Since December 2019, when the first case of Covid infection was reported in Wuhan of China, nearly four million people have died due to the disease. The World Health Organization (WHO) declared Covid-19 a global pandemic on March 11, 2020. In countries with high rates of imported cases and local transmission, governments and communities have been mobilized to contain the further spread and mitigate the impacts on people, health systems, and economies.
Covid-19 affects vulnerable people such as elderly, prison inmates, and immunocompromised individuals, such as people living with HIV and those affected by other diseases such as tuberculosis (TB). Covid-19 has constrained the capacities of health care systems across the globe. Because of lockdowns, restrictions in movement, psychological fear of contracting the disease in health care facilities, and diversion of health care workers for containment and management of Covid-19, TB care and control in Nepal has received little attention.
Tuberculosis and Covid-19
TB is an ancient infection known to affect humanity for many years. This was declared a global health emergency by the WHO in 1993. An estimated 10 million people suffer from TB, and there are more than 1.4 million deaths per year. Both TB and Covid primarily attack the lungs and interfere with host immunity. Although both biological agents transmit mainly via close contacts, the incubation period from exposure to disease in TB is longer, with often a slow onset. Mycobacterium tuberculosis (M tb) is primarily transmitted through droplet nuclei of aerosols generated by people with TB, who may be infectious for months to years. Covid has an incubation period of a few days and can spread via droplets and fomites, although a recent study shows aerosols may also play a role. Both diseases can cause mild or severe forms of symptoms such as dry cough, fever and shortness of breath.
In Nepal, the first case of local transmission of Covid was confirmed on April 4, 2020 in Kailali district and the first death was recorded on May 14. Over 8,000 people have lost their lives due to Covid-19.
The Covid-19 pandemic has placed an unprecedented pressure on the health system. Health facilities and workforce are focused on controlling the outbreak. In doing so, other essential health services have been severely compromised. People do not tend to seek health care for other ailments because of physical distancing requirements and the perceptions that visiting health facilities may result in infection.
But while focusing on Covid control, it is also necessary to provide care for other ailments to minimize an increase in morbidity and mortality from other health conditions. During the Ebola outbreak in 2014/15, for example, an increased number of deaths was caused by measles, malaria, HIV/AIDS and tuberculosis (TB) because of failure of the health systems to provide care to the patients of these diseases.
Prevention and treatment services for non-communicable diseases (NCDs) have been severely constrained since the start of the pandemic. A WHO survey in May, 2020 confirmed that more than half (53 percent) of the 155 countries surveyed partially or completely suspended services for hypertension treatment, 49 percent for treatment of diabetes and diabetes-related complications, 42 percent for cancer treatment, and 31 percent for cardiovascular emergencies. Rehabilitation services have been disrupted in almost two-thirds (63 percent) of the countries.
Because of diversion of resources and health care workers to prevention and containment of Covid-19, TB care and control in Nepal has received little attention.
There are some similarities and differences between Covid-19 and TB. Preliminary observations suggest that TB infection is likely to increase susceptibility of people to contract Covid-19. This surely will have a major impact on the 117,000 TB infected population of Nepal.
Both TB and Covid-19 cause major infection-related morbidity and mortality. While Covid-19 has caused over three million deaths so far, TB was the leading cause of mortality worldwide in 2019. In Nepal, Covid-19 mortality is above 8,000. On the other hand, in 2019, 31,397 new TB cases were reported. Around 5.5 percent of cases were registered as child TB cases while the remaining 94.5 percent were registered as adult cases. Among them, male TB cases were reported nearly two times more than female cases. Among the child TB cases, most of them (63 percent) were ages 5-14.
During the pandemic, diagnosis and treatment of TB or TB and Covid-19 co-infection are likely to be compromised. Elderly and associated co-morbidities are increased risk factors for severe disease and cause adverse outcomes in both conditions. Social stigma and discrimination are associated with both the diseases.
There are some important differences between the two as well. TB has been labelled as the pandemic many times over the past three centuries, whereas this is the first time Covid-19 is declared as a pandemic. Poorer people have a higher likelihood of TB infection. Moreover, unemployed people and construction workers experience increased risk of TB. While most of the cases and deaths from TB occur in low and middle-income countries, Covid-19 affected developed countries more. More global resources have been mobilized for Covid control in a few months than for TB in decades.
The clinical and epidemiological interactions of Covid-19 with TB seem to be highly complex. Transmission of TB might rise because of increased respiratory symptoms associated with Covid-19, or it may even decline due to compliance of Covid protocols. Millions of people treated for TB that have residual, long-term lung damage are likely to be at a higher risk of severe infections and deaths from Covid-19. Because of extreme pressures on health systems exacerbated by Covid-19, people with TB are likely to have lower access to diagnostic and treatment services, which might also result in adverse outcomes. The Covid-19 pandemic will impact existing public health programs including the TB control programs.
There are likely to be grave consequences for the existing and yet to be diagnosed TB patients, more so in low-and middle-income countries like Nepal where TB is endemic and health services are not well equipped. TB control programs will be under severe strain due to diversion of resources and lack of focus with increased attention on Covid care. Overutilization of laboratories meant for TB work, issues related to unavailability of TB care workers and restriction of movements of patients are likely to result in low quality of TB care.
What should be done?
Urgent measures need to be taken to minimize the impact of Covid-19 pandemic on TB and to save lives of TB patients. Steps should be taken to ensure that TB diagnostic services, treatment and prevention services are in place and efforts should be made to actively diagnose, trace, treat the patients. Stop TB Partnership and partners have called upon the leadership of all countries, particularly those with high TB burdens, to ensure the continuity of the TB response in the time of Covid-19, to take proactive measures to protect the most vulnerable people and to provide them protection against economic hardship, isolation, stigma and discrimination. TB prevention treatment should be ensured alongside Covid response. The goal should be to control infection of both the diseases.
Urgent measures need to be taken to minimize the impact of Covid-19 pandemic on TB and to save lives of TB patients.
As importantly, TB care providers who work as the front-line warriors, should also be protected. Positively, Covid-19 pandemic has raised awareness regarding infection control practices, including use of face masks, cough etiquettes, and social distancing which, if followed properly, will help in TB control as well.
Staff at healthcare facilities should be provided with protective gears to reduce Covid infections at TB clinics. TB patients should wear surgical masks while attending TB clinics.
It should be ensured that TB patients receive necessary psycho-social, nutritional, and economic support. Besides, there should be an uninterrupted supply of TB drugs through effective procurement and careful planning followed by effective distribution at local levels. Federal, provincial and local governments should support the people at greater risk of TB.
Tuberculosis is one of many areas in the global public health system that will be adversely affected by the Covid-19 pandemic. Thus comprehensive mitigation plans have to be developed to ensure treatment. Otherwise, cases of TB and the deaths by it will increase globally, and countries like Nepal will suffer even more.
Let’s look forward to a time when infectious diseases are taken more seriously, the link between infectious disease and poverty recognized and investment for their control increased.
Ashfaque Raza Mikrani is a public health professional.