In the Shadows of the COVID-19 Pandemic

In this issue of our journal, there are three articles reporting on tuberculosis, a disease which has historically been a big problem in our country – much longer than the current COVID-19 pandemic.It cannot be denied that COVID-19 is a big problem right now and should indeed be a priority. As of October 24, 2020,the DOH reports that there have been 367,819 cases of COVID-19 from the time it began monitoring the numbers some nearly nine months ago.1The effect of COVID-19 goes beyond these number of cases, as many of them have already died.However, against this alarming situation, even more concern lurks underneath. Just 10 days previously, the WHO released its 2020 Global Tuberculosis Report.2Among other things, prominent mention in the 2020 Report is the threat that theCOVID-19 pandemic can reverse the gains made in TB control over recent years in many countries, including the Philippines.In 2019, prior to the COVID-19 pandemic, the Philippines is reported to rank fourth in terms of the number of TB cases,contributing 6% of the total global burden of TB.3 Computing this on a per capita basis paints an even darker picture: the Philippines has 554 TB cases per 100,000 population, exceeded worldwide only by Lesotho, a small country in Southern Africa with a population of just around 2% that of the Philippines.4Identifying new TB cases is a key strategy in TB control. It is an important step in identifying and initiating treatmentfor those who need it. However, gaps in estimated incidence and notifications have long been a problem in the Philippines.2,3And with the COVID-19 pandemic, this has now become bigger. The 2020 WHO Report says that there has been a dropof 50 to 75% in the monthly notifications for the April to June period compared to January 2020 in the Philippines. Sucha trend – reported in other countries as well – is attributed to under-reporting of new TB cases during this COVID-19pandemic.5-13 The sudden drop over a few months cannot be due to any sudden improvement of TB control but more to the challenges that the pandemic has had on the TB control programs. In many TB high burden but low-income countries like the Philippines, reallocation of human, financial and other resources from TB to the COVID-19 response is happening. For example, GeneXpert™ machines are being diverted for use in COVID-19 testing.14 Staff in national TB programs as well as healthcare frontliners are being assigned to COVID-19 related duties. Similar to other countries, community lockdowns, patient concerns on getting infected, lack of public transportation, and loss of jobs and its attendant financial consequences, among others, are also serious considerations limiting access to TB diagnosis and treatment in the Philippines.15Any benefit from social distancing and wearing of face masks to reduce TB transmission are likely outweighed by health service disruption.16 As is the case with other patient co-morbidities, the interaction between COVID-19 and tuberculosis have also been looked into. However, current data do not allow any meaningful conclusions.14,17 Because of similarities in presentation symptoms such as fever, cough and difficulty of breathing, the recognition of tuberculosis may also be confused with COVID-19.18,19All of these are predicted to further worsen TB incidence due to increased transmission and along with greater diseaseseverity will have a larger negative effect on GDP per capita, undernutrition and catastrophic costs to families.2According to the model presented in the 2020 Global TB Report, assuming a more conservative 50% decrease in case detection over a six-month period could result in 700,000 excess deaths due to TB, globally.2The economic burden of additional cases has also been estimated for other countries and is quite substantial.20In an article published in this issue of our journal, drug resistance is identified as the biggest risk for unsuccessfultreatment outcomes in patients with tuberculosis.21 There are already increasing RR/MDR TB cases in the country based on the results of the 2016 National TB Prevalence Survey and other data.2,4,22 Previous unsuccessful treatment continues to be a big driver in the development of this drug resistance; and unsurprisingly, we now see that drug resistance in turn further drives even more unsuccessful TB treatment.In the latest WHO country profile report, RR/MDR TB incidence is estimated at 3.8% overall; but shoots up to 28%in previously treated cases.23 Most importantly, success of treatment was reported in only 58% of RR/MDR TB cases started on second-line drugs. As MDR-TB becomes more prevalent, and person-to-person transmission becomes more common, we may soon end up with MDR-TB as a major initial presentation of TB in our country. This is definitely undesirable as treatment of MDR-TB requires significantly more financial resources compared to DS-TB and can further strain the already limited resources allocated for TB control in our country.
 With the big challenges we face with the COVID-19 pandemic and the resulting effect it presents to ongoing TB control,it is reasonable to fear that we will have more unsuccessful treatment of TB in the country. Even as this potentially increases the number of TB cases in general, the even greater threat of further increasing MDR-TB should make us even more concerned.We cannot afford to lose focus and momentum in our efforts to control TB. Others have in fact stated that the currentpandemic may actually be a good opportunity to evaluate and if needed, to revise some of the programs we have in TBcontrol.24,25 The WHO has also made some recommendations which we can hopefully follow as we maintain our vigilance on TB control during this pandemic.26The 2020 WHO Global Tuberculosis Report highlights many of the gains we have made in the Philippines. Hopefully,this COVID-19 pandemic will not push it back.
