As the number of people affected by covid-19 continues to increase worldwide, there is growing concern over the massive collateral damage to routine health services in all settings.

Among the biggest casualties of the pandemic are the hard-won gains made in controlling the epidemics of AIDS, tuberculosis (TB), and malaria. Due to large service disruptions in many countries, it is predicted that covid-19 could potentially double the number of malaria deaths in sub-Saharan Africa in 2020 in comparison to 2018. Further, a six-month disruption of antiretroviral (ARV) therapy could lead to more than 500 000 extra deaths from AIDS-related illnesses in sub-Saharan Africa between 2020–2021. 

As for TB, the leading infectious killer, even before covid-19, TB affected over 10 million people and caused 1.5 million deaths each year. Now, because of severe disruptions in routine TB services, it is estimated that we could see an additional 6.3 million cases of TB and 1.4 million TB deaths between 2020 and 2025. This implies a 5 to 8 year set back in the efforts to end TB.

Several of the highest TB burden countries are now seeing alarming increases in covid-19 cases, including India, Russia, Brazil, Pakistan, Indonesia, Bangladesh, Peru, and Nigeria. Nearly all of these countries are in full or partial lockdown. TB services are badly impacted. Countries are reporting large reductions in routine TB case notifications. Globally, TB diagnostic services have declined, and TB hospitals and wards are being used for covid-19. National TB programme staff are engaged in covid-19 response, and patients with TB are struggling to access medication and treatment support.

Despite rising case numbers, many countries are now starting to ease lockdowns and restrictions. This will result in a large surge of people seeking care after weeks of deferring medical consultations. They will present with more advanced TB disease for two reasons: long delays in diagnosis of undiagnosed patients and interrupted treatment for those who had TB when lockdowns were imposed.

To prepare for this, countries can learn from each other and implement these 10 strategies:  

1. Resume case detection: Fever and cough are symptoms of both TB and covid-19, this commonality can be leveraged to encourage simultaneous screening and resume TB screening and diagnostic services in both public and private health sectors. Mobile phones calls can also be used for contact screening where possible.
2. Leverage multi-disease platforms: Rapid testing for SARS-CoV2 is now avaliable. While it is good to leverage testing platforms to increase covid-19 testing capacity, it is critical that TB testing is not stopped. TB programmes must continue running the Xpert MTB/RIF TB test since this test is critical for early detection of drug-resistant TB in many settings.
3. Ensure access to medicines: As lockdowns are easing slowly in many settings, all TB patients should be provided with at least 2 to 3 months supply of medications to decrease frequency of consultations at TB facilities. Countries could also set up alternative medication delivery networks such as courier services. 
4. Activate remote treatment support: Using telemedicine, digital adherence technologies, and call centres to support TB patients may allow for frequent consultations but limited in-person visits to health centres. 
5. Emphasize community-based care: Community-based care is a critical, felt-need in TB. Community-based groups, including TB survivors, are generally closer to patients than TB program staff, and could be engaged to provide peer-to-peer patient support via WhatsApp, social media, and mobile phones.
6. Switch to oral regimens for drug-resistant TB: Injectable second-line TB drugs are not easy to administer during lockdowns. It is critical for TB programs to switch to all-oral shorter drug regimens recommended by WHO.
7. Prioritize TB drug supply: Every TB program must carefully track and forecast drug supplies, to avoid stock-outs. Globally, TB drug production must be resumed to avoid major drug stockouts. India’s generic drug industry has been gravely affected by the lockdown, limiting the supply of essential medicines.
8. Engage private health services: Some of the highest TB burden countries also have the largest private health sectors. In these settings, it is unlikely that the public health system alone can deal with this massive surge in patients. Governments must adopt a whole of government, whole of society approach, mobilizing both public and private health sectors, including community-based groups, in the collective covid-19 and TB response.
9. Re-imagine TB care: As healthcare rapidly transitions towards online, e-health-based models, there is a need to leverage various technologies and digital connectivity solutions, bring them together, to implement an integrated model which is based on human-centered design.
10. Share best practices: As the pandemic evolves, many innovative approaches are being tested to ensure TB services align with the covid-19 response. Communities of practice (e.g. TB PPM Learning Network) could help with sharing of best practices and lessons learnt.

Even as countries are responding to the covid-19 pandemic, they must not abandon the provision of essential and critical healthcare services. As governments begin to lift lockdowns, high TB burden countries must have a clear plan on how to resume and ramp up routine TB services, leveraging public as well as private health sectors.

Nathaly Aguilera Vasquez is a Program Officer at the McGill International TB Centre, McGill University, Montreal. Twitter: @av_Nathaly

Tripti Pande is a Lead Program Officer at the McGill International TB Centre, McGill University, Montreal Twitter: @tripti_pande

Petra Heitkamp is Manager of the TB PPM Learning Network at the McGill International TB Centre, McGill University, Montreal Twitter: @PetraHeitkamp

Madhukar Pai is the Director of the McGill International TB Centre, McGill University, Montreal. Twitter: @paimadhu

Competing interests: None declared