The Impact of COVID-19 Pandemic on Tuberculosis Patient Treatment Adherence

Coronavirus disease 2019 (COVID-19) pandemic caused a lack of attention to treatment of tuberculosis (TB). TB patients who do not adhere to treatment during a pandemic can cause various health problems in various countries. COVID-19 pandemic adversely affects TB patients such as increasing psychological stress, triggering non-adherence to treatment, affecting quality of life, and even increasing the number of deaths of TB patients. The increasing number of deaths and decreasing success of TB treatment during the pandemic are serious problems that must be addressed immediately. Various efforts were made to overcome the barriers for TB treatment during pandemics. Health workers can provide health education and rehabilitation programs in another media such as tele-health. Digital media can provide health information about TB, improve medication adherence, emphasize the benefits of medication adherence, and motivate patients to undergo treatment.


INTRODUCTION
The 2019 Coronavirus Disease (COVID- 19) and tuberculosis (TB) can affect the respiratory system, especially the lungs, such as coughing, fever, and difficulty breathing. 1   and TB have similar transmission, through airborne, but COVID-19 transmission is faster and difficult to control than TB. 2 People diagnosed with TB and COVID-19 may have a poorer prognosis and have a higher risk of death. The current COVID-19 pandemic may pose obstacles to TB prevention and control. 3 Lack of attention in the treatment of TB patients and lack of medication adherence during the pandemic can lead to various problems including the increasing number of deaths of TB patients in various countries. TB detection is reduced by 25% as TB health services are hampered during COVID-19 pandemic in many countries. World Health Organization (WHO) estimated that between 2020 and 2025 there will be an additional 1.4 million TB deaths as a direct result of COVID-19 pandemic. 4 They also estimated that about ⅓ of people living with TB are currently undiagnosed, untreated, and unreported. COVID-19 pandemic has led to an increase in the number of people who are not diagnosed with TB and is a major source of transmission leading to high morbidity and mortality. 5 TB cases during COVID-19 pandemic are estimated to have an increased incidence of death. 6 TB patient deaths is estimated to increase between 2020 and 2035. The estimated increase in the number of deaths occurs in various countries such as 4.65% in India, 7.64% in Indonesia, 2.09% in Kenya, and 8.68% in Pakistan. This estimated increase in TB incidence and mortality are associated with the impact of COVID-19 on TB surveillance and treatment. 6 The success rate of TB treatment has decreased by 69% during COVID-19 pandemic. Some of the reasons for this decline occurred due to the closure of healthcare facilities and laboratories, sick health workers, and limited healthcare facilities during the pandemic. 7 Other barriers to TB treatment during COVID-19 pandemic are challenges in accessing healthcare facilities, stigma in the community, and lack of information, motivation, or support. 8 Access to healthcare facilities may decrease due to limited health workers and material resources, and social stigma in TB patients. The stigma of disease transmission in TB patients has been exacerbated by COVID-19 pandemic. 5 Regional quarantine can also cause problems for TB patients seeking healthcare facilities and may result in delays in diagnosis and treatment. 9 These obstacles cause TB patients to be prone to stress. The stress experienced by TB patients will affect them in undergoing treatment, therefore it can result in non-adherence to treatment and the risk of death. 10 Various efforts were made to overcome the barriers for TB treatment during the pandemic. Health workers can provide health education and rehabilitation programs in another media such as tele-health. Digital media can provide health information about TB, help improve and emphasize the benefits of medication adherence, and motivate patients to undergo treatment. 8 This literature review discussed the effects of COVID-19 pandemic on adherence of TB treatment.

Lung Tuberculosis in the Era of COVID-19 Pandemic
TB is a disease which attacks the lungs caused by Mycobacterium tuberculosis. It is spread through the air when a person with pulmonary TB coughs, sneezes, or spits. A person who inhales some of the germs from a TB patient can immediately become infected with TB. Every year, 10 million people are diagnosed with TB. Despite being a preventable and curable disease, 1.5 million people die from TB every year, making it the world's top infectious killer. 11 However, COVID-19 had a record of high death toll surpassing the death toll of TB patients in early April 2020. 3,12 COVID-19 is an infectious disease caused by SARS-CoV-2, a member of the beta family Coronaviridae, which also includes SARS-CoV-1 and MERS-CoV (Middle East respiratory syn-coronavirus). 13 COVID-19 virus can spread from an infected person's mouth or nose in small liquid particles when they cough, sneeze, speak, or breathe. These particles range from larger respiratory droplets to smaller aerosols. 14 The world has been forced to adapt to a new disease called COVID-19 which has become a pandemic and infected more than 200 million people with a death rate of over 4.6 million people worldwide since December 2019. 15 Patients with chronic diseases such as TB have higher risk of death during COVID-19 pandemic. 3 WHO continues to monitor the prevention and care of TB patients during the COVID-19 pandemic. Health services need to be involved in providing effective and fast services against COVID-19 while ensuring that health services for TB patients are also maintained. 16

Impact of COVID-19 on TB Treatment
Compliance patient adherence to treatment can be observed from various factors, such as from individual patients, health facility providers, and community. Health workers are expected to help each other in overcoming the non-compliance of TB treatment. Healthcare workers should provide health education to solve patients' medical problems, develop short-term treatment regimens, give motivational support, counseling session, social and family support for patients, and raise patient's awareness about the disease. 17 Poor adherence can lead to prolonged infectious disease, drug resistance, relapse, and death. 18 COVID-19 pandemic is placing enormous pressure on healthcare services around the world. Some suggested solutions, such as social distancing and quarantine in some areas, can help contain the spread of the virus. However, such solutions may also affect special patient populations such as patients with chronic illnesses that limit access to healthcare facilities for routine care and treatment. 19 Some of the impacts of COVID-19 pandemic on TB patients are triggering nonadherence to treatment and even increasing the number of deaths of TB patients.

