SARS CoV-2 infection, called COVID-19, began in China and spread to the rest of the planet with harmful impacts on public health and the world economy. Brazil was the first country in Latin America, to report a case, in February 2020, followed by gradual spread to the rest of the continent ¹1. Rodríguez-Morales AJ, Gallego V, Escalera-Antezana JP, Méndez CA, Zambrano LI, Franco-Paredes C, et al. COVID-19 in Latin America: the implications of the first confirmed case in Brazil. Travel Med Infect Dis 2020; 35:101613., with a heterogeneous pattern in time and in the number of cases, and homogeneous in terms of the socioeconomic effects. As of mid-August, South America had recorded more than 5 million cases and 200,000 deaths ²2. Dong E, Du H, Gardner L. An interactive web-based dashboard to track COVID-19 in real time. Lancet Infect Dis 2020; 20:533-4.. In Peru, following confirmation of the first case in early March ³3. Aquino M, Garrison C. Peru records first confirmed case of coronavirus, President Vizcarra says. Reuters 2020; 6 mar. https://www.reuters.com/article/us-health-coronavirus-peru/peru-records-first-confirmed-case-of-coronavirus-president-vizcarra-says-idUSKBN20T1S9.
https://www.reuters.com/article/us-healt... , the measures adopted by the government aimed to mitigate mass transmission and the impact on vulnerable populations through the imposition of an early quarantine, border closings, restriction of domestic and international travel, social distancing, a relief allowance for poor and extremely poor Peruvians, early withdrawal of deposits from private pensions, and closing of schools and universities in order to avoid the collapse of health systems, already weakened ⁴4. Amazonas Explorer. Coronavirus in Peru: the latest updates. https://amazonas-explorer.com/is-there-coronavirus-in-peru/#Timeline_of_coronavirus_cases_in_Peru (accedido el 20/Ago/2020).
https://amazonas-explorer.com/is-there-c... .

Nevertheless, despite these containment measures, the Peruvian health systems have been overloaded to the point of collapse. The country has a high number of cases, more than 550,000, the second most in Latin America after Brazil. Of the confirmed cases, some 15,000 Peruvians are hospitalized, with more than 500 receiving mechanical ventilation ⁵5. Ministerio de Salud. Sala situacional: COVID-19 Perú. https://covid19.minsa.gob.pe/sala_situacional.asp (accedido el 20/Ago/2020).
https://covid19.minsa.gob.pe/sala_situac... . More than 25,000 deaths have been reported ²2. Dong E, Du H, Gardner L. An interactive web-based dashboard to track COVID-19 in real time. Lancet Infect Dis 2020; 20:533-4., with mortality disproportionately affecting the older adult population ⁶6. Munayco C, Chowell G, Tariq A, Undurraga EA, Mizumoto K. Risk of death by age and gender from COVID-19 in Peru, March-May, 2020. Aging 2020; 12:13869-81. and making Peru one of the world’s ten countries with the most deaths from the novel coronavirus ⁷7. Worldometer. COVID-19 coronavirus pandemic. https://www.worldometers.info/coronavirus/ (accedido el 20/Ago/2020).
https://www.worldometers.info/coronaviru... . The pandemic’s magnitude has been compared to that of critical areas in Europe ⁸8. Burki T. COVID-19 in Latin America. Lancet Infect Dis 2020; 20:547-8., with the number of cases and deaths increasing rapidly and with a continuously heterogeneous regional distribution in relation to the temporal spread, initially hitting the national capital Lima, regions of the east and north, spreading successively to the south and with no distinction according to climate, geography, or altitude ⁴4. Amazonas Explorer. Coronavirus in Peru: the latest updates. https://amazonas-explorer.com/is-there-coronavirus-in-peru/#Timeline_of_coronavirus_cases_in_Peru (accedido el 20/Ago/2020).
https://amazonas-explorer.com/is-there-c... .

