COVID-19 Information Note: Considerations for Global Fund
Date Issued: 6 April 2020
Tuberculosis (TB) is the main cause of mortality from infectious disease, killing 4,000 people every day. This guidance note has been developed by the Global Fund to provide information when considering Global Fund TB investments in the context of COVID-19. The information note also provides links to resources and references on TB and COVID-19. This information note will be updated regularly as new information becomes available Although the impact of COVID-19 on TB is not yet known, available evidence suggests people with active TB and people with latent TB will be disproportionately impacted. Both TB and COVID-19 are respiratory conditions and affect everyone, especially the most vulnerable segment of the population. Preliminary reports from countries severely affected by COVID-19 show a sharp decline of TB notification, interruptions in the continuity of services and diminished quality of
The guiding principle when considering TB in the context of COVID-19 is to respond to both COVID-19 and TB together, not one at the expense of other and preserve essential TB services and mitigate the negative impact to health providers, TB patients and those seeking care. The Global Fund is making funding and flexibilities available to support countries as they responding to the COVID-19 pandemic, more information is available here.
- Supporting Countries Preparing Funding Requests
As the response to COVID-19 imposes greater restrictions on travel, movement and gatherings, countries are experiencing challenges accessing the required technical assistance and support from partners and consultants. TB technical partners are exploring ways to provide remote support to countries in the process of developing funding requests and are deploying local consultants when feasible.
At the country level, difficulties with teleworking and with virtual convening (especially for those with limited bandwidth at home) raise both organizational and governance challenges for Global Fund-related processes. Considering these extraordinary circumstances due to COVID-19 pandemic, the Global Fund is introducing flexibilities in the timing of funding request submissions for Windows 2 and 3. Additional dates for submission have been added in Window 2 and 3.
COVID-19 Information Note: Considerations for Global Fund TB Support, April 2020 02
- Diagnosis of TB
Preliminary data shows TB diagnosis is among the first interventions to be impacted by the COVID-19 pandemic. This is due to the overlap of TB and COVID-19 symptoms, restrictions placed on movement affecting case finding, and stigma attached to the symptoms such as cough. TB diagnosis could also be affected since both diseases use the same infrastructure such as
laboratory network and staff.
There are many commercially available tests for COVID-19 and many are still under development (see WHO Emergency use listing website for SARS-CoV-2 in vitro diagnosis and the FIND’s website).
The Xpert Xpress SARS-CoV-2 test, developed by Cepheid, approved by the US Emergency Use Authorization (EUA) FDA, is one of the tests that can be performed using the same GeneXpert machines used for TB diagnosis. This development presents an opportunity for most Global Fund-supported countries to massively expand testing for COVID-19 by leveraging more than 10,000 GeneXpert machines already available in these countries. However, due consideration should be given, when using these machines for COVID-19 tests, to the potential disruption of TB diagnosis and the diagnosis of other infectious diseases, for which the success of treatment depends on rapid diagnosis. Global Fund supported programs should consider procuring new GeneXpert machines and increasing their diagnostic capacity as COVID-19 might also increase demand for TB diagnosis due to the overlap of respiratory symptoms. More information on Xpert Xpress SARS-CoV-2 is found here.
- Due to overlap of TB and COVID-19 symptoms more resources might be required to increase diagnostic capacity. If GeneXpert machines will be used for COVID-19 testing, consider increasing the number of GeneXpert machines required in order to mitigate the impact to the TB program.
- In addition to placing additional Gene Xpert instruments to match testing needs for both diseases, countries may consider other measures including increasing number or length of laboratory shifts so that TB testing continues unfettered.
- There may be opportunity to leverage TB sample transportation systems. However, the transportation systems in countries will be strained and major delays in transporting samples should be anticipated. If the same transportation system will be used for COVID19, consider strengthening the system to avoid overloading it and improving the triple
packaging of samples.
- People handling respiratory samples especially TB laboratories need to strictly observe
infection control measures. Investments may be required to institute or strengthen infection control measures for TB lab staff and other health workers.
- For more technical details, please refer to the WHO Global TB Programme Updated Information Note on COVID-19 and TB.
- TB Treatment
Although there is currently not enough evidence on the impact of COVID-19 on TB treatment outcomes, it is expected that TB patients (and TB survivors) infected with COVID-19 could be at a higher risk of presenting a negative outcome. TB patients (and TB survivors) should be considered COVID-19 Information Note: Considerations for Global Fund TB Support, April 2020 03 as high-risk group for COVID-19 infection and measures should be put in place to decrease their risk of acquiring the infection, such as fast track services at facilities. TB patients with co-morbidity (HIV, diabetes) and with drug-resistant TB (DR-TB) are even at a higher risk of poorer treatment outcomes. Reduction of the number of visits to health facilities by TB patients (to prevent them from acquiring the COVID-19 infection in the health facilities) and provision of enough TB drugs to cover a longer period of treatment should be prioritized. Adequate information on the importance to remain compliant with the TB or DR-TB treatment and monitoring of adverse effects should be provided to patients, and appropriate (virtual) measures to still follow-up patients under treatment should be put in place.
