Transforming essential services for tuberculosis during the COVID-19 pandemic: lessons from New York City

The global impact of COVID-19 on tuberculosis: A thematic scoping review, 2020-2023

BACKGROUND

This thematic scoping review of publications sought to understand the global impact of COVID-19 on tuberculosis (TB), interpret the scope of resonating themes, and offer policy recommendations to stimulate TB recovery and future pandemic preparedness.

DATA SOURCES

Publications were captured from three search engines, PubMed, EBSCO, and Google Scholar, and applicable websites written in English from January 1, 2020, to April 30, 2023.

STUDY SELECTION

Our scoping review was limited to publications detailing the impact of COVID-19 on TB. Original research, reviews, letters, and editorials describing the deleterious and harmful--yet sometimes positive--impact of COVID-19 (sole exposure) on TB (sole outcome) were included. The objective was to methodically categorize the impacts into themes through a comprehensive review of selected studies to provide significant health policy guidance.

DATA EXTRACTION

Two authors independently screened citations and full texts, while the third arbitrated when consensus was not met. All three performed data extraction.

DATA SYNTHESIS/RESULTS

Of 1,755 screened publications, 176 (10%) covering 39 countries over 41 months met the inclusion criteria. By independently using a data extraction instrument, the three authors identified ten principal themes from each publication. These themes were later finalized through a consensus decision. The themes encompassed TB's care cascade, patient-centered care, psychosocial issues, and health services: 1) case-finding and notification (n = 45; 26%); 2) diagnosis and laboratory systems (n = 19; 10.7%) 3) prevention, treatment, and care (n = 22; 12.2%); 4) telemedicine/telehealth (n = 12; 6.8%); 5) social determinants of health (n = 14; 8%); 6) airborne infection prevention and control (n = 8; 4.6%); 7) health system strengthening (n = 22; 13%); 8) mental health (n = 13; 7.4%); 9) stigma (n = 11; 6.3%); and 10) health education (n = 10; 5.7%).

LIMITATIONS

Heterogeneity of publications within themes.

CONCLUSIONS

We identified ten globally generalizable themes of COVID-19's impact on TB. The impact and lessons learned from the themed analysis propelled us to draft public health policy recommendations to direct evidence-informed guidance that strengthens comprehensive global responses, recovery for TB, and future airborne pandemic preparedness.

Impact of COVID-19 on TB diagnostic services at primary healthcare clinics in eThekwini district, South Africa

We assessed the impact of the pandemic on TB diagnostics at primary healthcare clinics (PHCs) during the different stages of COVID-19 in eThekwini district, South Africa. Data from the District Health Information System (DHIS) were used to conduct an interrupted time series analysis that assessed the changes in TB investigations and confirmed TB cases during four pandemic periods: lockdown and the subsequent three peaks of infection compared to the two years prior (2018-2022). The initial lockdown resulted in - 45% (95% CI - 55 to - 31) and - 40% (95% CI - 59 to - 28) immediate declines in TB investigations and confirmed cases, respectively. Both indicators showed substantial recovery in the months after the first wave (p < 0.05). However, while TB investigations sustained smaller declines throughout the pandemic, they rebounded and surpassed pre-COVID-19 levels by the end of the investigation period. On the other hand, confirmed cases experienced reductions that persisted until the end of the investigation period. TB diagnostic services at PHCs were considerably disrupted by COVID-19, with the confirmation of cases being the most adversely affected throughout the pandemic. The reasons for these persistent declines in TB detection must be determined to inform the development of sustainable diagnostic systems that are capable of withstanding future pandemics.

Cohort study of the mortality among patients in New York City with tuberculosis and COVID-19, March 2020 to June 2022

Both tuberculosis (TB) and COVID-19 can affect the respiratory system, and early findings suggest co-occurrence of these infectious diseases can result in elevated mortality. A retrospective cohort of patients who were diagnosed with TB and COVID-19 concurrently (within 120 days) between March 2020 and June 2022 in New York City (NYC) was identified. This cohort was compared with a cohort of patients diagnosed with TB-alone during the same period in terms of demographic information, clinical characteristics, and mortality. Cox proportional hazards regression was used to compare mortality between patient cohorts. One hundred and six patients with concurrent TB/COVID-19 were identified and compared with 902 patients with TB-alone. These two cohorts of patients were largely demographically and clinically similar. However, mortality was higher among patients with concurrent TB/COVID-19 in comparison to patients with TB-alone, even after controlling for age and sex (hazard ratio 2.62, 95% Confidence Interval 1.66-4.13). Nearly one in three (22/70, 31%) patients with concurrent TB/COVID-19 aged 45 and above died during the study period. These results suggest that TB patients with concurrent COVID-19 were at high risk for mortality. It is important that, as a high-risk group, patients with TB are prioritized for resources to quickly diagnose and treat COVID-19, and provided with tools and information to protect themselves from COVID-19.

Cost-effectiveness of video-observed therapy for ambulatory management of active tuberculosis during the COVID-19 pandemic in a high-income country

OBJECTIVE

The coronavirus 2019 (COVID-19) pandemic caused suspension of directly observed therapy (DOT) for patients with active tuberculosis (TB). This study aimed to estimate the outcomes of pandemic-related DOT suspension and the cost-effectiveness of video-observed therapy (VOT) during the pandemic.

