Medical Focus - GPH - Vol 3 No 2 250521

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Outlook of paediatric tuberculosis in theCovid-19 pre-vaccine eraDr Ray Ezekiel OnojaDepartment of Paediatrics & Child Health, University of Ilorin Teaching Hospital, Ilorin, NigeriaProfessor S. Kolade Ernest MBBS(Ibadan), FWACP(Paed), Cert. HP & Mgt., FSM, MNIM, FRCPCH (UK)Department of Paediatrics & Child Health, University of Ilorin Teaching Hospital, Ilorin, Nigeriahe COVID-19 pandemic caused by the novelcoronavirus (SARS-CoV-2), commenced in Wuhan,China in late 2019 with rapid global spread, sparingno continent, with the first African case beingreported in Egypt in February 2020. By the 20th of February2021, more than 111 million cases globally had been reportedwith almost 2.5 million deaths. 1Nigeria who has been battling other infectious diseases liketuberculosis, HIV and malaria for decades without significanteradication success, has also been affected with the pandemic.Nigeria had reported 150,908 cases and 1,813 deaths as at20th February 2021. The impact of this pandemic is far reachingand the consequence of both the disease and measuresput in place to control the disease are beginning to emerge. 2The burden of TB/HIV and multidrug-resistant TB is high inNigeria. The country is ranked seventh among the thirty highTB burden countries and second in Africa. It is estimated that407,000 HIV negative people in Nigeria have TB each year. 3In addition there are an estimated 63,000 HIV positive peoplethat get TB each year. An estimated 115,000 HIV negative peopledie from TB in Nigeria each year and an estimated 39,000HIV positive people also die from the disease.TB incidence is anticipated to increase in high burden HIV/TB countries including sub-Saharan African countries with increasingCOVID-19 burden. 4In a retrospective cohort study 5 involving a review of medicalrecords of children (0-14 years) with TB in 3 states in Nigeria,it was discovered that of 724 childhood TB cases registeredduring the review period, 220 (30.4%) were aged 0-4 years.Fifty-eight percent had pulmonary TB. New TB infection in98.5%, and human immunodeficiency virus (HIV) coinfectionwas found in 108 (14.7%). About 28% (201) were bacteriologicallydiagnosed. The proportion of TB treatment success was83.0%. Treatment success was significantly higher in childrenaged 5-14 years than those 0-4 years (85.3% vs 77.7%, P = .01).Factors associated with poor outcomes in patients aged 0-4years were male sex, HIV-positive status, and clinical methodof diagnosis. The arrival of COVID-19 would possibly be a ‘doubleburden’ that must be continuously evaluated to see whatdifference vaccines would make.COVID-19 and TB co-infectionCOVID-19 is a highly contagious acute viral disease, whereasTB is a chronic bacterial disease. Both COVID-19 and TB affectthe respiratory system, primarily the lungs, and have similarsymptoms such as cough, fever and breathing difficulty, althoughthe severity and duration of the symptoms may vary.While the route of transmission for COVID-19 and TB may besimilar and require close contact with infected people, the efficiencyin transmission is better in COVID-19 compared to TB.For COVID-19, the source of infection can be both symptomaticand asymptomatic patients, while for TB the main sourceof infection is symptomatic patients with productive cough. 6,7Coinfection of TB and SARS CoV-2 is of particular concern dueto several reasons: 8,9• Concern #1:Diagnosis of TB is likely to be missed due to non-specificclinical features in both (TB & COVID-19) and lack of radiologicalfindings specific to TB.• Concern #2:COVID 19 or use of immune-modulators in moderate-severeCOVID-19 may lead to reactivation of latent TB in highendemic areas.• Concern #3:Co-existing active TB disease may predispose to severeCOVID 19 illness from basic immunology considerations.• Concern #4:Possibility of drug-drug interactions (e.g. rifampicin andremdisivir) due to simultaneous use of anti-TB medicationsand available COVID 19 therapeutic options.Disease outcomesSome studies have described the outcome of COVID-19 inpeople and children with current or active TB disease. TB diseasewas either diagnosed before contracting COVID-19 orwas diagnosed at the time of COVID-19 diagnosis, due to someoverlapping symptoms in people with COVID-19 and or TB. 5,6Most of these studies reported that current TB disease wasassociated with severe COVID-19 that required hospitalisationand oxygen supplementation or ventilation. However, most ofthe patients recovered from COVID-19 and were dischargedfrom hospital. Some studies reported increased mortality inpeople with COVID-19 and active TB, and concluded that TBwas associated with prolonged recovery from COVID-19 andor mortality. All studies with data on COVID-19 in people withprevious TB reported that previous TB was associated with severeCOVID-19, though most of the patients recovered afterprolonged stay in hospital. In the future, lung lesions associatedwith COVID-19 may increase the risk of PTB, which inducesa true vicious circle of HIV-TB-COVID-19 co-infection. Generally,children with TB and COVID-19 have mild COVID-19 disease.Reasons for this require critical evaluation in the future.4Vol 3 No 2 - 2021
