Effects of COVID-19 on Tuberculosis Prevention, Detection, and Treatment

ROBERT JOHNSON:
This is Public Health Review. I'm Robert Johnson.

On this episode: the curious case of tuberculosis, getting a handle on the number of infections, and mapping a plan to reach people who have TB but don't even know it.

JOSÉ ROMERO:
So, we need to reeducate physicians about the presence of disease. And not just physicians—healthcare providers, right, and all the physician extenders so that they can consider this as a possibility in that diagnostic scheme.

PHILIP LOBUE:
Before COVID, TB was clearly the number one infectious cause of—certainly respiratory infection—in terms of causing deaths and substantial morbidity. So, globally, there are probably about 10 million or so cases of TB every year and probably about one and a half million deaths. And when COVID ends—you know, pandemics generally end—that's what we're going to go back to, right. So, TB will be number one, again.

JOHNSON:
Welcome to Public Health Review, a podcast brought to you by the Association of State and Territorial Health Officials. With each episode, we explore what health departments are doing to tackle the most pressing public health issues facing our states and territories.

Today: the question of tuberculosis and how many cases went undiagnosed during the pandemic. Did we lose ground because of COVID-19? We're talking about that and a new effort to find people who've got the disease, but have no idea they're infected.

Dr. Philip LoBue is director of the Division of Tuberculosis Elimination at the CDC. He's along later to tell us about a new campaign to find people with cases of latent TB.

But first, we hear from Dr. José Romero. He was the Arkansas secretary of health when he gave this interview, but soon he'll take a new position at the CDC as director of the National Center for Immunization and Respiratory Diseases.

Is tuberculosis making a comeback in the United States?

ROMERO:
I think, unfortunately, it is. We've seen the recent MMWR report and even looking at our data, you know, we've seen a reversal in the trend that we saw since 2016 of decreasing cases. So, it's back, and I think we'll be seeing more cases, I think, going forward.

JOHNSON:
What role has the pandemic played in rising cases of the disease?

ROMERO: Yeah, I think it's multifactorial. You know, part of it has to do with the fact that people were not seeking medical attention because they weren't going out into the world, if you will, so as to avoid exposure to COVID. By spending more time at home, they were in closer contact, there's greater chance for spread.

We know, for example, that clinics might've been closed for a while, and so individuals weren't able to come in. Emergency rooms were discouraging people to come in that didn't need an urgent care because of being overloaded due to patients being seen. There was also, to some degree, a refocusing of staff use for contact tracing and followup individuals that have tuberculosis to the COVID effort. And I think that all of those factors have played into seeing an increase in cases.

JOHNSON:
And yet the number for 2020 was a historic low. Do you think those are the same reasons why the number in the numbers actually fell? Maybe they weren't that low after all?

ROMERO:
I think that's correct. I mean, my opinion is exactly that. I mean, our cases in 2020 were very, very low, and continue that trend downward. I think that's exactly right. It was artificial. It was artificial, if you will.

JOHNSON:
Let's talk about some of the groups that are most at risk for TB. Can you take us through those?

ROMERO:
Yeah, I'll give you what I think they are here.

You know, it's certainly foreign-born individuals. They're an important group that can reactivate if they have latent tuberculosis.

Those individuals, those community members that have lack of easy access to healthcare, that don't have a primary care provider or access to a clinic, certainly.

And then, I'd like to bring out children. I think children are very high risk in part because, as the old adage goes, if you see a case of TB in the children then, you know, it's widespread in the community. Because kids are, if you will, the sentinel chickens of tuberculosis in our community: they're very susceptible to it, it tends to spread quickly within themselves, they can develop TB disease very quickly, they have a hard time bringing it under control. So, I really want to draw emphasis on children being a high risk group in this search.

JOHNSON:
You're a physician. What are some of the challenges associated with diagnosis and treatment of TB, with or without the pandemic?

ROMERO:
I think the challenges are reaching those groups that are at higher risk for it. So, if we deal with our foreign-born individuals, they tend to live in their own communities, so there's a linguistic and a cultural challenge to getting to them. And that's true for Latinos or for our Marshalese population.

