World Health Organization (WHO) Information Note

Tuberculosis and COVID-19

Date: 4 April 2020

COVID-19: Considerations for tuberculosis (TB) care

As the world comes together to tackle the COVID-19 pandemic, it is important to
ensure that essential services and operations for dealing with long-standing health
problems continue to protect the lives of people with TB and other diseases or health
conditions. Health services, including national programmes to combat TB, need to be
actively engaged in ensuring an effective and rapid response to COVID-19 while
ensuring that TB services are maintained.

The World Health Organization (WHO) is advising Member States that are leading the
response to the unfolding COVID-19 pandemic (1). The WHO Global TB Programme,
along with WHO regional and country offices, has developed an information note, in
collaboration with stakeholders. This note is intended to assist national TB programmes
and health personnel to urgently maintain continuity of essential services for people
affected with TB during the COVID-19 pandemic, driven by innovative people-centred
approaches, as well as maximizing joint support to tackle both diseases. It is important
that the progress made in TB prevention and care is not reversed by the COVID19
pandemic. Finding and treating people with TB remain the fundamental pillars of TB
prevention and care and those would require maintained attention.

The COVID-19 pandemic has provoked social stigma and discriminatory behaviours
against people of certain ethnic backgrounds as well as anyone perceived to have
been in contact with the virus. Stigma can undermine social cohesion and prompt
social isolation of groups, which might contribute to a situation where the virus and TB
are more likely to spread. This can:
• Drive people to hide the illness to avoid discrimination
• Prevent people from seeking health care immediately
• Discourage them from adopting healthy behaviours.

Stigma and fear around communicable diseases like TB hamper the public health
response. What works is building trust in reliable health services and advice, showing
empathy with those affected, understanding the disease itself, and adopting
effective, practical measures so people can help keep themselves and their loved
ones safe (2). Governments, citizens, media and communities have an important role
to play in preventing and stopping stigma. We all need to be intentional and
thoughtful when communicating on social media and other communication
platforms, showing supportive behaviours around COVID-19, as well as older diseases
like TB.

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1. Are people with TB likely to be at increased risk of COVID-19
infection, illness and death?
While experience on COVID-19 infection in TB patients remains limited, it is anticipated
that people ill with both TB and COVID-19 may have poorer treatment outcomes,
especially if TB treatment is interrupted.

TB patients should take precautions as advised by health authorities to be protected

from COVID-19 and continue their TB treatment as prescribed.

People ill with COVID-19 and TB show similar symptoms such as cough, fever and
difficulty breathing. Both diseases attack primarily the lungs and although both
biological agents transmit mainly via close contact, the incubation period from
exposure to disease in TB is longer, often with a slow onset.

2. What should health authorities do to provide sustainability of

essential TB services during the COVID-19 pandemic? What services
can be leveraged across both diseases?
All measures should be taken to ensure continuity of services for people who need
preventive and curative treatment for TB. Health authorities should maintain support
to essential TB services, including during emergencies such as COVID-19. People-
centred delivery of TB prevention, diagnosis, treatment and care services should be
ensured in tandem with the COVID-19 response.

Prevention: Measures must be put in place to limit transmission of TB and COVID-19 in

congregate settings and health care facilities, as per WHO guidelines (3),(4). Although
modes of transmission of the two diseases are slightly different, administrative,
environmental and personal protection measures apply to both (e.g. basic infection
prevention and control, cough etiquette, patient triage). Provision of TB preventive
treatment should be maintained as much as possible.

Diagnosis: Accurate diagnostic tests are essential for both TB and COVID-19. Tests for
the two conditions are different and both should be made available for individuals
with respiratory symptoms, which may be similar for the two diseases. TB laboratory
networks have been established in countries with the support of WHO and
international partners. These networks as well as specimen transportation mechanisms
could also be used for COVID 19 diagnosis and surveillance.

Treatment and care: TB programme staff with their experience and capacity,
including in active case finding and contact tracing, are well placed to share
knowledge, expertise, and to provide technical and logistical support.

People-centred outpatient and community-based care should be strongly preferred

over hospital treatment for TB patients (unless serious conditions are requiring
hospitalisation) to reduce opportunities for transmission.

