Time to push panic button on TB as Covid retreats, say worried experts

When Zolani Manzini developed a dry cough in June, his first thought was that he had Covid-19. But his test was negative.

It was only in the first week of September that the 70-year-old grandfather and diabetic from Butterworth in the Eastern Cape had a tuberculosis test, after almost three months of coughing and weight loss.

“On my first visit, the clinic was closed because several staff members tested positive for Covid-19. On one of my visits to the clinic I couldn’t really wait in queue due to heavy rain, as we sat outside to allow social distancing,” said Manzini.

“The constant closure of clinics due to the Covid-19 pandemic became a problem, as many patients like me were forced to leave and told to seek health care in alternative clinics. That is why it took so long before I had the TB test.”

Manzini is among thousands of people who struggled to have a TB test during lockdown. According to the National Institute for Communicable Diseases (NICD), there were 308,000 fewer tests and 17,700 fewer positive samples detected between the beginning of April and the end of July compared with 2018.

The institute’s vector control expert, Prof Basil Brooke, said the decline in tests was due to factors including restricted movement, avoidance of public transport and reluctance to visit clinics for fear of contracting Covid-19.

While SA’s Covid-19 death toll was 16,586 on Monday, the World Health Organisation (WHO) estimates that 36,750 people will die of TB in the country this year.

Public health expert Keertan Dheda, professor of pulmonology at the University of Cape Town (UCT), said the dramatic reduction in TB testing and diagnosed cases was alarming.

“To claim back lost ground we need to resort to active case-finding ... that is, reaching out into the community to find cases, rather than waiting for them to present to healthcare services,” he said.

“It is a shocking statistic that even before the Covid-19 pandemic, two in every five TB cases remained undiagnosed or undetected.”

Dr Jennifer Furin, an infectious disease clinician for Medecins Sans Frontieres (Doctors Without Borders), said Brooke’s report reflected what was happening at clinics in the Western Cape and KwaZulu-Natal.

Out of 13 million Covid-19 tests in SA, only 10,000 had requested simultaneous TB tests. “These figures show that there is an urgent need for integration of TB and Covid-19 testing, as they share similar symptoms,” said Furin.

“While South Africa has done very well in raising awareness and dealing with Covid-19, we feel that President Cyril Ramaphosa could have used his regular updates on Covid-19 to raise awareness about TB, just like he did with gender-based violence.”

Furin said if the decline in TB testing was not addressed urgently there was a risk of losing the gains the country had made in its fight against the disease.

Dr Helene-Mari van der Westhuizen, chair of TB Proof, said measures that were key to the Covid-19 response, such as tracing, screening, real-time dashboards on disease incidence and widespread use of masks, “should all be used to strengthen TB response as we build towards quality universal health care for all”.

Prof Harry Hausler, head of TB/HIV Care, said given the decline in testing “it is reasonable to assume that we have missed the opportunity to diagnose many cases”. Before 2020 the country had a target of identifying 160,000 missing TB cases, “so more missed diagnoses are a big concern”.

Hausler said while restricted movement and mask-wearing may have reduced the transmission of TB at community level, the spread of TB might have been “facilitated by the longer time spent indoors with a potentially infected household member”.

“Since household transmission is a significant mode of transmission of TB during normal times, this is also a concern. We need to integrate TB and Covid-19 testing to find the missing people with TB.”