South Africa’s extensive Covid-19 response is already impacting the fight against tuberculosis (TB) with a decline in TB testing and at least one TB ward being turned into a Covid-19 ward.
According to the World Health Organisation, TB caused around 63 000 deaths in South Africa in 2018 (2019 figures will only be available later in 2020). So far, fewer than 100 people are confirmed to have died of Covid-19 in the country, although this number is expected to shoot up into the thousands in the coming months.
“It’s really important that we don’t forget how bad TB is,” says Prof Harry Hausler, CEO of HIV/TB Care (an NGO), and a member of the World Health Organisation’s civil society task force.
Patients with TB are likely more vulnerable to severe Covid-19 and there is a risk of dual-disease, which will put further strain on the national healthcare system. The same may go for HIV, which is also highly prevalent in South Africa, although there is not yet enough data to know what impact HIV infection has on vulnerability to Covid-19.
Differences and similarities
While both TB and Covid-19 are infectious and can lead to severe respiratory complications, there are some key differences. TB is treatable and curable, although it lasts in the body for longer than Covid-19. TB is currently understood to be more fatal than Covid-19 and often causes severe disease in both children and the elderly.
There is an existing shortfall in TB testing, says Hausler, with more than 21% of South Africa’s 301 000 (in 2018) total cases never being diagnosed.
One risk is that when people with TB present with respiratory symptoms similar to Covid-19 they might only be tested for Covid-19 and not for TB. Hausler says this is a huge missed opportunity for case-finding of both Covid-19 and TB to take place at the same time.
Dr Anja Reuter is the manager of Doctors without Borders’s (MSF) Drug-Resistant TB (DRTB) medical activities in Khayelitsha. According to Reuter, health workers need to be made aware of the similarities and differences between TB and Covid-19 symptoms so that patients can be tested appropriately.
When Spotlight asked the National Institute of Communicable Diseases (NICD) whether they are considering testing for both TB and Covid-19 through the mass community screening campaign, Professor Nazir Ismael said it was proposed, but that priority was however given to Covid-19 “based on the unexpected rapid expansion of this disease”.
“The sample types being collected are different (sputum and nasal swabs) and this adds another dimension to the screening and testing,” he explained. “The opportunity cost is noted, and discussions are underway on how to best facilitate testing for both diseases with one sample type.”
Decrease in TB testing
Ismael says, “a quick analysis has shown that the weekly number of GeneXpert TB tests decreased by nearly 50% from the week commencing 9th of March compared to the week commencing the 6th of April”.
The reasons for this decrease are not known. It may be due to some patients avoiding healthcare facilities for fear of contracting Covid-19, or staying at home due to the lockdown regulations. It may also be that people who would normally be screened and/or tested for TB are now only being screened and/or tested for Covid-19.
Facilities are likely to become infection-hotspots for both Covid-19 and TB, says Reuter, and routine clinic visits for TB patients need to be minimised as much as possible. To that end, says Reuter, the Department of Health has provided some guidance to minimise health visits and change patient support models.
“Care needs to be taken to ensure TB patients are not left to stay at home without support and treatment,” says Reuter. She says that innovative solutions are needed to provide treatment and patient support to TB patients. For the most vulnerable patients, home-based care services should be considered.
Hausler believes that Covid-19 has “really made people reassess how things are done”, and argues that the easiest for patients is if medicines are delivered to their homes. In the Eastern Cape, HIV/TB Care has set up community pickup points. Hausler also says that multi-month dispensing is being encouraged, minimising contact between healthcare workers and patients.
Tele-medicine is another alternative punted by the South African Medical Association (SAMA).
Ismael, however, said that the NICD are “not aware” of efforts to develop virtual or telephonic treatment models, “but in principle would support such efforts”.
Meanwhile, many healthcare non-profits, in collaboration with the Department of Health, are actively involved in community messaging about Covid-19. In some cases, this messaging has been integrated with information about TB and HIV.
There are opportunities for Covid-19 messaging to be more nuanced with public health messages around TB, says Reuter. Community members should be made aware of the differences between the two diseases as much as possible. If people are not reminded about TB through messaging, Reuter says, it might be confused with Covid-19 and left undiagnosed and untreated.
The Covid-19 response may, however, also contribute to people taking precautions that could help prevent TB. According to Hausler, the huge increase in infection prevention through physical distancing, protective equipment and cough etiquette will help prevent the spread of TB.
TB ward converted to Covid-19 ward
But at the same time, it seems that in some instance’s resources are being diverted from the TB response to aid the Covid-19 response. According to Dr Jantjie Taljaard, head of infectious diseases at Tygerberg Hospital, this “is needed ... but the unintended fallout impacts on all services including TB”.
For example, Taljaard says the Tygerberg Hospital TB ward has been converted into the Covid-19 ward and TB patients have had to be moved or discharged, in order to create space for the expected surge in Covid-19 patients.
Another key priority, according to Reuter, should be to ensure an uninterrupted TB drug supply chain. Drug resistant TB patients need to take a cocktail of different medicines for months. Reuter says that some interruptions in the supply chain are already being experienced, but the Western Cape Department of Health is monitoring the situation.
Reuter also expects that healthcare workers will increasingly be asked to work on Covid-19, which may leave TB services understaffed.
Impact on labs
According to Dr Heidi Albert, head of FIND (Foundation for Innovative New Diagnostics) South Africa, lab staff may increasingly be seconded to Covid-19 work, thereby reducing the overall capacity to diagnose TB.
The capacity of lab equipment to test for both Covid-19 and TB is another concern. Albert says that it is all about having good data and the NHLS’ GeneXpert instruments (that will be used to test for both TB and Covid-19) are remotely connected, providing real-time data.
According to Ismael, the NICD does not “at this stage foresee a risk for TB testing as the number of tests for TB has been on the decline for several years and the Xpert platform does have spare capacity to accommodate both diseases”. “The restrictions on Covid-19 test (reagent) to leave the US will likely mean that testing for Covid-19 on Xpert (in SA) will be limited and multiple [other] testing platforms will be used for Covid-19.”