In March, 2019, the Lancet Commission on Tuberculosis 1 highlighted the opportunity to build a tuberculosis-free world. After years of neglect of this disease, the UN High-Level Meeting on Tuberculosis in September, 2018, made ending tuberculosis a global priority; global leaders committed to important steps, including ambitious country-specific tuberculosis case-finding and prevention targets, and a revitalised research agenda. 2 The Lancet Commission concluded that the prospect of a tuberculosis-free world was a realistic objective that could be achieved with sufficient accountability and resources, and detailed the catastrophic consequences of failing to build on that momentum. In India alone, deaths from tuberculosis would cost the economy at least US$32 billion each year over the next 30 years. 1 In October, 2020, however, the possibility of achieving a tuberculosis-free world seems challenging. Even before the COVID-19 pandemic, declines in tuberculosis incidence fell short of targets. 2 Despite consensus on the importance of global accountability, 1 efforts to secure meaningful global accountability were mired in obfuscation and bureaucracy. 3 Moreover, the COVID-19 response has reduced access to tuberculosis services worldwide, including in China, 4 India, 5 South Africa, 6 and Nigeria. 7 The potential advantages of physical distancing on tuberculosis transmission 8 notwithstanding, COVID-19 is also likely to reduce access to tuberculosis diagnostics, especially for those at greatest risk of drugresistant tuberculosis. The impact of the COVID-19 response on care-seeking behaviour among people with tuberculosis is unknown, but available data suggest that fewer people are accessing tuberculosis services than would usually be expected. 9 The potential impacts of these various challenges on tuberculosis transmission have been estimated; 10,11 even a temporary disruption resulting from COVID-19 societal lockdowns might cause a long-term increase in tuberculosis incidence and mortality. In India, Kenya, and Ukraine, a 3-month lockdown, followed by a 10-month recovery period, is projected to lead to an estimated 1·65 million, 41 400, and 7960 additional incident tuberculosis cases in the next 5 years, respectively, because of limited access to drugs, diagnostics, and prevention programmes in the past few months. 10 The economic burden due to these additional incident tuberculosis cases is likely to be profound.
We calculated the health spending due to these additional incident cases of tuberculosis using estimates of government tuberculosis spending per case 12 and outof-pocket spending on tuberculosis care and projected the additional annual health-care costs that would result from these excess tuberculosis cases in India, Kenya, and Ukraine. After accounting for annual growth rates, we estimate that a 3-month lockdown, followed by a 10-month recovery, would result in an excess cost of $1·95 billion in India, $29 million in Kenya, and $96 million in Ukraine with an increase of 7·9%, 5·5%, and 4·1% in average annual health spending on tuberculosis in each country over the next 5 years (table) . If the disruptions were to extend by an additional 3 months on top of the 3 months of lockdowns and 10 months of recovery (6 months of lockdown and 13 months of recovery), then these costs would Health spending categories include national tuberculosis programme, outpatient care, inpatient care, and drugs purchased in addition to those purchased by the national tuberculosis programme. We used the estimates by Cilloni and colleagues 10 to estimate the additional incident cases of tuberculosis that would result due to a 2-month lockdown with a 2-month recovery and a 3-month lockdown with a 10-month recovery. We calculated health spending due to the additional cases using estimates of tuberculosis spending per case, per year, in 2017, along with the annual growth rates reported by Su and colleagues. 12 All costs are reported in inflation-adjusted 2019 US$. Additional incident tuberculosis cases values are reported with 95% Bayesian credible intervals. increase to $3 billion in India, $45 million in Kenya, and $160 million in Ukraine. In India, as much as 44% of that additional cost will be borne by individuals and households (appendix). Our estimates do not take into account the excess health-system costs from COVID-19 alone, which are likely to be substantially greater still. Moreover, our estimates assume that the distribution of costs between the government versus the individuals and households, would remain unchanged over a 5-year period and that costs increase at a constant annual rate. Despite these challenges, there are opportunities for synergy to expand tuberculosis programmes, strengthen tuberculosis response, and increase resources towards ending tuberculosis as governments mobilise COVID-19 response efforts while maintaining existing tuberculosis programmes. Furthermore, many of the messages of the Lancet Commission on Tuberculosis are as relevant to national COVID-19 responses as they are to national tuberculosis programmes. COVID-19 and tuberculosis both require robust infection control strategies and similar diagnostic infrastructure. Community engagement has been essential in tuberculosis control to address stigma, 13 which has already been associated with COVID-19. Mitigation strategies that proved successful in tuberculosis can also be deployed to assist in the community control of COVID-19, although the infection dynamics are different. Moreover, peoplecentred models of care, community-based services, video-supported treatment, or home-based care that have been championed by tuberculosis care providers are relevant to COVID-19 screening and management programmes. 14 Leveraging the extended capabilities of the private sector to improve access to testing capability while pursuing a social protection agenda are important components of the global response to both diseases. In addition, given the scale of testing needed in the COVID-19 pandemic, the introduction of testing capabilities in low-income and middle-income countries should be used for tuberculosis and HIV as well. 15, 16 As the Lancet Commission emphasised, global tuberculosis efforts must move beyond traditional siloed development assistance approaches towards greater country ownership and holistic, multisectoral global cooperation. That same approach is crucial for the global COVID-19 response.
In the short term, COVID-19 has inevitably drawn attention away from tuberculosis services and might lead to an increase in tuberculosis burden and incidence. Now is the time to leverage the political capital that exists for the global COVID-19 response to enable lasting change in the tuberculosis response. COVID-19, like tuberculosis, reminds us of the importance of prioritising health and allocating financial and human resources for universal health coverage and addressing the needs of vulnerable populations. With sound science, effective collaboration, smart investments, and efficient synergies, COVID-19 efforts could strengthen the global tuberculosis response and not undermine it.