Thinking about tuberculosis in times of COVID‐19

The year 2020 brought us one of the biggest pandemics of the new era. During January of this year, the World Health Organization (WHO) declared the outbreak of coronavirus 2 (SARS-CoV-2) disease (COVID-19) a global health emergency due the fast spread, severe respiratory implications, high mortality and the catastrophic effects in social and economic life around the world [1]. Almost 30 years earlier, Tuberculosis (TB) was also declared as a global emergency [2], but this one had low relevance and impact at the global community at the time and sadly, it continues like that. We are worried about 1.053.994 confirmed deaths COVID-19 cases since the beginning of this outbreak [3], but not about the 1.2 million TB deaths among HIV-negative people during 2018 [4]; so maybe something is wrong in our perception about how deadly TB can be. The first deceased of COVID-19 in Paraguay was a physician and that same day the full quarantine was declared in the country. Two weeks earlier, on March 7 the first case of SARS-CoV-2 infection had been detected, but the Ministry of Health had already contacted to scientific societies and specialized epidemiological team to make a national plan design and to assemble clinical guidelines, proposing one of the earliest lockdown of South America. New hospitals were enabled in Asuncion to handle moderate to severe COVID-19 cases. Intelligent lockdown was implemented at June 15 and the COVID-19 numbers began to rise, mainly related to a major outbreak occurring at a state penitentiary. Closing the country’s borders delayed the COVID-19 attack on Paraguay, but the ‘stay home’ slogan probably increased the spreading of TB by putting entire families together in their (often) poor-ventilated houses. Unfortunately, this coronavirus was eventually able to slowly cross the borders of our country and now we need to fight against two enemies in our own house. At the time of writing this note, Paraguay reports 45.647 confirmed COVID-19 cases, 28.546 recoveries, 693 hospitalized patients (152 in ICU), and 966 deceased [5]. The TB situation differs significantly from the COVID-19 outbreak. Comparing the numbers of adult TB suspects in the country between the period March-August 2019 and at the same period in 2020, we found an alarming decrease of 80.8% in notifications of respiratory symptoms and a 42.4% reduction in adult patients with confirmed respiratory TB. We wonder if this is only the tip of the iceberg. The decline in TB cases may be the herald that announces that we are failing to diagnose new and relapse cases of TB, as well as treatment failures. The eventual interruptions in therapy may facilitate the probable increase/appearance of multi-drug resistant cases. This marks an unfavourable trending for the good results that were seen in the last ten years in our country (TB incidence: 37 cases per 100 000 inhabitants) [4]. A prediction made by the STOP TB partnerships shows that globally a quarantine of 3 months with a slow restoration of the situation would generate 6.3 million new TB cases in a 5 years period, with a devastating increase of 1.4 million deaths during that time [6]. The new pandemic could decrease the prioritization of TB programme services, limiting the access to resources and drug availability in developing countries like Paraguay, increasing stigma and discrimination among this group of people. Together, both diseases show their most perverse face in vulnerable and comorbid populations. This COVID-19 outbreak situation determines a critical point that requires complete attention from the minister of health of the country. Nonetheless, this health event, that involves scientific and industrial international communities, may represent one of the major chances to finally be able to learn about a new disease without forgetting an oldest one. This is the opportunity for a global health paradigm shift. Using this point of view, the COVID-19 pandemic should not be considered as a completely negative situation, but instead, it should be seen as a possibility to change and improve the global health system perspective that has neglected TB for so many years. It´s time to take real and concrete actions if we want to eliminate TB. None. Rosarito Coronel Teixeira: Conceptualization (equal); Formal analysis (equal); Investigation (equal); Supervision (equal); Writing-original draft (equal); Writing-review & editing (equal). Sarita Aguirre: Data curation (equal); Formal analysis (equal); Software (equal); Writing-review & editing (equal). Domingo Pérez Bejarano: Conceptualization (equal); Formal analysis (equal); Methodology (equal); Writing-original draft (equal); Writing-review & editing (equal).