Why cases of tuberculosis, HIV and flu are rising amid the COVID pandemic

The concern of experts from the World Health Organization (WHO) about the impact of several diseases postponed by the outbreak of the COVID-19 pandemic became a reality.

For example, globally, there were 7 million cases of tuberculosis in 2019 and increased to 5.8 million in 2020, a decrease that experts say was “not real” because there was no good diagnosis of cases”, which meant the breaking of years of progress in controlling this disease.

And in 2021, that was reflected in the new alarming figures: 1.5 million deaths were recorded in 2020 from tuberculosis, setting a sad record for the infectious disease that causes the highest mortality today after COVID-19.

“The death toll from tuberculosis has increased for the first time in more than 10 years as the coronavirus pandemic made access to health services difficult and still difficult. This is alarming news that should serve as a global alarm signal about the urgent need to invest and innovate to overcome gaps in diagnosis, treatment and care for the millions of people affected by this preventable and treatable disease,” said the Director-General of the World Organization of Health (WHO), Tedros Adhanom Ghebreyesus, in a statement at the end of February this year.

Analysts say that the effects of the COVID-19 pandemic on health services have led to years of fighting tuberculosis and other diseases such as HIV. And the situation does not seem to improve: a growing number of people do not know that they have the disease, for which treatment is available and can be cured, the WHO director added in his annual report on tuberculosis, which covers 2020, the year of the start of the coronavirus pandemic.

But tuberculosis was not the only disease that saw coronavirus pandemic spread in the last two years. The COVID-19 pandemic has had a “devastating” impact on the fight against other deadly infectious diseases, according to a report comparing 2019 and 2020 data on HIV, tuberculosis (TB) and malaria in more than 100 low- and low-middle-income countries.

The evaluation published in the scientific journal Nature was conducted by the Global Fund, an international organization that funds efforts to address these three health challenges. “COVID-19 has been the most significant setback in the fight against HIV, tuberculosis and malaria, that we have encountered in the two decades since the Global Fund was established,” writes the organization's executive director, Peter Sands, in an introduction to his Results report 2021.

As countries closed and resources were diverted to combat the pandemic, prevention, testing and treatment services for all three fell precipitously, although impacts vary for each. In some countries, Sands says, “the chain effects on HIV, tuberculosis and malaria could outweigh the direct impact of COVID-19.”

“What we have seen with tuberculosis, as in most chronic and prevalent pathologies, is that its care has been relegated by the COVID-19 epidemic, because virtually all medical services have gone from our usual routines to focus exclusively on the pandemic,” warned the doctor pulmonologist Matias Scafati (MN 97,513), head of the Pneumonology Hospitalization Unit of the Tornú Hospital. In addition, he added: “What we are beginning to see today is precisely the consequences: these diseases have continued their natural evolution.”

“Not everyone who is exposed to tuberculosis gets sick. Once it enters our body, the bacteria can go different ways: one way is that our immune system can completely eliminate it, the other way is that our immune system cannot eliminate it and the bacteria remain there, causing what is called a latent tuberculous infection. The bacteria are normally housed in the lung or in areas near the lung and infection can occur. If at any time the defenses are lowered or if immunity deteriorates, this latent disease can develop,” explained Dr. Scafati.

As early as October 2020, just over 6 months after the pandemic was declared, WHO published its Global Tuberculosis Report 2020, in which it warned that COVID-19 “threatened to reverse recent progress in reducing the global burden of tuberculosis.” “The clearest report of tuberculosis is that made annually by the World Health Organization,” said Dr. Scafati. What is evident in this report is that between 2019 and 2020 there was a significant drop in tuberculosis reporting of nearly 20%: in 2019 around 7,100,000 cases were reported, while in 2020 fewer than 6,000,000 were reported.”

In Argentina, the most recent statistics on tuberculosis are pre-pandemic. In 2019, 12,499 new cases were reported, resulting in a reporting rate of 27.8 per 100,000 inhabitants. It is to be expected that in the following bulletins the numbers of notifications will be lower, but not because of a reduction in infections, but because many patients did not agree to the diagnosis because of the health system situation during the COVID-19 pandemic.