Non-Adherence
Patients with chronic diseases such as TB require proper disease management and follow-up for successful treatment. If TB patients do not get proper treatment management, it can increase the risk of failure in treatment, especially in the era of COVID-19 pandemic. 20 The results showed that COVID-19 pandemic had an impact on decreasing the rate of diagnosis, decreasing treatment adherence of TB patients, and increasing the incidence of TB. It is estimated that if COVID-19 pandemic is assumed to last only 2 years, the long-term effects will last longer, a decade or more since the start of COVID-19 pandemic. In addition, in the absence of further intervention, the peak TB incidence caused by COVID-19 pandemic will not only result in new TB cases but also an increase in TB-related deaths worldwide. 6 The estimated number of TB deaths between 2020 and 2035 is 4.65% in India, 7.64% in Indonesia, 2.09% in Kenya, and 8.68% in Pakistan. The total number of deaths in the four countries is estimated at over 1.29 million people. 6 Several policies from healthcare facilities issuing advice on administering TB drugs to outpatients can affect patient's medication adherence. Policies such as patients should be given TB drugs for 1 to 2 months during the pandemic, to reduce patient visits and reduce the risk of disease transmission can lead to a lack of control over medication adherence. 27 Health workers are unable to provide intense motivation for treatment and monitoring the patient's health condition is also reduced. 21 TB patients experience recurrent TB for not complying with the treatment and experience worsening conditions and even death. 10 Treatment adherence is the key to ensuring a high success rate at the end of treatment and controlling TB. 28 Intensive counseling and monitoring of treatment are needed in overcoming patient non-adherence in undergoing TB treatment. 29 Number of Deaths Rising COVID-19 treatment will have an impact on TB services and treatment. Several factors which affect TB treatment during pandemic are lack of health workers due to handling the pandemic, health services that focus on dealing with COVID-19 pandemic, stigma and fear of COVID-19 infection in health services. These factors will contribute to the delay in diagnosis and treatment of TB patients. 3 Delay in TB diagnosis and treatment are even expected to persist for up to 1.5 years after the pandemic. 6 Studies suggest that the impact of a late diagnosis of TB can increase mortality by up to 20% in the next 5 years. 7 The decrease in healthcare services other than pandemic diseases has a negative impact on chronic diseases such as TB. TB patients get difficulty to monitor their health condition, hence patients who need regular care and follow-up are unreachable. 20 TB requires early detection and intense treatment to optimize the treatment. 6 Delay in diagnosis and treatment of TB can increase the risk of transmission, increase drug resistance, and increase mortality. 1 Delay in diagnosis and treatment of TB can increase the risk of transmission and death. 3 Some TB patients during COVID-19 pandemic stopped rehabilitation activities, got limited outpatient activities, avoided access to healthcare facilities even though they had severe symptoms that further aggravated their disease condition. 23

Impact of COVID-19 on Patient's Psychology
TB is a chronic disease that not only affects the patient's physical condition but also the patient's psychology. COVID-19 pandemic can increase the patient's stress level and reduce the quality of life in TB patients. 24 Stress TB patients can recover with a long duration of treatment for at least 6 months. The long treatment can cause psychological stress in the patient. A study stated that the majority of respondents experienced moderate stress levels in the intensive phase of 62.5% and the advanced phase of 75.86%. 20 Stress in TB patients not only caused by the duration of treatment but also drug side effects. 21 Some patients experience side effects in the beginning of TB treatment. Gastritis is one of the common side effects of anti-TB drugs. The patients will experience excessive stress and decide to stop taking medication because they do not know the drug side effect clearly. 22 Various other factors that influence the stress response internally and externally include age, gender, personality, cognitive function, family situation, and physical and social environment. 20 Lack of activity and social interaction make the stress level of TB patients higher. 23 Lack of social activities and interactions among TB patients is due to negative stigma in society that causes prolonged stress to patients. Negative stigma begins from family and friend. Sometimes patients get harsh words and people who are close with patient avoid them as they are an infectious agent. Emotional weakness can adversely affect the patient's psychology, hence patients become susceptible to secondary infections. Patients who repeatedly get questions about treatment and the effects of treatment by relatives also contribute to the cause of stress. Even after recovering, patients are still being avoided by relatives and are kept away from social gatherings by community members. 24 COVID-19 pandemic increases stress level of patients. Patients with chronic diseases such as TB may have a higher risk of the threat of COVID-19 pandemic. Chronic illness makes patients more susceptible to infection and experience difficulties in medication management, which can put some patients under stress during the pandemic. Stress and anxiety are normal reactions during crisis situations. The negative impact of COVID-19 outbreak may affect the clinical outcomes of patients with chronic conditions and psychological stress. 19 One of the supporting factors that must be considered is psychological stress management. Good management of psychological stress will enable TB patients to undergo treatment. 10 Family support, socioeconomics factors, support from doctors and nurses, availability of access to healthcare services, social stigma, psychological pressure, and knowledge about the success factors of TB treatment are needed to overcome the psychological problems of patients. 10,20 Proper management must be immediately established by governments, health workers and other stakeholders to prevent the psychological impact of pandemics. Developing advanced healthcare technologies that assist healthcare professionals is paramount to continue routine appointments. 26

