We must use lessons learned from tackling COVID to fight tuberculosis

Tuberculosis (TB) is the second leading global infectious killer after COVID-19, but efforts to stem its spread have been reversed by the coronavirus pandemic as health and socioeconomic systems were greatly strained. Now, we must use the technology, innovations and lessons learned from fighting COVID to tackle TB.

TB is caused by the bacterium Mycobacterium tuberculosis and usually attacks the lungs, but also affects other organs. Key symptoms include a cough, fever, night sweats and weight loss. Since its discovery by Dr Robert Koch in 1882, TB has been a leading cause of death from a single infection second only to COVID-19 in recent years. Tuberculosis alone was responsible for 1.5 million deaths in 2020, despite being a curable and preventable disease.

According to the World Health Organization (WHO), TB affected 10 million of the world’s population in 2020, 98% of which were in low and middle-income countries (LMICs). Thirty high TB burden countries account for 86% of new TB cases. Indeed, eight countries – India, China, Indonesia, the Philippines, Pakistan, Nigeria, Bangladesh and South Africa – account for two thirds of total cases.

Countries with a high disease burden have common predisposing factors leading to tuberculosis, including HIV/AIDS, poverty, malnutrition and poor housing conditions, particularly overcrowding. Other factors include health conditions that reduce the body's immunity, such as diabetes mellitus, alcohol use disorder and smoking. All of these increase the individual's risk of tuberculosis.

Due to the high mortality and morbidity associated with tuberculosis, the WHO has rolled out strategies aimed at the control and eventual eradication of the disease. TB was declared a public health emergency in 1993 and the End TB Strategy was adopted in a 2014 World Health Assembly meeting, with targets including a 95% reduction in deaths and 90% reduction in incidence rate by 2035.

These targets have only been achieved in some countries, mainly in the WHO European region, while 30 high TB burden countries still have incidence rates as high as 150-400 per 100,000 individuals.

With the advent of the COVID-19 pandemic, the world lost some of the gains made previously in the fight against TB. Global deaths from tuberculosis increased for the first time in more than a decade, rising from 1.4 million to 1.5 million.

This is due to the socioeconomic impact of the pandemic, with impacts including worsening poverty, malnutrition and the diversion of health resources initially used for TB to fight COVID-19, among others. Other effects suffered globally were a reduction in tuberculosis diagnoses due to lockdown, poor adherence to treatment, and an increasing incidence of drug-resistant TB.

However, the good news is that technological innovations and other lessons learned in the fight against COVID-19 can be used as a source of insights in tackling TB, regaining lost ground and pushing to end the globally tuberculosis scourge.

Technology in health refers to healthcare practices supported by electronic processes and includes technologies such as electronic health records, patient administration systems, and laboratory systems which can be managed using mobile health applications.

Innovation and technology have a pivotal role to play in the fight against TB, especially in the wake of the COVID-19 pandemic. However, the use of these tools must also take into consideration the complexity of health systems and the interplay of diverse factors, especially in emerging countries where there is still a high incidence rate.

One major success of innovation and technology use in tackling TB can be seen with the use of informal health providers (IPs) in LMICs, where 65-90% of rural dwellers use health attendants such as village doctors, drug compounders, traditional birth attendants and untrained allopathic practitioners as their first point of call on health concerns.

In Kolar and Tumkur districts of India's Karnataka state, for example, treatment completion and cure rates have been shown to be significantly higher using the IPs than the formal healthcare providers.

Technology has also enabled the simultaneous testing of TB and COVID-19 using nucleic acid amplification tests (NAATs), which is recommended in countries with a high burden of TB – particularly in light of the COVID-19 pandemic.

Mobile technology was also effectively used in India to monitor those diagnosed with TB in real time as they take their medication, thereby empowering the patient and reducing the physical effort for healthcare.

Technology can be used in ensuring more people take the TB vaccines and producing drugs which are more effective. It also plays a vital role in evaluating TB coverage rates and creating networks among public-private health institutions in high burden countries.

Meanwhile, interfaces such as chatbots or SMS-based systems used to answer basic queries, and enable inputs of basic data of those suffering from tuberculosis, can be used to link up healthcare workers within a geographical location, provide referral networks and guide on national TB protocols.

Social media platforms and apps, accessible via mobile devices, can also be leveraged to improve awareness of tuberculosis among young people, who constitute a major percentage of TB cases in high burden countries.

In 2005, the WHO encouraged countries to move towards achieving universal health coverage (UHC), enabling all individuals and communities to receive healthcare services they need without having to face financial hardship. This includes the full spectrum of essential health services and ensures that, even in the wake of COVID, they are decentralized with a reduction of costs borne by those suffering with TB.

Although global funding is important in helping the resource-poor countries fund the provision of services needed for the fight against tuberculosis, national TB programmes should be seen to start to take up responsibilities. Such schemes should be incorporated into existing health programmes, along with input from the private health sector.

Universal access to healthcare needs to made a global priority for TB treatment coverage in many poorer countries to regain lost ground following the pandemic. Tuberculosis coverage is a key indicator of overall UHC coverage compared to other disease-specific indicators of service provision – particularly in LMICs.

In the words of Dr Tedros Adhanom Ghebreyesus, Director-General of the WHO: "I want to remind you that the struggle to end TB is not just a struggle against a single disease. It’s also the struggle to end poverty, inequity, unsafe housing, discrimination and stigma, and to extend social protection and universal health coverage. If the pandemic has taught us anything, it’s that health is a human right, not a luxury for those who can afford it.

"If the pandemic has taught us anything, it’s that health is a human right, not a luxury for those who can afford it. With solidarity, determination and the equitable use of tools, we will defeat COVID-19. And with the same solidarity, determination and equitable use of tools, we can end TB."