Syndemic of Tuberculosis and COVID-19 in Bangladesh

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Brief Description: Bangladesh ranks seventh among the 30 countries with a high burden of tuberculosis (TB) and a considerable annual incidence of multidrug-resistant TB. Before the pan- demic, on average, 70 000 cases remained undiagnosed, and 40% of drug-resistant TB cases were enrolled each year. Despite actions taken, the TB care system of the country is riddled with limitations, including delay in diagnosis, lack of adequate diagnostic amenities, complex care pathways, and improper referral practices. These were markedly enhanced due to the ongoing coronavirus disease 2019 (COVID-19) pandemic and had a negative impact on the number of people seeking and receiving health care due to TB. The countrywide lockdown strategy and closure of public transport during the initial stages of the pandemic had put immense pressure on the national TB control pro- gram. Closure of routine care in many hospitals to facilitate COVID-19 management led to difficulty accessing directly observed treatment short course (DOTS) corners, interruption in the drug supply chain, and shutdown of essential laboratory services. Even the remaining open centers were hard to reach at that time, mostly due to the complete closure of private and public transports. Thus, a significant disruption occurred in the prevention, monitor ing, and treatment of TB. A drop in TB notifications, delayed treatment initiations, reduced treatment adherence, and, in general, a significant reduction in TB services was obvious. The number of persons admitted for inpatient treatment also fell significantly than that in the previous year. Data on the actual disruption of the TB care system as well as potential medium- and long-term consequences of such disruption are currently lacking. However, a national dedicated TB hospital statistic suggested a significant decline in the admission rate and outpatient visits during the crisis (Figure 1 and Supplementary Figure 1). Overall reporting system of the country went down as well. Mathematical models suggest that disruption of TB services might substantially increase TB mortality and incidence in the near future. One model indicated that a 50% drop in TB case detection over 3 months could increase the number of TB deaths worldwide by nearly 400 000 in 2020
alone. The TB burden will also increase several-fold due to the syndemic effects of COVID-19 with social inequalities, pushing the people to extreme poverty. Although we are facing a more significant challenge of managing COVID-19 cases at this moment, the burden of TB may bounce back and exceed previous levels in the coming years unless proper strategic steps are taken immediately. There is an urgent need for a recovery plan to obtain TB responses back on track.
Extensive catch-up works and ramped-up essential service packages, particularly routine immunization, enhanced diagnosis and treatment, advocacy, and funding, are needed as immediate measures. Prompt identification of missing TB patients is required. Some approaches for this purpose might include concomitant TB-COVID-19 screening and intensified case finding through reinforcement of sputum smear microscopy with rapid molecular testing and homebased sample collection. Treatment could be ensured through TB medicine delivery at home and by modification of the DOTS approach to include digital adherence technologies, call centers, and family members to provide treatment support. Additionally, repurposing a corona tracer (a mobile application used for COVID-19 contact tracing in Bangladesh) for contact tracing, reporting, and establishing a national TB helpline can also strengthen the overall TB care system. A long-term targeted investment is crucial for strengthening community responses to both COVID-19 and TB and addressing poverty, malnutrition (by food rationing), overcrowding, poor housing, and unemployment. Coordinated dissemination and sharing of knowledge and a community-centered approach to mitigate the burden of TB could be other essential steps. Commitment from high-level.