Factors in the country’s insufficient response to COVID-19 include lack of infrastructure and deficient logistics in the health systems at the national level, centralization of the response plan in hospitals in the capital Lima, low initial budgeting to deal with disease, which includes insufficient medical supplies, limited commitment by the population to comply with the containment measures imposed by the government, and precarious job security and high labor informality ⁹9. Taj M, Kurmanaev A. El virus exhibe las debilidades de la historia de éxito de Perú. The New York Times 2020; 12 jun. https://www.nytimes.com/es/2020/06/12/espanol/america-latina/peru-coronavirus-corrupcion-muertes.html.
https://www.nytimes.com/es/2020/06/12/es... ^,1010. Castillo M. Peru seemed to do everything right. So how did it become a Covid-19 hotspot? CNN 2020; 27 may. https://edition.cnn.com/2020/05/25/americas/peru-covid-hotspot-why-intl/index.html.^,1111. Pighi P. Cuarentena en Perú: 5 factores que explican por qué las medidas de confinamiento no impiden que sea el segundo país de América Latina con más casos de covid-19. BBC News 2020; 22 may. https://www.bbc.com/mundo/noticias-america-latina-52748764.
https://www.bbc.com/mundo/noticias-ameri... . The results are the consequences of decades of low investment in health, education, and labor.

Our underlying concern is with the situation after the pandemic for patients diagnosed with pulmonary tuberculosis (TB), the seventeenth leading cause of mortality in the country ¹²12. Ministerio de Salud. Principales causas de mortalidad por sexo. Perú - año 2017. https://www.minsa.gob.pe/reunis/recursos_salud/MORTG002017.asp (accedido el 20/Ago/2020).
https://www.minsa.gob.pe/reunis/recursos... , due to its important social component, associated with poverty and malnutrition, endemic problems in Peru. In 2019, 32,970 cases were reported, with an incidence rate of 88.6 new TB cases per 100,000 inhabitants. The statistics reveal an upturn in the number of reported cases compared to previous years. However, the absolute number of individuals with respiratory symptoms has also increased consistently in the last 5 years, reaching 2,049,897 identified cases last year ¹³13. Dirección de Prevención y Control de la Tuberculosis, Ministerio de Salud. Perfil de la tuberculosis - Perú. http://www.tuberculosis.minsa.gob.pe/DashboardDPCTB/PerfilTB.aspx (accedido el 20/Ago/2020).
http://www.tuberculosis.minsa.gob.pe/Das... . Uncertainty concerning the pandemic’s impact on the sustained growth in the national reporting and surveillance system, alongside the impending socioeconomic crisis, may deepen the health problem with TB in the country.

TB patients are at high risk of succumbing to the novel coronavirus due to their vulnerability from chronic lung damage, associated comorbidities, including HIV infection and diabetes mellitus, malnutrition, and poverty ¹⁴14. Abdool Karim Q, Abdool Karim SS. COVID-19 affects HIV and tuberculosis care. Science 2020; 369:366-8.. A preliminary observational study in China had already identified pulmonary TB as a risk factor for severe COVID-19 ¹⁵15. Liu Y, Bi L, Chen Y, Wang Y, Fleming J, Yu Y, et al. Active or latent tuberculosis increases susceptibility to COVID-19 and disease severity. medRxiv 2020; 16 mar. https://www.medrxiv.org/content/10.1101/2020.03.10.20033795v1.
https://www.medrxiv.org/content/10.1101/... , corroborating previous findings with other viral pneumonias: influenza, MERS-CoV, and SARS-CoV-1 ¹⁶16. Alfaraj SH, Al-Tawfiq JA, Altuwaijri TA, Memish ZA. Middle East respiratory syndrome coronavirus and pulmonary tuberculosis coinfection: implications for infection control. Intervirology 2017; 60:53-5.^,1717. Walaza S, Cohen C, Nanoo A, Cohen AL, McAnerney J, von Mollendorf C, et al. Excess mortality associated with influenza among tuberculosis deaths in South Africa, 1999-2009. PLoS One 2015; 10:e0129173.. In addition, case series of coinfection have already been reported that involve a diagnosis of TB following infection with the novel coronavirus ¹⁸18. Motta I, Centis R, D'Ambrosio L, García-García J-M, Goletti D, Gualano G, et al. Tuberculosis, COVID-19 and migrants: preliminary analysis of deaths occurring in 69 patients from two cohorts. Pulmonology 2020; 26:233-40.. However, the high overall prevalence of TB and the growing burden of COVID-19 suggest higher likelihood that coinfection involves simultaneous occurrence rather than a causal association ¹⁹19. Tadolini M, García-García JM, Blanc FX, Borisov S, Goletti D, Motta I, et al. On tuberculosis and COVID-19 co-infection. Eur Respir J 2020; 56:2002328.. Additional risks have also been discussed, involving insufficient attention to diagnosis, case follow-up, access to treatment, and research in new drugs, diagnostic tests, and vaccine trials to orient efforts and resources to fight COVID-19. The expected results are predictable and include an increase in case reporting, community transmission, and multidrug resistance ²⁰20. Togun T, Kampmann B, Stoker NG, Lipman M. Anticipating the impact of the COVID-19 pandemic on TB patients and TB control programmes. Ann Clin Microbiol Antimicrob 2020; 19:21.. This population is thus at a disadvantage in the race to survive the novel coronavirus.

