key: cord-0962669-8cm89d39
authors: Nhari, Leroy Gore; Dzobo, Mathias; Chitungo, Itai; Denhere, Knowledge; Musuka, Godfrey; Dzinamarira, Tafadzwa
title: Implementing effective TB prevention and treatment programmes in the COVID-19 era in Zimbabwe. A call for innovative differentiated service delivery models
date: 2020-12-01
journal: Public health in practice
DOI: 10.1016/j.puhip.2020.100058
sha: ce761483b009aeeb8a79d91f16ddf32b0ec6e1c3
doc_id: 962669
cord_uid: 8cm89d39

The arrival of COVID-19 has disrupted health service provision globally. In this note, the authors discuss the impact of the COVID-19 pandemic on the provision of tuberculosis (TB) services in Zimbabwe. TB is endemic in the country and disruption of services may potentially have serious consequences for patients with existing and undiagnosed TB. In this letter, the authors discuss the need for innovative strategies that ensure TB prevention and treatment services in a manner which reduces COVID-19 risk of patients and healthcare workers.

The Coronavirus disease 2019 (COVID- 19) pandemic is a respiratory illness caused by the novel coronavirus SARS-CoV-2. The disease can be a mild common cold or more severe pneumonialike sickness (1) . The common transmission routes of the coronavirus include direct transmission (cough, sneeze, and droplet inhalation transmission) and contact transmission (contact with oral, nasal, and eye mucous membranes) (2). Contaminated air or environmental surfaces are possible sources of infection (2). The standard of care for COVID-19 is symptomatic therapy with antipyretics, hydration for mild cases and provision of ventilatory support if a patient develops respiratory distress. At the time of writing, there is no proven cure for COVID-19 and global efforts are in progress to find a vaccine (3). COVID-19 exhibits some similar symptoms with tuberculosis (TB) (4) . According to the World Health Organisation (WHO), about 10 million people fall ill with TB every year and approximately 1.5 million people die from TB each yearmaking it one of the major causes of mortality worldwide (5). TB is highly endemic and a major public health problem in Zimbabwe with an estimated incidence of 210 per 100,000 population in 2018 (6).

The gains realized over the years in the fight against TB are under threat due to the COVID-19 pandemic (7) (8) (9) (10) . The pandemic has resulted in a diversion of resources meant for other existing public health threats, including TB. Threats to the TB response in the COVID-19 era have been well established elsewhere (10) . These include movement restrictions due to the implemented lockdowns (11) (12) (13) , diversion of human and diagnostic resources from TB services (10), misdiagnosis of TB in areas where COVID-19 testing is not available (14) and tuberculosis stigmatization as some of the symptoms of TB and COVID-19 are similar. All these threats to the gains observed in TB control in Zimbabwe require swift strategic measures to mitigate the effects of, and manage the COVID-19 pandemic while implementing effective TB prevention and treatment programs (10) Since COVID-19 and TB infections present with similar symptoms, an extensive range of differential diagnosis should be considered, including TB at first clinical presentation. Significantly, similar general preventive measures for all respiratory tract infections should be implemented for safety and the prevention of more transmissions in health facilities and to health-care workers. The overlap and commonalities for surveillance, screening, diagnosis, care, and management can be exploited (15) and increase the rate of TB treatment initiation. The management of patients with respiratory symptoms should encompass combined testing for both infections, hypothetically increasing the sum of people tested for TB. Also, due to the comparisons of two diseases, there is a great opportunity to leverage the infrastructure (16), extensive experience, and knowledge of TB researchers and healthcare workers on infection control.

Health promotion interventions are important to manage TB in the context of COVID-19. Most factors that lead to TB propagation are modifiable through health promotion. To prevent stigma and discrimination towards people affected or suffering from COVID-19, the government has to embark on a massive community engagement initiatives. This can be done in conjunction with civic groups, media organizations, and community leaders. Communities can be empowered through education and awareness campaigns and education on COVID-19 and TB. Such platforms can also encourage citizens to seek medical attention without fear of discrimination at health centres.

The healthcare system in the country was sub optimal pre-COVID-19 and the pandemic has worsened the situation. There is a need for political commitment to strengthen the healthcare system that can adequately address gaps in the health systems in the long term (10) . In the immediate response, TB programs may use locally derived, simple risk stratification methods to focus interventions like active case finding and preventive treatment to family members at high risk of infection to increase their impact and cost-effectiveness (17) . The scaling up of TB prevention and control initiatives involves monetary, material resources, as well as investments in the workforce to fight the disease together with patients (18, 19) .

During this COVID-19 pandemic the country should redefine the minimum package of HIV care and stregnthen differentiated service delivery (DSD) models to include TB prevention therapy (TPT). DSD is a client centric approach that streamlines TB services that address the needs of patients and minimise the burden on healtcare facilities. TB patients will benefits from five common models of DSD for effective TPT. Firstly, health facilities to remain open and offer fast track refills of anti-TB medications. Secondly, since the distribution of TB medication to patients may prove to be difficult, health facilities ought to consider a two-tiered approach: make delivery of medications to patients communities or arrange specific days where patients can come to collect their medication. To minimize frequent travelling by patients to healthcare facilities to collect their medication, patients can be given a one time six-month dosage of anti-TB medication (19) . A recently concluded clinical trial has revealed that 4 months of treatment for TB works as well as a 6-month regimen (20). This will create more treatment success and less cost. Fourthly, creation of healthworker managed groups at healthcare centres or in communities to encourage treatment adherence, medication refills and teen support. Healthcare workers must provide information on dosage, frequency of medication, and possible adverse reactions to the medications. Fifthly, TB infected managed groups such as community anti-TB treatment groups that facilitate refills may be utilized. For each model, there is need to facilitate documentation and identification of best practices and taking these to scale. Widespread implementation of DSD for TPT is inexpensive, with potential to prevent advancement to clinical disease, decreasing TB associated mortalities, morbidities, including hospitalizations and eventually decreasing TB transmissions and, thus, unburdening healthcare systems.

Finally, the COVID-19 pandemic has strained the country healthcare and affected TB care continuum. The country can benefit from adopting innovative strategies such as incoporation of TPT in DSD models. Widespread implementation of DSD for TPT is inexpensive, with potential to prevent advancement to clinical disease, decreasing TB associated mortalities, morbidities, including hospitalizations and eventually decreasing TB transmissions and, thus, unburdening healthcare systems.

J o u r n a l P r e -p r o o f

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Current status of epidemiology, diagnosis, therapeutics, and vaccines for novel coronavirus disease

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Potential impact of the COVID-19 pandemic on HIV, tuberculosis, and malaria in low-income and middle-income countries: a modelling study. The Lancet Global Health

Impact of COVID-19 on tuberculosis services in India

Maintaining robust HIV and TB services in the COVID-19 era: A public health dilemma in Zimbabwe

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COVID-19: a perspective for lifting lockdown in Zimbabwe

The fight to end tuberculosis must not be forgotten in the COVID-19 outbreak

Quality of life, tuberculosis and treatment outcome; a case-control and nested cohort study

Coronavirus Disease 2019 (COVID-19) Response in Zimbabwe: A Call for Urgent Scale-up of Testing to meet National Capacity

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