As the world grapples with the global pandemic of COVID-19, Médecins Sans Frontières/Doctors Without Borders (MSF) is concerned for vulnerable groups worldwide.
On World TB Day we wish to draw attention to people with tuberculosis (TB), as they are among the groups that may be doubly affected. Special attention will be needed to safeguard the continuity of prevention, diagnosis, treatment, and care for people with TB worldwide.
TB is the world’s leading infectious disease killer with nearly 10 million people affected and 1.5 million deaths in 2018. Half a million people have drug-resistant forms of TB for which the treatment is long and toxic. TB is also the leading cause of death among people living with HIV. Many countries – such as India and South Africa – have large numbers of people living with both HIV and TB.
As with TB, COVID-19 typically affects the lungs and people who contract it may show similar symptoms to TB, such as coughing and fever. It’s likely that people with lung damage, such as TB patients, or those with weak immune systems, such as those with poorly controlled HIV, may suffer from more severe forms of COVID-19, if infected. In addition, many people with TB live in densely populated areas and this close proximity further increases their risk of getting COVID-19, especially for those living in overcrowded settlements with little access to clean water or healthcare.
This already concerning situation will become even more grave if diagnosis and treatment for HIV or TB is interrupted. As such, MSF supports the World Health Organization’s (WHO) information note on strategies to maintain continuity of essential services – prevention, diagnosis, treatment, and care – for people living with TB and drug-resistant TB during the COVID-19 pandemic.
Leonid, 53, from Belarus, spends his days and nights alone in a locked room in the intensive care unit of the Republican TB Institute. Leonid has nightmares and he is convinced that they are caused by loneliness. Leonid has a daughter and grandchildren, but has not seen them since he got sick several years ago. All of his family are afraid of catching TB from him. “Living with TB is very bad. You might as well be dead – no one needs you. There’s nothing worse than loneliness. No one wants to visit me, I’m alone here.”
Photograph by Viviane Dalles
Grace Siemtharmawi, 17, from India, is an MDR-TB patient. She is still at the beginning of treatment. MSF has built her a small house next to her family home where she can live in order to prevent the rest of her family becoming infected.
Photograph by Jan-Joseph Stok
Leonid, 53, from Belarus, spends his days and nights alone in a locked room in the intensive care unit of the Republican TB Institute. Leonid has nightmares and he is convinced that they are caused by loneliness. Leonid has a daughter and grandchildren, but has not seen them since he got sick several years ago. All of his family are afraid of catching TB from him. “Living with TB is very bad. You might as well be dead – no one needs you. There’s nothing worse than loneliness. No one wants to visit me, I’m alone here.”
Photograph by Viviane Dalles
Grace Siemtharmawi, 17, from India, is an MDR-TB patient. She is still at the beginning of treatment. MSF has built her a small house next to her family home where she can live in order to prevent the rest of her family becoming infected.
Photograph by Jan-Joseph Stok
Health care systems, particularly those in low-resource settings, will be put under considerable pressure by the COVID-19 virus. We know from previous epidemics that reduced access to care, medicines, and diagnostics for people with life-threatening conditions like TB can lead to an increase of deaths from these underlying conditions. In Guinea, one of the countries at the epicentre of the 2014-2015 Ebola epidemic, reduced health services led to a 53% decrease in the diagnosis of TB, and a doubling of the mortality rate from it from direct and indirect impacts on TB health services.
Concurrent to the global response needed to tackle COVID-19, health authorities, implementing partners, and international funders must make every effort to maintain essential services, while reducing the risks for vulnerable populations.
To reduce the risk of COVID-19 infection amongst people with TB and HIV, we will need to see innovative changes to the ways in which healthcare is provided: this includes decentralised and outpatient treatment, access to treatment through community and ‘physically distant’ models of care, and follow-up through telemedicine and web applications. The implementation of all-oral treatments for drug resistant TB as recommended by WHO is now an imperative that cannot be delayed, as is the implementation of community supported treatment to reduce contact with health structures.