Provision of anti-tuberculosis treatment, in line with the latest WHO guidelines, must be
ensured for all TB patients, including those in COVID-19 quarantine and those with
confirmed COVID-19 disease. Adequate stocks of TB medicines should be provided

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to all patients to take home to ensure treatment completion without having to visit
treatment centres unnecessarily to collect medicines.

Use of digital health technologies should be intensified to support patients and

programmes through improved communication, counselling, care, and information
management, among other benefits. In line with WHO recommendations,
technologies like electronic medication monitors and video-supported therapy can
help patients complete their TB treatment.

Proactive planning, procurement, supply and risk management: Appropriate

planning and monitoring are essential to ensure that procurement and supply of TB
medicines and diagnostics are not interrupted.

WHO is monitoring medicine supply at the global level, while The Global Fund, the
Stop TB Partnership Global Drug Facility (GDF), USAID, Unitaid and other donors play
an essential role in supporting countries to secure adequate and sustainable supplies
of TB medicines drugs and diagnostics. Countries are advised to place their orders for
2020 delivery as soon as possible given anticipated delays in transport and delivery
mechanisms.

Human resources: Respiratory physicians, pulmonology staff of all grades, TB specialists

and health workers at the primary health care level may be points of reference for
patients with pulmonary complications of COVID-19. They should familiarize
themselves with the most current WHO recommendations for the supportive
treatment and containment of COVID-19 (4). Detection and effective supportive
treatment may reduce morbidity and mortality from both COVID-19 and most forms
of TB.

Capacity building: The response to COVID-19 can benefit from the capacity building
efforts developed for TB over many years of investment by national authorities and
donors. These include infection prevention and control, contact tracing, house-hold
and community-based care, and surveillance and monitoring systems.

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Added on 4 April 2020

3. What measures should be in place to protect staff working in TB

laboratories and healthcare facilities, and community health
workers, from COVID-19 infection?
Health care facilities, including those that diagnose and care for TB and lung diseases,
are bound to receive patients with COVID-19, many of whom may be undiagnosed.
Additional measures may be needed to avoid that staff in these centres are exposed
to COVID-19 infection.

Staff should familiarize themselves with WHO recommendations for the containment
of COVID-19 (4). The networks of TB laboratories that countries have established in
recent years are one of the important assets that should be leveraged in the response
to COVID-19. Lessons learnt over many years of TB infection prevention and control,
contact tracing, investigation and management can benefit efforts to stop the
spread of COVID-19. Existing WHO recommendations for infection prevention and
control for TB and for COVID-19 (3),(5),(6) should be strictly implemented, including
personal protection equipment. The following additional, temporary measures should
be considered during the COVID-19 pandemic to minimize risks of infecting the staff
and vice versa:

o Subject to local circumstances, alternative arrangements should be made to

reduce visits for TB follow-up, e.g. spreading appointments on specific days or
times to avoid exposure to other clinic attendees; using innovative
communication technologies to maintain treatment support; limiting to when
follow-up testing is needed
o Enough TB medicines will need to be dispensed to the patient or caregiver to
last until the next visit - or the end of treatment if no other visit is planned. This
will limit interruption or unnecessary visits to the clinic to collect medicines.
o Special precautions are needed when collecting and transporting sputum
samples and bronchoalveolar lavage fluid, as well as reception and unpacking
in the laboratory, to avoid exposure of staff, patients and other individuals to
both COVID-19 and TB (7),(8),(9). Sputum collection for TB at home should be
encouraged with specific instructions (e.g., to be done in open area outside
the home and away from others). If this is not possible, sputum should be
collected in an open, well-ventilated space – preferably outside of the health
facility - and staff should not stand near the patient during collection.
o When testing for TB, the use of biosafety cabinets would be preferred when
handling sputum and any other infectious specimen during the pandemic.
However, if a cabinet is not available the enforcement of all other
requirements, such as consistent use of the N95 respirator, handwashing, use of
gloves, goggles or protection shield, waterproof aprons, regular
decontamination of surfaces, staff distancing in the laboratories, ventilated
workplaces and safe transportation should be observed by operators in basic
units. The staff responsible for transport of samples to the site of testing and
operators of the machines should also follow existing requirements to process
COVID-19 samples.