So, you know, working with our community partners to talk about this disease, to get them to understand the importance of screening for it and reporting. I mean, a lot of time, there's a lot of secrecy. You know, you have a case and you're trying to do the contact investigation and they're reluctant to let the investigator know who they'd been exposed to. So, that's very important. I think resources are very important, financial resources, getting into those communities.

JOHNSON:
We've heard that most providers will never see a case of TB. How does that impact the work to control the disease?

ROMERO:
I think that's very true, and it's been the case I think for quite a number of years—maybe, you know, a couple of decades. This is not a disease that's commonly seen; and because it's not a disease that's commonly seen, physicians don't keep it in the front of their mind.

As an anecdotal case, in point, we have seen cases of tuberculosis in children where they've been to the emergency room two or three times with, quote, "recurrent pneumonia," and what it actually turns out to be is that they have tuberculosis, but the physicians weren't thinking about it. So, you have to think about this. And you see this in adults also. They're hospitalized for pneumonia, and the last thing they think is tuberculosis.

So, we need to reeducate physicians about the presence of disease. And not just physicians—healthcare providers, right, and all the healthcare providers, physician extenders, so that they can consider this as a possibility in that diagnostic scheme.

Also, we have to reeducate them about how to test for this, right? Because many physicians were trained in an era of the skin test before the era of the IGRA. And, so we now know that the IGRA is a better test. And when it comes to children, you know, there's a different way of diagnosing them because not all age groups are appropriate for use of an IGRA. So, there's a lot of education that has to go forward.

And then, depending on who manages the patients—I mean, in my state, in Arkansas, all TB care, whether adult or children, is managed by the health department. So, we have a uniform way of evaluating and treating them. That may not be the case in other states where you have physicians who have little or no experience in how to do this, and we need to provide them the support in order to treat those patients appropriately and evaluate them appropriately.

JOHNSON:
Can you dive into that a little bit more for the public health audience here on this podcast? Why does Arkansas' public health department manage this?

ROMERO:
It really goes back decades. When we first started with this, the system was set up in such a way that in order to really bring this under control, the health department felt that it was best to have a uniform approach to the evaluation and management of these children, as well as the actual contact tracing.

So, that has gone forward and really has, I think, nets just very positive gains in our state. We have a well-oiled machine for managing these patients. We have a local health unit in every county, and our local health unit nurses are the ones that will give directly observed therapy, or will give out the medication as necessary. Our TB nurses can travel to these sites and follow up.

So, I think that's good. It's also very good because it's not a disease that's commonly seen, right? So, it allows a group of physicians who have experience in the diagnosis, management, and evaluation of complications of therapy to really be able to do this in a uniform manner.

JOHNSON:
Do you think this approach versus just leaving it to the provider community actually helps bring or keep the numbers down?

ROMERO:
I think it does. I mean, I really do because it allows us to really have a better handle on where the disease is and how the disease is managed and managed appropriately. So, you know, some cases are more complex than others. Sometimes we're dealing with multiple resistant TB and DRTB, and that's where you really need somebody that has the expertise to do so. And we can evaluate the patient for those conditions, evaluate the patient appropriately for children in particular for, you know, more disseminated disease than would normally be thought.

JOHNSON:
We talked earlier about how the pandemic we think has led to cases being underreported might have something to do with the number of cases going up, but is there a benefit at all to this issue from all of the attention on public health? Does TB and the fight to control that get anything out of that as positive?

ROMERO:
Well, I think that much of the public views public health as heroes, right, as individuals who were there championing and trying to maintain the health of the community and the state. And I think that for those, we will continue to be that group of individuals are trying to promote the health and safety of the population.

There's a significant population that views us with some skepticism with distrust. And so, you know, it'll be difficult to work with those groups, I think, in the future, as a result of the pandemic.

JOHNSON:
Finally talking about the role of public health: we know that in Arkansas you are really involved in the TB issue—not just monitoring it, but also going out and trying to find it and treat it. Is that the correct role, or is there something that's more of a happy medium, especially for those states and territories where they don't have that program in place? How can they still play a role here? How are they doing that?