 Joven Q. Tanchuco, MD, MHAEditor-in-ChiefActa Medica Philippina
 REFERENCES1. COVID 19 Case Tracker. DOH COVID 19. Case Bulletin # 224[Internet]. [cited 2020 Oct 25]. Available from: https://www.doh.gov.ph/covid-19/case-tracker2. Global tuberculosis report 2020. Geneva: World Health Organization.License: CC BY-NC-SA 3.0 IGO [Internet]. 2020 [cited 2020 Oct25]. Available from: https://www.who.int/tb/publications/global_report/en/3. Global tuberculosis report 2019. Geneva: World Health Organization;License: CC BY-NC-SA 3.0 IGO.4. Tanchuco JQ. Risk factors, molecular mechanisms and testing of drugresistance in Mycobacterium tuberculosis: Focus on the Philippines.Philipp J Intern Med. 2020; 58(3):72-105.5. Jain VK, Iyengar KP, Samy DA, Vaishya R. Tuberculosis in the eraof COVID-19 in India. Diabetes Metab Syndr. 2020 Sep-Oct;14(5):1439-43. doi: 10.1016/j.dsx.2020.07.034.6. Amimo F, Lambert B, Magit A. What does the COVID-19 pandemicmean for HIV, tuberculosis, and malaria control? Trop Med Health.2020; 48:32. https://doi.org/10.1186/s41182-020-00219-67. Ong CWM, Migliori GB, Raviglione M, Mac Gregor-Skinner G,Sotgiu G, Alffenaar J, et al. Epidemic and pandemic viral infections:impact on tuberculosis and the lung. Eur Respir J. 2020; 56(4):2001727.https://doi.org/10.1183/13993003.01727-20208. Fei H, Yinyin X, Hui C, Ni W, Xin D, Wei C, et al. The impact ofthe COVID-19 epidemic on tuberculosis control in China. The LancetRegional Health – Western Pacific. 2020; 3:100032 https://doi.org/10.1016/j.lanwpc.2020.1000329. Komiya K, Yamasue M, Takahashi O, Hiramatsu K, Kadota J, KatoS. The COVID-19 pandemic and the true incidence of Tuberculosisin Japan. J Infect. 2020; 81(3):e24–e25. https://doi.org/10.1016/j.jinf.2020.07.00410. Togun T, Kampmann B, Stoker NG, Lipman M. Anticipating theimpact of the COVID-19 pandemic on TB patients and TB controlprogrammes. Ann Clin Microbiol Antimicrob. 2020; 19(1):21.https://doi.org/10.1186/s12941-020-00363-111. Ribeiro VST, Telles JP, Tuon FF. Concerns about COVID-19 andtuberculosis in Brazil: Social and public health impacts. EnfermInfecc Microbiol Clin. 2020; S0213-005X(20)30278-0. https://doi.org/10.1016/j.eimc.2020.08.01312. Alene KA, Wangdi K, Clements ACA. Impact of the COVID-19Pandemic on Tuberculosis Control: An Overview. Trop Med InfectDis. 2020; 5(3):123. https://doi.org/10.3390/tropicalmed503012313. Magro P, Formenti B, Marchese V, Gulletta M, Tomasoni LR, CaligarisS, et al. Impact of the SARS-CoV-2 epidemic on tuberculosis treatmentoutcome in Northern Italy. Eur Respir J. 2020; 56(4):2002665.https://doi.org/10.1183/13993003.02665-202014. Karim QA, Karim SSA. COVID-19 affects HIV and tuberculosiscare. Science. 2020; 369(6502):366–8. doi: 10.1126/science.abd1072.With the big challenges we face with the COVID-19 pandemic and the resulting effect it presents to ongoing TB control,it is reasonable to fear that we will have more unsuccessful treatment of TB in the country. Even as this potentially increases thenumber of TB cases in general, the even greater threat of further increasing MDR-TB should make us even more concerned.We cannot afford to lose focus and momentum in our efforts to control TB. Others have in fact stated that the currentpandemic may actually be a good opportunity to evaluate and if needed, to revise some of the programs we have in TBcontrol.24,25 The WHO has also made some recommendations which we can hopefully follow as we maintain our vigilanceon TB control during this pandemic.26The 2020 WHO Global Tuberculosis Report highlights many of the gains we have made in the Philippines. Hopefully,this COVID-19 pandemic will not push it back.15. Adepoju P. Tuberculosis and HIV responses threatened byCOVID-19. Lancet HIV. 2020; 7(5):e319-e320. doi: 10.1016/S2352-3018(20)30109-0.16. McQuaid CF, McCreesh N, Read JM, Sumner T, Houben RMGJ,White RG, et al. The potential impact of COVID-19-relateddisruption on tuberculosis burden. Eur Respir J. 2020; 56(2):2001718.https://doi.org/10.1183/13993003.01718-202017. Crisan-Dabija R, Grigorescu C, Pavel CA, Art