CHALLENGES OF CIVIL SOCIETY ORGANIZATIONS AND NATIONAL TUBERCOLOSIS PROGRAMS IN THE COVID-19 CONTEXT
BROU K. Félix, Kampoer Bertrand, Sansan Kambou ÉdouardArticle Type:
Article Number: 3
Strategies to ensure continuity of tuberculosis services within the COVID-19 context
ABSTRACT In September 2020, DRAF TB and its partners (which include Alliance Côte d’Ivoire) conducted a rapid assessment of the challenges and responses of civil society organizations and NTPs to ensure continuity of TB services within the COVID-19 context. This was funded by the Initiative against HIV/AIDS, Tuberculosis and Malaria implemented by Expertise France.
COVID-19 impacts on the health care system and continuity of care for tuberculosis (TB) patients
The Secretariat of the Stop TB Partnership, in collaboration with the Global Coalition of Tuberculosis Activists (GCTA), have conducted situational analyses since April 2020. The survey results indicated that 40 percent of the National TB Control Programs (NTPs) that participated in the survey had reported that TB facilities (hospitals, clinics) were being used for the COVID-19 response. All NTPs reported that they were witnessing a decrease in the number of people attending TB services. Active TB case-finding activities had ceased at the onset of the COVID-19 outbreak. In addition to the lack of personal protective equipment (PPE), the huge workload proved to be demoralizing for health care providers. The Global TB Caucus noted that in several countries, including countries in Africa, government measures to curb the COVID-19 pandemic (including lockdowns, quarantines, curfews, reduced working hours, or even the shutdown of some public services) were significantly disrupting TB control programs. These disruptions could have a great impact on communities and individuals suffering from TB, especially the most vulnerable patients.
It is within this framework that the DRAF TB network conducted a rapid assessment of the responses of NTPs and community organizations to mitigate the impact of COVID-19 and ensure the continuity of TB services in francophone West and central Africa from March to September 2020.
Objectives of the study
The overall objective of this study was to help reduce the impact of the COVID-19 pandemic on the continuity of treatment and care for TB patients in the 13 member countries of DRAF TB. More specifically, it involved:
- analyzing the situation and taking stock of the impact of COVID-19 on the continuity of care for TB patients in the 13 member countries of DRAF TB
- analyzing the responses developed by NTPs, civil society organizations (CSOs) involved in TB control and TB patient organizations to ensure continuity of treatment and care for TB patients
- making recommendations to inform advocacy for continuity of care for TB patients.
It is a quantitative analysis through an online questionnaire administered to the 13 member countries of DRAF TB: Benin, Burkina Faso, Burundi, Cameroon, Central African Republic, Chad, Congo Brazzaville, Côte d’Ivoire, Gabon, Guinea, Niger, DRC, and Senegal. DRAF TB sent the questionnaire to representatives of its member organizations and NTPs in the 13 countries. The study lasted ten days and commenced on 13 September 2020.
Geographic scope of the survey and profile of respondents
Of of the 13 countries surveyed, seven countries, four from West Africa and three from central Africa, responded to the questionnaire. More than half (57 percent) of respondents were leaders of TB control networks and organizations, while about a third (29 percent) were representatives of NTPs and 14 percent were leaders of former TB patient associations. In terms of gender, 14 percent of the respondents were female while 86 percent were male. This result is consistent with the representation of women among the DRAF TB country focal points because the referent from Côte d’Ivoire is the only woman among them currently.
Impact of COVID-19 on TB services: Situation in West and central Africa?
TB services are still available, although highly disorganized and on the downturn
Since the onset of the COVID-19 pandemic in March 2020, TB diagnosis and treatment services remained open in all seven countries. Community-based activities continued for 79 percent of cases in five countries, except in Côte d’Ivoire and Chad, where they were suspended from March to June 2020. All TB services, including community services, are now available in all seven countries: since May in Côte d’Ivoire and June in Chad.
|TB in prison*||TB control activities in prisons continued, except in Chad, where they were suspended at the outbreak of COVID-19 and resumed in June 2020.|
In Cameroon and Chad, because MDR-TB patients are hospitalized in a specialized center, access to treatment and care services was not interrupted since the outbreak of COVID-19. In other countries, NTPs incurred the cost of transportation of MDR-TB patients from their homes to DTCs.
*Note: Information on TB activities in prisons in Benin and Guinea was not available.
TB services are available, but tattendance at health facilities is still low
The survey found that patients avoided seeking TB services in health facilities due to various reasons, including stigmatization (since TB and COVID-19 have the same symptoms), financial difficulties, and a lack of transport.