The potential impact of COVID-19 pandemic ontuberculosis 10,11COVID-19 could impact TB control in several ways, includingincreasing transmission of TB in the household, delaying thediagnosis and treatment of TB, increasing poor treatmentoutcomes and risks of developing drug-resistant TB.Impact on TransmissionLockdown was one of the measures used by countries toprevent the spread of COVID-19. This measure may facilitatehousehold transmission of TB as over-crowding was prevalentin developing countries during the lockdown.A study conducted in Brazil showed that intensity of householdexposure increased the risk of TB infection and diseaseamong household members. Post lockdown periods stillpresent the same risk to under-5 year old children becausethey depend on adults to walk away from such overcrowdedhomes with heightened transmission.Impact on treatment and diagnostic servicesOverwhelming of health care systems by COVID-19 cases islikely to impact on TB treatment and diagnostic services inseveral ways:• Diversion of resources (including human and financial)away from routine services, to manage the pandemic• Limited oversight and accountability of TB programmes• Reduced number of health care personnel either due toisolation or due to the illness• Stigma and fear of COVID-19 infection at health care facilities,discouraging people from visiting TB services• Screening services for TB have experienced competition,e.g. gene expert cartridges for TB being used for COVID-19;sputum specimens being prioritised for COVID-19 testingdelaying diagnosis of TB• Inappropriate use of BCG in response to the unproven theorythat BCG may protect against COVID-19All of these seven factors will contribute to delays in thediagnosis and commencement of treatment. Late diagnosisand inappropriate treatment of TB can also increase therisk of poor treatment outcomes and development of drugresistantTB. Misdiagnosis and under-detection of TB areongoing problems for TB programmes. It was estimated that3 million TB cases were undetected in 2018. This numberis likely to increase due to our current diversion of healthfacility toward the containment of COVID-19 pandemic.Impact on prevention and control of tuberculosisPrevention and control strategies for TB have already beencompromised due to the COVID-19 pandemic. Many fora forexchanging TB research and information, such as seminars,workshops and annual conferences, have not been conductedin 2020. For instance, the World Tuberculosis Day, which iscelebrated on March 24 each year, to build public awarenessabout the prevention and control of TB and to raise fundingto support TB control efforts, has been cancelled in severalcountries.Vaccination programmes, including the BCG vaccination thathas been given to prevent childhood TB, have been negativelyaffected by COVID-19.Furthermore, TB preventive therapy, which is often given tohigh-risk groups to prevent the progression of latent TB to activeTB has also been affected by COVID-19. The worldwidepandemic of COVID-19 may affect the global strategy of endingTB by 2035 in several ways.Many of the factors affecting diagnostic and testing servicesalso affect prevention and control programmes. Shortages ofresources, either directly due to diversion towards pandemicmanagement or indirectly due to broader economic consequencesof the pandemic and stretched national budgets, arelikely to impact on routine public health programmes.The COVID pandemic has left a devastating effect on the poor,through job losses, rising prices, and disruptions to servicessuch as education and health care. As a result of this, morepeople have fallen into extreme poverty. This will have a longtermimpact on the burden of TB because poverty is widelyrecognised as an important risk factor for being infected anddeveloping active TB.Strategies to mitigate the effect 8,9,13• Apply infection prevention and control measures (e.g.cough etiquette, personal protective equipment)• Separate or isolate people with presumed or demonstratedinfectious TB• Provide TB preventive treatment for high-risk groups andinitiate TB treatment early• Maintain supports to essential TB services during and afterthe COVID-19 pandemic• Provide information to patients about COVID-19 and TB sothey can protect themselves and continue their TB treatment• Decentralise TB treatment to community health workersand increase access to TB treatment for home-based TBcare• Provide adequate supply of TB medication to patients forsafe storage at home• Design mechanisms to deliver medicines and to collectspecimens for follow-up testing at home• Integrate TB and COVID-19 services for infection control,contact tracing, community-based care, surveillance andmonitoring• Train health professionals and recruit additional staff towork on TB programmes• Use virtual care and digital health technologies (e.g., videoobserved therapy) for adherence support, early initiationof treatment, remote monitoring of TB patients, counselling,and follow-up consultations• Design strategies to deliver BCG and TB preventive therapyat home• Create community awareness of the importance of TB services• Conduct research to identify the impact of COVID-19 onreactivation of TB and to design interventions mitigatingthis problem5 Vol 3 No 2 - 2021
Page 1: Volume 3 No 2 - 2021HIV, TB and Men
Page 6 and 7: What to expect as COVID-19 vaccine
Page 8 and 9: be used to diagnose someone with PA
Page 10 and 11: Managing schizophrenia with long-ac
Page 12 and 13: The introduction of LAIs should alw
Page 14 and 15: recent data from the Botswana Tsepa
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