U.S. TB Efforts Falling Behind During Pandemic

The coronavirus pandemic is threatening to undo the progress made in tuberculosis (TB) eradication.

A new survey of TB healthcare workers from 89 countries has made clear which of these two, highly infectious respiratory diseases is getting all the attention, and which one has been forced to take back seat.

Released in mid-September, the report, entitled The Impact of COVID-19 on the TB Epidemic: A Community Perspective, suggests that because of the money and personnel rerouted to the COVID-19 epidemic, an additional 525,000 TB deaths could occur this year, totaling 2 million worldwide. It also revealed that 75% of TB advocates in the approximate 100 countries receiving money from the Global Fund saw a substantial decrease in TB testing in 2020. The Global Fund is an international organization that financially assists countries grappling with TB, HIV and malaria.

The report was created and written by researchers at McGill University in Montreal, Canada, and many TB-associated organizations, including the Global TB Caucus and Stop TB Partnership.

The Global Fund said on its website that TB deaths between 2000 and 2018 were reduced by 27%. Now, because lab services are so busy, the percentage of new TB notifications has dropped immensely. If people don’t know they have TB, they don’t get treated quickly, as contact tracing for latent TB has virtually come to a halt. The survey found that 87% of TB policy and program officers in the U.S. were reassigned to care for COVID-19 patients.

In the United States alone, the drop-off was considerable: 45% of U.S. healthcare workers said they had witnessed fewer people seeking treatment for TB in healthcare facilities. Those working strictly with TB policy and programs said the drop-off was 68%.

In 2019, New York City reported 566 TB cases ; 2020 saw even fewer cases of people with active TB “during the peak months [March through May] of the pandemic in New York City,” Pedro F. Frisneda, deputy press secretary of the city’s Department of Health and Mental Hygiene, confirmed to Medical Daily. “We are currently working with our community partners to develop a plan to ensure that testing and treatment continue in the case of a second surge,” Mr. Frisneda said.

About 1,000 people, including patients, answered the survey earlier this year from both private and public settings.. Of the 173 global healthcare workers surveyed, fewer than half were from the U.S. or Canada; the same was true of the 137 global TB program officers. Other survey participants were largely from Kenya and India.

TB officers reassigned

Donna Hope Wegener, executive director of the National TB Controllers Association, told Medical Daily that before the COVID-19 pandemic struck, TB programs were already experiencing challenges in staffing due to reduced funding from national, state and local governments. “Further erosion of TB staff due to COVID-19 response, combined with the public’s fear of seeking diagnosis and treatment of symptoms, are a perfect storm leading to decreased reporting and delays in diagnosis,” Ms. Wegener said.

In New York City and Los Angeles, most TB staffers were redeployed to take care of the pandemic. Mr. Frisneda said staff from New York’s TB control unit, who possess expertise in contact investigations, were “instrumental in COVID response activities.”

The situation is not very different in Los Angeles County, said Julie Higashi, MD, PhD, director of the TB Control Program, Los Angeles County Department of Public Health. “LA County is a high morbidity county for TB disease because of our diverse population with close international ties, and a large homeless population,” she told Medical Daily.

Private sector sees fewer patients

In the private sector, only high-priority patients are being seen. Here, too, TB services have been cut, the survey found. Globally, 50% of healthcare workers reported a decrease in TB services provided by private players.

It’s not just that services are not being provided. People are also hesitant to seek treatment for TB. “COVID-19 has made it difficult for patients with risk factors for TB and TB symptoms to want to seek treatment, and sometimes to have access to treatment,” Dr. Higashi said.

In LA County, another barrier is the fear of co-infection. “Some patients have had delays in diagnosis because their symptoms were first thought to be COVID-19 disease,” Dr. Higashi said. “We also have concerns that the COVID-19 and TB co-infection can worsen the severity of each disease, or cause a resurgence of TB.”

In steps telemedicine

As healthcare systems have shifted gears to confront the ongoing pandemic, healthcare workers have been forced to do their job in unsafe conditions. The report said that 36% of U.S. healthcare workers do not have personal protective equipment, or PPE, to handle people with both COVID-19 and TB. Furthermore, the report advised that since fever and cough are symptomatic of TB and COVID-19, diagnosing and treating patients with both could help strengthen weakened health systems.

Keeping safety and limited resources in mind, the New York City Health Department has staff using telemedicine, while limiting in-person TB appointments to focus on high-priority cases. “This means that we are still [managing contacts] and managing patients with active [TB] disease,” Mr. Frisnada said. Non-essential appointments are being postponed.

Delay in TB drug supply

Diverting TB assets to address COVID-19 caused medicine stockouts and delays, said 62% of U.S. policy and program officers. The report's authors suggested giving people with TB a shorter supply of oral drugs to last two or three months. Also, they suggested alternate means of delivering medicine, like courier services, so that people can receive the treatment they need.

Annually, the world reports 1.5 million deaths due to TB. But countries have come together several times to devise strategies and provide timely intervention. In 2015, the World Health Organization’s End TB Program set a goal to reduce TB deaths by 90% by 2030.

Things have changed. The WHO said if TB detection is reduced by 25% over a period of three months, “then we could expect a 13% increase in TB deaths, bringing us back to the levels of TB mortality that we had 5 years ago.” One paper, awaiting publication, said this estimate could be low, as it does not include all factors, including poorer outcomes for those with both diseases.

Seema Prasad is a freelance health reporter based in Bengaluru, India. She tweets @SeemaPrasad_me​