Figure 1: Key Challenges of Access to Health Services by TB Patients
|Q1||The results of the survey show that in 86 percent of the countries surveyed, with the exception of Guinea, patients avoided going to health facilities (hospitals and medical clinics) for fear of contracting COVID-19.|
|Q2||In 71 percent of countries – apart from Benin and Niger – patients avoided going to TB diagnostic and treatment centers for fear of being stigmatized (since the symptoms of TB and COVID-19 are the same). Distance from health centers, financial difficulties and a lack of transport were the other reasons given for non-attendance at treatment centers.|
|Q3||In 71 percent of countries – excluding Niger and DRC – patients avoided going to TB diagnosis and treatment centers because of government measures due to COVID-19 (such as quarantine, physical distancing, and limited gatherings).|
|Q4||In nearly 43 percent of countries, TB patients resumed visits and appointments at TB diagnosis and treatment facilities.|
Community health workers on the front line against TB and COVID-19 without personal protective equipment in many countries
Community health workers stopped some of their activities due to the lack of PPE such as face masks, while others continued providing services without the protective gear, putting themselves and others at risk:
|Q5||From March to June 2020, 29 percent of community health workers (in Côte d’Ivoire and Chad) stopped active search activities and home visits to TB patients due to a lack of facemasks.|
|Q6||In Benin, Côte d’Ivoire and Chad, community health workers have resumed home visits to TB patients but do not have protective and hygiene equipment such as facemasks, hydro-alcoholic gels, and gloves).|
|Q7||In countries such as Chad, Niger and DRC, community health workers continued to carry out home visits to TB patients despite the lack of protective and hygiene equipment, thus running the risk of being infected.|
Responses of NTPs and CSOs to mitigate the impacts of COVID-19 and ensure continuity of diagnostic, treatment and care services?
Since the outbreak of the COVID-19 pandemic, NTPs have tailored their reception, consultation and treatment services in DTCs to strengthen prevention, infection control and hygiene measures for both TB and COVID-19. These new measures complement or are related to government measures.
The survey assessed the measures countries were taking in the provision of TB services amid the pandemic:
|On-call duty at the sites (health centers) continues while ensuring that patients respect the distancing measures of at least 1 to 2 meters.||No||Yes||Yes||Yes||Yes||Yes||Yes|
|During the early stages of COVID-19, TB patients were given anti-TB drugs for one to three months to avoid interruptions to treatment.||No||Yes||Yes||Yes||Yes||No||Yes|
|Continuation of community home distribution of TB drugs (health workers, paramedics or community health workers supply TB patients with TB drugs at home) and continued patient visits to DTCs or approved treatment centers (ATCs) for check-up appointments.||No||No||Yes||Yes||No||No||Yes|
|Distribution (or planned distribution) of PPE (face masks, hydro-alcoholic gels, and hand washing devices) to TB patients visiting diagnosis and treatment facilities.
|Distribution (or planned distribution) of PPE (face masks, hydro-alcoholic gel, hand-washing devices) to community health workers before resumption of home visits to patients or any other activity in the community.||Yes||No||Yes||No||No||No||Yes|
|The continuation of one or more of the following activities: home visits, family surveys, and referrals of people with a cough that has lasted longer than two weeks to health centers.||No||Yes||Yes||Yes||Yes||Yes||Yes|
|Financial support to patients for transport to collect TB drugs.||No||No||Yes||No||No||No||No|
|Increased airtime credit allocations to allow community health workers to call and ensure that patients are not running out of TB drugs and are complying with their treatment.||No||No||Yes||No||No||No||No|
|Continuation of active screening in the community (e.g. collection and transportation of sputum specimens, slide calibration and transportation to DTCs).||No||No||Yes||Yes||No||Yes||No|
Since the funding of the COVID-19 contingency plans by the Global Fund, all francophone countries interviewed took measures to ensure the continuity or resumption of TB control activities. As indicated in the table above, Côte d’Ivoire, Chad and Guinea took the greatest number of measures (six to eight measures) to mitigate the impacts of COVID-19 and ensure continuity of TB services.
Most countries took measures to:
- retain community workers on duty at DTC sites: in 86 percent of cases, community health workers were maintained on duty at the DTC sites to receive patients, increase awareness of TB and COVID-19, and ensure compliance with barrier measures. In Côte d’Ivoire, COLTMR (the Network of TB Control NGOs) and Alliance Côte d’Ivoire supported the NTP by installing handwashing facilities at the entrance to DTCs.
