Tuberculosis in the age of Covid-19

Tuberculosis is associated mainly with the 19th century. But it is still present and there is a danger that it is not getting the attention it needs in the current pandemic. Radhika Holmström reports

As the world looked for the first Covid-19 vaccination, researchers turned their attention to an already widely available and cost-effective inoculation: the Bacillus Calmette-Guérin (BCG) vaccine, used to prevent tuberculosis (TB). Studies had shown that the beneficial nonspecific effects on the immune system of the BCG jab could protect against other viral infections such as coronavirus. As we now know the Pfizer/ BioNTech Covid-19 vaccine beat everyone else to it when the UK’s Medicines and Healthcare products Regulatory Agency approved its use in December last year. But the BCG vaccination is still being researched as a way to prevent Covid. And it is not surprising that scientists would look to an inoculation for TB. Both are diseases that primarily attack the lungs, and both have similar symptoms. Although TB has a longer incubation period, both diseases can cause cough, fever and difficulty breathing.

The incidence of TB is relatively low in the UK and peaked at 8,919 cases in 2011, according to Public Health England (PHE) figures. There was a 38% drop in new diagnoses from 2011 to 2017 (from 8,280 to 5,102), PHE data also show.  However, the disease has not been eliminated and the World Health Organization (WHO) has called for a continuation of essential TB services during the pandemic. It has suggested that ‘major disruption in TB case detection could result in an additional 400,000 lives lost’ worldwide. While the fight against TB might help against Covid – with the BCG vaccine – Covid might be impeding the fight against TB as the world’s focus shifts to the virus. 

The Covid effect

PHE data between January and March this year reveal the number of notified TB cases in England remained relatively consistent compared with 2019; however, there is a difference after that. Typically, the number of TB notifications increases from March to a peak during the summer months of June and July, before declining in the autumn and winter months. Although an increase in TB notifications was observed between May and July 2020, these numbers were substantially lower than in 2019. In August 2020, there was a 26.1% reduction in TB notifications compared with August 2019 – 283 versus 383. In the third quarter of 2020, 1,007 TB cases were notified in England – but this was a 15.5% decrease compared with the same quarter in 2019.

In other years, this decrease might well be encouraging. This year, though, it may point to something else. Mike Mandelbaum, chief executive of the charity TB Alert, explains it is likely this lower figure is being ‘driven primarily by less diagnosis’. ‘Either people are not going to the doctor, or they are confusing their symptoms with those of Covid, particularly given that only about half of this is pulmonary TB.’

Mr Mandelbaum adds: ‘It’s very easy to get that wrong.’ He says there is a possibility that social distancing might mean there is ‘less chance for community transmission’ of TB. But TB is more usually transmitted in a domestic setting. ‘Our assumption is that there is probably, as with so many other conditions, a lack of diagnosis. The problem is that it is infectious, so there is a greater risk of infecting others.’

PHE had a five-year strategy for TB until April this year. Mr Mandelbaum has said another strategy is needed, but one that recognises TB needs to be tackled alongside coronavirus. ‘[The strategy] needs to be updated,’ he tells Nursing in Practice. ‘The impact of Covid-19 on it has to be reviewed; but, like the previous five-year national strategy it takes a broad holistic view of the pathway and the populations at risk. And that informs the way in which services are designed and delivered.’

Hanna Kaur, lead nurse for TB services in Birmingham and Solihull and TB representative for the Royal College of Nursing public health forum, explains how difficult it was to keep TB services going at the beginning of the pandemic. She and her colleagues worked around the restrictions but it was difficult to know what to do, she says.

It was not always obvious which guidelines applied to those working with TB, Ms Kaur explains. ‘All the guidelines were for hospital PPE. We were already working with a very infectious disease and wanted to protect against Covid-19 as well. It was challenging but most services kept running.’

