantined. There is a need for more education on human rights around COVID.”

The full report is available here.