Using COVID to Spur TB Program Innovations in the Kyrgyz Republic: Ainura Ibraimova shares her reflections

When COVID-19 hit Kyrgyzstan, the government turned to tuberculosis (TB) resources for help with the respiratory pandemic. Hospitals repurposed TB beds for COVID-19, and the National Reference Laboratory (NRL) for TB shifted to testing for COVID-19. Many doctors and other health workers who usually provided TB services were re-deployed to work on COVID-19. But TB didn’t go away when COVID-19 came, so TB providers had to find a way to treat both diseases.

JSI’s Dr. Ainura Ibraimova leads the USAID Cure Tuberculosis Project, a five-year project that works with the government of Kyrgyzstan to decrease the burden of TB, especially drug-resistant TB (DR-TB) in all seven oblasts (regions) and the capital city of Bishkek. She and her staff were ready to help TB providers mitigate the challenges in March 2020 when Kyrgyzstan declared an emergency, introducing strict restrictions on movement and transportation, and scrambling to help patients who had COVID-19.

In 2020, the number of TB notifications fell by 39% compared to 2019, because people could not access services. At its most acute in July 2020, there was a 71% decrease in TB notifications compared to the same period in 2019 (Figure 1). “The level of TB services sharply decreased,” says Dr. Ibraimova. 

The trend in the number of TB samples brought to the NRL for testing followed a similar pattern, reaching a maximum decline of 64% in July 2020 compared to July 2019:  “Can you imagine?” asks Dr. Ibraimova. “Half of the tests were not being brought to the facilities.” Since then, the number of TB tests has gone up, but has yet to reach pre-pandemic levels.

Infection rates among health workers in Kyrgyzstan have been high: approximately 40% of the Cure Tuberculosis Project staff has been diagnosed with COVID-19. This contributed to a scarcity of TB services and a difficult time for many medical providers. 

Despite this, Dr. Ibraimova highlights several key program adaptations to improve the health of TB and COVID-19 patients in Kyrgyzstan. 

When the NTP was repurposed as a COVID-19 department, Cure Tuberculosis helped the NTP to plan and implement updated infection control strategies, including developing trainings for NTP and NRL staff and organizing medical brigades to work in “Red Zones” –health facilities repurposed for COVID. 

Paper-based reporting for COVID-19 testing proved slow and inadequate given the testing volume. Cure Tuberculosis helped the MOH adapt the Laboratory Data Management Information System (LDMIS), originally developed and operated for TB, by developing an electronic module for COVID-19 testing. The new module helped to automate COVID-19 testing forms, with components added for results notification using SMS and for certification via QR codes. “We’re proud of that contribution… Our project helped to not just develop, but to implement the information system in 13 laboratories,” says Dr. Ibraimova. Cited as the only source of reliable testing data during the COVID-19 lockdown, this module is still working, increasing health system transparency and paving the way for inclusion of other diseases in the LDMIS.

To assist TB and DR-TB patients getting care at the primary health care level, Cure Tuberculosis developed a special MOH order that recommended giving patients drugs for 14 days, using video for directly observed therapy (DOT), and linking patients to community-based treatment supporters. Community-based treatment supporters from two sub-grantees, Red Crescent Society and TB People, provide social support for TB patients and help them get medical care. This approach is being scaled up nationally.

As the COVID-19 emergency unfolded, many DR-TB patients transitioned from in-patient care to home-based treatment with ambulatory services. This accelerated Kyrgyzstan’s transition from injectable drugs to all-oral DR-TB regimens. 

Cure Tuberculosis trained health workers on the all-oral DR-TB regimens and is providing technical assistance to the NTP to develop a DR-TB protocol promoting transition to all-oral regimens. Dr. Ibraimova explains that “the epidemic showed that this is possible.” The NTP is now adopting and rolling out this approach, and, as of June 2021, all new DR-TB patients are prescribed all-oral regimens.

To combat the decrease in TB case notifications, Cure Tuberculosis worked with the MOH to develop an algorithm and pilot an intervention to conduct simultaneous testing for COVID-19 and TB. Initiated in January 2021, the intervention guides testing decisions for mobile brigades when visiting community members who have requested a COVID-19 test. Brigade team members also screen these clients for TB and, if TB symptoms are present, the mobile brigade will test that person for TB as well as COVID-19, including taking sputum samples. Results from this pilot should be available soon. 

Although the mobile brigades are an emergency approach, Cure Tuberculosis will recommend that the MOH include the simultaneous testing approach as part of primary health care services. “I think that this experience will be very helpful for the country… What we understand is that COVID has now just come into our lives and will stay. So the COVID diagnosis will not disappear…it’s really important for us to organize the simultaneous testing of COVID and TB,” says Dr. Ibraimova.

As in most countries, the COVID-19 epidemic in Kyrgyzstan has been a painful, difficult time, especially for TB service providers and patients. “It’s really hard to talk about the positive impact of COVID-19 because we had many more serious consequences.” That said, Dr. Ibraimova acknowledges that COVID accelerated program adaptations that have made TB services more patient-centered. While such adaptations arose out of a crisis, they are also investments for the future. 

Dr. Ibraimova is hopeful that these changes will solidify commitment to taking action to end TB in Kyrgyzstan: “I think the government and the public have started to understand that we must confront the infectious diseases burden that is TB.”

Click here to watch the full video interview. 

Written by Sabrina Eagan, Senior Technical Advisor