Increased demand for health care services due to COVID-19 can challenge health facilities and health care systems. Previous global and regional health emergencies, like Severe Acute Respiratory Syndrome (SARS) and Ebola virus disease, negatively impacted TB care. These challenges often resulted in disruption of TB health care services, delayed diagnosis and treatment and increased morbidity and mortality for patients with TB.
During the current COVID-19 pandemic, it is important that TB services are prioritized as essential, and that access to care is assured and effectively maintained to avoid a negative impact on TB care and adverse patient outcomes.
COVID-19 and TB share some common clinical features. Exposure to both diseases can occur simultaneously and the presence of comorbidities can result in poor outcomes. A positive test result for COVID-19 does not rule out the presence of TB disease, particularly in high TB burden settings. In these settings, implementation of simultaneous testing for both diseases is recommended for persons with respiratory symptoms, as noted by the World Health Organization (WHO).
Sputum specimens for treatment follow-up should be collected in a safe location. Collection of specimens should be done outside the home in open space away from others. The use of biosafety cabinets is recommended when handling sputum. However, if a cabinet is not available, the enforcement of all other requirements, such as consistent use of the N95 respirator, handwashing, use of gloves, goggles or protection shield, waterproof aprons, regular decontamination of surfaces, staff distancing in the laboratories, ventilated workplaces and safe transportation should be observed.
Globally there is mounting evidence that patients with chronic respiratory diseases, including TB, are at increased risk of severe outcomes or dying from COVID-19. The risk and severity of coronavirus infection in young people with comorbidities such as TB is not fully known, although there is reason to believe that the presence of comorbidities may increase risk of symptomatic and severe disease in these children. Children with co-morbidities should be closely monitored for signs of severe disease. Globally, there have been interruptions in routine vaccination programs for children. In countries or settings with a high incidence of TB, Bacille Calmette-Guerin (BCG) vaccine, prevents severe forms of TB in children, including TB meningitis. There have been reports of diversion of this vaccine to support other populations from the effects of COVID-19.
It is likely that some patients with COVID-19, many of whom might be undiagnosed, will seek care at TB clinics. Robust implementation of infection prevention and control measures is critical to ensure the safety of health care workers and patients accessing care at health facilities.
Respiratory infection control measures, are of even greater importance now, as are general precautions, such as frequent handwashing, disinfecting of surfaces, and avoiding touching one’s face
Respiratory infection control measures for COVID-19 that should be implemented or integrated into TB infection control measures include triage and early identification and separation of symptomatic patients, fast tracking or expedited service, implementation of droplet and contact precautions, frequent handwashing, environmental engineering controls and use of personal protective equipment.
Efforts should be made to minimize the amount of in-person patient contact at health care facilities to reduce the risk of infection to health care workers, as well as patients visiting these facilities. Multi-month drug supplies for TB patients on treatment and those on TB preventive treatment are a good alternative to ensure treatment continuity and completion. In settings where movement restrictions have been instituted, safe home delivery of medicines may be necessary. Use of alternative modalities such as community-based treatment monitoring or digital adherence interventions should be considered to monitor TB treatment and associated adverse events.
The public health platforms that CDC have been built, as well as the innovative approaches to TB surveillance, treatment, prevention and infection control, have improved country-level and global health care systems. These same platforms are being leveraged in the fight against COVID-19.