Managing TB during the COVID-19 Pandemic

Due to the COVID-19 pandemic, managing TB has become even more of a challenge. As it has interrupted the ways we reach out to the patients affected by TB.  It is vital to have regular contact with patients undergoing treatment for TB. This is to ensure treatment monitoring; checking for adverse reactions, concordance and completion of the regimes. TB nurses are adaption and finding different ways to make regular contact with their patients, without sacrificing quality.

TB is a deadly disease; with more than 4,000 deaths a day worldwide, making it the largest infectious disease killer in the world. It is not yet clear whether having a disease like TB, will increase the severity of disease from coronavirus infection. There is, however, evidence that having underlying health condition such as a chronic respiratory disease will increases the chance of exacerbation of symptoms of the other and have negative impacts on a person’s health, following contracting COVID-19.

Many of the events that are held annually to mark World TB day have inevitably been cancelled this year, but The Union (Tuberculosis and Lung Disease) launched guidance, recognising that people living with TB are likely to be more vulnerable to COVID-19. It also reiterated that it is essential to ensure that access to TB prevention, diagnosis and treatment should continue and maintained during the COVID-19 pandemic. The World Health Organization as well as NHSE and Improvement have also released information statements echoing this.

Since the pandemic began, there have been concerns raised about some areas of the TB care the control. Given the impact that COVID-19 has nationally and globally, TB nurses have expressed the need for the TB management and control to continue, while adapting to new and different ways of working:

Face-face contact reduced

Face-face contact is important for when diagnosis are made as other investigations take place. As this is essential, consideration should be taken by maintaining physical/social distance. Follow-up consultations are suggested to be booked via a tele-consultation (telephone) or video-consultation (virtual). 

Case management follow-up can also be undertaken by tele or video consultation but there needs to be some flexibility in the approach taken. 
For example; TB nurses are required to check/count all medication e.g. doses taken etc. This cannot be done over the telephone but can be via video-consultation. 
Where patients can only be followed-up by home-visits, then appropriate personal protective equipment should be used, or to protect patients, who already may have a severe lung disease, and some have co-morbidities making them part of the COVID-19 vulnerable group.

Direct observed therapy

As all TB patients are risk assessed for compliance, should they require support with medication, they are started on Direct Observed Therapy (DOT), which is face-to-face daily. Some patients are started on video observed therapy (VOT), however, this does not suit all patients. DOT or VOT should include and ensure that patients are assessed for any side effects from the medications as well as assessment and support for any psycho-social issues. 

TB contact screening

It has already been observed that contacts of infectious TB cases not attending vital screening appointments, due to concerns of COVID-19. It is difficult to undertake TB screening remotely, as it often involves an investigation such as a skin test, blood test or chest-x-ray.

Contact screening is the cornerstone of TB management and control. It is the process that detects cases early and identifies Latent TB cases. Some vulnerable groups are most are risk of disease progression, these include children under the age of 2, individuals who are immunosuppressed, pregnant or have one or more social risk factors such as dependence on alcohol and illicit drugs, and homelessness. Early diagnosis is important to prevent severity of the disease and mortality.

This remains a challenge; locally contacts are contacted prior to their appointments, explaining the importance to attend their screening investigation.  This gives an opportunity to asses for coronavirus symptoms it also avoids patients’ suffering from TB symptoms and not seeking medical help, which can result in more severe disease.

Conclusion

It is very important that TB services continue, and that people have access to diagnostic services, treatments and support services for TB during this time of COVID-19. Treatment interruptions and no concordance will lead to drug resistance disease. Monitoring supply of medications is also vital and any procurement issues, to prevent a shortage.

Despite the challenge's teams can embrace and adapt to new ways of using technology, not only for patient consultations but team meetings and multi-agency/disciplinary etc.

Some suggestions (Tips):

• Where home visit or clinic attendance necessary, pre assess patient/s e.g. via telephone for COVID-19 symptoms
• Provide adequate supply of TB medication to patients for safe storage at home, this to avoid a visit to the clinic or a home visit by the TB team member and to ensure treatment completion
• Provide information to patients about COVID-19, so they can protect themselves and continue with their TB treatment
• Provide basic infection prevention and control measures for TB and COVID-19 e.g. cough etiquette, physical distancing
• Use personal protection equipment where required. Masks have been used in TB infection prevention and control for many years to lessen the risk of further transmission of TB amongst close contacts of the affected person, the community and healthcare. Please also check out the latest guidance published by Public Health England.
• Maintain the provision of TB contact tracing and preventive treatment, particularly in high risk groups

Links for Information:

• What are the similarities between COVID-19 and TB?
• Tuberculosis in complex emergencies
• World Health Organization (WHO) Information Note; Tuberculosis and COVID-19
• COVID-19 in focus on World TB Day: The Union stands in solidarity and with resilience in the fight against two airborne diseases - TB and COVID-19