In the case of HIV, the number of people reached by prevention programmes providing condoms or clean needles and syringes, for example, fell by 11 per cent. HIV testing decreased by 22%, delaying treatment and contributing to continued transmission of the virus. However, the number of people living with HIV who received antiretroviral drugs increased by 9%, in Africa, for example. Grace Ngulube, an HIV activist in Malawi, is particularly concerned about adolescent girls and young women, who account for six out of seven new HIV infections among people aged 15 to 19 in sub-Saharan Africa.

Africa is also suffering from the increase in tuberculosis. Insufficient funding and COVID-19 are hampering the fight against tuberculosis in Africa, which accounts for 36 percent of the world's deaths from this disease. The African continent is home to 17 of the 30 countries with a high incidence of tuberculosis worldwide. According to WHO, the estimated 2.5 million cases in the region in 2020 accounted for a quarter of the world's number, “with more than half a million African lives sadly lost to this curable and preventable disease.”

Dr. Joan Caylá, a member of the Spanish Society of Epidemiology (SEE) and president of the Foundation of the Tuberculosis Research Unit in Barcelona, is a leader in tuberculosis research and agrees that the pandemic led to delays in the identification of the disease. “The great impact of COVID-19, which has occurred in the form of epidemic waves, and close to any peak generated a barrage of cases that outstripped the healthcare system, and caused tuberculosis doctors, for example, to care full time for patients with SARS-CoV-2 infection; so that the tuberculosis and other diseases have been relegated by the impact of COVID,” says the epidemiologist.

Thus, he emphasizes that the problem that has occurred is a delay in diagnosis due to this great impact on the work of health workers. “This has meant that, sometimes, even the patient himself due to the saturation of hospital services has not consulted for weeks, does so late despite the symptoms, or they are scheduled tests that are delayed, or the patient has still been labeled for possible COVID and the diagnosis is not made,” says Caylá, who also recalls that if there is a delay in the diagnosis of an infectious disease, the transmission of this disease is favored.

Increased flu

In 2020, when the coronavirus that causes COVID-19 began to circulate and there was a massive confinement in the country and in the world, cases of infections such as influenza and other respiratory viruses were significantly reduced. The flu almost didn't exist. But last year, as mobility was restored, cases rose again.

In Argentina, starting in December 2021, a progressive increase in the number of cases of Influenza A was detected, in particular the H3N2 subtype. From an epidemiological point of view, it was a circulation during a period of the year that was not usual for this respiratory virus. The flu virus is generally expected to circulate during late autumn and winter (mainly between May and August).

“There was a resounding change of scenery between last summer and the current summer,” Teresa Varela, director of Epidemiological Surveillance and Outbreak Control at the Ministry of Health in the province of Buenos Aires, told Infobae. “The flu season, which usually starts after March, has been brought forward,” said the official.

Europe is also anticipating the arrival of influenza, which, for example, has been hitting hard these last two weeks in Spain and there are numerous cases that are appearing.

“We must relate it to the situation we have in the circulation of SARS-CoV-2 and, specifically, to the circulation of the Ómicron variant, which is highly transmissible and which has occupied the space of influenza transmission in the months of December, January, and February. On the one hand, this would explain that, as the transmission of SARS-CoV-2 decreases, the influenza virus has a greater capacity to produce cases and be transmitted,” explained the expert of the Spanish Society of Epidemiology, Angela Domínguez.

On the other hand, it also considers that measures have been relaxed when it comes to curbing the spread of COVID-19, such as the use of masks, hand hygiene, or ventilation, for example, have an influence, and that they contribute to reducing the likelihood of respiratory infection. either by SARS-CoV-2 or by another virus such as influenza that causes the flu.

Towards endemic

For most scientists, we are going towards a world where coronavirus will be an endemic disease, so we must learn to live with it and pay attention to other existing pathologies.

“It is at this point in the pandemic that the past, the present and the future are coexisting: the wave of infections, variants and vaccines that work, and endemic COVID-19 on the horizon. But we are neither in the past nor in the future. The present is complex but hopeful,” explained Ernesto Resnik, a scientist, molecular biologist, immunologist and biotechnologist based in Minnesota, United States. For him, “although it may not seem today, thanks to vaccines, he is moving to the endemic phase, the phase in which the virus will exist, there will be contagions, but it will not turn our lives upside down”.

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