Zenner, D

The International Journal of Tuberculosis and Lung Disease

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Queen Mary Research Online

For Review OnlyTB and COVID-19 in migrants- Why we need to focus on bothJournal: The International Journal of Tuberculosis and Lung DiseaseManuscript ID DraftManuscript Type: EditorialDate Submitted by the Author: n/aComplete List of Authors: margineanu, ioana; UMCG, Clinical Pharmacy and Pharmacology; Rijksuniversiteit Groningen, Clinical Pharmacy and PharmacologyMor, Zohar; State of Israel Ministry of Health,  Tel Aviv Department of Health; Ashkelon Academic College, School of Health SciencesGarcia, Deliana ; Johns Hopkins School of Medicine, Migrant Clinicians NetworkGilpin, Christopher; International Organization for Migration, Global Laboratory (Coordinator)Dhawan, Shikha;  Partasia Biopharm, Executive Director; Society for Health Allied Research and Education (SHARE), Director of ProgramsRitz, Nicole; University Children’s Hospital Basel,  Paediatric Infectious Diseases and Vaccinology Unit; Mycobacterial and Migrant Health ResearchZenner, Dominik; Queen Mary University of London, Centre for Global Public Health, Institute for Population Health SciencesKey Words: migration, pandemic, SARS-COV-2, tuberculosis control For Review OnlyUnion TB & Migration Group Editorial1 TB and COVID-19 in migrants- Why we need to focus on both23 Ioana Margineanu1, Zohar Mor2,3, Deliana Garcia4, Christopher Gilpin5, Shikha Dhawan6,7, Nicole 4 Ritz8, Dominik Zenner95 1 - Rijksuniversiteit Groningen, University Medical Centrum Groningen, Department of Clinical 6 Pharmacy and Pharmacology, Groningen, the Netherlands7 2 - Ministry of Health, Tel Aviv Department of Health, Tel Aviv, Israel8 3 -  Ashkelon Academic College, School of Health Sciences, Ashkelon, Israel9 4 - Migrant Clinicians Network, Austin, Texas, USA10 5 - International Organization for Migration, Geneva, Switzerland11 6 – Partasia Biopharm, India12 7 – SHARE INDIA, India13 8 - University of Basel, University Children’s Hospital Basel, Paediatric Infectious Diseases and 14 Vaccinology Unit; Mycobacterial and Migrant Health Research, Basel, Switzerland15 9 -  Queen Mary University of London, Centre for Global Public Health, Institute for Population Health 16 Sciences, London, UK1718 Running head: Tuberculosis and COVID-19, keep focus on both1920 Word count: 104921 Keywords: Migration, Pandemic, SARS-CoV-2, Tuberculosis control 2223 Corresponding author:  Ioana Margineanu, Rijksuniversiteit Groningen, University Medical Centrum 24 Groningen, Department of Clinical Pharmacy and Pharmacology, Hanzeplein 1, Groningen, 25 Netherlands, i.s.margineanu@umcg.nl , ismargineanu@gmail.com26Page 1 of 6For Review OnlyUnion TB & Migration Group Editorial27 In the board game called “Pandemic”, players form a team of medical and para-medical staff 28 attempting to control ongoing outbreaks concurrently. It is a cooperative game and winning requires 29 careful planning, attention to multiple events simultaneously, and the ability to adapt swiftly. Whilst 30 in reality, the prevention and mitigation of pandemic also require resources and involve personal and 31 public tragedies, economic effects, political needs, overcoming "pandemic fatigue", and international 32 cooperation, the game does have important lessons. 3334 Disease outbreaks and pandemics have been characterized by periodical occurrence throughout 35 history, and can be accelerated by population density, lower level of hygiene, travel, and migration. 36 In addition, a number of countries have more than one concurrent epidemic, as illustrated by the 37 ongoing Ebola outbreak [1]3839 Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has been spreading highly efficiently 40 since the first months of 2020 and disproportionally affects populations living in overcrowded 41 conditions [2]. Therefore, migrants and those who are detained or do not have stable housing are 42 more susceptible to SARS-CoV-2 [3,4]. The morbidity and mortality of COVID-19 can be significant, 43 particularly in settings where medical systems are already fragile or inefficient or among migrants, 44 whose eligibility to medical care is limited [5]. In addition, migrants may be stranded in host 45 countries with increased vulnerability because of unemployment, social instability, and loss of 46 income, which may decrease their a priori limited access to food, housing, and healthcare services. 