METHODS

A decision-analytic model was constructed to project outcomes of adult patients with active TB from the perspective of a US healthcare provider. Two model-based analyses were conducted: (1) before (with DOT) and during [with self-administered therapy (SAT)] the pandemic; and (2) VOT vs SAT during the pandemic. The primary outcome measures were direct medical costs and disability-adjusted life years (DALYs).

RESULTS

In the base-case analysis, care during the pandemic (with SAT) increased the cost (by US$285 per patient) and DALYs (by 0.2155 per patient) in comparison with DOT. Care with VOT reduced DALYs (by 0.4870) and costs (by US$1797) in comparison with SAT. On probabilistic sensitivity analysis, care during the pandemic (with SAT) increased DALYs in 100% of 10,000 simulations, and increased costs in 55.52% of instances. Care with VOT reduced DALYs and costs in 99.7% and 68.79% of instances, respectively. The probability of VOT being cost-effective was 99.4% at the willingness-to-pay threshold of 50,000 US$/DALY.

CONCLUSION

Suspension of DOT during the COVID-19 pandemic worsened treatment outcomes. VOT was found to be a cost-effective option for active TB care in an outpatient setting.

Evidence of TB Services at Primary Healthcare Level during COVID-19: A Scoping Review

Tuberculosis (TB) is still a major public health concern, despite the availability of preventative and curative therapies. Significant progress has been made in the past decade towards its control. However, the emergence of the novel coronavirus disease 2019 (COVID-19) has disrupted numerous essential health services, including those for TB. This scoping review maps the available evidence on TB services at the primary healthcare (PHC) level during the COVID-19 period. A comprehensive literature search was conducted in PubMed, Web of Science, Medline OVID, Medline EBSCO, and Scopus. A total of 820 articles were retrieved from the databases and 21 met the eligibility criteria and were used for data extraction. The emerging themes were the effect of the COVID-19 pandemic on TB services, patient and provider experiences, recommendations for TB services during the COVID-19 period, and the implementation of the recommendations. The review found that the mitigation strategies, as well as fear and stigma experienced at the start of the COVID-19 pandemic may have led to TB cases potentially going undetected, which may threaten TB treatment outcomes. Therefore, efforts must be directed at finding these missing cases and ensuring that PHC facilities are equipped to adequately diagnose and treat them.

Clinical significance of serum transforming growth factor-β1 and procollagen type I N-propeptide in post-tuberculosis tracheobronchial stenosis

Non-invasive strategies for monitoring post-tuberculosis (TB) tracheobronchial stenosis (PTTS) are clinically important but currently lacking. Transforming growth factor-β1 (TGF-β1) and procollagen type I N-propeptide (PINP) have been identified as markers of fibrosis. The present study aimed to investigate the clinical significance of serum TGF-β1 and PINP in PTTS. Serum samples were collected from 119 patients with tracheobronchial TB after the condition was treated for at least 6 months (59 patients with airway stenosis and 60 patients with no stenosis). Serum TGF-β1 and PINP levels were measured using ELISA and compared between the groups. Relationships between serum TGF-β1 and PINP levels and clinical characteristics, interventional bronchoscopy and outcomes of airway stenosis were analysed. The correlation between TGF-β1 and PINP, and their diagnostic efficacy for airway stenosis were also analysed. The TGF-β1 and PINP levels in the airway stenosis group were higher than those in the non-stenosis group. Furthermore, airway stenosis with atelectasis or mucus plugging was associated with higher TGF-β1 levels, and airway stenosis with atelectasis, mucus plugging, right main bronchus stenosis or severe airway tracheal stenosis was associated with higher PINP levels. In addition, TGF-β1 and PINP levels increased after interventional bronchoscopy therapy and airway stenosis with recurrent stenosis was associated with higher baseline levels of both markers. Finally, TGF-β1 levels were positively correlated with PINP levels in patients with airway stenosis. The area under the receiver operating characteristic curve of TGF-β1 and PINP for distinguishing airway stenosis from non-stenosis cases was 0.824 (95% CI: 0.748-0.900) and 0.863 (95% CI: 0.796-0.930), respectively. Therefore, TGF-β1 and PINP are potential biomarkers that may be useful for diagnosing and monitoring PTTS.

COVID-19 Blind Spots: A Consensus Statement on the Importance of Competent Political Leadership and the Need for Public Health Cognizance

As the COVID-19 pandemic continues, important discoveries and considerations emerge regarding the SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) pathogen; its biological and epidemiological characteristics; and the corresponding psychological, societal, and public health (PH) impacts. During the past year, the global community underwent a massive transformation, including the implementation of numerous nonpharmacological interventions; critical diversions or modifications across various spheres of our economic and public domains; and a transition from consumption-driven to conservation-based behaviors. Providing essential necessities such as food, water, health care, financial, and other services has become a formidable challenge, with significant threats to the existing supply chains and the shortage or reduction of workforce across many sectors of the global economy. Food and pharmaceutical supply chains constitute uniquely vulnerable and critically important areas that require high levels of safety and compliance. Many regional health-care systems faced at least one wave of overwhelming COVID-19 case surges, and still face the possibility of a new wave of infections on the horizon, potentially in combination with other endemic diseases such as influenza, dengue, tuberculosis, and malaria. In this context, the need for an effective and scientifically informed leadership to sustain and improve global capacity to ensure international health security is starkly apparent. Public health "blind spotting," promulgation of pseudoscience, and academic dishonesty emerged as significant threats to population health and stability during the pandemic. The goal of this consensus statement is to provide a focused summary of such "blind spots" identified during an expert group intense analysis of "missed opportunities" during the initial wave of the pandemic.