While COVID-19 has made the headlines every day over the past two months, services for tuberculosis (TB), one of the oldest diseases in the world, have been interrupted due to the lockdown. According to the World Health Organization’s (WHO) Global Tuberculosis Report 2019, India had an estimated 27 lakh new cases and 4.4 lakh deaths due to TB in 2018—the highest in the world. Despite such numbers, India has not taken any targeted measures to tackle the spread of TB during the ongoing pandemic.
The WHO has set global targets to reduce new cases of TB by 90 percent and deaths by 95 percent between 2015 and 2035. The Indian government launched the TB Free India campaign with the target of eliminating TB in the country by 2025.
However, it is estimated that the fight against TB faces a setback of five to eight years, globally, due to COVID-19. Specifically for India, a two-month lockdown and a two-month recovery period for restoration of full TB services will result in an additional 5.1 lakh TB cases and 1.5 lakh TB-related deaths, between 2020 and 2025. With a three-month lockdown and ten-month recovery period, the numbers would be 17.8 lakh and 5.1 lakh respectively.1
The COVID-19 pandemic has compounded the TB epidemic
The internationally recognised Directly Observed Treatment Short-course (DOTS) strategy entails the diagnosis of TB through sputum testing and a treatment regimen of six to nine months, using appropriate drugs and observation by a healthcare worker. The Indian government promises free diagnosis and treatment to all patients. However, the COVID-19 pandemic has brought to light several gaps in India’s healthcare system. There is a shortage of functioning sputum testing centres, DOT centres, and other facilities to identify and treat new patients of TB. Healthcare workers are also wary of going on-ground and carrying out tests and diagnoses.
Migrant workers with TB, who are travelling away from their workplaces, are at risk of treatment interruption, which may lead to an even more severe form of TB, called multi-drug-resistant TB. Additionally, due to the stigma attached with the symptoms of COVID-19, people are now afraid to get tested for TB. This is because TB symptoms (such as coughing), are similar to those of COVID-19. People also fear being taken away from their families and isolated for unspecified durations. This can exacerbate the problem, as undiagnosed patients can infect many more. Not to mention, those with lung injuries due to TB may be prone to more severe outcomes if infected with COVID-19.
In April, the nonprofit TB Alert India’s Delhi branch, which works in some of the most underprivileged communities in Delhi’s slum areas, found out that average TB testing per month had fallen by 80 percent during the lockdown. They recorded only 25 percent of the new TB cases that they did, on average, before the lockdown, and only 15 percent of the new drug resistant TB cases.
In India, health-seeking behaviour has completely changed after COVID-19. People think twice before seeking a doctor.
According to Khasim Sayyed of TB Alert India, “In India, health-seeking behaviour has completely changed after COVID-19. People think twice before seeking a doctor.” He adds, “We are expecting a very high number of patients across all DOT centres and outpatient departments (OPDs) once the lockdown is lifted, because the patients are afraid to get diagnosed right now. Once things become better, we will witness more and more patients emerging with symptoms.”
We need targeted inventions for TB
A combination of strategies will be required to restore normal TB services, with the objective to reduce the accumulated pool of undetected TB patients. The Ministry of Health and Family Welfare has already asked states and union territories to ensure that the diagnosis and treatment of TB continues unhindered, despite COVID-19. It has directed measures, including doorstep delivery of drugs and providing one month of drugs at a time.
Here are some other steps that can be taken to strengthen both diagnosis and treatment:
- The government should collaborate with nonprofits and use technology to ramp-up active case-finding, contact tracing, and spreading awareness about the symptoms of TB and its precautions.
- Community health workers or local nonprofits should conduct door-to-door sample collection.
- The government should ensure that diagnostic services for TB are maintained. Currently, most labs are being used for COVID-19 testing only.
- For multi-drug resistant TB cases, the government must enable the CB-NAAT (or Genexpert) test, as it diagnoses patients quicker and also shows if a person has resistance to the treatment drug.
- Healthcare workers and nonprofits should help TB patients adhere to their treatment by using tele-counselling to sensitise their family members about the possible side effects and severe symptoms of TB.
- The government, in collaboration with nonprofits, should run a helpline that can provide important information to TB patients, such as advice on managing severe symptoms or side effects.
- Health practitioners should leverage digital tools to diagnose patients and prescribe first-line treatment (which is the first treatment administered for a disease). Although there are limits to the effectiveness of this approach, it could allow patients to start medication and reduce the risk of spreading the disease.
Additionally, government, nonprofits, and private institutions must also collaborate to strengthen infection control to safeguard healthcare workers from TB, as well as COVID-19, during any intervention.
As more private practitioners turn to digital facilities for diagnosis and consulting, there is a need to design solutions for marginalised communities, who might not have access to digital facilities. The projected numbers for TB highlight the urgency for a better intervention strategy. While the COVID-19 pandemic deserves attention and intervention, the response to it should not come at the cost of another disease.
- These numbers have been estimated assuming that TB services would continue indefinitely at pre-lockdown levels.
- Understand more about what TB is, and the symptoms, risks, and treatments associated with it.
- Explore how TB programmes can leverage technology to function virtually during the COVID-19 pandemic.
- Read WHO’s information note on how national TB programmes and healthcare workers can ensure the continuity of TB services during the COVID-19 pandemic, through innovative people-centred approaches.