47 As migrants are often ineligible for social benefits and lack health or economic safety nets, they may 48 be forced to work even when they are ill or under isolation or quarantine, sometimes to obtain basic 49 necessities. Furthermore, enforcing travel restrictions by national authorities can potentially 50 decrease migrants' access to medical care by requirements of documents on their way to the clinic or 51 by aggravating the attitudes of the authorities due to their unstable legal status.5253 Mycobacterium tuberculosis and SARS-CoV-2 share some commonalities, including the respiratory 54 transmission route and several risk factors of the patients, such as older age and pre-existing 55 pulmonary diseases. Migrants are at a greater risk for Mycobacterium tuberculosis infection because 56 of the higher incidence in countries of origin or adverse circumstances during transit and arrival in 57 the country of destination [6]. New evidence, including mathematical modelling [7], demonstrates 58 that tuberculosis (TB) incidence is predicted to significantly increase as a result of direct and 59 particularly indirect impacts of COVID-19 [8,9]. Furthermore, although current evidence is still scarce 60 and ambivalent, TB--COVID-19 co-infection may lead to worse treatment outcomes [10,11], and this, 61 together with the higher incidence, could lead to increased TB mortality and morbidity.Page 2 of 6For Review OnlyUnion TB & Migration Group Editorial62 Healthcare systems globally have been allocating resources to control the rapid spread of SARS-CoV-63 2. Consequently, medical personnel, equipment, and materials have been diverted to diagnose, treat 64 and research COVID-19. In line with the re-prioritisation, the gap in TB care has widened. Whilst 65 medical attention and resources have decreased [12], travel restrictions and lock downs have also 66 hindered individuals from diagnosis and treatment for TB [13]. Additionally, border closures can 67 interfere with the global TB drug distribution chain, which in turn increases the risk for the 68 development of drug resistance. Further, the global distribution of anti-TB drugs is being disrupted, 69 which risks the interruption of necessary continuous and appropriate treatment regimens and may 70 increase the risk for developing drug resistance. Finally, the BCG vaccine (the only vaccine licenced 71 against TB) is being sought for its potential protection against SARS-CoV-2 infection ([14,15]. 7273 While the scientific community is gaining experience in understanding and controlling COVID-19, 74 lessons from the TB field can be used in the fight against COVID-19 [16].  Practitioners who work in 75 TB programs have gained wide experience in treating vulnerable and hard-to-reach populations. 76 Many have already established effective communication channels with the foreign community, 77 reduced knowledge gaps, built trust, and established effective mechanisms for support and 78 involvement of migrants. The medical expertise and current infrastructure which has been 79 established for TB-care is a valuable resource which can also be used to respond and control for 80 COVID-19 among migrants. Integration of TB and COVID-19 efforts among the migrants could have a 81 synergistic effect, as illustrated through a few country examples.8283 In India, whilst the ongoing COVID-19 pandemic has stressed healthcare systems and interrupted TB 84 programs, there have also been considerable synergies found. For example, district health officers 85 have systematically visited COVID-negative patients with respiratory symptoms to test them and 86 their contacts for TB, often using GeneXpert and TrueNat tests. In Switzerland, a low-TB incidence 87 county, contact tracing for TB has continued with less cases notified than in the last 10 years and the 88 need for continuous care for patients with TB has been highlighted by the Swiss National Lung 89 Association [17].  COVID-19 contact tracing has been scaled-up extensively by cantonal authorities 90 for all individuals with infection according to recommendations from the Federal Office of public 91 health. In Israel, another low TB incidence country, the Ministry of Health issued guidelines for the 92 continuum of care for TB patients very soon after the detection of the first COVID-19 patient in Israel 93 and new technologies, including video observed therapy (VOT) were introduced to support TB 94 treatment during lockdown. However, in all three settings, a shifting of resources from TB to COVID-95 19 has also been observed, and loss of key trusted individuals, such as for example the Eritrean Page 3 of 6For Review OnlyUnion TB & Migration Group Editorial96 community worker in Tel Aviv who acted as a ‘bridge’ to his community, has had a negative effect on 97 TB care.9899 After one year since the detection of this new and likely persistent pathogen, we need to ensure 100 sustainable continuation of TB care in all countries [18]. The Union and its TB and Migration Group 101 have therefore issued recommendations regarding TB and COVID-19 among migrants. They 102 emphasise a strong need to continue to pay attention to TB control, to ensure early and appropriate 103 diagnosis and care of COVID-19 and TB for all, including migrants, and to ensure that TB care in 104 migrants is not neglected so that the control of both diseases can be optimised or even synergised, 105 where appropriate.106107 Indeed, it is harder to tackle more than one epidemic at once, but like the game “Pandemic”, 108 neglecting a disease to focus solely on another means losing in the first turn. 109110 The authors have no conflicts of interest to declare. 