COVID-19 and forgotten enemy tuberculosis

Dr. Dharmakanta Kumbhakar

(He can be reached at drkdharmakanta1@gmail.com)

Dr. Dimpee Lahkar

(She can be reached at daina59@rediffmail.com)

COVID-19 is now a pandemic affecting 89,21,618 people; 4,66,850 confirmed deaths and has already spread to 216 countries globally on June 21, 2020. India is the fourth most heavily affected country worldwide behind the US, Brazil and Russia. As on June 21; 4,11,727 people are affected, 13,277 have died and many more are living with fear of COVID-19 disease and death in India. India is fighting a battle today against COVID-19. The battle has brought the country almost to a standstill leading to major medical, social and economic problems.

It is seen that most of the medical facilities including infrastructure and manpower are diverted to tackle the COVID-19 in India. People are getting more concerned about the threat of COVID-19 than the diseases they are already burdened. The regular treatment has become irregular, follow-up is neglected and other health measures are pushed aside. The pandemic has somewhat pushed a few important infectious diseases and some non-communicable diseases (like hypertension, diabetes, coronary artery diseases. chronic renal failure, chronic respiratory diseases, etc.) to the backyard in India. Patients, caregivers, doctors and activists are now worried that the nation's attempts to address one public health crisis might end up severely jeopardizing efforts to end others. We may survive the COVID-19 pandemic now but succumb later to other diseases- the old enemies within.

Tuberculosis is a very old enemy in the health sector. Tuberculosis is caused by bacteria (Mycobacterium tuberculosis) and it most often affects the lungs. It is spread through the air when people with pulmonary tuberculosis cough, sneeze or spit. It is rather a thing to worry that while fighting against COVID-19, we seem to have forgotten our very old enemy –Tuberculosis! Every year, about 10 million people fall ill worldwide with tuberculosis (TB). Despite being a preventable and curable disease, 1.5 million people die worldwide from TB each year – making it the world's top infectious killer. India reports more than 25 lakh active tuberculosis patients and more than four lakh TB deaths every year – the highest in the world. India also has the largest number of cases of multidrug-resistant TB, a more virulent form of the disease that is harder to cure.

As we know that most of the healthcare professionals are now busy focusing on COVID-19 cases, patients suffering from tuberculosis, considered one of the biggest killers in India, are facing difficulties in getting the optimum health care. TB patients are getting affected in every way, from testing, diagnosis and registration of new cases, to follow-ups and access to medicines. As per a report, in Mumbai, the diagnosis of individuals with TB in outpatient department has dropped to 1,235 in March from 1,418 in January, 2020 and follow-up of old TB patients has dropped to 1,050 in March from 1,125 in January, 2020. The Government has no sufficient grassroots health workers like ASHAs (accredited social health activists), ANMs (auxiliary nurse midwives) and community volunteers who could be deployed to hand out TB or HIV medicines to patients in villages as most of them are now been asked to prioritize COVID-19 works such as community surveillance for COVID-19 and screening of migrant workers in quarantine centres. Moreover, the lockdown has also disrupted the supply-chain of essential goods and services, including the medicines that patients with tuberculosis, HIV/AIDS, cancer, diabetes and other life-threatening diseases rely on to stay alive.

Modelling work suggests that if the COVID-19 pandemic led to a global reduction of 25% in expected TB detection for 3 months – a realistic possibility given the levels of disruption in TB services being observed in multiple countries – then we could expect a 13% increase in TB deaths, bringing us back to the levels of TB mortality that we had 5 years ago. This may even be a conservative estimate as it does not factor in other possible impacts of the pandemic on TB transmission, treatment interruptions and poorer outcomes in people with TB and COVID-19 infection.

On the other hand, due to lockdown and the fear of contracting COVID-19 has driven many parents stay inside their homes. As the health care providers are also forced to divert their attention to COVID-19 pandemic, there has been a compromise in the number of man power available to work for the vaccination process resulting in the decrease in the vaccination rate. This may impose a serious risk to the resurgence of the vaccine preventable diseases. Similarly, the vaccination of BCG has also decreased which may, in coming times, decrease the herd immunity against tuberculosis in the society. It has been found from various studies that if these restrictions in vaccination start to reach three months or more, the herd immunity rates that protect vulnerable individuals in the community could crumble.

Tuberculosis prevention and care during the COVID-19 pandemic is an important issue that needs immediate attention. Health services need to be actively engaged for an effective and rapid response to COVID-19 while ensuring that TB and other essential health services are maintained. While experience on COVID-19 infection in tuberculosis 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. On March 24, the World Health Organization (WHO) also directed countries with high TB burden to ensure that essential health services and operations are continued to protect the lives of people with TB. Patients with TB suffer from compromised lungs. If they contract COVID-19 infection, their survival chances will be extremely low. TB cases will raise drastically post this pandemic. As per a study, for every month of lockdown to contain the spread of COVID-19, India may witness an additional 71,000 TB deaths and more than 2,32,000 TB cases in the next 5 years. People suffering from COVID-19 and TB show similar symptoms such as cough, fever and breathing difficulty. Both the diseases attack primarily the lungs. With symptoms of TB similar to COVID-19, many patients in overcrowded slums may go undetected with improper screening. The Union Government will have to take proactive steps for TB along with COVID-19, if the Government is serious about ending TB by 2025 in India.

The Union Government need to take measures to ensure continuity of services for people who need preventive and curative treatment for tuberculosis. People-centred delivery of tuberculosis prevention, diagnosis, treatment and care services should be ensured in tandem with the COVID-19 response. Measures must be implemented to limit transmission of TB and COVID-19 in congregate settings and health care facilities. Administrative, environmental and personal protection measures apply to both (e.g. basic infection prevention and control, cough etiquette, patient triage). Tests for TB and COVID-19 are different and both should be made available for individuals with respiratory symptoms. People-centred outpatient and community-based care should be strongly preferred over hospital treatment for TB patients (unless serious conditions require hospitalization) to reduce opportunities for transmission. Anti-TB treatment, in line with the latest WHO guidelines, must be provided for all TB patients, including those in quarantine and those with confirmed COVID-19 disease. Adequate stocks of TB medicines should be provided to all patients to reduce trips to collect medicines. Use of digital health technologies for patients and programmes should be intensified. In line with the WHO recommendations, technologies like electronic medication monitors and video-supported therapy can help patients complete their TB treatment. In a context of widespread restriction of movement of the population in response to the pandemic and isolation of COVID-19 patients, communication with the healthcare services should be maintained so that people with tuberculosis, especially those most vulnerable, get essential services. This includes management of adverse drug reactions and co-morbidities, nutritional and mental health support, and restocking of the supplies of medicines. Enough TB medicines will need to be dispensed to the patient or caregiver to last until the next visit. This will limit interruption or unnecessary visits to the clinic. Mechanisms to deliver medicines at home and even to collect specimens for follow-up testing may become expedient. Home-based TB treatment is bound to become more common during COVID-19 pandemic.