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There is an ethical obligation for healthcare workers to deliver care to patients. The
rights and responsibilities of healthcare workers in the context of COVID-19 are listed
elsewhere (10). Governments and people responsible of organizations delivering
health care have the ethical obligation to ensure that health care workers can
operate under the recommended safety standards that are provided. Healthcare
workers should follow all recommendations to protect themselves, other health care
workers, patients and other caregivers (11).

4. How can we protect people seeking TB care during the COVID-19

pandemic?
The sudden surge in demand for care of COVID-19 patients is presenting a challenge
for health services worldwide. During this exceptional period it is important that TB
prevention and care continue uninterruptedly (12). Past emergencies, like influenza
and Ebola, have impinged negatively upon TB care by, for example, requiring a
reassignment of staff and inpatient facilities for patients with serious respiratory
complications. Similar measures are already being taken by several countries during
this pandemic. Prolonged disruptions in the production of consumables in countries
under lock-down and of international and local transportation are expected to
impact upon the stocks of medicines and laboratory supplies in many places.

In many countries restriction of movement has been imposed for much of the
population in response to the pandemic. Isolation of individuals with presumptive or
confirmed COVID-19 exposure or disease is also commonplace. Advice on
quarantine for people with COVID-19 have been published by WHO (13).
Communication with the healthcare services should be maintained so that TB
patients, especially those most vulnerable, get essential services in case of need, such
as management of adverse drug reactions and co-morbidities, nutritional and mental
health support, and restocking of the supplies of medicines. Mechanisms to deliver
medicines at home and even to collect specimens for follow-up testing of TB - as well
as COVID - may become expedient. As visits to health centres will be minimised,
home-based TB treatment is bound to become the norm. Community health workers
become more critical as treatment, including for drug-resistant TB, is more
decentralised. More TB patients will probably start their treatment at home and
therefore limiting the risk of household transmission of TB during the first few weeks are
important. Under such circumstances it is important that vulnerable and marginalised
populations who have poor access to healthcare services do not get further
disadvantaged as a result of this episode.

Despite differences in the modes of TB and COVID-19 transmission (Box), certain

measures are relevant to both diseases. Infection control measures for healthcare
facilities highlighted under Question 3 above may also limit transmission to patients.
Usual precautions to protect from TB must continue along with additional action to
protect workers from COVID-19. A number of these precautions apply also to TB care
in institutions like prisons and long-term care facilities where reduction in outside
visitors, special arrangements for treatment and follow up and other measures may
be necessary to avoid explosive spread of COVID-19 (14),(15).

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Box: Transmission of TB and COVID-19

While both TB and COVID-19 spread by close contact between people the exact
mode of transmission differs, explaining some differences in infection control measures
to mitigate the two conditions. TB bacilli remain suspended in the air in droplet nuclei
for several hours after a TB patient coughs, sneezes, shouts, or sings, and people who
inhale them can get infected. The size of these droplet nuclei is a key factor
determining their infectiousness. Their concentration decreases with ventilation and
exposure to direct sunlight. COVID-19 transmission has primarily been attributed to the
direct breathing of droplets expelled by someone with COVID-19 (people may be
infectious before clinical features become apparent). Droplets produced by
coughing, sneezing, exhaling and speaking may land on objects and surfaces, and
contacts can get infected with COVID-19 by touching them and then touching their
eyes, nose or mouth1. Handwashing, in addition to respiratory precautions, are thus
important in the control of COVID-19. Hospital procedures that generate aerosols
predispose to infection of both conditions and should only be conducted within
recommended safeguards.

Under the current circumstances the rapid roll-out of measures that reduce the need
for daily encounters with healthcare staff becomes more critical. These include WHO
recommended, all-oral TB treatments for multidrug-resistant TB and extensively drug-
resistant TB; TB preventive treatment with recommended shorter regimens and
increased testing to find more of the ‘missing’ or undiagnosed TB cases. More
experience will be acquired in the effective use of digital technologies for patient
support, such as adverse event reporting. Nonetheless, any redeployment of staff
treating TB and drug-resistant TB to work on COVID-19 should consider the long-term
consequences that this may have on the wellbeing of TB patients and programmes.

