According to the Global TB Report 2022 [1], the COVID-19 pandemic significantly impacted TB services in both high and low TB burden countries. In 2020, there was in fact a widespread decline in the number of new TB diagnoses and case notifications, which reflects a reduced disease detection and, consequently, access to treatment. This severely affected TB disease burden, with an increased incidence and mortality in both 2020 and 2021. Nevertheless, African countries have apparently been less impacted by the COVID-19 pandemic, showing a less significant drop in TB notifications in 2020. However, it has to be considered that for sub-Saharan Africa only a limited amount of data is available [2, 3].
Senegal is a high TB incidence country, with an estimated incidence rate of 113 cases/100,000 population and a total amount of estimated cases equal to 19,000 in 2021. The estimated HIV-negative TB mortality rate is 16 cases/100,000 population and the total amount of deaths due to TB reached 2,800 in 2021. For People Living With HIV (PLWH), the estimated TB mortality rate is 1.3 cases/100,000 population, with a total amount of deaths related to TB of 230 [1]. Regarding COVID-19 pandemic, Africa resulted to be the less affected region in the world. Senegal, in line with the continent’s data, presented few cases and deaths: from 3rd January 2020 to 12th July 2023, there have been 89,007 confirmed cases of COVID-19 with 1,971 deaths, as reported to WHO [4].
The Fimela district, an administrative district of the region of Fatick located in the Southwest part of the Northern outcrop of Senegal, has an estimated population of 80,599 people, mostly farmers, fishermen and merchants living in rural and sub-urban settings, organized in villages. The only tertiary level healthcare centre, the Health Centre of Diofior (HCD), serves the whole Fimela district, an area of 1,115 km2. The HCD hosts an integrated outpatient clinic for TB and HIV infection. Since 2013, the Italian non-governmental organization StopTB Italia has been supporting the Senegalese National Tuberculosis Programme (NTP) to deliver TB awareness, appropriate and updated diagnostic tools, treatment consultation and economic support to TB patients at the HCD.
The aim of our study was to investigate the impact of COVID-19 pandemic on TB outpatient services in this rural area of Senegal.
References:
1.Global Tuberculosis Report 2022. World Health Organization 2022. 2.Migliori GB, Thong PM, Alffenaar J-W, Denholm J, Tadolini M, Alyaquobi F, et al. Gauging the impact of the COVID-19 pandemic on tuberculosis services: a global study. Eur Respir J. 2021 Aug 26:2101786. 3.McQuaid CF, Vassall A, Cohen T, Fiekert K, White RG. The impact of COVID-19 on TB: a review of the data. Int J Tuberc Lung Dis. 2021;25(6):436–446. 4. World Health Organization COVID-19 Dashboard, Geneva, 2020.
Introduction
Impact of the COVID-19 pandemic on tuberculosis
services in a rural area of Senegal
Study design
This is a retrospective, observational, monocentric study performed at the TB outpatient clinic of the HCD, from 1st January 2018 to 31st December 2022. Data were collected from the registers of TB cases at the HCD, which are carefully compiled by the Health Care Workers (HCWs) in charge, under the supervision of the NPT. Data were analysed annually and then divided in two phases: pre-COVID-19 period (from 1st January 2018 until 31st March 2020) and post-COVID-19 period (from 1st April 2020 until 31st December 2022). Inclusion criteria: all TB cases registered during the study period. Definition of TB case: any person receiving treatment for active TB.
The study was endorsed by the NTP of Senegal. The lack of informed consent is due to the retrospective nature of the study.
Study procedures
Thanks to the intervention of StopTB Italia NGO, since 1st February 2013, the TB diagnosis in Fimela district is facilitated by trained women (badieu’ngox) involved in house-to-house clinical screening aimed to find subjects presenting TB suggestive symptoms (productive cough, fever, weight loss and night sweats). All presumptive TB cases are referred to the TB outpatient clinic of the HCD, where a sputum sample is collected to perform smear microscopy. Culture is not employed due to technical limitations of the laboratory. Presumptive TB individuals with a negative microscopic examination are then tested with Xpert MTB/RIF. Chest X-ray (CXR) is performed if both smear microscopy and Xpert MTB/RIF result negative. Those diagnosed with TB are offered an HIV test and, in case of a positive result, are linked to outpatient HIV care. In addition, blood glucose dosage is performed. Once antitubercular treatment is started, all subjects undergo follow-up visits at the second, fifth and sixth month of treatment, during which sputum smear microscopy is performed. To ensure optimal adherence to treatment, Directly Observed Therapy (DOT) is offered. In order to stimulate retention in care, financial support is provided upon completion of the treatment. This amount of money derives from the profits generated by an agricultural cooperative run by former TB patients under the supervision of StopTB Italia NGO.
During the COVID-19 pandemic, the outpatient clinics did not observe any closure period, but attendance was considerably reduced.
Materials and Methods
Results
Despite limited impact of COVID-19 pandemic in African countries has been described, our work highlights how significant the impact of the pandemic period was on the provision of and access to essential tuberculosis services and on TB treatment outcomes in a rural area of Senegal.
Conclusions
G. Menotti1,2,3 M. Giglia1,2,3 M. Tadolini1,2,3 N. Riccardi1,4 M. D. Yacine1,5 M. Ndiaye1,6 G. Besozzi1 G. Sotgiu1,7 L. Saderi1,7 L. R. Codecasa1,8
1Stop TB Italia, Milan (Italy). 2Infectious Diseases Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Italy. 3Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna (Italy) 4Clinic of Infectious Diseases and Tropical Medicine, Azienda Ospedaliero Universitaria Pisana, Pisa (Italy) 5Ministry of Health, Dakar (Senegal), 6Health Care Centre of Diofior (Senegal) 7Faculty of Medicine and Surgery- University of Sassari (Italy) 8Tisiologia Villa Marelli- Ospedale Niguarda, Milan (Italy)
Overall, 246 individuals were diagnosed with TB in the study period; 94 (38%) and 152 (62%) subjects were recruited during the pre and post COVID-19 periods, respectively. The geospatial distribution of TB cases diagnosed during the study period is displayed in Figure 1, with most of the cases diagnosed in people living at Diofior (n = 38), Palmarin (n = 33), Dangane (n = 19) and Samba Dia (n = 18). Patients were generally male (156; 63%) and young (median age of 35.5). Annual reported cases ranged from 34 (2020) to 65 (2022) cases. In 2020, TB cases notifications decreased by 24.4% compared to 2019, with a subsequent increase of 70.6% in 2021 and 91.2% in 2022 [Figure 2]. Pulmonary TB was the main form (233/246, 95%); HIV co-infection was documented in 16/246 individuals (7.1%). 242/246 individuals 99% were enrolled on stardard regimen 2 RHZE/4RH.
Treatment outcomes are displayed in Figure 3. During the study period, treatment success was achieved by 198/246 (80.5%) individuals, whereas 10 (4.1%) died, 30 (12.2%) were lost to follow-up, and 4 (1.6%) failed. TB treatment success rate decreased from 85.1% in the pre-COVID-19 to 77.6% in the post-COVID-19 period. In addition, mortality increased from 2.1% to 5.3% and the lost-to-follow-up rate increased from 8.5% to 14.5%, in pre and post-COVID-19 periods, respectively.
Figure 1. Place of residency of TB cases�
Figure 2. New TB cases between 2018 and 2022
Figure 3. Treatment outcome from 2018 to 2022