Tuesday August 4, 2020
begins with a mild fever and malaise, followed by a painful cough and shortness of breath. The infection prospers in crowds, spreading to people in close reach. Containing an outbreak requires contact tracing, as well as isolation and treatment of the sick for weeks or months.
This insidious disease has touched every part of the globe. It is tuberculosis, the biggest infectious-disease killer worldwide, claiming 1.5 million lives each year.
Until this year, TB and its deadly allies, H.I.V. and malaria, were on the run. The toll from each disease over the previous decade was at its nadir in 2018, the last year for which data are available.
Yet now, as the coronavirus pandemic spreads around the world, consuming global health resources, these perennially neglected adversaries are making a comeback.
“Covid-19 risks derailing all our efforts and taking us back to where we were 20 years ago,” said Dr. Pedro L. Alonso, the director of the World Health Organization’s global malaria program.
It’s not just that the coronavirus has diverted scientific attention from TB, H.I.V. and malaria. The lockdowns, particularly across parts of Africa, Asia and Latin America, have raised insurmountable barriers to patients who must travel to obtain diagnoses or drugs, according to interviews with more than two dozen public health officials, doctors and patients worldwide.
Fear of the coronavirus and the shuttering of clinics have kept away many patients struggling with H.I.V., TB and malaria, while restrictions on air and sea travel have severely limited delivery of medications to the hardest-hit regions.
About 80 percent of tuberculosis, H.I.V. and malaria programs worldwide have reported disruptions in services, and one in four people living with H.I.V. have reported problems with gaining access to medications, according to U.N. AIDS. Interruptions or delays in treatment may lead to drug resistance, already a formidable problem in many countries
In India, home to about 27 percent of the world’s TB cases, diagnoses have dropped by nearly 75 percent since the pandemic began. In Russia, H.I.V. clinics have been repurposed for coronavirus testing.
Malaria season has begun in West Africa, which has 90 percent of malaria deaths in the world, but the normal strategies for prevention — distribution of insecticide-treated bed nets and spraying with pesticides — have been curtailed because of lockdowns.
According to one estimate, a three-month lockdown across different parts of the world and a gradual return to normal over 10 months could result in an additional 6.3 million cases of tuberculosis and 1.4 million deaths from it.
A six-month disruption of antiretroviral therapy may lead to more than 500,000 additional deaths from illnesses related to H.I.V., according to the W.H.O. Another model by the W.H.O. predicted that in the worst-case scenario, deaths from malaria could double to 770,000 per year.
Several public health experts, some close to tears, warned that if the current trends continue, the coronavirus is likely to set back years, perhaps decades, of painstaking progress against TB, H.I.V. and malaria.
The Global Fund, a public-private partnership to fight these diseases, estimates that mitigating this damage will require at least $28.5 billion, a sum that is unlikely to materialize.
If history is any guide, the coronavirus’s impact on the poor will be felt long after the pandemic is over. The socioeconomic crisis in Eastern Europe in the early 1990s, for example, led to the highest rates in the world of a kind of TB that was resistant to multiple drugs, a dubious distinction the region holds even today.
The starting point in this ruinous chain of events is a failure to diagnose: The longer a person goes undiagnosed, and the later treatment begins, the more likely an infectious disease is to spread, sicken and kill.
For malaria, a short delay in diagnosis can swiftly turn fatal, sometimes within just 36 hours of a spiking fever. “It’s one of those diseases where we cannot afford to wait,” Dr. Alonso said.
Apprehensive about malaria’s rise in West Africa, the W.H.O. is now considering giving entire populations antimalarial drugs — a strategy of last resort used during the Ebola epidemic in West Africa and the Boko Haram insurgency.
Across sub-Saharan Africa, fewer women are coming to clinics for H.I.V. diagnosis. A six-month disruption in access to drugs that prevent H.I.V.-positive pregnant women from passing the infection to their babies in utero could increase H.I.V. infections in children by as much as 139 percent in Uganda and 162 percent in Malawi, according to U.N. AIDS.
Diminishing diagnostic capacity may have the greatest effect on TB, leading to dire consequences for households because, like the coronavirus, the bacterium spreads most efficiently in indoor air and among people in close contact.
Each person with TB can spread the disease to another 15 individuals over a year, sharply raising the possibility of people infected while indoors spreading it among their communities once lockdowns end. The prospect is especially worrisome in densely populated places with high rates of TB, such as the favelas of Rio de Janeiro or the townships of South Africa.
“The more you leave undiagnosed and untreated, the more you will have next year and the year after,” said Dr. Lucica Ditiu, who heads the Stop TB Partnership, an international consortium of 1,700 groups fighting the disease.
The infrastructure built to diagnose H.I.V. and TB has been a boon for many countries grappling with the coronavirus. GeneXpert, the tool used to detect genetic material from the TB bacteria and from H.I.V., can also amplify RNA from the coronavirus for diagnosis.
But now most clinics are using the machines only to look for the coronavirus. Prioritizing the coronavirus over TB is “very stupid from a public health perspective,” Dr. Ditiu said. “You should actually be smart and do both.”
In country after country, the pandemic has resulted in sharp drops in diagnoses of TB: a 70 percent decline in Indonesia, 50 percent in Mozambique and South Africa, and 20 percent in China, according to the W.H.O.
In late May in Mexico, as coronavirus infections climbed, TB diagnoses recorded by the government fell to 263 cases from 1,097 the same week last year.
Dr. Giorgio Franyuti, the executive director of Medical Impact, an advocacy group based in Mexico, normally works in the country’s remote jungles, diagnosing and treating TB in the Lacandon people. Unable to travel there during the pandemic, he has worked at a makeshift army hospital treating Covid-19 patients in Mexico City.
There, he has seen nine patients with a sputum-filled cough — characteristic of TB — that began months earlier but who were presumed to have Covid-19. The patients later contracted the coronavirus in the hospital and became seriously ill. At least four have died.
“Nobody is testing for TB at any facility,” he said. “The mind of clinicians in Mexico, as well as decision makers, is stuck with Covid-19.”
“TB is the biggest monster of them all. If we’re talking about deaths and pandemics, 10 million cases a year,” he said, Covid doesn’t compare yet to that toll.
India went into lockdown on March 24, and the government directed public hospitals to focus on Covid-19. Many hospitals shuttered outpatient services for other diseases.
The impact on TB diagnoses was immediate: The number of new cases recorded by the Indian government between March 25 and June 19 was 60,486, compared with 179,792 during the same period in 2019.
The pandemic is also shrinking the supply of diagnostic tests for these killers as companies turn to making more expensive tests to detect the coronavirus. Cepheid, the California-based manufacturer of TB diagnostic tests, has pivoted to making tests for the coronavirus. Companies that make diagnostic tests for malaria are doing the same, according to Dr. Catharina Boehme, the chief executive of the Foundation for Innovative New Diagnostics.
Coronavirus tests are much more lucrative, at about $10, compared with 18 cents for a rapid malaria test.