5. Should all people being evaluated for TB also be tested for COVID-
19 and vice-versa?
Simultaneous testing of the same patient for both TB and COVID-19 would generally
be indicated for three main reasons, subject to the specific setting in the country:

1. clinical features that are common to both diseases; or

2. simultaneous exposure to both diseases; or
3. presence of a risk factor for poor outcomes to either disease.

Even if both TB and COVID-19 commonly involve the lungs and have similar symptoms
such as cough, fever and difficulty breathing, clinical features differ in certain
respects. While fever and cough in COVID-19 have a rapid onset and an incubation
period of about one to two weeks, the clinical manifestations of TB typically develop
over a much longer period. The coughing in TB is usually productive of sputum and
even blood, while in uncomplicated COVID-19 it is more commonly a dry cough at
presentation. When shortness of breath occurs in COVID-19 it develops early after
onset; in TB this usually happens at a much later stage or as a long-term sequela.
Outbreaks of COVID-19 in the same household or in a congregate setting usually

1
Human coronaviruses in general are known to persist on inanimate surfaces such as metal, glass or plastic for
up to a maximum of 9 days (16)

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becomes apparent within a week or two while in TB the progression is rarely abrupt
and may only become apparent after several months.

As the pandemic advances, more people and TB patients of all ages will have been
exposed to COVID-19 when they first present for diagnosis. A positive result for COVID-
19 infection does not exclude the possibility of concomitant TB, particularly in high TB
burden settings. Healthcare workers need to consider the possibility of TB in a patient
with COVID-19 if the course of the illness after the first weeks suggests so, e.g.
progression to haemoptysis, persistent fever, night sweats or weight loss. A careful
history of exposure to TB or even a past episode of TB in the same patient or in the
family may clinch the diagnosis. Chest radiography or imagery may help differentiate
TB from other pathologies.

An early diagnosis of both TB and COVID-19 is important in the care of people who
are vulnerable to unfavourable outcomes, including death. Older age and certain
comorbidities like diabetes mellitus and chronic obstructive pulmonary disease
increase the likelihood of severe COVID-19 and the necessity for intensive care and
mechanical ventilation. These risk factors are also poor prognostic factors in TB. TB
patients who have lung damage from past tuberculosis sequelae or chronic
obstructive pulmonary disease may suffer from more severe illness if they are infected
with COVID-19. There is thus a stronger case for concurrent testing for both conditions
in these individuals even if the clinical picture is atypical. The understanding of how
COVID-19 impacts on TB outcomes of people with other risk factors - such as
malnutrition, renal failure and liver disease - is still developing. While untreated HIV is
an important risk factor for progression to TB or for poor outcomes in TB patients, its
influence on the prognosis of COVID-19 patients is unclear. Nonetheless additional
precautions for all people with advanced HIV or poorly controlled HIV are
recommended by WHO (8). Updates will be released by WHO as evidence accrues
on these interactions.

Countries are advised to adopt diagnostic algorithms that adhere to WHO

recommendations for testing for TB or COVID-19 based on the clinical features and
history of a patient and local TB burden (17),(18). Programmes need to be wary that
the diagnostic needs of TB patients are not neglected while COVID-19 testing is rolled
out.

6. Can TB and COVID-19 be tested on the same type of specimen?

The diagnostic methods for TB and COVID-19 are quite distinct and individuals being
evaluated for both conditions require specimens which are commonly different.2

Sputum, as well as many other biological specimens, can be used to diagnose TB

using culture or molecular techniques (19).

Tests for COVID-19 are done most commonly by nasopharyngeal or oropharyngeal

swab or wash in ambulatory patients, but sputum or endotracheal aspirate or
bronchoalveolar lavage may be used in patients with severe respiratory disease.

2
Testing sites are likely to be different as well, and tests for COVID-19 may be less decentralised than for TB
early on until capacity increases.

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Molecular testing is the currently recommended method for the identification of
infectious COVID-19 and just as for TB, serological assays are not recommended for
the routine diagnosis of COVID-19 (17),(20).

