TB patients have become collateral damage in the train wreck that is COVID-19.
Until the emergence of COVID, tuberculosis was the deadliest infectious disease in the world. But health care workers were making slow, steady progress to contain it. Now for the first time in more than a decade the death toll from TB is rising.
Tuberculosis killed roughly 1.5 million people in the first year of the COVID-19 pandemic, up from 1.4 million in 2019. And researchers say COVID is to blame.
"The COVID-19 pandemic has reversed years of progress and efforts in the fight against tuberculosis," says Dr. Tereza Kasaeva, head of WHO's global TB program. Speaking at a news conference as WHO released its annual Global Tuberculosis Report, Kasaeva said that COVID lockdowns, limited access to health care and patients' concerns about visiting medical clinics made TB far more deadly during the pandemic.
COVID-19 has "severely impacted access to essential TB services," Kasaeva says. "With far fewer people being diagnosed and treated or provided with TB preventive treatment in 2020 compared with 2019."
How COVID-19 is leading to more TB deaths
We reached out to Dr. Francesca Conradie, a tuberculosis researcher and doctor in South Africa, to get a better understanding of how COVID-19 is leading to more TB deaths. Conradie is a lecturer at the University of the Witwatersrand in Johannesburg. She oversees three clinical research sites for tuberculosis patients in the country.
"South Africa initiated its first lockdown around March of last year and the number of cases of TB declined," notes Conradie. She then quickly stresses that "diagnosed" cases declined. She doesn't believe fewer people were infected in that period. The drop in detected TB cases was partly driven by the fact that South Africans weren't seeking medical care.
"The vast majority of South Africans rely on public transport, and public transport became very limited (during the lockdowns). That was mixed in with the fear that 'If I go to a clinic, I will get COVID. That's where sick people are,'" Conradie says. "So it was a combination of things that stopped people accessing health services."
Fear has kept people from seeking health care
Even though the lockdowns have lifted, she says the number of cases of TB being diagnosed in the country remains below pre-COVID levels. "I do not think for one second that it's because we've cured the problem. I think it's because people are no longer presenting to clinics," she says.
Many South Africans started to view health clinics as hotbeds for COVID-19 infection, she says.
"The reason that people didn't come for (TB) treatment is principally because they were afraid that they would get COVID at a health care facility. And let's face it, that's not impossible," Conradie says.
A simple case of tuberculosis takes at least six months to treat. Complicated, drug-resistant cases can take years before a patient is cured. In South Africa, two-thirds of patients with TB are also HIV-positive. That created two massive challenges for health care workers: In the midst of several waves of COVID-19 lockdowns when people weren't supposed to be leaving their homes and public transportation drastically contracted, they had to find new ways to get HIV and TB patients their medications.
"What COVID forced us to do was multi-month dispensing," Conradie says. "Suddenly, instead of giving a week or two (supply of pills), we would give two months of anti-retrovirals." This strategy was also applied to TB medications. In the past, TB meds were dispensed under what Conradie calls a "very paternal system" known as directly observed therapy or DOTS. Under DOTS, a health care worker had to stand and watch the patient swallow their pills.
Even before the COVID-19 pandemic clinicians were moving away from DOTS to an ethos of patients owning their own therapy and taking personal responsibility for their daily medications. The lockdowns in South Africa accelerated this trend. "So I think that's a good thing," she says.
TB patients who were already on treatment when the pandemic hit fared well, Conradie says. The problem was the patients with TB who hadn't yet shown symptoms and hadn't yet sought care when the first COVID lockdown hit in March of 2020.
Conradie says she doesn't have hard evidence to prove this but she believes the increase in TB deaths during the pandemic was among "patients who were brewing TB during the epidemic and who died prior to initiation of therapy."
Many South Africans were delaying seeking medical care at all until they were terribly ill, she says. In South Africa, 90% of TB patients are diagnosed and treated at primary health care clinics, but that changed during the pandemic. And the change, she says, resulted in patients growing notably sicker before seeking help.
Patients are showing up with advanced TB
"Now we're seeing more and more TB diagnoses being made in hospitals, which means that you went from having a cough for two weeks to sweating profusely. You've lost weight and finally you went off to a hospital," Conradie says. Doctors are now seeing far more advanced, complicated cases of TB. Patients are showing up with significant damage to their lungs.
"Of course, those are the ones that are at hospital, which means they're still alive," she says. "I think that what has happened is that the diagnosis is being made later and that's being shown by the hospital burden of TB."
One of the most concerning aspects of the impact of the COVID-19 pandemic on TB, Conradie says, is that even if the coronavirus disappeared tomorrow, the damage has already been done.
She thinks it might take five years for South Africa to get TB back to its pre-pandemic levels.
"If you have untreated TB, you're going to infect eight other individuals in your community every year," she says. "So it's going to take us a long time to rebound from this."