It is vital to have regular contact with patients while they are undergoing therapy for TB, to monitor treatment, check for adverse reactions and complete regimes. Ms Kaur told Nursing in Practice: ‘Some patients we saw on alternate weeks, or with a teleconsultation to check their symptoms. We also had a couple of patients who needed hospitalisation and were reluctant to go, but did so in the end.’

Health teams are looking to keep TB management and control – like other services – going during the second and any subsequent waves of Covid. Ms Kaur explains face-to-face contact is important when a diagnosis is made but says nurses can adapt and use new ways of working for follow-up consultations, such as via teleconsultation or video consultation. But, she stresses, it is important to keep services going. ‘Treatment interruptions and no concordance will lead to drug-resistant disease,’ she says.

Pre-pandemic

For years – before the pandemic – TB has been a priority disease to tackle. While rates are relatively low in the UK, significantly, the proportion of people with additional risk factors has increased. TB is mostly a disease of older people in the UK, and we have an ageing population. But it is also a disease of health inequality and is more common among people who are homeless and people in prison. Social risk is a significant factor in determining who is more likely to get the disease. The rate of TB among the most deprived 10% of the population is six times higher than among the least deprived, according to official data from 2018.

‘The number of cases fell just over 40% between 2012 and 2018, before showing a small rise in 2019,’ says Mr Mandelbaum. ‘Within this figure the number of people with social risk factors such as homelessness remained steady, so they were therefore an increasing proportion of overall cases, which suggests the health inequalities in TB have increased.’

Ms Kaur agrees. ‘Over the years, we’ve seen that a wide range of comorbidities mean that complexity of cases has been rising even as numbers were falling.’

Older people with TB in the UK are often people who were exposed many years ago and have only now developed active TB – or they are in families who have moved to the UK from places where the disease is prevalent, such as sub-Saharan Africa, South-East Asia, Eastern Europe and Central America. Around half of the TB is pulmonary and half extrapulmonary. Younger patients tend to be most at risk for severe cases, but (unlike Covid-19) that does not mean that their peers are likely to be infected. TB is not a disease of the playground, it is a disease of the family.

When a child is diagnosed, the first thing clinicians do is look at the adults in the household, because that is where the infection has probably come from.

TB is spread by tiny drops of saliva from coughs or sneezes and most people will fight off the infection straight away, but for some it will attack the lungs (pulmonary TB) and possibly also other organs (extrapulmonary TB). This is known as active TB. Pulmonary TB is infectious, whereas extrapulmonary is not. Other people will develop a form known as latent TB, where the bacteria remain in the body, and may become active later, especially if the immune system is weakened. This is why it is also called ‘the hidden disease’.

A recent report from the WHO found that before the pandemic, many countries were making progress, but access to TB services was a challenge, and global targets for prevention and treatment will likely be missed without urgent action and investment. According to WHO, 1.4 million people died from TB-related illnesses in 2019. Of the estimated 10 million people who developed TB that year, some three million were not diagnosed with the disease, or were not officially reported to national authorities.

On 20 November 2020, WHO and other organisations launched a global action plan to accelerate access for children to HIV and TB diagnostics and medicines. It was recognised there was a lot of cross-over with TB and AIDS. In 2018 an estimated 36,000 children who were living with HIV died from TB across the globe, the health organisation said. At the launch, Dr Tereza Kasaeva, director of WHO’s global TB programme, said: ‘Any child who dies from TB, HIV, Covid-19 or any infectious disease is one too many’.

Prevention and treatment

But tackling TB is not easy. The BCG vaccination only offers, at best, 80% protection – and this only lasts for around 15 years. It does reduce the likelihood of infection and importantly (especially in very young children) it reduces the chance of an infected person getting the severe form. A few new vaccines to replace the BCG are at trial stage, but are still nowhere near licensing stage.