- encourage patients to return to DTCs: in Côte d’Ivoire, COLTMR and Alliance Côte d’Ivoire supported the NTP by distributing hygiene kits (bleach and detergent) to DTCs. At the same time, Alliance Côte d’Ivoire provided special food support through the distribution of food kits to patients that are food insecure and who come to DTCs.
In the community:
Home provision of anti-TB drugs to patients for one to three months:
- With the exception of Benin and DRC, countries provided TB patients with anti-TB drugs for one to three months at the beginning of the COVID-19 outbreak.
- In Guinea, Cote d’Ivoire and Chad, community home distribution of anti-TB drugs continued from June 2020, while ensuring that patients kept their checkup appointments at the DTCs or ATCs).
- In Côte d’Ivoire, airtime credit allocations allowed community health workers to call patients and ensure that they did not run out of anti-TB drugs, were compliant with their treatment and remembered their check-up appointment dates at the DTC.
Provision of PPE to community health workers
- In Benin, Chad and Côte d’Ivoire, community health workers were provided with PPE (face masks, hydro-alcoholic gel and hand washing devices) to enable them to carry out home visits to patients or for any other activity in the community.
Community mobilization and advocacy to get patients back into DTCs
- Artists, religious leaders and men and women in public life were mobilized to increase the population’s awareness that they needed to protect themselves from COVID-19, but also to emphasize the importance of getting tested and treated for TB in DTCs if experiencing a prolonged cough.
TB in prison
- Fewer measures were taken to mitigate the impacts of COVID-19 on prisoners in all countries surveyed. Only Côte d’Ivoire carried out advocacy actions with judicial authorities, which resulted in the isolation of new detainees in separate cells to prevent the spread of COVID-19.
- In addition, hygiene kits were distributed to the 33 prisons in the country involved in TB control.
Multi drug resistant-TB
- The key measures taken to ensure continuity of services for multi drug resistant (MDR) TB are presented in the table below. However, these measures existed prior to the COVID-19 health crisis.
|The transportation costs of MDR-TB patients are covered by the NTP or by an NGO.||No||Yes||Yes||No||Yes||No||No|
|Medical or paramedical staff visit homes of MDR-TB patients to ensure continuity of treatment and care to avoid interruption.||No||No||No||No||No||No||No|
|Community health workers visit homes of MDR-TB patients to ensure continuity of treatment and care to avoid interruption.||No||No||Yes||No||No||Yes||Yes|
|Follow-up of MDR-TB patients is excluded from our organization’s mandate.||Yes||No||No||Yes||No||No||No|
To ensure continuity of care for TB patients in the COVID-19 context, CSOs and NTPs made the following recommendations in the DRAF TB survey:
1. Equip community health workers with PPE against COVID-19 (surgical masks, hydro-alcoholic gels, gloves, etc.).
|Cameroon, Guinea, Niger, DRC, DRAF TB|
2. Strengthen communication and awareness reduce stigma, discrimination and human rights violations for TB patients in the COVID-19 context.
3. Remove all consultation fees for any patient with signs of TB, which are the first barrier to care.
4. Strengthen the referral and counter-referral system between DTCs and COVID-19 screening facilities.
5. Empower community health workers to provide active community-based screening (for example, collection and transportation of sputum specimens, slide calibration and transportation to DTCs) to increase the detection and notification of new TB cases and the demand for treatment. This would help to reduce the stigma associated with the treatment of COVID-19 patients at DTCs.
6.Strengthen social mobilization, communication and advocacy to encourage patients to come back to TB diagnosis and treatment services.
7.Equip community health workers/community relays with ice packs to transport sputum specimens to the laboratories.
All countries except Côte d’Ivoire and DRC
All countries except Côte d’Ivoire and DRC
8.Enable community health workers to be on duty at DTC sites to ensure that people with TB comply with barrier measures (such as wearing of masks, washing of hands, distancing of at least 1-2 meters from the sorting room).
9. Establish a system of one to three month drug provisioning or home distribution of anti-TB drugs to TB patients in this COVID-19 context.
|Benin, Cameroon Niger, DRC
10. Equip community health workers with communication tools (airtime credits and internet data) for community-based patient follow-up (reminder of appointments, monitoring of side effects and adherence to treatment via WhatsApp, Messenger, etc.).
|All coun7tries except Côte d’Ivoire
11. Provide PPEand hygiene equipment to DTC health workers (surgical masks, hydro-alcoholic gels, gloves, etc.).
|Cameroon, Côte d’Ivoire|