"Our TB patients were neglected during the time of COVID-19." - Community health worker from Hammanskraal, Gauteng Province.
While COVID-19 wreaks havoc across the South African health care system, another airborne infectious killer has continued to silently spread through communities, despite being preventable and curable. As early as May 2020, the National Institute for Communicable Diseases released data demonstrating a catastrophic 48% drop in the number of molecular Xpert MTB/RIF tests done to diagnose tuberculosis (TB) in South Africa, meaning that thousands of people with TB had missed or delayed diagnoses.
The Stop TB Partnership recently released a data brief demonstrating a global decline of one million less people being diagnosed and initiated on TB treatment in nine high TB burden countries, including South Africa. This equates to a return to 2008 levels, representing a 12-year setback, which is considerably worse than the prior projections had feared. A combination of factors including COVID-19 lockdown restrictions, resource shifting of personnel and laboratory facilities, impact of COVID-19 on the healthcare workforce, and patient concerns about acquiring COVID-19 at health facilities, has severely limited the access to and quality of TB care delivery.
In contrast to the rapid efforts to enable access to local, regional, and national COVID-19 epidemiologic data to understand disease trends in real-time, we only recently learned the sobering results of the first-ever National TB Prevalence survey (conducted to provide more accurate data on the number of people affected by TB in South Africa), which began in August 2017.
Findings from this survey demonstrated that 58% of people with laboratory-confirmed TB, reported no symptoms, but had detectable abnormalities on chest x-rays prompting sputum-based diagnostic testing. This has major implications for national guidelines, which currently focus on TB symptom screening and will thus miss large numbers of people with undiagnosed TB. It is also notable that almost two-thirds of people with TB symptoms had not sought care by the time they were assessed for the prevalence survey.
There is an urgent need to improve community awareness highlighting that TB can be life-threatening but is curable, and to implement concerted efforts to decrease TB-related stigma, which negatively impacts care-seeking behaviour.
"When you have a disease like TB, you are not supposed to go to work for a certain amount of time." - Goodman Makanda, TB survivor and advocate with TB Proof.
We note that TB prevalence was highest amongst the 35 - 44 year age group, which is the most economically active age group, emphasizing the need for TB programs to address social protection to mitigate the catastrophic costs often associated with a TB diagnosis.
The survey also revealed that TB was 1.6 times more common in males compared to females. This means we need to focus on more gender-specific community awareness and consider how TB care delivery can be better tailored to meet the needs of both men and women. This necessitates consideration of how gendered behavioural norms affect men's experiences of TB and resultant care seeking behaviours.
It is critical for South Africa to adapt and integrate effective strategies that have been rapidly implemented to address COVID-19 to concurrently address TB. These include intersectoral collaboration, integrated tracing and screening, real-time dashboards on disease incidence, quality assurance processes for personal protective equipment and widespread use of masks. Since TB and COVID-19 present similarly, integrated testing, along with promotion of self- screening applications such as TB HealthCheck can help to decrease the TB care seeking gap. The Global Fund's "Catch-up" Plans to Mitigate the Impact of COVID-19 on TB Services, emphasises that TB programmes should focus on behaviour changes used for COVID-19, such as mask-wearing, which prevents against both TB and COVID-19 transmission.
Role of CHWs
Community health workers (CHWs) facilitate decentralised TB testing and treatment by providing TB care at the household level and can play a key role in decreasing gaps in the TB care cascade, with an emphasis on improving care seeking behaviour and reducing loss to follow up.
Yet despite their frontline work supporting health system preparedness to respond to health emergencies such as COVID-19 and TB, CHWs are chronically neglected in key discussions to provide guidance regarding their scope of work at a national level. Moreover, CHWs are not adequately protected against infectious diseases including TB and COVID-19 due to the lack of available high quality PPE and requisite training.
"Working in a community is different from the clinic, we go house to house without PPE, without knowing if those people already have TB or are lost to follow-up." - CHW from KwaZulu-Natal.
Policies such as the Ward-Based Primary Healthcare Outreach Teams (WBPHCOT) policy, released 3 years ago, could help to facilitate CHWs finding missing people with TB but to date, no implementation plan has been released.
In conclusion, despite the devastating impact of COVID-19 on TB care thus far, the astounding response and political commitment to ending COVID-19 demonstrates that more can and must be done to address TB in South Africa. It is time to engage communities through CHWs and leverage COVID-19 innovations to advance the urgent need for high-quality, person-centred TB care for all.
*The authors are all members and/or board members of TB Proof, a leading TB advocacy organisation in South Africa.