COVID Pandemic Devastating to Global TB Care, But Could Bring Positive Change

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PIH doctor reflects on challenges, setbacks, and silver linings for health systems

Posted on April 5, 2021

Mabatloung Mofolo (right), nurse in charge at PIH’s Botsabelo Hospital in Maseru, Lesotho, talks with patient Aria Matsepe in October 2019 at PIH’s Botsabelo Hospital, the only facility for multidrug-resistant tuberculosis )MDR-TB) in Lesotho. Improvements fueled by the COVID-19 response this year could have long-term benefits for TB patients at the hospital, and around the world. (Karin Schermbrucker / for PIH).

The COVID-19 pandemic has severely disrupted care and services for people living with tuberculosis—until recently the world’s deadliest infectious disease—draining or diverting resources and potentially costing hundreds of thousands of lives that could have been saved with adequate screening and treatment.

“Modelling work suggests that if the COVID-19 pandemic led to a global reduction of 25% in expected TB detection for six months, then we could expect a 26% increase in TB deaths, bringing us back to the levels of TB mortality that we had in 2012,” reads a December statement from the World Health Organization. “Between 2020 and 2025 an additional 1.4 million TB deaths could be registered as direct consequence of the COVID-19 pandemic.”

The WHO added that those “are likely to be conservative estimates” because of other pandemic-related impacts on TB care, such as treatment interruptions and potentially greater transmission of the disease.

Dr. Michael Rich, senior global health physician for Partners In Health and co-leader of the international project known as endTB, acknowledged those impacts—saying the numbers could translate to 400,000 additional deaths from TB this year alone—but also noted that the WHO estimates are just one possible scenario.

“Now it’s our duty to make sure that doesn’t happen,” Rich said.

As the global health community marked World TB Day on March 24, Rich reflected on the past year and praised PIH and endTB teams around the world, who have kept clinical trials afloat despite health systems stretched beyond capacity. It’s vital work: the endTB partnership is a multi-year, international effort that is running the biggest trials in the world for severe TB, led by PIH and conducted in partnership with Médecins sans Frontières, Interactive Research & Development, and financial partner Unitaid.

EndTB’s overarching goal is to find better, shorter regimens for hard-to-treat, multidrug-resistant TB (MDR-TB) through greater use of the first new TB medications in nearly 50 years—bedaquiline and delamanid. The partnership is working to improve MDR-TB treatment in 17 countries, including six that are involved in clinical trials.

Rich said teams in those six countries—Kazakhstan, Lesotho, Peru, India, Vietnam, and Pakistan—marshalled resources last spring to keep the trials going, while using lessons from one deadly respiratory disease to help the world respond to another.

“Once COVID hit, there was an all-out heroic response from the teams involved in these clinical trials, to keep TB staff and patients safe from COVID, and to keep the trials intact,” Rich said. “The trials are going to be delayed about a year, but they haven’t been compromised, and that is due to the work of all the teams on the ground, and Unitaid support.”

Dr. Michael Rich, senior global health physician for Partners In Health and co-leader of the international project known as endTBsaid the global COVID-19 response has much to teach us about the potential for controlling disease outbreaks when resources and partnerships are aligned. (Zack DeClerck / PIH) 
Regional Impacts on TB Care

The effects from COVID-19 have varied among endTB countries. But the pandemic has hit hard in Peru and Kazakhstan, two of the three endTB countries—along with Lesotho—that PIH supports on a long-term, systemic level, working with the government to strengthen health systems.

“Our highest-enrolling country for endTB trials was arguably the worst-hit country for COVID-19 in the whole world,” Rich said, referring to Peru and pointing to the very high COVID-19 mortality rates it suffered for much of the past year.

EndTB teams in Peru, he said, worked with Socios En Salud, as PIH is known there, to support high-quality testing for COVID-19. Teams also adapted many TB screening measures, such as door-to-door visits and mobile testing units, to the COVID-19 response. 

On the other side of the globe, Kazakhstan remains among countries with the highest MDR-TB burdens in the world, and has been hit very hard by COVID-19. In fact, in the largest city of Almaty, a TB hospital had to be fully converted to take care of COVID-19 patients.  PIH and endTB clinical teams have met those challenges by conducting screenings on roadsides or open fields, among other measures, to maintain social distance, continue TB treatment and keep patients and health care workers safe.

