2. Materials and Methods
- Studies reporting on TB services during COVID-19;
- Studies reporting on TB services at PHC;
- All of the publications reporting evidence on TB services during COVID-19 at PHC, regardless of study design;
- Studies from all countries around the world.
- Studies reporting on TB services outside the PHC level;
- Studies reporting evidence on TB services and viral diseases other than COVID-19;
- Studies reporting evidence on health services other than TB during COVID-19;
- Publications from before 2020.
2.2. Quality Appraisal
2.3. Collating, Summarizing, and Reporting Results
3.1. Screening Results
3.2. Characteristics of the Included Studies
3.3. Quality Appraisal
3.4. Summary of the Evidence
3.4.1. Consequences of the COVID-19 Pandemic on TB Services
3.4.2. Patient and Provider Experiences
3.4.3. Recommendations and Adaptations of TB Services
3.4.4. Implementing the Recommendations for TB Services
4.1. Implication for Research
4.2. Strengths and Limitations
Data Availability Statement
Conflicts of Interest
|Section and Topic||Item No.||Checklist Item||Reported on Page|
|Identification||1||Evidence of TB services at the primary healthcare level during COVID-19: A scoping review.||1|
|Registration||2||Open Science Framework: https://osf.io/pq3ba (accessed on 16 September 2021)|
|Rationale||3||Despite the availability of vaccinations and chemotherapy for prevention and treatment , 10 million new cases of tuberculosis (TB) were recorded in 2019 . A third of these cases were missed by health systems , and considerably more were not started on an appropriate treatment . These missed cases contribute to the ongoing transmission , while prolonged diagnosis and treatment initiation exacerbate disease severity and continued spread . Interrupting transmission through early and accurate detection, rapid treatment initiation, and completion, preferably at the primary healthcare level (PHC), aids efforts in ending the TB epidemic [3,6]. In 2020, COVID-19 emerged, hindering global TB control efforts , many routine TB services were sidelined in response to the COVID-19 pandemic [8,9]. These services suffered a sharp decline due to lockdowns limiting access to healthcare and a rise in fear and stigma since the advent of COVID-19 [8,10,11].|
Studies that predict the potential impact of COVID-19 on TB services suggest that temporary disruptions in response to COVID-19 will likely affect all aspects of the TB care cascade [12,13,14]. Even small disruptions to these services could have long-term consequences on TB control . These will especially be felt by high burden countries where TB incidence and mortality have been predicted to increase by 6.3 and 1.4 million between 2020–2025, respectively . Delays in patients seeking timely diagnosis and treatment are listed as the potential drivers for these grim outcomes [12,14].
The World Health Organization’s (WHO) End TB strategy and the sustainable development goal (SDGs) 3.3 aim to end TB through timely diagnosis and treatment, treatment adherence, and preventative therapy [15,16]. The WHO aims to eliminate the TB epidemic by 2035 and has also set short-term milestones to reduce TB deaths and incidence rates by 2020 and 2025 [3,15]. Findings from the TB global health report showed that 2020 milestones were not achieved . Similarly, interim targets were set by the United Nations (UN) to diagnose and treat 40 million additional people by 2022 . Although progress towards these goals has been made, it is below the threshold that would make TB elimination attainable [3,18]. It is also possible that the small gains made towards controlling TB were disrupted by the COVID-19 pandemic, pushing the global TB targets further into the future [7,19].
As the first point of contact with health services, PHC can reach large proportions of the population. It also promotes equitable access to health services and continuity of care and is thereby recognized as a powerful way that health SDGs can be achieved [16,20]. The WHO has also emphasized that progress towards containing the TB epidemic can accelerate when TB control has been integrated with PHC . Furthermore, high-quality PHC services are an important predictor for whether TB control strategies will realize their promise .
Despite the emergence of other public health priorities, such as the COVID-19 pandemic, uninterrupted TB services at PHC are crucial for TB targets to be reached. Given the novelty of the COVID-19 pandemic, its effects on TB services at the PHC level remain unclear and require further exploration. Therefore, this review aimed to systematically map evidence on TB services at the PHC level during the COVID-19 pandemic. The evidence obtained from the study will be used to develop primary research that is aimed at addressing and improving TB services at the PHC level during the COVID-19 pandemic to accelerate global efforts to end TB.
