By Amyn A. Malik, Saira Khowaja (Global Health Directorate, Indus Health Network)
In this blog series we are giving a voice to practitioners, implementers and policy-makers involved in national COVID-19 responses in low- and middle-income countries. These posts seek to facilitate timely cross- learning by sharing opinions, insights and lessons on the challenges and actions taken by those on the COVID-19 front line.
Since March 2020, the COVID-19 pandemic has disrupted usual healthcare related services in many cities and countries. This includes limiting tuberculosis (TB) related services in part because lockdown resulted in stoppage of other services and relevant staff have been diverted for COVID-19 care and facilities and laboratories being repurposed for the same. Many other healthcare services have also suffered including immunization with vaccination coverage, including BCG coverage (the TB vaccine) decreasing. This has both short- and long-term implications for public health and TB care in these settings. We know from previous experiences that such disruptions can lead to high sufferance including increased morbidity and mortality. The Ebola outbreak in Liberia led to a decrease in TB patients being notified to the public health system and a decrease in successful TB treatment from 80 to 69%. The effects remained even after the outbreak had resolved indicating long-term sequalae for the system that need to be addressed.
Integration of services
With COVID-19 and TB affecting similar groups, there is an opportunity for integration of both these services to avoid prioritizing one over the other. In this regard there are important lessons that can be adopted in countries where both COVID-19 and TB are prevalent. In Pakistan, efforts have been made to co-screen individuals for both TB and COVID-19 related pneumonia. Initially, this was done only in a hospital setting but is now being rolled out in community settings as well. The only activities being allowed in the country during the lockdown were for COVID, which presented an opportunity to use our contact tracing teams for TB to contact tracing COVID-19 patients but allow for some TB activities to continue. The existing skills of the contact tracing team allowed them to mobilize quickly and get to the patients homes. Unfortunately families refused to get COVID 19 testing due to the fear of a loved one being taken away into isolation or being ostracized by their neighbors. We recognised walk-through and drive-through TB and COVID-19 screening at hot spot locations was more successful as it reduced the fear of people of being ostracized and of getting infected through hospital emergency rooms.
Public health programmes globally will need to reevaluate their strategies for delivering health care. In the current era of COVID-19 and for health system resilience from future pandemics we must ensure if we want to limit impact on health services, that there is a need for an integrated, adaptive and comprehensive approach to health delivery. For TB services business as usual is not a choice they can make, the siloed approach has put us back many years in gains in detection and averting deaths. Governments need to engage and plan for provision of other essential public health services such as vaccination including catch up for missed opportunities to avoid deaths from preventable diseases that may overshadow the deaths caused by COVID-19. The discussions and stakeholder engagement must start now to be able to generate and build integrated health systems in a timely manner to provide the care that is needed. Otherwise, we may be playing catchup for some years to come.