Introduction by Croakey: As we look to 2021, governments, agencies and health sectors around the world must address the wider health impacts of the COVID-19 pandemic, including the neglect of other critical diseases and health conditions.
Global health journalist Meera Senthilingam reports that India is preparing for a surge in tuberculosis cases this year, while many countries are working to adapt immunisation programs that have been disrupted by the pandemic, and others are struggling to incorporate non-communicable diseases strategies into their COVID responses.
Experts are also preparing for an increase in late-stage cancer cases due to delayed diagnoses and treatment last year, she reports.
Meera Senthilingam writes:
Many people don’t know that tuberculosis (TB) was the leading infectious killer worldwide before COVID-19 arrived at our feet, despite the World Health Organization (WHO) giving the disease this spot on the podium for some years.
A total of 1.4 million people died of TB in 2019 — a figure only surpassed by COVID-19 in recent months — and this number is expected to be higher in 2021 as people fail to get tested, diagnosed and treated in the current climate.
“TB notifications in three of the highest-burden countries – India, Indonesia, and the Philippines – fell by 25 percent to 30 percent from January to June compared with the same period in 2019,” said Dr Grania Brigden, Director of TB at the International Union Against Tuberculosis and Lung Disease (The Union).
Brigden says this will have a number of longer-term repercussions, including more severe cases and deaths from TB and greater transmission of the airborne disease in communities. “There will be years of impact with regards to infection, illness and mortality,” she said.
Nowhere is this more evident than India, which has the greatest burden of TB of any country, with more than 2.6 million cases and 445,000 deaths in 2019, according to WHO figures. In some regions of the country, experts have already seen a 30 to 40 percent reduction in the number of TB cases being reported in some parts of the country.
There are multiple reasons for this, says Vikas Panitabala, Chief Executive of the India branch of UK charity TB Alert. Restrictions meant people couldn’t reach services and even if they could, many were too scared to present, Panitabala told Croakey.
He believes a crucial point is that some of the disease’s key symptoms resemble those of COVID-19 – namely a cough and fever. “People were afraid to go for TB testing because they were afraid that if they find out it’s COVID, then they’ll keep them in quarantine,” he said.
The similarity between the two diseases also meant that experienced TB staff were moved onto the COVID response. “Services were interrupted … and patients were not aware of where to go.”
Brigden points out, however, that in high burden TB countries like India, “more people are dying of TB than are dying from COVID-19”. Panitabala believes the country’s TB efforts have now been set back by five to 10 years, taking the country off track for its target to eliminate the disease by 2025.
In response, TB Alert India changed strategies last year in an attempt to mitigate the surge in cases expected this year. The team acknowledged that if people were not willing to come out of their homes, then services would need to go to them, both physically and digitally.
To date this has involved setting up Whatsapp networks to spread messaging about the differences between TB and COVID-19 symptoms – such as TB having a wet or productive cough while COVID’s is dry.
It has also involved taking testing services to people’s doorsteps using networks of community health workers, and setting up call centres where patients can leave a missed call for someone to call them back and discuss symptoms and, more recently, telephone consultations.
Have these measures been effective?
“They are working, but they are cost intensive and people-intensive,” said Panitabala, who believes the measures have, however, helped them catch up with some of the setbacks.
The next step is to strengthen the load health services can handle, he said, because “we will be getting more TB cases going forward”.
Preventable infections are not being prevented
While research teams worldwide raced to develop, test and, remarkably, implement vaccines against COVID-19 in the space of one year, the delivery of vaccines against other already preventable infections was severely disrupted in 2020.
This will inevitably result in a greater number of disease outbreaks in 2021 — predominantly in low and middle income countries.
In May, the WHO warned that at least 80 million children under one were at risk of diseases such as measles, diphtheria and polio due to routine immunisation services having to be postponed or cancelled. By July the agency was reporting a substantial drop in the number of children receiving the standard DTP3 vaccine, which protects against diphtheria, tetanus and pertussis and is used as a marker for vaccine coverage worldwide.
“Many countries have reported drops in coverage up to 50 percent of pre-COVID coverage,” said Frank Mahoney, Senior Immunization Officer for the International Federation of Red Cross and Red Crescent Societies, warning that this is likely to lead to outbreaks. “Of greatest concern is the resurgence of polio and measles,” he said.