|Objectives||4||This review aimed to systematically map evidence on TB services at the PHC level during the COVID-19 pandemic.||4|
|Eligibility criteria||5||Inclusion criteria|
Publications that adhere to the following criteria were included:
This review excluded studies based on the following:
|Information sources||6||We conducted an advanced search using the following five academic databases: PubMed, Web of Science, Medline OVID, Medline EBSCO, and Scopus.||5|
|Search strategy||7||Studies were identified using the following keywords and medical subject heading (MeSH) terms: “TB diagnostics”, “Health Service” “TB testing” “COVID-19”, “SARS-CoV-2”, “COVID-19 Pandemic”, “COVID-19 era” and “Primary healthcare”. A combination of medical subject headings (MeSH) and free word texts of the keywords were used when conducting the searches. WHO and Stop TB partnership websites were accessed for reports and the reference lists of all the included studies were consulted for additional literature.||5–6|
|Data management||8a||Describe the mechanism(s) that will be used to manage records and data throughout the review.|
|Selection process||8b||The studies were selected in three phases. First, the principal investigator screened the titles of each article using the eligibility criteria as a guide. Eligible articles were exported to an EndNote20 library where duplicates were identified and removed. In the second phase, two independent reviewers screened the abstracts of the included articles using a screening tool developed through the use of the inclusion and exclusion criteria. The screening tool was piloted and adjusted using 10 articles before the screening process was conducted. The reviewers discussed any discrepancies that arose until they reached a consensus on the articles to select. In the third phase, the two reviewers screened the full texts of the relevant articles using a screening tool guided by eligibility criteria. Before use, the screening tool was piloted by both screeners, and changes were made accordingly. Discrepancies during full-text screening were resolved by a third reviewer. The level of agreement between the two reviewers was calculated using McNemar’s Chi-square statistic.||6|
|Data collection process||8c||An electronic data charting form containing variables relevant to the research question was developed. Two independent reviewers then piloted the data extraction tool using 10 of the included studies. The necessary changes were applied according to the feedback given by the reviewers.||7|
|Data items||9||Data were extracted from the included studies based on the following categories: Author, aim, type of publication, country, type of TB service, and primary healthcare provider.||7|
|Data synthesis||10||We employed thematic analysis to extract relevant evidence to answer our research questions and presented a narrative summary that centered around the emerging themes. The themes that arose most from the included studies were as follows: The unintended consequences of COVID-19 on TB services; comparison of TB services before and after COVID-19; patient experiences of TB services during COVID-19; and recommendations for TB services at PHC during COVID-19.||7|
|Confidence in cumulative evidence||11||To assess the risk of bias we determined the quality of the included studies using the mixed methods appraisal tool (MMAT) V.2018 software . The tool assessed the methodological quality of the included primary studies. The particular study design guided how the article was appraised, following stipulations by the MMAT guidelines. Once the scores for each study were calculated as a percentage, they were given a specific rank. Studies equal to or below 50% were ranked as low quality, those between 51–75% were deemed average quality, and those ranging from 76–100% were given a high-quality score.||7|
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|Population||Primary healthcare providers—healthcare practitioners providing TB services, which are the first point of contact between people in a community and the healthcare system.|
|Concept||TB services—the processes involved in finding, diagnosing, treating, and preventing TB, which leads to cases being notified to national health systems.|
|Context||COVID-19 era—the time since COVID-19 emerged, from January 2020 to date.|
|Date||Database||Keywords||Number of Results Retrieved|
|7 June 2021||PubMed||((“Health Services” [Mesh] OR “primary health care” [MeSH Terms] OR “Primary health care” [Text Word] OR “health care” [Text Word] OR “health service*” [Text Word] OR “Primary healthcare” [Text Word]) AND (“sars-cov-2” [MeSH Terms] OR “covid-19” [MeSH Terms] OR covid [Text Word] OR coronavirus OR “corona virus”)) AND (“tuberculosis” [MeSH Terms] OR tuberculosis [Text Word])||191|
|7 June 2021||PubMed||((“primary health care” [MeSH Terms] OR “Primary health care” [Text Word] OR “Primary healthcare” [Text Word]) AND (“sars-cov-2” [MeSH Terms] OR “covid-19” [MeSH Terms] OR covid [Text Word] OR coronavirus OR “corona virus”)) AND (“tuberculosis” [MeSH Terms] OR tuberculosis [Text Word])||13|
