Covid-19 effects on TB treatment and recovery

In Summary

• Despite these assurances, concerns that the TB treatment and management has been impacted by Covid19 still remain. 

Eva Mueni is living in fear. As a recovered TB patient, Eva is afraid that she, like others suffering from Tuberculosis, is extremely vulnerable to the Covid19 virus.First diagnosed with TB in 2016 when she was a second year university student, Eva was put on a six-month treatment plan. She is fully recovered now.

She was keenly following the outbreak of Covid19 in Wuhan, China and hoped that the virus would not reach Kenya. She read up on how the virus was transmitted and realised that she needed to take drastic measures to protect herself.When Kenya reported its first case of Covid19 on March 13, Eva was devastated.

Understanding she would need to take every conceivable measure to protect herself, Eva decided to  immediately leave the city for her rural home.“I did not want to take any chances.  I just packed my things and left Nairobi. I was really scared. I told my friends that if we were to get Corona I would be the first one to get infected,” she says.Two days after the first case was reported, Eva and her mother left Nairobi for their rural home in the village.

Eva says she feels much safer in the village in Makueni  than in Nairobi as interactions with neighbours are almost nonexistent. The knowledge that her immunity is already compromised by her TB and Pneumonia infections a couple of years ago causes her constant worry. Even a simple cough or a headache causes her anxiety and fear.Globally, more than  2 million people have become infected with the virus and another 169,000 people have died since the disease was first reported in Wuhan, China last December. 

In Kenya, the daily updates indicate that the infections are spreading and the numbers are likely to rise once the government starts testing people. Only those who are suspected to have the virus and those who have been in contact with them are being tested. Mass testing is expected to start this weekend in targeted areas considered to be the epicentre of the disease.There is growing anxiety for people like Eva and others whose immunity has been compromised by pre-existing health problems or age as the disease spreads its tentacles out of the city and into the rural areas.

Eva is lucky as she has completed her TB treatment and is free of the disease. But others who are undergoing treatment run a higher risk of not just contracting but possibly dying from the virus. 

People living with TB are extremely vulnerable to COVID19. They already have a compromised immune system, according to the Center for Disease Control, anyone with a pre-existing medical condition is at a higher risk of experiencing the severity of the Covid19 virus. Globally, 10 million people are infected with TB. Even before COVID-19, TB has held a notorious track record as a ‘Captain of the Men of Death’, a term coined by Madhukar Pai, a Canadian epidemiologist and director of the McGill International Tuberculosis Centre in Montreak Canada. According to the 2019 Global report, TB kills 4000 people each day, and 1.5 million people each year. TB is the leading killer of people living with HIV/AIDS. An estimated 10 million people developed TB in 2018, and nearly half a million people developed drug-resistant TB (DR-TB).

Kenya is one of the countries with a high TB burden globally, putting a strain on an already overwhelmed healthcare system. According to a 2019 survey conducted  by the National Tuberculosis, Leprosy and Lung Disease Program, an estimated 558 people in every 100,000 people have TB.  

TB and the Covid 19 primarily affect the lungs and suppress the host’s immunity system and some of the symptoms mimic each other.  The disruption of the health services means that treatment for TB patients has not been as regular as it should be. Treatment and follow-up of patients usually done by community based TB health workers has also been disrupted as many are not able to continue due to the limitations on movement initiated by the government to stop the spread of Covid19 virus.

With government attention and resources focused on fighting COVID19, the treatment and management of TB has been halted or at the very least disrupted. These disruptions mean that TB patients run the risk of not being able to access their medication thereby increasing the possibility of infecting others and giving rise to the number of those with multi drug resistant TB (MDR-TB). This is a form of TB which is resistant to the two most powerfiul anti-TB drugs— isoniazid and rifampicin.

