A patient suffering from tuberculosis rests inside a hospital in Agartala, Tripura. Photo: Reuters/Jayanta Dey/Files
COVID-19 continues to rage across the world, with some countries in a comparatively better position than the rest. India, for once, does not belong to the ‘rest’. The number of confirmed cases or deaths from COVID-19 is significantly low in the country despite the enormity of our population size or population density.
The same, however, cannot be said about the other infectious diseases that continue to ravage large sections of the population. While the reasons behind India’s ‘success’ in COVID-19 management remain highly debated, what has attracted far less attention is how ‘covidisation’ of the health system has impacted these other killers, especially tuberculosis (TB), the erstwhile ‘Captain of all these men of death’.
TB, of course, continues to kill. It kills more than 1,400 people in India every day. In comparison, COVID-19 has so far resulted in 3,435 deaths (as of May 21) since the first death was reported on March 12. Clearly, there’s no comparison.
India bears approximately one-third of the world’s TB burden, with the estimated number of new TB cases in 2018 at 2,800,000. The country also has the most number of MDR-TB cases in the world—one-fourth of the global burden. Given the disease burden of TB – ranking third in India in terms of DALY’s lost and deaths caused – it remains a major public health problem. Unfortunately, the problem is likely to get worse with the TB services emerging the biggest collateral damage of the COVID-19 pandemic in India.
More ‘missing millions’?
India’s battle against TB has been a long and protracted one, beginning with the National Tuberculosis Programme (NTP) in 1962 and continuing with the two phases of Revised National Tuberculosis Control Programme (RNTCP) between 1997 and 2019. Now in 2020, we have the National Tuberculosis Elimination Programme (NTEP) which intends to eliminate TB by 2025, five years before the global target.
While considerable strides have been made against TB, undetected or missing cases pose a huge challenge to the End TB Strategy. In 2018, close to three million new cases across the world remained missing – the ‘missing millions’ – due to underdiagnosis and underreporting. Ten countries accounted for 80% of this gap, led by India (25%), Nigeria (12%) and Indonesia (10%). In fact, India has more than a million such missing cases every year, who remain either undiagnosed or unaccounted for.
The highly fragmented and unregulated private sector is India’s blind spot in TB care, where about 60% of TB patients seek care but very few get notified. The complicated and protracted pathway of care, pre-treatment loss to follow up and post-treatment recurrence create leakages in the cascade of care, adding more to the missing pool. Identifying these patients is critical as each undetected patient can potentially infect 15-20 new people in a year.
Noting the urgency of the situation, and also the low impact of prior efforts, the National Strategic Plan for Tuberculosis Elimination 2017-2025 (NSP) adopted the DTPB (Detect-Treat-Prevent-Build) approach to hasten TB elimination. The focus is mainly on engaging the private sector to account for and support patients therein and improving TB surveillance by screening high-risk populations, such as prisoners, migrant workers, people living with HIV/AIDS etc. Early diagnosis and timely treatment are vital for cutting down transmission of infection, better treatment outcomes and reduced socio-economic distress.
A combination of measures – incentives for private-sector TB care providers, making non-notification punishable, active case finding, scaling up of diagnostic capacity, direct benefit transfer to the patients for nutritional support etc. – were initiated to achieve the elimination target. As a result, India actually got close to closing the gap, with notification shooting up 16% between 2017 and 2018. More importantly, 25% of the total notification was from the private sector, up 40% from 2017.
All these efforts now stand threatened with reports of disruption of the TB services emerging from different parts of the country. New case diagnosis appears to have majorly suffered due to travel restrictions, OPD shutdowns, diversion of medical teams and diagnostic facilities to COVID-19 management. As the lockdown continues and the health system continues to on prioritise COVID-19 over other pressing health issues, it is likely more will keep getting added to the ‘missing millions‘.
Impact on TB notification
While it is too early to realise or estimate the actual impact of COVID-19 on the efforts to prevent and cure Tuberculosis, preliminary assessment clearly shows a declining trend in fresh recorded cases in India as COVID-19 pandemic worsened. In Feb 2020, a total of 209,649 cases were recorded while in March the number of cases fell to just 156,205 which further dropped to only 64,415 in April, a decline of 69% between February and April. The total number of cases notified between March and April (220,620) this year is almost half of what was reported (434,609) for the same period last year.
The top five high TB burden states in India have registered huge declines in case notifications (UP 85.6%, Maharashtra 68.7%, Rajasthan 74.3%, MP 77.2%, Gujarat 68.6%) for the period of the lockdown (March 25-May 7 2020) when compared to the same period the previous year. Incidentally, all these states are also struggling with significant COVID-19 caseload.
In another setback to NSP, TB notification from the private sector—which has also come under scrutiny with reports of non-COVID-19 patients being refused treatment—for the period of the lockdown (March 25-May 7 2020) saw a staggering drop of 84%, compared to the same period last year.
