A letter to the Editors of the IJTLD on adaptations to TB services that could help ensure continuity of services for RR/MDR-TB during COVID-19.
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Article submitted 13 July and accepted for publication on 14 July 2020. Read the full text for more information, including the acknowledgements and citations.
A. C Meneguim, L. Rebello, M. Das, S. Ravi, T. Mathur, S. Mankar, S. Kharate, P. Tipre, V. Oswal, A. Iyer, H. Mansoor, S. Kalon, D. Garone, G. Ferlazzo, P. Isaakidis
The COVID-19 pandemic has resulted in rapid and profound changes in health systems worldwide to cope with the unexpected challenges. Essential health services, such as TB services, have been neglected, which poses a major risk of reduced TB diagnosis and treatment initiation leading to a potential significant increase in TB-related morbidity and mortality in the future. The WHO has provided guidance for TB care, but these adaptations need to be tailored according to the context.
In Mumbai, the most populous city in India, Médecins Sans Frontières (MSF) provides diagnostic and treatment services to patients with rifampicin/multidrug-resistant TB (RR/MDR-TB) in collaboration with India’s National TB Elimination Programme at the outpatient department of Shatabdi Hospital. The hospital offers care to patients residing in M-East Ward, where nearly 73% of the 800,000 inhabitants live in slums, which presents a major TB hotspot in the state and the country. The ambulatory model of care entails free of cost services comprising early diagnosis, treatment, including treatment with bedaquiline, delamanid and imipenem if required, decentralised follow-up at health posts, and adherence support including counselling. As of June 2020, there were 1451 active RR/MDR-TB patients on treatment, 60% were females, approximately 37% had fluoroquinolone resistance, 1.9% were HIV-positive and 10% had diabetes.
In July 2020, more than 85,000 cases of COVID-19 were reported in Mumbai. Whereas stringent COVID-19 responses may curb its spread and avoid deaths attributable to COVID-19, modelling has shown the potential long-term effects of the disruption to TB care. Three months of lockdown in India, followed by a 10-month recovery period could incur 1,788,100 excess TB cases and 511,930 excess TB deaths between 2020 and 2025. It is essential we avoid such catastrophic outcomes and adapt services to provide continuity of care.
As the first cases of COVID-19 were identified in India, the provision of essential services in Mumbai, including those for TB/DR-TB, were heavily affected by lockdown regulations and reassignment of health care workers to COVID-19. To ensure continuity of care, MSF-supported TB services have been adapted to protect both health care workers (HCWs) and patients, focusing on infection prevention and control (IPC) measures, screening, linkage to COVID-19 care and the avoidance of non-essential visits.The Table summarises the main challenges faced during adaptation of TB services and the proposed solutions. The patient flow and adaptations are described below:
- Patient flow. Upon arrival, patients receive a token with a serial number according to the service needed: report collection, sputum sample delivery, consultation. Patients line up in one of three queues in an external waiting area, where crowd controllers ensure social distancing. Here, laboratory reports are distributed and sputum containers collected. Patients are screened for COVID-19 by a nurse using an infrared thermometer and a clinical screening tool to identify presumed cases or history of contact. In case of temperature ≥38⁰C (or any positive answer in the questionnaire), patients are directed to a secondary screening area, where a designated doctor assesses and refers patients to the COVID-19 clinic available at the same hospital complex for further management and testing.
- TB/DR-TB treatment and follow-up. The need to reduce visits to health centres and contact with HCWs has represented the opportunity to finally switch from injectable-based to oral regimens for DR-TB, as recommended by the WHO. The follow-up visits take place at 2 weeks, 4 weeks and monthly thereafter in case of bedaquiline and/or delamanid-containing regimens, and every 3 months when new drugs are not administered. Visits include ECG and laboratory analysis if required. Patients with drug-susceptible TB are given appointments at Months 2 and 6.
- Drug dispensing. Drug dispensing is decentralised with the exception of delamanid and imipenem, which is provided intravenously twice per day via a PICC (peripherally inserted central catheters) line or port-a-cath by community nurses conducting home visits with appropriate personal protective equipment (PPE).
- Patient support activities. The counselling session at treatment initiation is performed face-to-face following strict IPC measures, whereas follow-up sessions take place via telephone or video call. At each remote contact with the patients, counsellors also ask for onset of any COVID-19 symptoms and/or adverse events during DR-TB treatment. In case of severe symptoms, patients are directed to the clinic; if mild, they are listed for tele-consultation with a doctor. A social worker connects patients facing severe socio-economic challenges with individual donors or NGOs that provide financial and social support.
- Health promotion. Community HCWs provide health education messages in the external waiting area, whereas informative videos are displayed in the internal waiting area. Posters are distributed in the clinic premises. Messages are also conveyed during face-to-face and tele-counselling sessions and sent via digital platforms.
- Telemedicine. Doctor calls patients at the scheduled time for clinical consultation. Prescriptions are sent via digital platforms; patients are booked for face-to-face consultations if needed.
- PPE. Adequate PPE is provided to HCWs according to the risk exposure, which may include N95 respirators, face shields, gloves, gowns and/or hoods, as well as aprons, gumboots and duty gloves for hygiene workers.
- Staff management. Reduced numbers of HCWs work in weekly shifts. In case of any new respiratory symptoms or fever, the staff is requested to inform a designated doctor for further management and refrain from coming to work.
Although these changes are adaptations to a negative situation, positive aspects should be acknowledged and included in the advocacy agenda for overall improvement of TB services. The most important positive aspects include the accelerated switch from injectable-based to all-oral regimens for RR/MDR-TB, and a more robust shift towards decentralisation and community delivery of services. This includes home-based care, thereby decreasing the visits to health facilities to a minimum, while enhancing support through new technologies. Furthermore, reduced dependence on directly observed treatment (DOT), including exploration of video-observed therapy (VOT) and other forms of patient-centred adherence support should be highlighted. Finally, the integration of COVID-19 screening in the patient flow shows potential for becoming a model for other forms of integrated services such as non-communicable disease screening, mental health, health promotion and future epidemics.
To conclude, continuity of services for RR/MDR-TB care during the COVID-19 pandemic is of utmost importance, and requires adaptations to the existing system to protect both patients and HCWs. This article is designed to guide other services to maintain their activities and integrate new technologies. Some lessons learned in this scenario may have beneficial long-lasting impact in the approach to TB care, with more emphasis on a patient-centred approach.