COVID-19 pandemic and lockdowns impact TB mortality

25 March 2022 | Story Wendyl Martin. Photo Torange. Read time 8 min.

There was a significant reduction in tuberculosis (TB) testing and case detection across South Africa in the past two years, and these reductions directly coincided with each wave of the COVID-19 pandemic and the related tightening of lockdown regulations, according to recent data. This emerges as new papers involving University of Cape Town (UCT) researchers, just published in The Lancet and Lancet Respiratory Medicine, revealing vital information about the effects of the pandemic on TB detection and care.

To coincide with World TB Day on 25 March, the paper, ‘Accelerate Investment and Action to Find the Missing Patients with Tuberculosis’ in The Lancet, aims to draw attention to the “missing” TB diagnoses that occurred over the past two years.

The missing 4 million

“COVID-19 was associated with an estimated increase in the number of missing new tuberculosis diagnoses to about 4 million worldwide in 2020,” wrote the paper’s authors. “The COVID-19 pandemic has disrupted access to tuberculosis services, resulting in multi-dimensional effects, including increased tuberculosis morbidity and mortality.”

Credited among the paper’s authors is Professor Keertan Dheda, director of the Centre for Lung Infection and Immunity (CLII), a unit of the UCT Lung Institute (UCTLI).

Dheda is also an author of the paper, ‘The Intersecting Pandemics of Tuberculosis and COVID-19: Population-Level and Patient-Level Impact, Clinical Presentation, and Corrective Interventions’, which was published in Lancet Respiratory Medicine.

 

“The most drastic reduction showed that in May of 2020, TB testing had fallen by more than 50%, the diagnosis of drug-sensitive TB had fallen by 40%, and rifampicin-resistant TB by about 50%.”

Dr Tahlia Perumal is named as a co-author with Dheda on the Lancet Respiratory Medicine paper. A clinical researcher at the CLII, Perumal works on clinical trials specialising in TB and COVID-19, and says that data received from the National Institute For Communicable Diseases (NICD) indicates that there was a “substantial reduction” in TB testing and case detection nationwide as the country went through each of its COVID-19 waves and hard lockdowns.

“The most drastic reduction showed that in May of 2020, TB testing had fallen by more than 50%, the diagnosis of drug-sensitive TB had fallen by 40%, and rifampicin-resistant TB by about 50%. Additionally, we saw an 18% reduction in attendance of primary healthcare facilities nationwide,” confirms Perumal.

Restriction of movement over this period is attributed as a factor for the decrease in TB diagnosis and care.

“Although there may have been outside influence in reduction attributed to infection-prevention-and-control interventions put in place for COVID-19 such as mask wearing, hand hygiene and social distancing, it is widely assumed that the restrictions to access to healthcare (testing, treatment, and prevention) offsets any transmission reduction,” she added.

Perumal's keen interest in epidemiology led to her becoming familiar with COVID-19 modelling studies that described the potential effects of lockdowns on core health services.

The Lancet Respiratory Medicine paper she worked on with Dheda is a systematic review commissioned by Lancet Respiratory Medicine looking at current evidence available. Perumal noted that more than 20 people worked on it, including Dr Ali Esmail, a specialist pulmonologist and the head of the clinical trials unit at the CLII, and Dr Alex J Scott, a clinician at the CLII.

 

“The WHO estimates an 18% global reduction in TB case detection.”

“This was a collective from many researchers… The paper included TB experts, researchers and doctors from all over the world: representatives of the CLII, representatives from the NICD and South African Medical Research Council, and representatives from India, China, the United States and Canada.”

A massive drop in TB testing and detection

Through individual country analyses, large global reporting services like the World Health Organization (WHO) global TB reports, and national laboratory data, Perumal says they saw a massive reduction in TB testing, TB case detection and access to TB care (including treatment and prevention services) as a result of the pandemic and the associated control efforts.

“The WHO estimates an 18% global reduction in TB case detection (from 7.1 million in 2019 to 5.8 million in 2020). Major reductions were recorded in the Philippines (37%), Indonesia (31%), South Africa (26%) and India (25%). The COVID-19 pandemic has also interrupted TB prevention services, accounting for up to 60% reduction in BCG vaccination globally.”

Data shows that the reduction in TB services has lead to an increase in TB-related deaths.

“There are a wide variety of modelling studies that estimate the effects the reduction to TB services may have (had) — they all have one thing in common: significant increases in tuberculosis-associated mortality, worsened by every month taken to restore TB services.

“Analysis from the WHO and the StopTB Partnership predicted 190 000 additional deaths in 2020, and 1.4 million additional tuberculosis deaths between 2020 and 2025. Additionally, the reduction in access to BCG vaccination (delayed or missed) may account for up to 33 074 additional TB-associated paediatric deaths.

 

“South Africa is considered one of the top TB-burdened countries in the world — notifying [around] 200 000 cases every year.”

“This was supported by data presented to and reported by the WHO in their global TB report for 2021, showing 1.32 million tuberculosis deaths worldwide in 2020 — the first increase in TB morality in over a decade.”

Tough road ahead for curbing TB deaths

Perumal predicts a “long and winding road” ahead in addressing morbidity and mortality associated with TB and COVID-19 in South Africa. Dheda adds that “major investments into TB R&D are required by African governments, where TB sets back national GDPs by between 2 and 3%”.