Leakage from the cascade of care
The T of the DTPB approach denotes Treat-initiating and sustaining TB treatment from wherever care is sought. This too became affected with treatment interruptions and failure of follow-up during the lockdown. With the frontline health workers deployed for COVID-duty, tracking of the existing TB patients, home delivery of medicines to ensure continuity of treatment or follow-up also suffered.
The migrant workers, already vulnerable to TB infection due to their poor nutrition, living and working conditions, came under additional risk due to the lockdown. The sudden announcement of lockdown forced many, including those undergoing TB treatment, to walk back to their home states while scores of others were housed in quarantine facilities, often without sufficient TB drugs. While frontline workers have been following up returning migrant workers for COVID-19 symptoms, the same is not being done for Tuberculosis.
Such interruptions faced by those who are yet to be diagnosed or are undergoing treatment for tuberculosis will not only increase the likelihood of disease transmission among contacts but also could potentially lead to a surge in MDR TB cases. Treatment interruption is known to be associated with poor treatment outcome and occurrence of drug-resistant TB.
Exacerbation of existing inequalities
Socio-economic conditions are known to determine exposure and susceptibility to TB, usually affecting the poor, undernourished people living in unhealthy habitations. The ongoing lockdown has exacerbated the existing inequalities and created additional economic hardship for the poor in general and TB patients in particular – leading to an unprecedented humanitarian crisis.
Newspapers have quoted cases where TB patients who, because of the loss of their livelihood, have not been able to afford a proper diet. Nutritional status is closely related to TB susceptibility and treatment outcome. India already accounts for a third of the global burden of malnutrition which is likely to increase following the pandemic, endangering many more.
The prolonged lockdown has led to the loss of livelihood of a vast population, especially those in the unorganised sector. India’s unemployment rate stands at a staggering 27.1 % now with 122 million people having lost their jobs in April alone. For the first time after the 1990s, global poverty is also expected to rise, pushing as many as half a billion people into destitution. The links between poverty, undernutrition and TB are already well established, and if things transpire as predicted, we are staring into a grim future.
COVID-19: A wake-up call
TB, unlike COVID-19, has a known cure but still kills more than a thousand people in India every day. Clearly, active case finding, accurate diagnosis, timely treatment, treatment adherence, drug resistance, all remain significant challenges. Challenges that require considerably more efforts and resources if we are to achieve the elimination of Tuberculosis by 2025.
The COVID-19 outbreak may have captured the headlines lately but at the cost of diverting attention away from many other worthy issues, including TB. But we simply cannot afford to ignore a disease that killed 440,000 Indians in 2018, almost two hundred times the mortality from COVID-19 so far. Mathematical models predict that each month of lockdown can lead to additional 40,685 deaths in India over the next five years.
Experience from the Ebola outbreak in Liberia shows that even in the post-Ebola period case detection and treatment success rate continued to plummet. Reduced diagnosis, high losses to follow up and interruption of treatment were found to be mainly responsible for such poor outcomes. Early reports indicate similar worrying trends for India.
Evidently, our health system was ill-prepared to fight an outbreak of this magnitude. India’s GDP expenditure on health being one of the lowest in the world didn’t exactly help matters either. What is, therefore, required at this hour of need is strategic planning for the present as well as the future and its swift implementation.
There is considerable overlap between TB and COVID-19 in terms of case detection, contact tracing, non-pharmaceutical interventions etc. which can offer the unique opportunity of consolidating efforts to tackle both. Lakhs of community health workers are out every day searching for COVID-symptomatics, Influenza-like Illness (ILI) etc. While TB and COVID may have similar symptoms, they have significant differences too. If the peripheral workers can be trained to discern between them, it can majorly complement the active case finding efforts promoted by NSP. Similarly, continuity of care or follow up of TB patients can be ensured by the same workers.
TB patients, especially those with HIV+TB coinfection, are likely to be susceptible to COVID. The health ministry needs to issue specific guidelines for TB patients at risk of COVID on an urgent basis. At the local level, the DOTS centres can connect with the existing patients and disseminate relevant information through mobile or internet services.
Lest we forget, COVID-19 is a wake-up call to a health system that was already underfunded, overburdened, poorly staffed, wasteful, and provided care of questionable quality. The lessons from the Ebola outbreak have taught us that without a robust and responsive health system, we can neither hope to eliminate TB nor weather the COVI-19 storm.
Strengthening the health system as a whole requires efforts beyond the health sector. To end the global TB epidemic WHO End TB strategy envisions partnerships across different sectors, such as social protection, labour, immigration, and justice. Similarly, in the present crisis, augmentation of social protective measures for the vulnerable, economic support to the needy, centring of health in all policy and increased spending on the public health system can be measures that’ll go a long way in ensuring a better health tomorrow.
Sayan Das is a PhD research scholar at Jawaharlal Nehru University, Ramila Bisht is a professor at the Center for Social Medicine and Community Health, JNU and Yasir Hamid is an assistant professor at the Department of Psychology, University of Kashmir.