ROMERO:
So, I always had an interest in tuberculosis, even as a medical student. Carried it through it in all my academic positions, and now here, and as a pediatrician and ID specialist—I mean, I was designated as the TB control physician for children prior to the pandemic and coming into the health department.

I think my situation may be different, but I think that public health leaders, directors of health departments, really are important for bringing this situation—now that we're seeing more cases—to public view, making sure that we have allocation of appropriate funds to the TB control groups within our departments, and really serving as champions for securing funds in the future to bring this under control and keep it under control.

JOHNSON:
Do you have any concerns at all that this could make such a comeback? That it has the effect on populations as it did 60, 70, 80 years ago when people were really dying from this and getting sick and being shipped off to the middle of nowhere to get better air—so to speak—or better treatment? Do you think that we're anywhere near those days? Are we going to be able to head it off before we get to that point?

ROMERO:
No, I don't think we're anywhere near that. And I do think we're going to be able to head it off.

And, you know, speaking about, you know, the significance of this disease, unfortunately—you know, we had not had a TB death in a child for, you know, five or six years, and unfortunately last year we did. So, you know, it does have the potential to really impact in a negative way if not brought under control, if the attention is not brought to it. So, I don't think we'll ever get to that point, but we do have a lot of work to do in going forward to bring it back under control.

JOHNSON:
Dr. Philip LoBue has been tracking TB for 30 years, mostly at the CDC but also from his work in the field. He tells us what it will take to understand what happened to cases during the pandemic and explains a new campaign to find people infected but not yet sickened by the disease.

How close have we come to eliminating TB in the U.S.?

LOBUE:
We've actually, over the last two and a half to three decades, made really good progress. We had a resurgence of TB in the early 1990s and we had about 26,000 cases of TB in the U.S., and that was a case rate of about 12 per a hundred thousand. And over the next 25 to 30 years, we actually have reduced it substantially. Before COVID, we had about 8,900 cases—so, that's quite a drop—and the case rate got down to less than three per 100,000.

So, substantial improvement, but the actual target for elimination is 0.1 cases per 100,000, or one per 1,000,000.

So, pre-pandemic, we were still at about 27, 28 times what the elimination rate would be. I mean, we are—we do have one of the lowest rates in the world, so I don't want to downplay the success, we have been successful. But the goal is elimination, so we still have a ways to go.

JOHNSON:
The point is, though, you were making progress, and then here comes COVID-19.

LOBUE:
Yeah, that end—actually, even before COVID 19, the progress was slowing. So, we were seeing decreases in cases from year to year, but those decreases were getting less and less. So, there was even a leveling effect before COVID.

JOHNSON:
Was the pandemic, though, a key moment in the fight against TB? Did it make things harder?

LOBUE:
Yes. And I think, you know, it's going to take a little while to figure out exactly what the effect was and exactly what happened globally. I think it's been quite clear it's really had a major, major impact. Many countries really just were so stretched that TB just couldn't get the attention it needed.

And in the U.S.—it's, I think, a little more complicated to know, because our cases actually went down. And this happened globally also, and they went down substantially. In the global situation, there's a pretty good reason to think that a lot of those cases were just not found because there weren't, people weren't looking for them.

We don't think that's exactly the situation in the U.S. There are actually multiple factors and some would be actually working in favor of decreasing TB cases, and others might be working in favor of increasing TB cases—especially down the road. So, we're still trying to sort through that.

So, some of the things we know, for example, as we have heard from local and state health departments of delays in diagnosis—so, people who didn't go to seek healthcare because they were concerned about being exposed to COVID. And also, some of the activities that health departments do had to be diverted. Some of the active case-finding activities related to contact tracing, immigrant screening, couldn't be done as well because there just weren't the personnel to do them. They were transferred to COVID.

So, those things very well could result in future TB cases because when diagnosis delayed there's time for additional spread of TB. And we know—we've heard from health departments as these things happen. We don't really have the systematic data on it, but there's good reason to think that there was that effect.

