Dear Editor,

More than two years after the beginning of the COVID-19 pandemic, the direct clinical consequences of the global spread of SARS-CoV-2 and the indirect ones related to non-pharmacological interventions and public reactions are better recognized. On one hand, millions of people died or are suffering from long-term sequelae of the disease; on the other, social restrictions and “stay-at-home” mandates had a negative impact on the global economy and probably contributed to an important rise in mental health issues, particularly in young people. In addition, fears of catching SARS-Cov-2 infection in the healthcare settings, or the need of shifting resources from routine health services to COVID-19 emergency responses, had a negative impact on important screening or preventive programs, such as immunization campaigns1,2 or detection of new cases of HIV or TB.3

In particular, TB is still the number-one infectious disease killer in the world with African countries having the highest rate of contagion. The importance of a well-conducted clinical surveillance for this pathology rests on the necessity of identifying people with the disease to offer access to treatment early, and to offer preventive therapy to those with latent infection and at higher risk to progress to TB (eg HIV infection or exposed children).4 In our previous pilot study5 available online already in 2020, we evaluated the impact of COVID-19 on active TB screening in the Community Health Post of Tombo, a village of Western Rural Area in Sierra Leone. We compared the number of patients tested with sputum smear and confirmed Acid Fast Bacilli (AFB)-positive during the first 4 months of the year 2020 (January, February, March, April) with the cases reported in 2018 and 2019. Although with the limitations of a retrospective study restricted to a small region, we showed a significant drop of confirmed TB cases in April 2020, the first month of lockdown in Sierra Leone; additionally, the number of TB suspected cases decreased in March and April 2020. This was the first description of a drop of new TB suspected or confirmed cases, which unfortunately was confirmed later by several international studies.6-8 However, as restrictions have lifted with the beginning of vaccinations and public awareness on the transmission routes, our aim in the present study was to assess the potential change of this trend in the setting of Sierra Leone. Therefore, we continued collecting aggregated anonymized data about the number of patients tested for TB and those who tested positive in the Community Health Post of Tombo until April 2022. The study was approved by the authorities for the TB unit of the local health centre (J.S.B.). As shown in Fig. 1 the number of patients tested and diagnosed with TB in the first quarter period of 2021 compared to that of 2022 was similar to that recorded in the pre-Covid period. In particular, we tested 119 patients in the first 4 months of 2018 (50 resulted positive, 42%), 224 patients in the first four months of 2019 (58 resulted positive, 25,9%), 132 patients in the first four months of 2020 (40 resulted positive, 30,3%), 122 patients in the first four months of 2021, (65 resulted positive, 53,3%), 168 patients in the first four months of 2022 (60 resulted positive, 35,7%). This evidence, with the constraint of this small and retrospective study, suggests that local TB services in very resource-limited settings are returning to pre-pandemic activity standards and that patients are recovering trust in the health services and seeking medical advice when needed. This has important consequences because if true, we may contain the previously missed TB diagnoses that otherwise can lead to an additional increase of cases in the community and we may lose decades of progress in TB control programs. A similar trend of recovery of outpatient TB services has also been reported by Rodrigues and colleagues in Portugal,9 which reported that TB diagnosis, treatment, and prevention services were only affected during the 1st State of Emergency. However, as Covid-19 cases still keep rising across the globe, given the possible interactions of TB and Covid-19 (reactivation or worsening of TB during SARS-CoV-2 infection, use of steroids during Covid-19),10 it is of primary importance to further reinforce TB preventive programs globally.

Figure 1.

The number of presumptive TB and confirmed TB cases in Tombo Health Centre, Sierra Leone, in the first months of 2018, 2019, 2020, 2021 and 2022. April 2020, the month of the beginning of the first lockdown in Sierra Leone, was the month with the lowest number of people tested and tested-positive while it is possible to observe a positive trend in the number of the following two years.

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However, despite the positivity of this trend which gives us hope, there is still the need to be vigilant aboutthe problem of facing the need to maintain effective health surveillance and management of TB programs. Considering what is observed, it is essential to promote and facilitate access to primary care to allow a broader and more accurate screening for TB.