|11 June 2021||Web of Science||(TITLE-ABS-KEY (tuberculosis OR tb) AND TITLE-ABS-KEY (sars-cov-2 OR covid-19 OR covid OR coronavirus OR“corona AND virus”) AND TITLE-ABS-KEY (“primary health care” OR “primary AND healthcare” OR “primary AND care” OR “Health Services”))||5|
|7 June 2021||Medline OVID||(((MH “COVID-19”)) OR “covid-19” OR ((MH “SARS-CoV-2”)) OR “sars-cov-2”) AND (((MH “Tuberculosis+”)) OR “tuberculosis”) AND (((MH “Primary Health Care”)) OR (“primary health care”) OR ((MH “Health Services+”)) OR (“health services”) OR (“primary health”))||223|
|7 June 2021||Medline EBSCO||(((MH “COVID-19”)) OR “covid-19” OR ((MH “SARS-CoV-2”)) OR “sars-cov-2”) AND (((MH “Tuberculosis+”)) OR “tuberculosis”) AND (((MH “Primary Health Care”)) OR (“primary health care”) OR ((MH “Health Services+”)) OR (“health services”) OR (“primary health”))||189|
|7 June 2021||Scopus||(TITLE-ABS-KEY (tuberculosis OR tb) AND TITLE-ABS-KEY (sars-cov-2 OR covid-19 OR covid OR coronavirus OR “corona AND virus”) AND TITLE-ABS-KEY (“primary health care” OR “primary AND healthcare” OR “primary AND care” OR “Health Services”))||81|
|Author and Date||Aim of Study||Publication Type||Country||Primary Healthcare Provider||Type of TB Service(s) Reported|
|Fatima et al. 2021 ||To demonstrate how TB services were strengthened during COVID-19||Research article||Pakistan||PHC centers, private healthcare providers (PHCP)||General TB services and case notifications|
|Aguiar 2021 ||To show the changes made at a TB outpatient center as a result of COVID-19||Letter||Portugal||Outpatient center||TB case finding and treatment|
|Beyene et al. 2021 ||To assess the impact of COVID-19 on TB control programs at various clinics in Addis Ababa||Research article||Ethiopia||Public health clinics||TB screening and testing|
|Comella-del-Barrio et al. 2021 ||To give an overview of the effects of COVID-19 on TB control||Editorial||Low to middle-income countries (LMIC)||Primary healthcare in general||TB testing|
|Fei et al. 2020 ||To show how COVID-19 has affected TB control in China||Research article||China||Primary healthcare workers and clinics||General TB services|
|Adewole 2020 ||How COVID-19 has impacted TB care in Nigeria||Letter||Nigeria||TB clinic||TB case notification and detection|
|Burzynsky et al. 2020 ||To show how TB services have been adapted for COVID-19 during the closure of non-essential services in New York||Letter||United States of America||TB clinics||TB detection, testing, and treatment|
|Cox et al. 2021 ||To provide recommendations for TB care during COVID-19 in high burden settings||Letter||Countries with a high TB burden||Clinics||TB treatment|
|Keene et al. 2020 ||How TB and HIV services can leverage the COVID-19 pandemic||Expert Opinion||South Africa||Clinics||TB screening, testing, treatment, and detection|
|Rai and Kumar 2020 ||How TB patients were affected by the lockdown in India||Letter||India||Pharmacists, outpatient department, and general practitioners (GP)||TB treatment|
|World Health Organization 2020 ||To give guidance on how TB care should be conducted during COVID-19||Report||All countries||Outpatient centers and primary healthcare workers||TB treatment|
|Stop TB partnership 2020 ||To show how COVID-19 has impacted different TB stakeholders around the world||Report|
|Global fund implementing countries||Clinics||General TB services|
|Soko et al. 2021 ||To estimate the impact of COVID-19 on TB case notifications||Research Article||Malawi||Primary healthcare centers||TB case notifications|
|Meneguim et al. 2020 ||How a TB center adapted its service for COVID-19 in India||Letter||India||Outpatient hospital department||TB diagnostics, treatment, follow-up, and adherence support|
|Pilane et al. 2020 ||Reporting disruption of TB and HIV services due to COVID-19||News Article||South Africa||PHC facilities||General TB services|
|Datta et al. 2020 ||To show how COVID-19 disrupted a TB free block model pilot study||Report||India||Mobile diagnostic services||Active case-finding and TB diagnostics|
|Debriche Health and Development Center 2020 ||To discuss how TB and PHC services have been impacted by COVID-19 and propose solutions||Webinar||Nigeria||PHC centers||General TB services|
|Adepoju 2020 ||To demonstrate how COVID-19 has affected TB care||Feature||Nigeria||PHC centers and clinics||TB screening and treatment|
|Jamal et al. 2020 ||To detail how TB services were maintained in the private sector during COVID-19||Letter||Pakistan||GPs||TB treatment and diagnostics|
|Ongole et al. 2020 ||To give insight into how TB care can be conducted during COVID-19 through strengthened|
|Letter||South Africa||PHC centers||General TB services at PHC|
|Senoo et al. 2020 ||To report on the shortages of the BCG vaccine||Letter||Japan||Clinics||TB vaccinations|
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