Though COVID-19 was the leading cause of death among infectious diseases globally in 2020, in Ghana, TB is still the leading cause of death above COVID-19: 14,900 estimated TB mortality in 2020 2 versus 333 reported COVID-19 deaths  in the same year. In 2020 both numbers screened for TB and TB cases notified declined as a result of the impact of COVID-19 . To mitigate the impact of COVID-19 on TB service, the NTP of Ghana started the implementation of bidirectional screening and testing of COIVD-19 and TB among facility attendees in the Greater Accra Region. Based on the experience observed in the five facilities, the programme scaled up the intervention in all COVID-19 and TB testing sites all over the country in the third quarter of 2021 (unpublished). After the scaling up of the intervention the TB case notification rate increased by 4% in 2021 compared to 2020 .
Both COVID-19 and TB are airborne diseases and manifest similar signs and symptoms such as cough, fever and breathing difficulty . The decision for simultaneous testing of both TB and COVID-19 for the same patient depends on the local epidemiology of the two diseases, clinical future and individual risk factors of a patient . The total number of COVID-19 positives in the study area (Greater Accra Region) as at February 19, 2023, was 97,242, while the total COVID-19 positive cases at the national level, excluding international travelers, was 163,477 . Greater Accra contributed 69% of the total COVID-19 cases detected at the national level . During the study period (January to March 2021), a total of 35,812 new COVID-19 cases were reported at the national level,  equivalent to 21% of the total cumulative cases notified in the country as at February 19, 2023.
This bidirectional screening and testing of the two diseases yielded a higher proportion of TB cases (3.7% point increased) and lower proportion of COVID-19 cases (2% point decreased) as compared to the yield of a single disease screening strategy at its respective screening unit of COVID-19 or TB during the study period. The test positive rate for TB and COVID-19 in the routine service at the national level during the study period was 10% for TB ( NTP report, unpublished) and 12% for COVID-19 14.
The yield of TB among presumed cases in our study (13.7%) is higher than the finding of Afum T et al., which reported 0.8% TB cases among COVID-19 presumed cases in Accra in 2021 . The yield of COVID-19 among presumed cases in our study (9.7%) is slightly less than the finding of Afum T et al., which reported SARS COV-2 infection of 14.7%.15 One possible reason for the observed variation in the yield of the two diseases between our study and the second study is a variation in the general characteristics of patients screened for the two diseases. In our study, the study participants were patients at the outpatient department. In contrast, the study participant in the second study is the COVID-19 presumed cases refereed from different facilities for COVID-19 testing using the routine COVID-19 surveillance activity.
The prevalence of both TB and COVID-19 were higher in males than in females. This finding is consistent with the finding of Afum T et al . The 2013 Ghana TB prevalence survey result also revealed a higher prevalence of TB among males than females .
Regarding to TB and COVID-19 comorbidities, among the total confirmed 14 COID-19 cases who had TB test result, one patient (7.1%) had also TB. A meta-analysis study done in 2021 reported a pooled estimate of 1.07% pulmonary TB among COVID-19 cases, with a range of 0.8–14.2% . However, there is variation in the study participants in the two studies: in our study participants were presumed cases of TB or COVID-19 who were evaluated for both TB and COVID-19 at the same time whereas the participants for the second study were CVID-19 cases who were assessed later for TB.
This study finding has revealed that implementing screening and testing of only one disease (TB or COVID-19) may lead to missing a significant number of cases for the second one. This study supports the recommendation of WHO, STOP TB Partnership, the Global Fund and USAID of implementing simultaneous testing of TB and COVID-19 to improve case detection for the two diseases . In a country like Ghana, where the prevalence of TB is high in the community,  implementing the COVID-19 Response Programme alone may interfere with TB diagnosis. The bidirectional screening and testing of COVID − 19 and TB will leverage the synergy of the two programmes and save resources as the same health worker and the same testing platform is used. However, the low testing rate for TB among presumed cases (95/208) is a concern. This is consistent with the routine intensified TB cases finding annual performance report 2015–2019 (unpublished), which reported that there was a 50% testing rate among presumed cases identified.
This study has the following major limitations: the study lacks information on the total number of people screened for COVID or TB. Facilities recorded only presumed COVID-19 and/or TB cases. The study also lacks information on the reason why some participants were not tested for TB.