How did people in Zimbabwe respond to drug-resistant tuberculosis alongside COVID-19?

By Neha MathurMar 1 2023Reviewed by Aimee Molineux

In a recent study posted to the medRxiv* preprint server, researchers described the experiences and coping strategies of people who suffered from drug-resistant tuberculosis (DR-TB) in Zimbabwe between 2020 and 2021. They conducted this study during the first year of the coronavirus disease 2019 (COVID-19) pandemic.

*Important notice: medRxiv publishes preliminary scientific reports that are not peer-reviewed and, therefore, should not be regarded as conclusive, guide clinical practice/health-related behavior, or treated as established information.

Background

Zimbabwe, a sub-Saharan African country experiencing economic hardship since 2000, witnessed a COVID-19-induced lockdown between March and August 2020. In Zimbabwe, 72% of the population lives in poverty due to widespread unemployment. Here, the incidence of DR-TB was 4.9/100,000 population in 2021, and human immunodeficiency virus (HIV) co-infections with TB also exceeded 50%.

During the lockdown, the condition of the impoverished people belonging to poor and distressed households in cities worsened further. They faced an increased risk of contracting COVID-19 due to overcrowded habitations and had to survive on daily earnings. In the absence of social security, the pandemic reduced their household income leading to food insecurity.

Thus, households affected by DR-TB suffered concurrently or sequentially during the COVID-19 pandemic. As they had no savings or insurance, they adopted reversible coping strategies. For instance, they delayed health-seeking for chronic diseases, relocated in search of food, and mobilized and spent their resources rapidly.

Indeed, COVID-19 emerged as a global stressor and a stress multiplier and had synergistic relationships that determined household coping strategies. Though several previous studies have explored the impact of DR-TB, few studies have examined it in the context of COVID-19.

About the study

In the present study, researchers conducted comprehensive interviews with DR-TB patients in Zimbabwe to understand their experiences and how they coped with two lockdowns imposed during the COVID-19 pandemic, i.e., between March and July 2020 and December and February 2021.

The study population comprised adult men and women who received two months of DR-TB treatment or had completed it in the past two months. The researchers identified them from TB registers of health facilities in two provinces in Zimbabwe, the urban province Harare and the rural province Matebeleland South. They examined the physical impact of DR-TB, its treatment, and changes in livelihoods due to DR-TB episodes.

Moreover, they explored the coping strategies adopted in response to DR-TB and the COVID-19 pandemic. In this way, the researchers identified setting-specific experiences and coping strategies adopted by people in Zimbabwe who experienced DR-TB during the pandemic.

The team conducted interviews lasting 35 to 45 minutes in local languages, Shona or Ndebele. It encompassed questions about these people's health-seeking patterns, DR-TB treatment-related experiences, and coping strategies. Finally, the team translated interview transcripts into English and analyzed data using thematic analysis.

This study had minimal recall bias, and since they recruited most participants during the first lockdown, it helped the researchers understand the challenges at the beginning of the pandemic. On the contrary, participants recruited later helped gain insights into their DR-TB diagnostic and treatment journeys though that introduced survival bias.

Study findings

The study had 16 participants, of which eight were women. In total, 12 participants were also co-infected with HIV. The researchers noted that 10 of the 16 participants experienced delays of up to four months in DR-TB treatment initiation due to under or misdiagnoses of TB, HIV co-infection, and seeking healthcare from other providers, e.g., traditional healers. These people also sought care from private pharmacies and clinics; thus, health system-related factors contributed significantly to these delays. Longer diagnostic journeys depleted the financial resources of households by the time of DR-TB treatment initiation.

Delayed diagnosis also worsened the DR-TB severity and incurred higher costs. Not only such households depleted their assets, but they also exhausted short-term coping strategies, such as borrowing, as they were no longer creditworthy. The study also revealed vast physical and psychological impacts of DR-TB on affected people and their households, including young children.

Further, the researchers noted a frequent shortage of DR-TB drugs during the COVID-19 pandemic. Together, COVID-19 and economic challenges amplified the impact of DR-TB on households, accelerating irreversible coping strategies, which had an extensive impact on their livelihoods. Though all the study participants eventually attained successful treatment outcomes, it came at the expense of their livelihoods.

Conclusions

Some government and non-governmental organizations in Zimbabwe provide cash disbursement every month (amounting to US dollar 25) for the duration of treatment to people receiving DR-TB treatment. Unfortunately, the impact of DR-TB extends beyond the duration of DR-TB treatment. Thus, this amount is inadequate to mitigate the financial losses experienced by DR-TB households.

More TB-sensitive approaches, focused on vulnerable households, could have a greater impact in Zimbabwe and will likely prevent future DR-TB episodes. Thus, the study highlighted the significance of raising community awareness about TB symptoms and the benefits of seeking help from public facilities early on. Further, there is an urgent need to address delays in diagnosis by increasing collaborations between private and public healthcare sectors and traditional healers.

More importantly, there is a need for multisectoral approaches that go beyond the DR-TB treatment period to improve the physical, mental, and socioeconomic well-being of people and households affected by this disease, alongside other shocks, including COVID-19 and drought, et cetera. The focus should also be on post-TB care to reduce the likelihood of DR-TB re-infection.

*Important notice: medRxiv publishes preliminary scientific reports that are not peer-reviewed and, therefore, should not be regarded as conclusive, guide clinical practice/health-related behavior, or treated as established information.