Since 2005, therefore, the policy of immunising all adolescents has changed. Broadly, the policy at the moment is to vaccinate babies, but only babies living in an area where the incidence of TB is higher than 40 cases to every 100,000 – or babies with parents or grandparents born in countries where TB is endemic. Unvaccinated adults under 35 are recommended to have the vaccination if they’re working with people or animals that are likely to have TB.

For people who do develop TB, the standard treatment is usually a mixture of four antibiotics – isoniazid, rifampicin, pyrazinamide, ethambutol – for a period of two months and then two antibiotics for a further four months. One of the challenges, though, is the length of treatment and the severity of side-effects, especially as most people start to feel better after the first month. It is crucial that patients take their treatment as prescribed and complete the course, to ensure they are completely cured and prevent them developing drug-resistant TB.

Drug-resistant TB has become a major global problem and is one of the big examples of antibiotic resistance. This form of TB requires a longer course of treatment, possibly over 18 months, with different combinations of drugs that can have more side-effects. These side-effects include nausea or dizziness, skin rashes, pins and needles, flu-like symptoms and occasionally jaundice. There are new drugs now available for treating this form of TB, but there are concerns that these too will become ineffective. At the moment, however, nearly 90% of cases of TB and 48% of cases of drug-resistant TB are cured worldwide.

Observing treatment

As already explained, it is important to support patients through treatment, even though this may be more challenging during Covid times. TB treatment can be complicated and some patients have difficulties sticking to it. Directly Observed Treatment (DOT) initiatives are one way of supporting people to complete their treatment. TB nurses, outreach volunteers or trained volunteers meet regularly with patients to watch them take their medication. This may take place at the patient’s home, in a clinic or pharmacy, or even a local shop. DOT ensures that the right medication is taken in the right doses, at the right time, for as long as it’s required.

Ms Kaur says: ‘Around 30% of our patients go on to DOT. It has to be sold to them right at the beginning that it’s going to benefit them. It is not just us watching them take the medicine – we support them and assess for side-effects.’

More recently, there is the option of video-observed treatment (VOT). This is done on a phone or app. ‘It tends to be for younger people but is offered to everyone,’ says Ms Kaur. This has, of course, become particularly useful over the past year. ‘When the Covid-19 pandemic started, we switched everyone feasible to VOT.’

Ms Kaur points out it is vital for nurses to be aware of the symptoms of TB. ‘It’s important for practitioners to know the symptoms, and take note of the people whose symptoms have been passed over. Remember that there are also extrapulmonary and latent forms of TB. And be aware of infection control measures when you suspect or know that someone has the disease.’

It is vital not to stop the fight against TB, even though this might be difficult during a global pandemic. The WHO warns:  ‘While experience on Covid-19 infection in TB patients remains limited, it is anticipated that people ill with both TB and Covid-19 may have poorer treatment outcomes, especially if TB treatment is interrupted.’

TB in prisons: a QNI project

There is a high prevalence of TB in prisons. PHE data released in 2018 showed 13% of people with TB have a ‘social risk factor’ such as a homelessness, a history of substance misuse or time spent in prison.

In 2018, the Queens Nursing Institute (QNI) announced 10 nurse-led projects that would receive a year-long programme of professional and financial support. One of them was to offer screening and treatment for latent TB for a cohort of prisoners at HMP Birmingham, along with raising awareness of TB more generally in the prison population (including the staff).

Hanna Kaur is the TB representative for the RCN’s public health forum, which is the partner on the QNI screening project at HMP Birmingham.

She says: ‘The outcomes showed that knowledge about TB was increased within the prison, and the prison nursing staff gained confidence in the assessment and referral to the TB service. A total of 10 prisoners were identified as having latent TB. Of these, eight agreed to have treatment and were either followed up at the prison, at another prison or in the community. One prisoner who was admitted to hospital was found to have active pulmonary TB.’

‘Without the QNI project test result, this would have put a large number of individuals and staff at risk,’ explains Sue Boran, QNI director of nursing programmes.