A new modelling report shows that a 3-month lockdown and a protracted 10-month restoration could lead to an additional 6.3 million cases of TB between 2020 and 2025, and an additional 1.4 million TB deaths during this time. The rates of TB incidence and death in 2021 will increase to levels last seen in 2013 and 2016 respectively.

Before the COVID-19 outbreak, we were eagerly awaiting the UN Secretary General’s report on progress that has been made against the targets in the landmark UN political declaration on TB in 2018, designed to accelerate progress on ending TB.

Big challenges remained, such as underfunding for TB programmes and TB research, issues with diagnosis leading to 30% of people with TB each year being “missed” and only 1 in 3 people with drug-resistant TB were enrolled on treatment.

But progress was being made. Organisations such as the Global Fund to Fight AIDS, TB and Malaria, the Stop TB Partnership and the World Health Organization were investing in approaches that worked, such as scaling up case finding.

Boars Mutuku (left) is a 22-year old cobbler in Kilala-Makueni, Kenya. He is pictured here with his community’s health volunteer Stanislaus who played a vital role in referring Boars to the public hospital for TB diagnosis and treatment, where he was successfully cured. There were still certain difficulties, such as the 300 KES (around US $3) cost for a frequent round-trip to the health facility, the difficulty of buying the food he was recommended to eat during treatment to help his recovery, and the loss of income after having to close his cobblers shop for 6-months. This story demonstrates the importance of community outreach for TB diagnosis, something that is being affected by the COVID-19 pandemic. Image: Rachael Hore.

The impact of COVID-19 on TB is due to a number of factors, including the impact of lockdowns on ability to access local health services. Other factors include, GeneXpert diagnostic machines are being repurposed for COVID-19 testing, personal protective equipment for health workers being used for COVID-19 leaving a shortage for TB workers, repurposing of national TB budgets, conversion of drug-resistant TB wards to COVID-19 wards, and disruptions to supply of essential TB medical commodities, including drugs.

These graphs show the dynamics of TB incidence and mortality following a COVID-19 lockdown, in the illustrative example of India. The grey shaded area shows the duration of the lockdown, while the vertical dashed line shows the point at which normal TB services are restored.

Time and again, people with TB face a double burden during epidemics or pandemics. During the 2014-15 Ebola epidemic, Guinea saw a 53% decrease in the diagnosis rate of TB, and a doubling of the TB mortality. Countries around the world are following the same pattern during COVID-19 which high TB burden countries, such as India and South Africa reporting significant drops in diagnosis rates. 10-15 additional TB infections are transmitted per person with untreated TB per year. Mortality rates for untreated drug-susceptible and drug-resistant TB are 23% and 30% respectively.

Twins Lynette and Anette watch as an elderly woman takes her TB medication, administered by volunteer Cathy Tolom in in ATS settlement, Port Moresby. Lynette, like her mother, has TB and Annette is taking preventive therapy. Prior to the COVID-19 pandemic, treatment often required daily trips to a community health post to receive drugs from community health workers. Image: Tom Maguire.

The progress made against TB must be regained through increased efforts and investments. This will include:

  • Scaling up case finding, contact tracing, community engagement and use of new, innovative digital tools. This can take place alongside contact tracing and testing for COVID-19.
  • Mitigating the impacts of interrupted supplies of quality assured, affordable treatment to prevent disruptions or delays to treatment.
  • Ensuring that the development of new tools for TB is continued or expedited once possible.
  • Protecting the most vulnerable people and ensuring that services reach everyone.
  • Providing adequate protection for all health workers.

Weathering the COVID-19 storm will create short and long term impacts for TB. But it could also create opportunities, such as through increased capacity for contact tracing and testing, as well as widespread recognition of the need for adequate protection for health workers, for equitable research and development, and to protect and prioritise the most vulnerable.

Loko Wako Molu, 21 years old, during a visit from a TB community health volunteer in Deep Sea slum, Westlands, Nairobi. She was visited by a community health volunteer, Camilla, who referred her to a clinic for TB and ensured that her children received preventative therapy. Image: Rachael Hore.