Meanwhile, COVID-19 survivors may run a high risk of acquiring TB, and infection with the novel coronavirus itself can increase the risk of progression of latent TB infection to the active disease ²¹21. McQuaid CF, McCreesh N, Read JM, Sumner T; CMMID COVID-19 Working Group; Houben RMGJ, et al. The potential impact of COVID-19-related disruption on tuberculosis burden. Eur Respir J 2020; 56:2001718.. The hypothetical mechanism lies in immunodepression. The initial unregulated immune response, through the phenomenon called cytokine storm, involves a stage of subsequent immune suppression characterized by a sustained and substantial drop in peripheral lymphocyte count, especially CD4 and CD8 T-cells ²²22. Mehta P, McAuley DF, Brown M, Sanchez E, Tattersall RS, Manson JJ, et al. COVID-19: consider cytokine storm syndromes and immunosuppression. Lancet 2020; 395:1033-4.. The mechanism for this lymphopenia is still unknown, but new studies hypothesize that the novel coronavirus may directly infect the lymphocytes, particularly T-cells, by initiating and promoting cell death, giving rise to damaged antiviral responses and predisposition to bacterial superinfection ²³23. Li H, Liu L, Zhang D, Xu J, Dai H, Tang N, et al. SARS-CoV-2 and viral sepsis: observations and hypotheses. Lancet 2020; 395:1517-20.. This hypothesis is based partially on findings of viral replication in the lymphocyte population in previous studies on SARS-CoV-1 ²⁴24. Gu J, Gong E, Zhang B, Zheng J, Gao Z, Zhong Y, et al. Multiple organ infection and the pathogenesis of SARS. J Exp Med 2005; 202:415-24..

A challenge for Peru’s national public health system is to mitigate the pandemic’s effects without failing to care for preexisting diseases. It is thus essential to anticipate the potentially destructive synergy between COVID-19, TB, and poverty. We support the health benefits of the work done over the years by TB programs in areas such as infection control, diagnosis, contact tracing, and isolation. There is a clear opportunity to take advantage of the acquired knowledge for the pandemic’s control ²⁵25. Saunders MJ, Evans CA. COVID-19, tuberculosis and poverty: preventing a perfect storm. Eur Respir J 2020; 56:2001348.. Meanwhile, any efforts in coronavirus management should be applied to care for TB patients, citing as examples effective social isolation, hand-washing, and mandatory mask-wearing in public places. Likewise, the implementation of new molecular laboratories should serve to optimize and streamline TB diagnosis in the future. Equally important is the development of longitudinal studies to identify the pandemic’s future consequences. The current situation is radically changing the way we will manage TB in the immediate future and will further reveal the vulnerabilities. It is essential to reclaim the direction of TB control efforts in order to avoid an unprecedented health crisis.

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