“South Africa is considered one of the top TB-burdened countries in the world — notifying [around] 200 000 cases every year, including both multi and extensively drug-resistant cases.”

The paper advocates for improved funding for diagnostic, treatment, and prevention services including vaccine development, and dedication to healthcare workers and services.

“Significant improvements to the methods of diagnosis for both TB and COVID-19 are required: faster, more sensitive point-of-care testing for TB, as well as consideration into joint screening strategies for the twin pandemics.

“Investment in active case finding strategies need to be made to treat TB early and curb transmission… Improvements in the care and protection of healthcare workers and healthcare services are essential for building lasting interventions.”

As the paper is published, CLII’s work to dig deeper into TB research that could unlock breakthroughs continues. Perumal said she is project managing a trial funded by the Wellcome Trust, UK MRC and the European and Developing Countries Clinical Trials Partnership (EDCTP) called XACT-3 (with Dheda as PI), which aims to validate a scalable TB case-finding strategy.

“There is something different about working to incite change on a policy-changing level. UCT and the UCTLI give us an incredible springboard — connecting us to core research ventures and incredible people in healthcare. I really want to use our research platform to change the way we tackle infectious disease, something so often stigmatised and neglected.”

Watch the Brimstone and Groote Schuur Hospital "Dialogue on Tuberculosis 2022", featuring Professor Keertan Dheda here.


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UCT’s response to COVID-19

COVID-19 is a global pandemic that caused President Cyril Ramaphosa to declare a national disaster in South Africa on 15 March 2020 and to implement a national lockdown from 26 March 2020. UCT is taking the threat of infection in our university community extremely seriously, and this page will be updated with the latest COVID-19 information. Please note that the information on this page is subject to change depending on current lockdown regulations.

Minister of Health, Dr Joe Phaahla, has in June 2022 repealed some of South Africa’s remaining COVID-19 regulations: namely, sections 16A, 16B and 16C of the Regulations Relating to the Surveillance and the Control of Notifiable Medical Conditions under the National Health Act. We are now no longer required to wear masks or limit gatherings. Venue restrictions and checks for travellers coming into South Africa have now also been removed.

In July 2022, the University of Cape Town (UCT) revised its approach to managing the COVID-19 pandemic on UCT campuses in 2022.
Read the latest document available on the UCT policies web page.

 

Campus communications

 
2022

Adjusting to our new environment 16:50, 23 June 2022
VC Open Lecture and other updates 17:04, 13 April 2022
Feedback from UCT Council meeting of 12 March 2022 09:45, 18 March 2022
UCT Council
March 2022 graduation celebration 16:45, 8 March 2022
Report on the meeting of UCT Council of 21 February 2022 19:30, 21 February 2022
UCT Council
COVID-19 management 2022 11:55, 14 February 2022
Return to campus arrangements 2022 11:15, 4 February 2022

UCT Community of Hope Vaccination Centre

On Wednesday, 20 July, staff from the University of Cape Town’s (UCT) Faculty of Health Sciences came together with representatives from the Western Cape Government at the UCT Community of Hope Vaccination Centre at Forest Hill Residence to acknowledge the centre’s significance in the fight against COVID-19 and to thank its staff for their contributions. The centre opened on 1 September 2021 with the aim of providing quality vaccination services to UCT staff, students and the nearby communities, as well as to create an opportunity for medical students from the Faculty of Health Sciences to gain practical public health skills. The vaccination centre ceased operations on Friday, 29 July 2022.

With the closure of the UCT Community of Hope Vaccination Centre, if you still require access to a COVID-19 vaccination site please visit the CovidComms SA website to find an alternative.

 

“After almost a year of operation, the University of Cape Town’s (UCT) Community of Hope Vaccination Centre, located at the Forest Hill residence complex in Mowbray, will close on Friday, 29 July 2022. I am extremely grateful and proud of all staff, students and everyone involved in this important project.”
– Vice-Chancellor Prof Mamokgethi Phakeng

With the closure of the UCT Community of Hope Vaccination Centre, if you still require access to a COVID-19 vaccination site please visit the CovidComms SA website to find an alternative.


Thank You UCT Community

Frequently asked questions

 

Global Citizen Asks: Are COVID-19 Vaccines Safe & Effective?

UCT’s Institute of Infectious Disease and Molecular Medicine (IDM) collaborated with Global Citizen, speaking to trusted experts to dispel vaccine misinformation.



If you have further questions about the COVID-19 vaccine check out the FAQ produced by the Desmond Tutu Health Foundation (DTHF). The DTHF has developed a dedicated chat function where you can ask your vaccine-related questions on the bottom right hand corner of the website.

IDM YouTube channel | IDM website
 

 

“As a contact university, we look forward to readjusting our undergraduate and postgraduate programmes in 2023 as the COVID-19 regulations have been repealed.”
– Prof Harsha Kathard, Acting Deputy Vice-Chancellor: Teaching and Learning

We are continuing to monitor the situation and we will be updating the UCT community regularly – as and when there are further updates. If you are concerned or need more information, students can contact the Student Wellness Service on 021 650 5620 or 021 650 1271 (after hours), while staff can contact 021 650 5685.

 

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