Some countries have seen setbacks. South Africa was involved in the endTB clinical trial, Rich said, and had to stop enrolling new TB patients because of the pandemic, choosing instead to only follow up with those currently enrolled.

“There’s a real risk that COVID is going to set research in a lot of diseases way back,” Rich said. “We have to preserve research and keep things moving forward.”

Testing, Diagnosis for TB and COVID

Some of that ongoing research, for example, is examining effects of COVID-19 on active TB patients. Rich said that, while “we know it’s not as bad as we feared,” much remains to be learned about how the diseases interact and how to best screen and test for both.

Because symptoms can be similar—persistent cough, fever, and shortness of breath, for example—a patient suffering from TB could get an inaccurate diagnosis, Rich said, because clinicians are focused on COVID. That patient could then unknowingly spread TB.

“There’s a super-strong case that we should be doing concurrent testing for both,” Rich said. “Many people who have symptoms of TB also meet the criteria for getting a COVID test.”

Scientists are still working out specifics of concurrent testing, such as whether you can test for both diseases on the same sputum sample.

“Right now, we’re mostly taking two different samples—a nasal sample with a swab for COVID, and a sputum sample for TB,” he said.

But, born out of these challenges, there is real promise for innovation in respiratory disease diagnosis and treatment.

“There’s a clear, feasible mechanism to really scale up molecular testing for TB based on what we’ve seen done for COVID,” Rich said. “It’s really allowed us to leapfrog what we think is possible.”

The massive global need for COVID-19 tests has exponentially increased demand for diagnostic equipment, Rich said, ultimately building long-term testing capacity that could bring prices down and lead to new innovations. Those could include screening for multiple diseases from single samples and applying methods of testing for TB drug resistance to COVID-19, as new strains emerge that could require targeted vaccines.

Overall, Rich said, the COVID-inspired global scale-up of molecular testing and diagnosis is creating lab capacity “in a much higher degree than even our imaginations were taking us.”

Improved Safety Protocols

A second silver lining of COVID-19, he said, is the dramatically heightened awareness of public health and safety protocols, such as wearing personal protective equipment (PPE) to prevent illness, and considering solutions for better ventilation in buildings.

In emergency rooms across the U.S. and Canada, doctors now are in full PPE for patients who have so much as a cough. 

“Maybe they should have been using more universal PPE before,” Rich said, comparing COVID protocols to TB care, which requires broad, standardized use of masks and PPE.

“The most dangerous part of TB care can be when people walk into a clinic to get diagnosed,” Rich said. “If protocols aren’t followed correctly from the start, those clinicians and other patients are just sitting there, getting exposed to TB. … We now have an opportunity for better infection controls and protocols everywhere.”  

Additionally, he said, new emphasis on ventilation, bacteria-killing UV lights, and administrative practices such as proper triage all could have lasting impacts for reducing infections far beyond COVID-19.

“All of those areas have been significantly boosted because of COVID, and that can be a good thing,” he said.

A vial of the COVID-19 vaccine. Dr. Michael Rich of PIH said the speed of development for COVID1-9 vaccines could be a “silver lining” for the medical community, potentially benefiting new vaccines for other diseases. (Jodi Hilton / for PIH) 
Fast Vaccine Development

Lastly, he said, the creation of COVID-19 vaccines within a year—granted, building on science that had been in the works for decades—shines new light on the potential for curtailing disease outbreaks when global interests and resources are aligned.

“That is a silver lining for the medical community—that we now have the ability to get a vaccine for a disease within a year,” he said. “What’s the list of diseases that we should now put out the full, same effort for?”

While not all diseases are appropriate for a vaccine, the COVID-19 response suggests that, when the next pandemic strikes, people might more willingly quarantine and slow the spread of a virus knowing that scientists can quickly develop medicines and vaccines.

Building that confidence, though, will require new levels of sustained, global collaboration, from academic institutions to national governments and international organizations.  Better surveillance systems looking for the next pandemic, and functioning globally, also will be critical.

“We now understand that clinical researchers need to be more collaborative,” Rich said. “The more people you have working on a problem, the better.”

Article originally published on pih.org.

The EndTB trial aims to improve treatment for MDR-TB. Learn how the PIH Kazakhstan team has been supporting patients through treatment and recovery.

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