London School of Hygiene & Tropical Medicine

As I left the UN General Assembly High-Level Meeting on Ending TB in New York two years ago, there was renewed hope that this could be a turning point for accelerating progress against tuberculosis (TB). But COVID-19 has shifted global TB control from acceleration into reverse. As the new Global Tuberculosis (TB) report highlights, World Health Organization (WHO) data from over 200 countries shows large drops  – up to 30 per cent - in the numbers of TB patients being diagnosed between January and June 2020 compared with the same period last year. This is predicted to result in a dramatic increase in deaths from TB, which is one of the top ten causes of death worldwide, killing approximately 4,000 people every day.

With COVID-19 cases rising again, it is critical to understand which elements of TB services have been most severely impacted, and why. This will enable urgent mitigation actions to prevent further disruptions to continuity of care. Through the LSHTM TB Centre network, colleagues and I conducted a rapid survey of 669 frontline professionals in 64 low- and middle-income countries to identify specific challenges posed by COVID-19 during the May to July 2020 period and practical strategies to address these. The results, recently published as a pre-print, highlight two major issues.

First, transport disruptions and restrictions on movement (lockdowns) had a large impact by impeding access to health facilities not only for patients, but also for healthcare providers that are needed to deliver services. Over 40% of respondents reported that it was much harder or impossible for patients to reach TB healthcare facilities during the survey period. These challenges are compounded by patient and healthcare providers’ fears of contracting COVID-19 during travel and at health facilities. This likely explains the decline in TB diagnoses highlighted in the Global TB report, at least in part.

Second, although there have been justified concerns about continuity of medical and diagnostic services, disruptions to essential nutritional and mental health support for patients (where available) appeared to be more severe. More than 70% of frontline health professionals surveyed said that nutritional or mental health support services were impacted by COVID-19. With the increased stress, unemployment and food insecurity caused by COVID-19, patients are in even greater need of these support services.

Frontline health professionals have critical insights to guide planning of mitigation strategies. Core strategies recommended to reduce disruptions to TB services were to:

• Adapt services to reduce the need for in-person health facility visits by providing medication for longer durations when possible, increasing community-based care and providing telemedicine services.
• Proactively address barriers relating to ease and cost of transport, possibly working with transport services, so that patients and healthcare providers who need to reach health facilities can do so. This can be supplemented with awareness campaigns to highlight that essential travel for healthcare is allowed and is safe even during ‘lockdowns’.
• Allocate resources to maintain or expand critical nutritional and mental health support services for TB patients.

From early on in the COVID-19 pandemic, doctors and scientists have warned that the impacts of disruptions to essential healthcare services may be even larger than the huge morbidity and mortality directly attributable to COVID-19. National health policies must therefore act on available evidence to stop the reversal of hard-earned progress against deadly infectious diseases.