The reasons for the disruption are multiple, explains Ann Lindstrand, Unit Head of the Expanded Programme on Immunization (EPI) at the WHO. They included travel disruptions affecting supply chains of vaccines, to lockdowns and fear of COVID-19 preventing people from getting them, as well as a lack of personal protective equipment preventing health workers from working, and COVID infections and diverted staffing meaning health workers were often unavailable.
“We have been very worried,” said Lindstrand, but also expressed her amazement at the level of adaptation put in place by many countries to try and buffer the disruption. She highlighted Latin America, where health services found new places to immunise people safely and at a distance, such as marketplaces and drive-throughs, and Rwanda, where children who missed out on vaccines were recalled via Whatsapp messages.
But multiple vaccination campaigns remain affected, with 46 still postponed or cancelled globally as of December, according to Lindstrand, and the resulting outbreaks that are expected this year mean that services will again be stretched to their limits, particularly in managing highly infectious diseases like measles.
Early on in 2020 in Burkina Faso, teams from Medecins Sans Frontiers (MSF) were preparing for a measles vaccination campaign in response to an outbreak in the country’s Eastern region that had infected more than 1,300 people by March. With the campaign prepped and ready to run during March and April, the arrival of the first COVID-19 case on March 19 saw those plans promptly change.
Postponing wasn’t an option because it would result in more deaths and a greater burden on health services given the outbreak was already spreading, explained Daouda Abass, Head of Mission for MSF in Burkina Faso. “We had to find a balance,” he said.
This meant devising strategies to go door to door in communities, as with the TB program in India, but in Burkina Faso this came with many obstacles.
These were security risks, the need to build trust on doorsteps, logistics around cleaning hands and equipment between every house visit, and extensive human resources with each team needing five to six people for vaccine administration, social support, data collection and paperwork. There were also restrictions such as curfews limiting the amount of time health teams could operate, explained Abass.
“When you have a fixed site, you can vaccinate around 1,000 people with one team in a day, in 8 or 12 hours … but the maximum door to door was 120,” he told Croakey. “But at the end of the day, the team managed to do a good campaign.”
Emergencies put chronic care on hold
Infectious diseases like COVID-19 strike hard and fast, causing immediate damage to people and health systems worldwide, while other conditions, such as obesity and the plethora of diseases that stem from it, are slow burning, but cause just as much damage, if not more.
Obesity rates have been growing at alarming rates worldwide – tripling since 1975, according to WHO figures — and have become a global epidemic in need of urgent attention.
“The fact they are chronic is the issue,” said Steve Gortmaker, Professor of the Practice of Health Sociology at the Harvard T.H Chan School of Public Health. “The average person in the United States is gaining an extra pound a year and that’s not a deal for 10 years, but after 40 it does become a bigger deal … and it becomes very hard at that point to turn it around.”
An estimated 13 percent of the world’s adult population (650 million people) was obese in 2016 and a whopping 1.9 billion people (over a quarter of the world’s population) were overweight. A range of conditions linked to obesity have been growing in unison, including diabetes, heart disease and certain cancers, known collectively as non-communicable diseases (NCDs).
Now, the pandemic has put the burden of these conditions in the spotlight, as people living with them are at an increased risk of developing severe COVID-19 disease or dying from the virus. It has also made the burden of NCDs worse, as people have been unable to access services to manage their condition.
“For the major NCDs, health services have been partially or completely disrupted at around 50 percent … so half of countries have been disrupted,” said Luis Manuel Encarnación, Capacity Development Manager at the NCD Alliance. “We can definitely expect an increase in the number of people dying or developing disease.”
Encarnación believes that while high-income countries have been more efficient at integrating NCDs into COVID-19 preparedness plans, low and middle-income countries have struggled. He has seen this first-hand where he lives, in Mexico, where obesity rates are among the highest in the world, with over a third of adults (36%) obese in 2018.
“The region of the Americas has been particularly affected … and the situation in Mexico has been dramatic,” he said. People living with diabetes have seen routine screenings cancelled, bringing delays in identifying any complications related to the condition, like retinopathy (damage to the back of the eye), and have faced insufficient access to medicines like insulin or heart medications, Encarnación explained.
