147 6 Tuberculosis services during the Covid-19 pandemic treatment, people being initiated on TB preventive therapy, a reduction in coverage of the bacille Calmette-Guérin (BCG) vaccine in children and a reduction in spending for TB prevention, diagnostics and treatment services.7,18 A recent study from Eswatini shows TB case notifications decreased during the pandemic compared to the period prior. Death rate increased to 21.3% compared to 10.8% and the odds of unfavourable outcomes were higher (aOR 2.91, 95% CI: 2.17–3.89) during the pandemic compared to the period prior.19 Findings from this study indicate a complex interaction of patient-level, socioeconomic, and health system factors with limited emergency response capability. These coupled with the urgent need to control a pandemic caused by a pathogen whose epidemiology was not fully understood vastly accounted for the reduced access to TB services; further contributing to the global reduction in TB achievement. A Nigerian survey describing TB and COVID-19 screening by healthcare workers during the lockdown indicates that 54% of healthcare workers were not screening patients for TB during this period.20 Similarly, a review of TB services in India during the COVID lockdown indicates there was a widespread disruption in services at both the primary and secondary health facilities; and that different health guidelines aimed at limiting COVID virus transmission limited access to TB services.21 This is similar to what we have reported as some services were temporarily suspended while others operated at half capacity. Reports from Sierra Leone 22, the United States 23 and Portugal 24 confirm similar findings. In a multi-country crosssectional survey, about 40% of respondents indicated it was more difficult for HIV and TB patients to access a health facility during the COVID pandemic and another 31% indicated access to TB patient support such as food and counselling was interrupted. 25 Another critical factor was the repurposing of TB resources for COVID-19 including the equipment GeneXpert used for TB diagnosis.18,26 This negatively impacted TB diagnosis, access to treatment and follow-up care as the number of TB samples that can be processed was reduced. Available human resources and clinic spaces were also reassigned in some instances to provide COVID-19 services. When combined with other related factors such as stock-outs of medications, reduced facility operational hours and movement restrictions, fewer patients access services.18 Several healthcare workers who were also the first responders got infected with COVID-19.27 While some died, others suffered different forms of physical, mental and psychological impact including fear, anxiety and depression.28–30 This was similarly reported in our study as healthcare workers were afraid of seeing patients due to fear of infection. This also contributed to a reduction in the quality and number of services provided. While the reduced number of healthy staff could have been responsible for the reduced quality of care, limited availability of personal protective equipment (PPE) and limited support to healthcare workers contributed to sub-optimal service delivery.18,31
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