Patients with MRD-TB require medicines which are usually extremely expensive and are not always available. Patients may also have adverse reactions to the drugs and in some cases, develop even more severe drug-resistant TB may develop. Extensively drug-resistant TB, XDR-TB, is a form of multidrug-resistant TB with additional resistance to more anti-TB drugs that therefore responds to even fewer available medicines. It has been reported in 117 countries worldwide including Kenya. In 2012, a woman designated as Patient X  had to go to court to compel the government to register Viomycin, one of the drugs she needed to treat her XDR-TB.  She won her case with the help of the Kenya Legal and Ethical Issues Network (KELIN). A spot check in 4 different chemists and pharmacies in Nairobi shows the drug is still not available. Dr Daniella Munene, the CEO of Pharmaceutical Society of Kenya says importation of the drug is still to be regularised.

Gladys Mugambi who heads the Division of Health Promotion in the Ministry of Health says the government has, through the Community Health Volunteers, been ensuring that patients registered for TB treatment do not miss their medicines or care. Regular tests are also being conducted on this vulnerable group to ensure they are not infected with the COVID19 virus. 

Dr. Elizabeth Mueni, Nairobi county TB coordinator has also allayed fears that the ongoing pandemic could cause disruption of TB treatment. Dr. Mueni acknowledged that though hospital wards and clinics are increasingly being cordoned off as a contingency measure to deal with possible Covid 19 patients, it has in no way affected or disrupted the treatment for TB patients. Dr. Mueni says her unit is testing all TB patients for Covid 19 when they show up to pick their medicines.

She further adds that health personnel in TB clinics are doing thorough follow-ups for all patients, as well as doing home calls for patients who miss their clinics or fail to go for medicine as required. For TB patients, Dr Mueni says the frequent handwashing, physical distance and other measures introduced to fight the pandemic are extremely important as is continuing their treatment program. “They are at most risk for catching the Covid19 virus,’ she says.

Due to the pandemic, the unit has been seeing patients at longer intervals instead of the weekly visits to the clinics that was in place before the pandemic. “We want to minimise their exposure but the level of care and treatment is being maintained,: she says,Patients needing specialized care are also being seen by community healthcare workers as their case warrants. Concerned about possible drug stock-outs, Dr. Mueni said the county currently has enough TB medicines to last for three months. “There’s really no cause for worry,” she says. 

Kenya is one of the countries that can take advantage of the Global Fund to procure TB medicines to avoid disruption in treatment, according to Grania Brigden of The International Union Against Tuberculosis and Lung Disease.

Despite these assurances, concerns that the TB treatment and management has been impacted by Covid19 still remain. This is because the Mbagathi hospital which is the city’s infectious disease hospital and has one of the largest TB clinic has since been converted into an isolation center for those suffering with Covid19. This has limited the diagnostic, treatment and management of TB patients in Nairobi. 

And as the number of COVID19 cases continue to rise, those with TB, particularly those with MRD-TB and need admission are being turned away to create room for Covid19 patients and also avoid the risk of cross-infection. 

Diagnostic laboratories are also prioritizing the testing of this virus, meaning delays in the testing of TB, increasing the risk of more TB transmissions. 

The diversion of resources or workforce could result in the poor quality of TB care, treatment interruptions and inadequate follow-up. Interventions such as TB contact investigation and preventive therapy are also likely to be completely deprioritized

The 1.5m physical distance recommended as a measure to prevent the spread of Covid19 or even TB has presented a big challenge to TB patients, particularly those in the informal settlements. For example, there are 300 households crammed in an acre of land in Mukuru informal settlement. This translates to 32 plots with each plot having an estimated 11 10x10 or 10x12 semi-permanent shacks which pass for housing in these informal settlements. It is impossible for a TB patient living in these places to maintain the physical distance needed to prevent the risk of cross-infection.

Even as the Health CS issues regular briefings on Covid19, TB survivors like Eva and other TB patients on treatment as well as the public need to know what measures the government has put in place to deal with their concerns.

One way of doing this would be to increase the number of community health workers to deal with TB patients. The health ministry and its TB agencies could consider offering services to patients by setting up a call centre, by using available technologies such as WhatsApp to reach out to those in need of services and  information.

But all these efforts require the government to be pro-active and directly deal with the misinformation that is surrounding the Covid19 pandemic and is also impacting those with TB. The fear of being mis-diagnosed and therefore forced into quarantine just because symptoms may be similar and the attendant stigma may be driving many TB sufferers to hide their illness and prevent them from seeing help.