World TB Day 2021 — lessons from our Covid-19 response to reach the END TB Targets

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On 24 March, the global community once again commemorated World TB Day. This year’s theme was “the clock is ticking”.  The Health Implementing Partners Group (a collective of health technical organisations in South Africa) hosted a webinar on 18 March 2021, ahead of World TB Day.  The webinar featured a number of South African and international speakers, who outlined the current challenges with TB control and the impact of Covid-19 on TB control activities.  

The Covid-19 pandemic provoked a global public health effort to combat the virus with life-changing measures put in place in many countries, a rapid evolution of new diagnostics and the fastest vaccine development and implementation the world has ever seen.  However, the pandemic has had a severe impact on the control of tuberculosis (TB), a disease that affects over 10-million people a year and leads to more than 1.4-million deaths globally every year.  

Dr Lindiwe Mvusi, the Acting TB Cluster Director in the National Department of Health, emphasised that: “The count-down to achieving the End TB Strategy targets by 2035 is getting ever closer. Our collective tasks are to: reduce deaths due to tuberculosis by 95%, cut new cases of TB by 90% of cases recorded in 2015, and to ensure that no family is burdened by catastrophic health care costs due to TB.”  She outlined the government’s ambitious and comprehensive plan to end TB.  

In South Africa, although progress has been made in recent years with a reduction of 43% of TB incidence since 2009, and a sharp decline in mortality since 2011, the recently released results of the first ever national TB prevalence survey undertaken estimated a TB incidence of approximately 700/100 000, one of the highest in the world, and more than 150 000 people with TB not diagnosed annually!  The Covid-19 pandemic restrictions increased the number of undiagnosed patients. Between April and September 2020  the number of people tested for TB reduced by 50% compared to the same period in 2019. This was a result of reduced access to healthcare and a reluctance to visit health facilities when available. In addition, TB is estimated  to be responsible for a significant proportion of the more than 100 000 excess deaths, reported by the South African Medical Council, during this pandemic.  

This means that even as South Africa battles Covid-19, routine services such as TB diagnosis and treatment must be provided without interruption. 

The country has benefited from additional resources to combat the TB epidemic. As described by Fund Portfolio Manager Dr Maxim Berdnikov, the Global Fund for HIV, TB and Malaria supports the South African government to address gaps in the current TB programme.  These funds are being used to provide support in the nine districts of the country that account for more than 50% of “missing TB cases”.  Through this support, 15 digital X-ray machines have been procured and are being used to enhance TB screening in health facilities.  Although the digital X-ray deployment is only three months old, there are early signs of progress.  Dr Refiloe Matji of AQUITY Innovations noted that: “Of 5 200 clients who were registered and screened with chest X-ray, 833 clients were identified for further testing, and 75 were found to have TB and started treatment.”  Similarly, Professor Deliwe Rene Phetlhu of TB HIV Care Association noted that her organisation has also started using  digital X-rays and among 1 300 clients X-rayed, 40 have tested positive for TB and are on treatment.  

South Africa’s TB incidence is about 700/100 000, one of the highest in the world. The disease is thought to be responsible for a significant proportion of the more than 100 000 deaths reported by the South African Medical Council during the Covid-19 pandemic. (Photo: Shehzad Noorani)

As TB is a disease most commonly affecting the poor, the response is incomplete without nutritional and social support.  The severe burden of TB on a person’s life was described by the very honest account given by TB survivor Sibusiso Zulu, who spoke of the difficulty of “taking 14 tablets a day, and they were so big, and having to deal with 21 side-effects including nausea, vomiting, diarrhoea and depression”.   A programme of social support is currently being implemented with over 3 000 beneficiaries, also funded by the Global Fund, and early results are encouraging — treatment adherence rates are higher when food parcels are provided to TB patients.  

Covid-19 and tuberculosis are similar in some ways as both are infectious respiratory diseases and spread by droplets in the air.  Many of the solutions and innovations that were crafted for the response to the Covid-19 pandemic have relevance for TB, with some adaptation. The National TB Think Tank, a body representing researchers, implementers, government  and civil society, that work together to advise the National TB Programme on TB policies, has proposed a number of interventions to combat TB in South Africa.  Professor Charalambous of The Aurum Institute outlined some of these interventions.  These include:

• The adaptation of the Covid-19 remote screening App to include TB screening, which allows for remote screening for TB and Covid-19.  To date, over 10 000 people have used the App and over 100 persons have reported testing positive for tuberculosis.

• Rapid implementation of new technologies to increase case finding for tuberculosis, including a new urine test to diagnose TB in people with advanced HIV disease.

• Increased use of mobile health technologies to communicate with patients, including notification of results, and providing support to improve treatment adherence.

• Increased rollout of new drugs to prevent TB, including a shorter-course regimen that reduces preventive treatment from a daily six-month regimen to a weekly treatment taken for three months.

• Increased use of chronic medication dispensing and distribution for TB treatment and TB preventive treatments, reducing the need for patients to attend in-person at clinics to refill their prescriptions.

• Increased use of the private sector, with better integration of public and private laboratory services and use of general practitioners to ensure TB testing is made available.

• Normalising the wearing of masks, including ensuring that all health workers wear protective masks, which protects against both Covid-19 and tuberculosis transmission. 

These interventions, inspired by our proactive and aggressive approach to combat Covid-19, should be implemented with equal determination for tuberculosis.  As mentioned by Dr Maxim Berdnikov of the Global Fund: “We must protect the gains made against TB.  Progress is clouded by the Covid-19 pandemic, but we must act with speed and scale to oppose the direct impact of Covid-19.  We need to leverage the experience of Covid-19 and improve surveillance.”  

Dr Lucica Ditiu of the Stop TB Partnership based in Geneva closed the session with a passionate call to action and a challenge to all South Africans to continue to lead the world in the fight against TB, harnessing the innovation and boldness of our public health response, and showing the world what needs to be done to end TB.

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