Reports by the NCD Alliance further highlight that measures such as social distancing and self-isolation are increasing the risk of people developing NCDs as they become less active and are more likely to resort to unhealthier diets as well as alcohol and tobacco to help them cope. Heart disease is already the leading cause of death worldwide and chronic obstructive pulmonary disease (COPD) and kidney diseases are in the top 10.
But preventing this onset of new cases is one area where Mexico has stepped up during the pandemic, Encarnación believes, with the introduction of front of package labelling regulations on unhealthy foods to makes people more aware and, in turn, improve their diets. Mexico City also introduced a ban on saltshakers being placed on restaurant tables in an attempt to reduce alt intake.
The country has already led the way with many prevention initiatives, being one of the first to introduce taxation on sugary drinks, for example, but gaps remain in the health system as a whole, particularly around diagnosis and treatment. This is following years of under spending in this area, Encarnación said.
“The COVID-19 pandemic exploded in everyone’s faces and it was a bad taste of reality on how the health system was … and how we’re not prioritising health enough.”
Cancer cases are down, but experts expect a ‘burst of cases’
Cancer continues to be among the leading causes of death worldwide. In 2018, there were 17 million new cases worldwide and cancer was the cause of an estimated 9.6 million deaths. To put these numbers into perspective, COVID-19 cases have now reached more than 86 million, with deaths totaling over 1.8 million.
Experts generally stress the importance of early diagnosis for cancer as this significantly improves the chances of successful treatment — something the COVID-19 pandemic has hindered significantly.
As with other areas of healthcare, cancer services saw a decrease in patients last year.
This is again due to fears around attending health services and transport restrictions, but also cancelled screenings and treatments as well as more complex resources being needed to help keep patients COVID-free, such as creating isolated cancer wards, explains Carey Adams, Chief Executive Officer for the Union for International Cancer Control (UICC).
Adams says that COVID will lead to an increased volume of cancer cases in future years, which are likely to be more complicated because the cancers will have progressed. He highlighted that this is not only bad for patients in terms of survival, but also governments in terms of cost. “The cost of treating stage three or four is much higher,” he said.
Countries like the UK have comprehensive data on cancer care and have therefore been able to highlight the impact of the pandemic in some detail. A recent study using data from Cancer Research UK showed that in May, two in three cancer patients reported their cancer care being affected and there was a 37 percent drop in cancer treatments when compared to May 2019.
The study also found that around three million people have not received invitations for national bowel, breast and cervical screening programs during the pandemic. Resurgence in COVID cases during the winter means the country’s health system is again under strain as the country battles a second wave of infections, meaning cancer services and treatment will see further disruption.
However, such clear data on such disruptions is rare and largely unavailable for many countries, particularly low and middle-income ones, making it hard to understand the true impact, said Isabelle Soerjomataram, Deputy of the Head Section of Cancer Surveillance at the International Agency for Research on Cancer (IARC). The gap in services, however, means we can expect “a burst of cancer patients coming up”, she said.
But Soerjomataram added that health services worldwide have been adapting to try and reduce the size of this burst. “It’s very impressive how fast things are changing,” Soerjomataram told Croakey.
Cancer patients are now being separated, creating hospitals or hubs only for cancer patients, and there is a push to do more screenings at home, such as self-tests for Human Papilloma Virus (HPV) as a means of cervical screening, as well as a greater use of telemedicine for patients, she explained.
The pandemic is “pushing technological advances forward,” said Soerjomataram, but she stressed the continued challenges around data, as without adequate systems of data collection, “we don’t know what’s working and what’s not”.
But what we do know, based on these testimonies from across the world, is that the pandemic has made a significant dent, and reversal of gains, in almost every other area of health, with this impact most significant in low and middle-income countries where health systems are weaker and health spending has been lower.
High-income countries have had certain buffers in place, enabling them to adapt faster to the emergency, but they too are expecting a surge in cases across these four diseases in 2021 — and inevitably a rise in deaths.
But one positive to come from this is a realisation by most governments of the need to invest more in health, having seen the repercussions of years of underfunding.
“They’ve realised that you need to invest in health,” said Adams. “I’m hopeful that health will continue to be at head of state level now and not stuck in the corner of a health ministry.”
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