As Pakistan braced for a wave of COVID-19 infections in late March, the government issued a call to shut down 12 mobile radiology vans offering tuberculosis (TB) screening in Karachi, a mega-city of 20 million people. The vans are a program of the Zero TB Initiative-Karachi (ZTBI-Karachi), and program leaders were told the risk of COVID transmission was too high in the dense and TB-burdened neighborhoods where the vans attracted large crowds for quick and free-of-charge screening. 

It was a moment of reckoning with potentially heartbreaking results. In Pakistan, TB continues to be a pervasive threat. With half a million new cases each year, TB stubbornly clings to its #6 ranking among leading causes of death in Pakistan. But those numbers obscure important progress. In the months before COVID-19, Pakistan logged a 10-year 15 percent decline in TB incidence. Contributing to these gains were investment in health workers, labs, a fleet of vans, free testing, and other infrastructure, all deployed through ZTBI- Karachi, funded by the Global Fund and led by the Global Health Directorate of the Indus Health Network (IHN-GHD). 

With the pandemic disrupting health systems, the team at IHN-GHD braced for devastating reversals in TB detection. Their data show identification of new cases dropped 83 percent, to just 129 diagnoses during the lockdown. In the same period the year before, more than 73,000 people were screened and 750 new cases detected. Watching these numbers play out in the lives of real people, the team scrambled to find new solutions. 

IHN-GHD went back to the government with a plan: they could deploy their vans to simultaneously screen for TB and COVID-19. And they could do it safely, closely following all infection control protocols to minimize the risk of transmission. Drawing on the trust of donors, the urgency of the pandemic gave these innovators leeway to adapt and move quickly, cutting through red tape to help save lives. The donors agreed to let TB-dedicated funds be used for COVID-19 interventions, such as expanded screening and lab testing.

“As public health professionals, we knew we had to respond to the pandemic and we could not afford to shut down. TB is a very serious and intractable disease in the country, and we can’t turn our backs on this threat. We realized these vans were a resource we could adapt to respond to the pandemic and continue to treat TB,” said Saira Khowaja, IHN-GHD’s Executive Director. 

IHN-GHD partnered with an artificial intelligence company, Qure.ai,  to pilot software that could assess risks for both COVID-19-associated pneumonia and TB using a single X-ray. A positive assessment triggered further diagnostic testing and was free of charge. The program established protocols for social distancing and infection control, with vans operating in open-air parks or parking lots in neighborhoods where TB burdens are high.  And, crucially, the community health workers had extensive experience and training with respiratory pathogens and swiftly adapted to provide COVID-19 care. When doctors and nurses were in short supply, community health workers stepped up to conduct COVID-19 nasal swabbing. 

In the months since the government approved the plan, the vans have been used to create Karachi’s first drive-through COVID-19 testing clinic. In addition, IHN-GHD has continued TB screening and preventive therapy. The program as a whole reversed the dangerous decline in TB case notification and access to treatment services. Shortly after COVID-19 and TB services were integrated, the third quarter of 2020 saw 693 new diagnoses and 60,000 screened; a huge improvement from the 129 diagnoses and 2300 screened during the height of the lockdown in Q2. These improved figures are not as high as pre-COVID numbers from 2019, but they represent recovery made possible by innovation, and a mighty effort to mitigate a disaster that remains a powerful threat.