111 This work has been self-funded.112Page 4 of 6For Review OnlyUnion TB & Migration Group Editorial113114 References 115116 1. Morens DM, Daszak P, Markel H, Taubenberger JK. Pandemic COVID-19 Joins History’s Pandemic 117 Legion. MBio. 2020;11. doi:10.1128/mBio.00812-20118 2. Rader B, Scarpino SV, Nande A, Hill AL, Adlam B, Reiner RC, et al. Crowding and the shape of 119 COVID-19 epidemics. Nat Med. 2020; 1–6. doi:10.1038/s41591-020-1104-0120 3. Bozorgmehr K, Saint V, Kaasch A, Stuckler D, Kentikelenis A. COVID and the convergence of 121 three crises in Europe. Lancet Public Health. 2020;5: e247–e248. doi:10.1016/S2468-122 2667(20)30078-5123 4. Brandenberger J, Baauw A, Kruse A, Ritz N. The global COVID-19 response must include refugees 124 and migrants. Swiss Med Wkly. 2020;150: w20263. doi:10.4414/smw.2020.20263125 5. COVID-19, crises and fragility. [cited 28 Oct 2020]. Available: 126 https://www.oecd.org/coronavirus/policy-responses/covid-19-crises-and-fragility-2f17a262/127 6. Walker TM, Merker M, Knoblauch AM, Helbling P, Schoch OD, van der Werf MJ, et al. A cluster 128 of multidrug-resistant Mycobacterium tuberculosis among patients arriving in Europe from the 129 Horn of Africa: a molecular epidemiological study. Lancet Infect Dis. 2018;18: 431–440. 130 doi:10.1016/S1473-3099(18)30004-5131 7. Developed by Stop TB Partnership in collaboration with Imperial College, Avenir Health, Johns 132 Hopkins University and USAID. THE POTENTIAL IMPACT OF THE COVID-19 RESPONSE ON 133 TUBERCULOSIS IN HIGH-BURDEN COUNTRIES: A MODELLING ANALYSIS. In: Stop TB Partnership 134 [Internet]. [cited 28 Oct 2020]. Available: 135 http://www.stoptb.org/assets/documents/news/Modeling%20Report_1%20May%202020_FINA136 L.pdf137 8. Global Tuberculosis Programme: Our response to COVID-19. [cited 24 Aug 2020]. Available: 138 https://www.who.int/teams/global-tuberculosis-programme/covid-19139 9. Migliori GB, Thong PM, Akkerman O, Alffenaar J-W, Álvarez-Navascués F, Assao-Neino MM, et 140 al. Worldwide Effects of Coronavirus Disease Pandemic on Tuberculosis Services, January–April 141 2020 - Volume 26, Number 11—November 2020 - Emerging Infectious Diseases journal - CDC. 142 [cited 28 Oct 2020]. doi:10.3201/eid2611.203163Page 5 of 6For Review OnlyUnion TB & Migration Group Editorial143 10. Motta I, Centis R, D’Ambrosio L, García-García J-M, Goletti D, Gualano G, et al. Tuberculosis, 144 COVID-19 and migrants: Preliminary analysis of deaths occurring in 69 patients from two 145 cohorts. Pulmonology. 2020;26: 233–240. doi:10.1016/j.pulmoe.2020.05.002146 11. Tadolini M, Codecasa LR, García-García J-M, Blanc F-X, Borisov S, Alffenaar J-W, et al. Active 147 tuberculosis, sequelae and COVID-19 co-infection: first cohort of 49 cases. Eur Respir J. 2020;56. 148 doi:10.1183/13993003.01398-2020149 12. WHO: Global TB progress at risk. [cited 28 Oct 2020]. Available: 150 https://www.who.int/news/item/14-10-2020-who-global-tb-progress-at-risk151 13. The impact of the COVID-19 epidemic on tuberculosis control in China. The Lancet Regional 152 Health - Western Pacific. 2020;3: 100032. doi:10.1016/j.lanwpc.2020.100032153 14. Fritschi N, Curtis N, Ritz N. Bacille Calmette Guérin (BCG) and new TB vaccines: specific, cross-154 mycobacterial and off-target effects. Paediatr Respir Rev. 2020. doi:10.1016/j.prrv.2020.08.004155 15. Schaaf HS, du Preez K, Kruger M, Solomons R, Taljaard JJ, Rabie H, et al. Bacille Calmette-Guérin 156 (BCG) vaccine and the COVID-19 pandemic: responsible stewardship is needed. Int J Tuberc Lung 157 Dis. 2020;24: 732–734. doi:10.5588/ijtld.20.0267158 16. Anonymous. Adapting a TB contact investigation strategy for COVID-19. [cited 28 Oct 2020]. 159 Available: https://theunion.org/news/adapting-a-tb-contact-investigation-strategy-for-covid-19160 17. Bag BFG. Zahlen zu Infektionskrankheiten. In: Bundesamt für Gesundheit [Internet]. [cited 30 161 Jan 2021]. Available: https://www.bag.admin.ch/bag/de/home/zahlen-und-statistiken/zahlen-162 zu-163 infektionskrankheiten.exturl.html/aHR0cHM6Ly9tZWxkZXN5c3RlbWUuYmFnYXBwcy5jaC9pbmZ164 yZX/BvcnRpbmcvZGF0ZW5kZXRhaWxzL2QvdHViZXJrdWxvc2UuaHRt/bD93ZWJncmFiPWlnbm9y165 ZQ==.html166 18. Keddy KH, Migliori G, van der Walt M. Developing health policies in patients presenting with 167 SARS-CoV-2: consider tuberculosis. The Lancet Global Health. 2020;8. doi:10.1016/S2214-168 109X(20)30413-7169Page 6 of 6

TB and COVID-19 in migrants- Why we need to focus on both

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TB and COVID-19 in migrants- Why we need to focus on both

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