There were some other things, though, that actually might decrease TB cases. So, there's evidence that there was decreased immigration to the U.S., especially in 2020 and to a certain degree in 2021. And we have seen fewer cases of TB among persons who are recent immigrants, and that appears to be just because there were fewer people entering the country. Also, the number of the interventions and precautions used to prevent COVID transmission would also help to prevent TB transmission: so, any social distancing, wearing masks, isolation, all those things could reduce TB transmission, too.

So, it's kind of a mixed picture. I think it's going to take a while to know exactly what the extent of the effects of the various factors were.

JOHNSON:
Because the numbers in 2020 really dropped significantly, and now they're kind of going back up again, but they're not where they were before the pandemic. So, it's all over the place right now.

LOBUE:
Right. And I don't—you know, I can't predict what's going to happen for 2022 or 2023. The question is will we be back to where we were before? And it's just, you know, the things have normalized and we're back on the kind of trajectory we were pre-pandemic. Could it be that some of these factors in terms of the delayed diagnosis allowing additional spread, actually push our case rates higher than they were pre-pandemic? I think it's just, it's too early to know that.

JOHNSON:
Given all of that, what is the CDC's response to TB right now? What does it look like today?

LOBUE:
So, I think the good news is things are starting to somewhat get back more to normal with people being able to get back to doing their TB work and not having to spend as much time on COVID. Of course, that kind of varies from place to place and time to time, depending on what the COVID situation is.

So, I think what number one is getting back to doing our usual contact tracing, getting back to getting, you know, the complete immigration evaluation, getting those things back to normal is kind of where we are now. I think what was put on pause was the efforts to actually expand some work that could help actually drive TB cases even lower, and that just had to be done because COVID was such a priority and had to be dealt with.

So, you know, the goal is, hopefully within the next year or two, we really, really get back to normal. And then, we can get back to not only doing the regular work that has been going on before, but actually to look at to expand into some new activities.

JOHNSON:
Have the audiences for this message changed at all during the last couple of years, or are you still working with the same populations that you've always been worried about?

LOBUE:
It's the same populations, but they're things that we recognize we need to do differently and more of. So, I would say that, you know, in the past, most of the work has really been focused within the health department and focused on people who have TB disease.

So that, you know, two different forms of TB. We have TB disease where people are sick, they can be infectious, and spread it to others. But when people initially get infected, most of them actually end up with what we call latent TB. So, they have some TB organisms, germs in their body, but they're controlled by the immune system. They don't get actively sick, but they're at risk for what we call reactivation, getting sick in the future. So, most people end up with latent TB, but that latent TB can be treated to prevent people from getting sick with active TB.

And so, we really needed to expand into that area and really needed to expand to work with providers outside of the health department. So, primary care, kind of integrating this into primary care for populations who are at risk, who should be tested for latent TB, and then treated if they are positive.

JOHNSON:
How are you doing that work? What is the messaging? How are you getting the word out that this is expanding?

LOBUE:
So, what we have started in the—this campaign actually began in March, it's called the Think Test Treat TB campaign, and it's focused on engaging both communities at risk and also providers who serve those communities.

The pilot began in two places, so in Seattle and Los Angeles, and focused on the population which has the highest case rate—so, they would be non-U.S. born Asian Americans, and particularly those two populations were Vietnamese Americans and Filipino Americans. Both a campaign through various media, print, digital radio, and these were also looking particularly at publications in native languages. And also working with providers who largely see those patient populations and to encourage people who are at risk, ask your doctor to be tested, ask your doctor to assess you. Are you at risk and, if you're at risk, ask your doctor to make sure you're tested. And if you're positive, you get treated and also work with the providers to encourage them to do testing and treatment.

So, that's the pilot, but we've also developed a lot of materials and we're making those available so other parts of the country can pick up these materials and replicate that. And you know, the goal is starting with the highest risk populations, but ultimately our goal would be to expand to others.

JOHNSON:
So, this is all part of that effort to go beyond just the work with the public health departments?

