Letter to the IJTLD's editors outlining key adaptations to TB service delivery that should be considered in high TB burden settings during the COVID-19 pandemic.
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This article was submitted on 1 April 2020 and accepted for publication on 2 April. Read the full text for more information, including the acknowledgments and citations.
Authors: V. Cox, L. Wilkinson, A. Grimsrud, J. Hughes, A. Reuter, F. Conradie, J. Nel, T. Boyles
To support tuberculosis (TB) patients during the COVID-19 pandemic, it is essential, both to patients and the healthcare system, to minimise unnecessary visits to health facilities. At this crucial point of time in the ongoing TB epidemic, we outline key adaptations to TB service delivery that should be considered in high TB burden settings. Our suggestions focus on the primary care level to reduce the risks of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) exposure during clinic attendance while prioritising the provision of uninterrupted TB treatment.
Healthcare providers in such settings are already familiar with TB infection control measures during their daily interactions with patients. However, it is paramount that resources are prioritised to remind and re-train staff on the importance of universal safety precautions, appropriate use of personal protective equipment and criteria for self-isolation to reduce the concomitant spread of COVID-19 in TB clinics. In addition, all TB patients should receive and wear a surgical mask while at the facility and be screened for COVID-19 through an appropriate triage system. TB patients screening negative for COVID-19 should be triaged directly to TB services. TB patients screening positive for COVID-19 should be kept separate within the COVID-19 investigative area (or at least 1.5 metres apart from another COVID-19 person under investigation) and TB services informed of their arrival. Following clinical assessment, visit frequency/treatment refill length should be determined by the clinician to avoid unnecessary visits during the COVID-19 pandemic. Specific adaptations are described for drug-susceptible TB patients (DS-TB), drug-resistant TB patients (DR-TB) and TB patients who are unwell.
Care for DS-TB patients
For DS-TB patients starting treatment who are relatively well, sufficient intensive phase TB treatment should be provided so that patients only return to the health facility for clinical assessment and to switch to the continuation phase. Where clinically appropriate, the full 4 months of continuation phase TB treatment should be provided. At the completion of treatment, patients should return for an exit clinical consultation.
For patients already on DS-TB treatment in the intensive phase, at their next visit, patients should receive the remainder of their intensive phase TB treatment. Those with a positive TB smear at diagnosis should receive labelled specimen jars with instructions to return sputum samples one week prior to the scheduled Week 8 clinical assessment visit. At the Week 8 visit, patients with no clinically significant deterioration and in whom smear conversion has occurred (if applicable) should be switched to the continuation phase and receive sufficient TB medications for the remaining four months of treatment. Those with a positive smear at diagnosis should again receive specimen jars with instructions to return sputum samples in the month prior to treatment completion. On completion of TB treatment, all patients should have a clinical assessment consultation at the health facility.
Where a patient is clinically deteriorating at the Week 8 visit, or sputum smear conversion has not yet occurred, TB culture and drug susceptibility testing (DST) should be requested. The patient should receive another 4 weeks of intensive phase TB treatment, return to the health facility at Week 12 for clinical review, and receive specimen jars to return with sputum samples for repeat smear analysis prior to the next appointment. Clinicians must recall patients if drug resistance is detected.
Patients already on DS-TB treatment in the continuation phase should be given sufficient TB medication to last until completion of the continuation phase. Those who had a positive smear at diagnosis should receive labelled specimen jars to drop sputum samples in the month prior to treatment completion as described above to allow for final assessment and treatment outcome in line with national policies.
HIV co-infected patients who are not on antiretroviral therapy (ART) should be started on ART on the same day as TB treatment with ART and TB prescriptions aligned (i.e., 2 months intensive phase TB treatment and 2 months ART supply). Patients with CD4 count <100 cells/mm3 should receive prednisone for 4 weeks (40 mg/day for 2 weeks, then 20 mg/day for 2 weeks).
Clinicians should telephonically recall those with urgent results (e.g., positive serum cryptococcal antigen test, TB drug resistance, etc.). Adherence counselling remains vitally important, particularly considering the limited in-person interactions with health care workers. The first counselling sessions should ideally be provided telephonically or near the health facilities where infection control measures are in place.
Care for DR-TB patients
DR-TB patients should be provided with DR-TB treatment refills to align with scheduled clinical visits at the health facility (Weeks 2, 4 and 8, and 2-monthly thereafter). Patients already on or starting an all-oral (injectable-free) DR-TB regimen and on linezolid require intensive monitoring of their haemoglobin (Hb) levels in the first 2 months of treatment, including Hb checks at Weeks 2, 4 and 8, and should receive treatment to align with this schedule. Clinicians should telephonically recall any patients with clinically significant myelosuppression and either modify treatment or monitor at least monthly (consider a rapid fingerprick Hb) while on linezolid. After 2 months, irrespective of DR-TB regimen, patients should receive 2-monthly treatment refills and clinical consultations with electrocardiograms (ECG) and Hb monitoring. Clinical consultations at Week 8, Month 4 and Month 6 are particularly important to assess treatment effectiveness, follow up on sputum culture results, make treatment modifications and monitor ECGs for patients receiving QT-prolonging drugs. Patients on DR-TB treatment need to give sputum samples every month until confirmed sputum culture conversion. Thereafter, 2-monthly samples are sufficient. At each 2-monthly visit, patients should be given labelled specimen jars to return with sputum between the 2-monthly clinical assessment visits. As noted above, telephonic adherence counselling remains critical. Patients on an injectable-containing DR-TB regimen should be urgently transitioned to an oral regimen as recommended by the World Health Organization (WHO). Returning 5–6 times a week during the COVID-19 pandemic for injectable treatment is ill-advised.
Care for patients who are unwell
All unwell patients should first contact the health facility by telephone, including those with TB. Where it is necessary to go to the heath facility, guidance on infection control and COVID-19 screening procedures on arrival should be discussed with the patient in advance. Other areas of consideration are outlined in the accompanying Table (in full text version).
Continued TB diagnosis and management remains critical during the COVID-19 epidemic. While we have focused on TB service provision for those patients on treatment, it is worth noting that patients with mild/moderate symptoms of COVID are currently being asked to self-isolate at home. However, these symptoms overlap with those of TB and it is important that such patients are investigated for TB if appropriate. We urge the TB community to act quickly to adapt and strengthen TB service provision to maximise the health and safety of our vulnerable TB patients and TB healthcare workers during these unprecedented times.