The pipeline for COVID-19 diagnostics has flourished impressively within a few months
(tests that are commercially available or in development are compiled by FIND, a
WHO Collaborating Centres for Diagnostics (21)). Amongst these is the Xpert® Xpress
SARS-CoV-2 cartridge for use on GeneXpert machines (22). The US FDA Emergency
Use Authorization for the Xpert® Xpress SARS-CoV-2 cartridge issued in March 2020 is
for nasopharyngeal swab and/or nasal wash/aspirate specimens; it has not yet been
evaluated to detect COVID-19 in sputum. WHO is currently evaluating this cartridge
as well as other tests (23),(24). By 4 April 2020, one test was eligible for procurement on
the WHO Emergency Use Listing for SARS-CoV-2 in vitro diagnostic products.

Additional resources to roll-out COVID-19 testing should be mobilised during this

episode, rather than relying only on existing resources that are used for TB, to ensure
that the diagnostic coverage for TB is maintained as necessary.

7. Is TB treatment different in people who have both TB and COVID-

19?
In most cases TB treatment is not different in people with or without COVID-19
infection. Experience on joint management of both COVID-19 infection and TB
remains limited. However, suspension of TB treatment in COVID-19 patients should be
exceptional. TB preventive treatment, treatment for drug-susceptible or drug-resistant
TB disease should continue uninterrupted as it is important to safeguard the patient’s
health.

Effective treatments to prevent TB and to treat active TB have been scaled up and
are in use worldwide. It is critical that people who need treatment continue taking it
during the pandemic, even if they acquire COVID-19, to increase chances of cure
and reduce transmission and the development of drug-resistance. The risk of death in
TB patients approaches 50% if left untreated and may be higher in the elderly or in the
presence of comorbidity.

Support for uninterrupted TB preventive treatment and treatment of TB disease should

be ensured alongside the COVID-19 response.

It is critical that TB services are not disrupted during the COVID19 response.

While treatment trials are ongoing, no medication is currently recommended for

COVID-19 and therefore no cautions on drug-drug interactions are indicated at
present (25). TB patients on treatment should nonetheless be asked if they are taking
any medicines, including traditional cures, that may interact with their medication
(e.g. risk of additive cardiotoxicity).

Gathering evidence as this pandemic unfolds will be very important, while upholding
the norms of professional conduct and patient confidentiality when handling clinical
details.

For more information on TB: www.who.int/tb Email: gtbprogramme@who.int

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References
1. WHO | Coronavirus disease (COVID-19) outbreak [Internet]. 2020. Available from:
https://www.who.int/emergencies/diseases/novel-coronavirus-2019

2. IFRC, UNICEF, WHO. Social Stigma associated with COVID-19. A guide to preventing and
addressing social stigma. [Internet]. 2020. Available from: https://www.who.int/docs/default-
source/coronaviruse/covid19-stigma-guide.pdf

3. WHO Guidelines on tuberculosis infection prevention and control, 2019 update

(WHO/CDS/TB/2019.1) [Internet]. Geneva, World Health Organization. 2019. Available from:
https://apps.who.int/iris/bitstream/handle/10665/311259/9789241550512-eng.pdf

4. WHO | Coronavirus disease (COVID-19) technical guidance: Infection prevention and control /
WASH [Internet]. [cited 2020 Mar 29]. Available from:
https://www.who.int/emergencies/diseases/novel-coronavirus-2019/technical-guidance/infection-
prevention-and-control

5. Infection prevention and control during health care when COVID-19 is suspected. Interim
guidance [Internet]. Geneva, World Health Organization; 2020. Available from:
https://apps.who.int/iris/rest/bitstreams/1272420/retrieve

6. Rational use of personal protective equipment (PPE) for coronavirus disease (COVID-19). Interim
guidance [Internet]. Geneva, World Health Organization; 2020. Available from:
https://apps.who.int/iris/bitstream/handle/10665/331498/WHO-2019-nCoV-IPCPPE_use-2020.2-
eng.pdf

7. Wang W, Xu Y, Gao R, Lu R, Han K, Wu G, et al. Detection of SARS-CoV-2 in Different Types of

Clinical Specimens. JAMA [Internet]. 2020 Mar 11 [cited 2020 Mar 27]; Available from:
https://jamanetwork.com/journals/jama/fullarticle/2762997

8. Laboratory biosafety guidance related to coronavirus disease (COVID-19). Interim guidance

[Internet]. Geneva, World Health Organization; 2020. Available from:
https://apps.who.int/iris/rest/bitstreams/1272450/retrieve