Given the high risk of severe disease in TB patients, efforts to minimise the impact of COVID-19 should also include the provision of protective measures for staff and those in contact with people with TB and the testing and isolation of confirmed or suspected COVID cases to avoid transmission to others.
Svitlana, 33, Ukraine: “For me, the worst thing about the treatment is that the days can be long and boring. I wish I could be at home with my dogs and cats, but I know that my diagnosis is serious and I need to be here [in TB hospital] until I am better. I am building friendships with the other people being treated here, too. There is a community spirit. It has to be this way – we look out for each other through the tough times. Sharing our fears and supporting one another helps us to stay positive.”
Photograph by Hannah Whitcombe
Both Meme Mahiro, 5, and his mother Kari Dusty from Papua New Guinea are on treatment for tuberculosis. In the beginning, the other villagers isolated them, but once they saw how both patients improved, they returned to normal behaviour. Stigmatisation is a severe additional burden for TB patients. It is crucial that TB patients are continuously provided with medication and take their medication regularly. However, access to health care is difficult in a country like Papua New Guinea.
Photograph by Sara Bechstein/MSF
Svitlana, 33, Ukraine: “For me, the worst thing about the treatment is that the days can be long and boring. I wish I could be at home with my dogs and cats, but I know that my diagnosis is serious and I need to be here [in TB hospital] until I am better. I am building friendships with the other people being treated here, too. There is a community spirit. It has to be this way – we look out for each other through the tough times. Sharing our fears and supporting one another helps us to stay positive.”
Photograph by Hannah Whitcombe
Both Meme Mahiro, 5, and his mother Kari Dusty from Papua New Guinea are on treatment for tuberculosis. In the beginning, the other villagers isolated them, but once they saw how both patients improved, they returned to normal behaviour. Stigmatisation is a severe additional burden for TB patients. It is crucial that TB patients are continuously provided with medication and take their medication regularly. However, access to health care is difficult in a country like Papua New Guinea.
Photograph by Sara Bechstein/MSF
Global solidarity is essential to tackling a global pandemic. Avoiding excessive stockpiling and export bans will ensure that essential medicines and supplies, including personal protective equipment, can reach all countries in need. Such collaboration and sharing will reduce the risk that people with TB are put at additional risk because of a lack of necessary drugs or ability to test. Without such an approach, the pressure on countries with already fragile health systems will be doubled. As countries struggle to deal with the COVID-19 pandemic, we must take all necessary steps to ensure that the impact of this pandemic does not create a second tragedy for vulnerable communities worldwide, including people with TB and HIV.
Media personality Gerry Elsdon from South Africa was diagnosed with TB in 2002, and has been publically raising awareness around TB for 17 years. “TB remains a highly stigmatised disease and so an important aspect of patient advocacy is to make people who are suffering with TB understand that they are not alone, that there are others like them, and that there is no shame in sharing the impact that TB has had in their lives,” she says.
Photograph by Jelle Krings
Media personality Gerry Elsdon from South Africa was diagnosed with TB in 2002, and has been publically raising awareness around TB for 17 years. “TB remains a highly stigmatised disease and so an important aspect of patient advocacy is to make people who are suffering with TB understand that they are not alone, that there are others like them, and that there is no shame in sharing the impact that TB has had in their lives,” she says.
Photograph by Jelle Krings
MSF and TB
MSF is one of the largest non-governmental providers of TB care in the world. In 2018, in projects in more than 20 countries across the globe, we started 16,500 people on treatment for TB, and 2,840 people for drug-resistant TB in 2018. Together with partners we are running two clinical trials for drug-resistant TB (TB PRACTECAL and endTB) aiming to find effective and short treatments, with manageable side effects.
MSF and COVID-19
In most countries where MSF works, we are coordinating with WHO and ministries of health to see how we may be able help in case of high numbers of people with COVID-19 and are providing training on infection control for health facilities. So far, we have initiated support in Belgium, Italy, France, Spain, and Iran.
A key priority for MSF is to keep our regular medical programmes running for the extremely vulnerable communities we are supporting around the world.
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