Quality of Life
Quality of life in TB patients includes complex elements, such as disease conditions, economic conditions, stigma in family life, work environment, and social activities. 30 In addition to drug management, TB patients require treatment such as pulmonary rehabilitation and socio-economic support. A study explained that quality of life was also influenced by treatment adherence for TB patients. Quality of life of TB patients will decrease if TB treatment is less than optimal, especially during pandemics. 2

Strategy to Overcome the Negative Impact of COVID-19 in TB Health Education
Knowledge is one of the domains of behavior formation in TB treatment. It can increase the success of treatment and prevent disease recurrence. 10 Most of the patients do not have good knowledge about the causative factors, mode of transmission, or duration of treatment. 18 Most TB patients also complain the side effects of treatment, which become the main reason for missing treatment. Some patients feel that the duration of treatment is very long and worry that there will be damage to internal organs if they continue to take the drugs for a long time. Some patients are also unaware of the consequences of non-adherence to treatment. 17 The most common reason for TB patients discontinuing treatment because they feel recovered from TB. Some patients did not know the standard duration of treatment and the consequences if TB patients stopped treatment. Some other reasons are patients lose their jobs when they were diagnosed with TB, weak body condition at work, or unable to find daily work due to long term treatment. Lack of knowledge, loss of income, negative community stigma, lack of social support, drug side effects, and long duration of treatment are barriers to medication adherence. Comprehensive health education at healthcare service for patients, family members, and the community is needed to address medication adherence in TB patients. 18 Health workers can provide information to patients about COVID-19 and TB in order to protect patients from COVID-19 infection while continuing TB treatment. 3 Counseling and motivation are also needed for patients to overcome the disease. Health workers can provide information regarding side effects of treatment, community stigma, duration of treatment, and the importance of medication adherence. 1 Psychosocial counseling includes understanding the patient's psychosocial problems and providing stress management coping skills. Healthcare workers can provide psychosocial counseling and coping strategies for patients regarding how to cope with stress and feelings of loneliness. Counseling can be a recommendation to start social activities and relationships with relatives and train patients to think positively and avoid negative thoughts. TB treatment should not only consist of TB drug therapy but also include psychosocial support for patients. Therefore, appropriate psychosocial education is needed for TB patients, especially when facing COVID-19 pandemic. 1

Rehabilitation
Rehabilitation is important to treat TB sequelae. After completion of anti-TB treatment, patients often experience various health problems, such as difficulty in doing physical exercise or even performing activities of daily lives, which results in a decrease of quality of life. These health problems can be solved by rehabilitation program. Some patients got advantages from pulmonary rehabilitation program. 12 During COVID-19 pandemic, patients are restricted from hospital visits and rehabilitation activities, which results in patients experience various health problems.

Tele-Health Service
Health workers can use virtual services and digital technologies such as video and text messages to avoid delays in TB diagnosis and treatment due to COVID-19 pandemic. Virtual services and digital technology have the aim of providing TB patients with treatment adherence support, health workers can also monitor the health of TB patients, conduct counseling, and follow-up consultations. 3 Therapy using video demonstration media can also support medication adherence and help TB patients complete treatment during the pandemic. 27 A study explained that video demonstration media significantly reduced non-adherence by 4 days per 2-week period. Moreover, it could save the patient's time, saving money, and increase satisfaction. 13 The use of tele-health services during COVID-19 pandemic also prevent transmission and focus on healthcare services. 23 The use of digital health technology should be intensified to support patients, improve communication, counselling, care, and provide health education. In accordance with WHO recommendations, technology such as treatment monitoring, educational facilities, and therapy supported by video can help patients complete TB treatment. 4 SUMMARY COVID-9 and TB can affect the respiratory system, especially the lungs, such as coughing, fever, and difficulty breathing. COVID-19 and TB have similar transmission, through airborne, but COVID-19 transmission is faster and difficult to control than TB. COVID-19 pandemic has an impact on controlling TB. TB patients experience psychological stress, lack of medication adherence, decreased quality of life, to increase the number of deaths. Various efforts were made to overcome the problem of TB patients during the pandemic. The provision of health education and medical rehabilitation is performed in various media such as telehealth services. Technological services such as treatment monitoring, educational facilities, and therapy supported by video can help patients to complete TB treatment.