LOBUE:
Exactly. Now, it's public health department is really important partner in this. So, we're working with local TB programs in Seattle and Los Angeles. So, we're working with them, but it's to expand that partnership, to go to the primary care providers. Because I mean, people don't wake up one morning and think, "Oh, I'm at risk for TB, I should go to the health department and get treated." But they do go and see their primary care provider for physicals, for blood pressure, diabetes, whatever. And so, the idea is we can really expand to more people by integrating this into primary care.

JOHNSON:
How long does the pilot run? And do you have any results back yet?

LOBUE:
Yeah, it's too early. It's too early. We just started in March. So, the initial's probably gonna run for about a year or so. We'll see if we can extend it, part of it depends on what funding is available. But the idea is we can least learn from that and then think about what are the next steps.

JOHNSON:
And you're measuring to see if people get the message and then raise it with their provider. Is that the ultimate outcome here?

LOBUE:
In this type of campaign, it's difficult to get beyond that kind of, did people get the message? You know, did providers get the message? We're looking at some other efforts which are more research-oriented to look at actually did people get tested and treated? And that's another project that just started. So, you know, there are a number of these projects. We're trying to glean as much information to really find what is the best way to do this.

JOHNSON:
How important is it to find people who have latent TB? Is this a key piece of stopping the spread?

LOBUE:
Yeah, in fact, not only in the U.S. but globally, all modeling has shown that at a certain point, if you just focus only on people with TB disease, you kind of reach a plateau and that's basically what was happening in the U.S. So, if you want to take the next step and really make an additional jump in reducing TB, that is what has to be done. You have to start finding people with latent TB and treating them so that they don't get TB disease. And that, ultimately, really can substantially reduce the number of TB cases in the long-term.

JOHNSON:
You mentioned that the materials are available from this campaign to any department that wants to get them. Would you encourage departments to get into this issue right now? Or should they wait until the pilot's done?

LOBUE:
I think they—if they have the resources or, you know, can do it—then there's no reason to wait on that. And I think if they can, you know, have the ability to collect information about how it worked for them, we'd love to hear how things worked and are there ways to improve this.

So, we encourage any health department that can do it, to do it, and you can contact our communications people if you need assistance on locating those materials.

JOHNSON:
Certainly, the spotlight on respiratory diseases has been turned way up during the pandemic. Why does TB, with everything else going on, need to be on the priority list right now?

LOBUE:
So I think, you know, you think about this globally, it's a pretty easy answer. Before COVID, TB was clearly the number one infectious cause of suddenly respiratory infection in terms of causing deaths and substantial morbidity. So globally, there are probably about 10 million or so cases of TB every year and probably about 1.5 million deaths. And when COVID ends—you know, pandemics generally end—that's what we're going to go back to, right? So, TB will be number one again. So I don't think there's really any question about the global significance.

And the U.S. we're a low incidence country, so it's not as great as it is globally. However, we still have about 7,000, 8,000, 9,000 cases, depending on where we end up after COVID. So, we still have morbidity, we have transmission—so when people get this disease, they can transmit to others. And because it's airborne, anyone is potentially at risk. So, all you have to do is share air with someone with tuberculosis and you can get tuberculosis. So, there's no kind of behavior you can engage in that makes you kind of immune from that.

So, clearly it poses potential risks. We still have outbreaks of TB that occur in the U.S. It's treatable and preventable, so we have interventions that work. These interventions are pretty inexpensive compared to a lot of other things. Most of the medications are generic, so they're not all that expensive. So, it's something that really doesn't require tremendous expense in terms of treatment or testing compared to a lot of other things. So, it's clearly something that's worthy to be addressed and that we can make progress with.

JOHNSON:
Thanks for listening to Public Health Review.

If you like the show, please share it with your colleagues on social media. And if you have comments or questions, we'd like to hear from you. Email us at pr@astho.org—once again, PR at ASTHO dot org. You can also follow us using the follow button on your favorite podcast player.

This show is a production of the Association of State and Territorial Health Officials. For Public Health Review, I'm Robert Johnson. Be well.