- Programs may need to invest in home-based treatment and care for TB patients. Interventions such as health education to patients, family and community health worker will be critical.
- Adherence is likely to be a major issue, programs should consider investing in digital adherence technologies and remote support systems. Phone, web, and other ‘virtual’ ways for patients to reach health providers in case of adverse effects should be set in place.
Examples of digital health technologies, virtual care and community based monitoring solutions for TB programs are found here.
- In countries where DR-TB treatment still requires daily injections, switch immediately to the new WHO recommendations (2019) of all-oral treatment regimens.
- Health facilities can provide multiple months of medicine to TB patients. This decision would however involve early procurement of medicines and proper planning to ensure that stockouts do not arise due to increased dispensing of TB medicines.
- The engagement of additional private sector providers such as pharmacies in the dispensing of TB medicines to patients should be explored.
- TB Prevention
TB infection control and prevention measures are not only critical to limit the spread of TB but also to prevent COVID-19. People who are vulnerable to get TB are also at a higher risk of adverse outcomes should they contract COVID-19.
- TB prevention measures should be strengthened in the wake of the COVID-19 pandemic. All patients presenting with cough should receive education in cough hygiene to reduce infections during a quarantine/lockdown.
- Investments in personal protective equipment (PPE) to protect health care workers (including community workers) especially those working with people with respiratory symptoms such TB is important.
- People living with HIV and contacts receiving TB preventive treatment (TPT) should be encouraged to complete their course of therapy. Drugs (preferably combined short regimens) may be provided for a longer period and supports could be provided remotely including using digital technologies.
- More technical details on TB prevention is found here.
- Health Systems and Community Challenges for TB Programs
during the COVID-19 Pandemic COVID-19 will present several health systems challenges which will directly or indirectly affect TB program and patients.
COVID-19 Information Note: Considerations for Global Fund TB Support, April 2020 04
- In order to minimize the risk of stock outs, countries should start procurement of TB
commodities early. Countries should ensure they have enough stock including buffer stock
at all levels. Contact Global Fund Health Product Specialist/ Global Drug Facility (GDF) if
you need further support.
- Consider early distribution of laboratory reagents and supplies to maintain TB diagnosis capacity.
- When feasible maintain a minimal essential staffing to complete high priority tasks related to TB or consider sharing tasks between TB and other services.
- Maintain essential routine data collection, and consider limiting surveys, evaluations and studies. Monitor routine data more frequently to serve as an early warning for any drop in TB case detection or treatment outcomes.
- Continue to reinforce efforts to strengthen TB surveillance systems during the COVID-19 response including exploring the use of simple mobile reporting apps.
- Community activities could be limited due to movement restrictions and the fact that community workers, many of them are also peer educators, could be at heightened risk of COVID-19 infection. If still feasible to conduct community TB activities, consider investments to enable community workers to conduct their work. Infection control measures to protect community workers should be strengthened.
- Ensure that psychological, wellbeing and rights of patients and people with symptoms of TB are protected; including addressing the stigma aspects related to the diseases and the possible need of isolation.
- Consider measures to protect TB patients especially those with DR-TB from incurring
additional and catastrophic costs.
- Useful Links on TB and COVID-19
World Health Organization (WHO): Country & Technical Guidance—Coronavirus disease (COVID-19). April 4,2020. This thorough guidance from WHO compiles information in 16 sectors of concern for detecting and treating COVID-19, plus information on media resources, donors and partners, travel, and advice for the public. Guidance topics are preparedness, laboratories, country coordination, rapid response, response by schools and workplaces, and operational support, among others. Updated WHO Information Note: Ensuring continuity of TB services during the COVID-19 pandemic. April 4, 2020. Developed in collaboration with stakeholders, this note is intended to assist national TB program and health personnel to urgently maintain continuity of essential services for people affected with TB during the COVID-19 pandemic, driven by innovative peoplecentered approaches, as well as maximizing joint support to tackle both diseases
The Union. April 4, 2020. News center on COVID-19 including FAQ. Includes access to fast-track articles on COVID-19 and on TB.
USAID response to COVID-19. April 4, 2020. Updated information on USAID response to COVID19. Includes COVID-19 guidance for USAID implementing partners.
Stop TB Partnership https://www.theglobalfund.org/media/9512/covid19_hiv_infonote_en.pdf
. Measures to be taken by people with Tto reduce their risk for COVID-19, support required for vulnerable population groups and how TB
programs can change to a virtual mode.