9. Tuberculosis laboratory biosafety manual (WHO/HTM/ TB/2012.11) [Internet]. Geneva, World Health
Organization. 2012. Available from:
http://apps.who.int/iris/bitstream/10665/77949/1/9789241504638_eng.pdf

10. Coronavirus disease (COVID-19) outbreak: rights, roles and responsibilities of health workers,
including key considerations for occupational safety and health. Interim guidance. [Internet]. 2020
[cited 2020 Apr 1]. Available from: https://apps.who.int/iris/bitstream/handle/10665/331510/WHO-
2019-nCov-HCWadvice-2020.2-eng.pdf

11. Ethics guidance for the implementation of the End TB Strategy (WHO/HTM/TB/2017.07) [Internet].
Geneva, World Health Organization. 2017. Available from:
http://apps.who.int/iris/bitstream/10665/254820/1/9789241512114-eng.pdf

12. COVID-19: Operational guidance for maintaining essential health services during an outbreak
[Internet]. Geneva, World Health Organization; 2020. Available from:
https://apps.who.int/iris/rest/bitstreams/1272981/retrieve

13. Considerations for quarantine of individuals in the context of containment for coronavirus disease
(COVID-19). Interim guidance. [Internet]. Geneva, World Health Organization; 2020. Available from:
https://apps.who.int/iris/rest/bitstreams/1272428/retrieve

14. Preparedness, prevention and control of COVID-19 in prisons and other places of detention. Interim
guidance [Internet]. Copenhagen, World Health Organization Regional Office for Europe; 2020.
Available from: http://www.euro.who.int/__data/assets/pdf_file/0019/434026/Preparedness-
prevention-and-control-of-COVID-19-in-prisons.pdf

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15. Infection prevention and control guidance for long-term care facilities in the context of COVID-
19Interim guidance. [Internet]. Geneva, World Health Organization; 2020. Available from:
https://apps.who.int/iris/bitstream/handle/10665/331508/WHO-2019-nCoV-IPC_long_term_care-
2020.1-eng.pdf

16. Kampf G, Todt D, Pfaender S, Steinmann E. Persistence of coronaviruses on inanimate surfaces and
their inactivation with biocidal agents. J Hosp Infect. 2020 Mar;104(3):246–51.

17. Laboratory testing strategy recommendations for COVID-19 [Internet]. Geneva, World Health
Organization; 2020. Available from: https://apps.who.int/iris/bitstream/handle/10665/331509/WHO-
COVID-19-lab_testing-2020.1-eng.pdf

18. GLI model TB diagnostic algorithms [Internet]. Geneva, Stop TB Partnership (GLI); 2017. Available
from: http://www.stoptb.org/wg/gli/assets/documents/GLI_algorithms.pdf

19. Implementing tuberculosis diagnostics: A policy framework (WHO/HTM/TB/2015.11) [Internet].

Geneva, World Health Organization. 2015. Available from:
http://apps.who.int/iris/bitstream/10665/162712/1/9789241508612_eng.pdf

20. Commercial serodiagnostic tests for diagnosis of tuberculosis. Policy statement

(WHO/HTM/TB/2011.5) [Internet]. Geneva, World Health Organization; 2011. Available from:
https://apps.who.int/iris/bitstream/handle/10665/44652/9789241502054_eng.pdf

21. FIND. SARS-CoV-2 diagnostic pipeline [Internet]. 2020. Available from:

https://www.finddx.org/covid-19/pipeline/

22. CEPHEID. Xpert® Xpress SARS-CoV-2 [Internet]. 2020. Available from:

https://www.fda.gov/media/136314/download

23. Coronavirus disease (COVID-19) technical guidance: Laboratory testing for 2019-nCoV in humans
[Internet]. [cited 2020 Apr 1]. Available from: https://www.who.int/emergencies/diseases/novel-
coronavirus-2019/technical-guidance/laboratory-guidance

24. WHO | COVID-19 Emergency Use Listing Procedure (EUL) [Internet]. Available from:
https://www.who.int/diagnostics_laboratory/EUL/en/

25. WHO | Global research on coronavirus disease (COVID-19) [Internet]. [cited 2020 Mar 29].
Available from: https://www.who.int/emergencies/diseases/novel-coronavirus-2019/global-
research-on-novel-coronavirus-2019-ncov

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