How COVID-19 has strained Ghana’s anti-TB programme

It all started six months ago when Karima (not her real name) started coughing but mistook it for a simple case of flu.  Even though Karima has a form of Tuberculosis (TB), which has been resistant to different drugs—known as Multidrug-resistant TB (MDR-TB), she said "this cough was different."

MDR TB is a particular type of drug resistant TB, where the TB bacteria that a person is infected with is resistant to two of the most important TB drugs, Isoniazid (INH) and Rifampicin (RMP). Karima was given antibiotics and syrup for the cough when she visited the clinic, but “after two weeks there was no improvement.”

Her doctor then decided to test her sputum for COVID-19, it was confirmed that she had the virus and was referred to the hospital for treatment.

"I told them (the nurses) that l did not know anyone with COVID-19 had l been in contact with anyone with COVID-19,” she told the Daily Graphic.

They told her COVID-19 was caused by the SARS-CoV-2 virus and spread between people when an infected person was in close contact with another person.

She learnt that the virus could spread from an infected person’s mouth or nose in small liquid particles when they coughed, sneezed, spoke, sniff or breathed heavily and that people could be infected with COVID-19, when the virus got into their mouth, noses or eyes when they were in direct or close contact (less than a metre apart) from an infected person.

"Then, it occurred to me that I might have been infected by someone with COVID-19 during my daily commute. The buses are often poorly ventilated with so many people beyond their capacity. I could also have been infected in the market where it is always congested," she said.

She said when she became ill; it was difficult to continue with her okro trade.

Battle

Karima is one of the 18 persons in the Greater Accra Region battling the dual burden of being infected with TB and COVID-19. (There is no data for the other regions in Ghana at the moment. Only the Greater Accra Region collated data on TB and COVID-19).

In 2020, a total of 210 MDR TB patients were detected and the World Health Organisation (WHO) estimates in 2019 that a total of 1200 people had MDR.

Medical officers attending to residents at Glefe

Health services under strain

Since the outbreak of COVID-19, Ghana is not only facing its usual health challenges, but has had to deal with both the direct cost of COVID-19 and the indirect consequences of it.

One of the consequences is Ghana’s anti-TB programme. TB is one of the major killer diseases and can present symptoms similar to COVID-19.

Though TB diagnosis and treatment is free in Ghana, it remains a major public health threat.

People with TB have reported experiencing increased stigma due to the symptoms they present, which are similar to those of COVID-19.

Many with these symptoms have been wary of presenting themselves at health facilities for testing for fear that they would be found to have contracted COVID-19, while those with TB are at higher risk of contracting the COVID-19.

Estimate

In 2019, an estimated 44,000 people fell ill with TB, and out of this number, a total of 15,000 died due to TB. From the total estimated cases in Ghana, males accounted for 51 per cent, while 31 per cent were women and children under 15 years constituted 14 per cent.

The Programme Manager of the National Tuberculosis Control Programme (NTCP), Dr Yaw Adusi-Poku, said about 66 per cent representing 29,000 of TB patients, remained undiagnosed in Ghana.

Currently, there is limited evidence on whether COVID-19 increases the risk of TB reactivation or not.

However, Dr Adusi-Poku said COVID-19 could potentially promote the development of active TB disease among COVID-19 patients with latent TB.

He explained that both TB and COVID-19 attacked the lungs and treatment outcomes for co-infected patients for the two diseases were difficult as compared to patients without dual infection.

"Patients with dual infection are highly likely to die as compared to single infection," he said.

To address the treatment, care of TB patients and increase access to TB diagnostic tests, the programme established a sputum referral system from 1,000 periphery facilities to 126 GeneXpert testing sites.

With that, patients do not have to travel to the testing sites, but can send samples through the Ghana post courier service to the testing site for diagnosis.

MDR TB patients now have to receive treatment in their district as the programme has decentralised the treatment at regional and district levels.

Dr Gloria Ivy Mensah, Research Fellow, Department of Bacteriology, Noguchi Memorial Institute of Medical Research, speaking during a TB Sensitisation programme

Incidence

In an attempt to reduce the incidence of TB in Ghana, the NTCP introduced a symptom-based screening tool (SBS tool) for active case finding.

This is where community health workers are trained in the use of the tool to carry out house-to-house screening to detect those with TB.

Other methods of detecting TB is screening that is usually done during community durbars — public gatherings convened by traditional leaders to consult with their people.

However, durbars have not been held due to the COVID-19 restrictions that banned public gatherings.

Ghana is implementing community Directly Observed Treatments (DOTS) to ensure that patients have access to treatment anywhere they are found.

DOTS is recommended by the WHO as the “the most cost-effective way to stop the spread of TB in communities with a high incidence by curing it and it is the best curative method for TB”.

DOTS involves diagnosis by sputum-smear microscopy and medication given under direct observation and supervision by health care workers to ensure drugs are taken at the right time.

But this means is resource intensive and expensive, making its implementation in low-resource settings difficult.

Voices

The National Secretary of TB Voice Network, an NGO, Mr Jerry Amoah-Larbi, is a trained accountant who started working on TB patients advocate after he became infected and affected by TB in 2010.

He said since the outbreak of COVID-19 the number of persons diagnosed of TB had gone down since people with symptoms suspected to be TB were shying away from getting tested.

"This development has consequences. It will affect plans of meeting the global target of ending TB by 2030," he said.

Because of the COVID-19 protocols, community awareness programmes have been suspended meaning citizens do not only receive information but screening programmes to detect TB have also stopped.

Interruption in treatment was inevitable when the government instituted lockdown measures to curb the spread of the COVID-19 virus. Health facilities gave patients additional medicines to continue treatment at home and minimise hospital visits.

However, their most urgent needs —non-medical support, including nutritional, economic and psychosocial support have not been met.

A 2018 study estimated that non-MDR TB patients spend GH¢2,475 on medicine while drugs for MDR TB patients cost GH¢3,794.

Those infected are not able to work which presents additional burdens on families. Treatment of TB can span from between six to nine months depending on the type of infection.

To encourage more TB patients adhere to the medications and the treatment plan, Mr Amoah-Larbi has been advocating for the government to ensure TB patients are covered by social protection programmes such as Livelihood Empowerment against Poverty (LEAP) programme during the period they are under treatment to relieve them of some of their financial burdens.

Under LEAP, the government provides cash and health insurance to extremely poor households to alleviate short-term poverty and encourage long-term human capital development.

"Most patients cannot work and the majority of them are the breadwinners of their families. Although TB treatment is free, the patients have to eat healthy and nutritious foods so the government must also provide nutrition at the centres where TB patients seek treatment,” Mr Amoah-Larbi says.

To prevent dual infection of TB and COVID-19, Mr Amoah-Larbi said there would be the need to strengthen promptness of response to the COVID-19 pandemic and treatment of TB patients in hospitals and health centres.

"TB can be prevented, diagnosed, treated and cured," he said and advocated the use of appropriate communication strategies and economic support for patients as essential tools to guarantee TB care and prevent the erosion of all results achieved in recent years in the fight against TB.