(L-R) Om Prakash, Manthi Devi and Yasmeen. Photos: Shruti Jain/The Wire.
Jaipur: As some government-run healthcare facilities in parts of India slowly decrease their focus on COVID-19 and refocus on other ailments and conditions, it’s becoming apparent that the national lockdown, which the Centre imposed in late March to arrest the spread of the novel coronavirus through India’s population, may have rendered more harm than the epidemic itself.
The lockdown began on March 24 and lasted until May, although many restrictions continued until July or so. And in this time, treatment for other diseases were deprioritised, if not put on hold, to free up as much of the state machinery as possible to deal with COVID-19. And among the people more affected by this shift in priorities are those with tuberculosis (TB).
TB is a contagious bacterial infection, and the lapse of over two months of regular treatment, and access to it, during the lockdown was bound to spell disaster. People with TB who weren’t diagnosed and thus not treated on time, because they couldn’t visit clinics or receive important medicines when they needed them, would have contributed to spreading the infection within the susceptible population as well as become more at risk of dying themselves.
“Impact on prompt initiation and uninterrupted completion of treatment will translate into millions of excess deaths from tuberculosis,” Zarir F. Udwadia, a consultant physician at the Hinduja hospital, Mumbai, told The Wire Science.
To ascertain the status of TB diagnosis in Rajasthan during the lockdown, The Wire filed an RTI request with the Rajasthan’s department of medical, health and family welfare. The reply indicates that the total number of cartridge-based nucleic acid amplification tests (CBNAATs) and acid-fast bacillus (AFB) tests from March until June was significantly lower than the number of these tests conducted in the same period last year.
Specifically, from March to July, 2019, 63,272 CBNAATs were conducted across Rajasthan – versus only 38,149 in March-July this year: 4,388 in April, 7,174 in May and 12,228 in June. Last year, there had been 16,482 CBNAATs in April, 17,506 in May and 14,486 in June.
This is a major concern for Rajasthan, which as a state has a high TB burden, around 222 people per lakh population. In 2017, the state had notified 1.08 lakh TB patients – up to 1.56 lakh in 2018 and to 1.75 lakh in 2019.
AFB tests are basic microbiological tests to check for active TB infections. They are available at the dispensary-level. Most of the tests conducted in the state are of this variety since there are only one or two CBNAAT machines available in each district.
An AFB test can only confirm the presence of Mycobacterium tuberculosis, the bacteria whose infection becomes TB. A CBNAAT is mandatory to detect whether a person has developed resistance to the potent TB drug rifampicin.
But despite the importance of CBNAAT tests, not every patient can undergo a CBNAAT – thanks both to the device’s short supply and the cost; each CBNAAT test costs about Rs 2,500. So in practice, AFB tests are conducted shortly after diagnosis to determine the course of treatment.
However, as state authorities diverted their attention to COVID-19, even the AFB tests performed across Rajasthan dropped by 36%. According to data obtained through the RTI, in the period of March to June, 2019, 1,77,978 AFB tests had been conducted across Rajasthan – but in 2020, this figure slipped to 1,13,813. There had been only 18,051 AFB tests in April, versus 46,947 tests in April last year, and only 19,593 AFB tests in May versus 45,360 tests in May last year.
Diversion of TB staff and machines
The primary reason for this fall in is that lab technicians at dispensaries and government TB facilities, who typically conduct CBNAATs and AFB tests, have been reassigned to conduct COVID-19 tests.
In its RTI, The Wire Science had also sought details of lab technicians deputed to conduct COVID-19 tests by state authorities. The information shared by the health department shows that in most districts, lab technicians were absent at TB dispensaries and health centres during most of April and May.
Further, the schedule of technicians deployed on COVID-19 duty, prepared by state authorities, had no indication that they had compensated for the personnel’s absence either. As a result, if a patient had visited a health facility during the lockdown, she would have found the place virtually shut down.
Further, state authorities also appropriated TB diagnostic machines to test COVID-19 samples. The Wire Science had previously reported in April that the Indian Council of Medical Research approved the use of CBNAAT machines to test COVID-19 samples as well.
To comply, the Government of Rajasthan had reallocated CBNAAT machines in different districts for COVID-19 tests, automatically bringing down its TB testing capacity.
No disruption, authorities insist
However, state authorities continue to deny that TB services were disrupted during the lockdown, and insist that diversion of staff didn’t hamper TB diagnosis.
“We cannot say there was any negligence on our part in TB treatment,” state tuberculosis officer in Rajasthan Vinod Kumar Garg said. “There are government orders” to use CBNAAT machines and to depute lab technicians for COVID-19 tests “that we follow. What can we say about the data?”
Jaipur district TB officer Sudhir Sharma said the low number of TB tests reflect patients not coming out of their homes to seek treatment. “Our facilities were always open. If the patients themselves didn’t come, it is not our fault.”
In fact, the authorities also claim that thanks to the spread of COVID-19, the spread of TB has dropped. “Earlier, when we asked TB patients to wear masks to stop the spread of TB, they never paid attention,” Dilbag Singh, a doctor at a state-run dispensary in Jaipur told The Wire Science. “But now, due to COVID-19, I see them wearing masks. This has significantly reduced the spread of TB.”
To understand the repercussions of the drop in TB diagnosis, this correspondent spoke to some patients who had developed the TB infection during the lockdown period when the state-run TB services were not adequately available.
Yasmeen, an 18-year-old from Sikar city, Rajasthan, had sought TB treatment in April, and found it an uphill task. She alleged that when she went to the Institute of Respiratory Diseases (IRD), a premier TB facility in Jaipur, the doctors refused to treat her because of her Muslim identity and asked her to get checked up at the city’s Sawai Man Singh hospital.
Also in April, some media outlets had sensationalised the Tablighi Jamaat congregation in Delhi, falsely claiming that it had been ‘super-spreader’ event.
“We tried getting the TB test done in Sikar but the government facilities told us that the CBNAAT test could be performed only in Jaipur. When we travelled to Jaipur, the doctor was not willing to medically examine me because I am Muslim,” Yasmeen told The Wire Science.
Similarly, when Manthi Devi (75) developed TB-like symptoms in May this year, she reached out to the nearest dispensary in Jaipur for a check-up. And there, she was told that she would have to be tested for COVID-19 before she could be treated for TB. But for her COVID-19 test, Devi had to wait for about a week.
“It is not like you go to a government facility and simply get a COVID-19 test done in a few hours,” her grandson Raju Prajapati told The Wire Science. “There are long queues. Your turn does not come in a day. Then getting the result also takes time.”
And in all this time waiting, according to Prajapati, Devi lost her appetite and became a lot weaker. “Due to excessive coughing, I didn’t feel like putting anything in my mouth. Only a glass of milk or tea felt good,” Devi said.
It was only after Devi tested negative for COVID-19 that her TB treatment commenced, in June.
In July, Om Prakash, a painter from Jaipur, found traces of blood in his cough. He rushed to a nearby private hospital in Nindar for a preliminary TB test done, as he was wary of traveling to IRD. His report suggested TB but the doctor recommended a CBNAAT in Jaipur to be absolutely sure.
He waited for a month; when it finally occurred to him that the situation had become normal, he underwent a CBNAAT. He is currently availing treatment at the government-run TB dispensary in Nindar.
Shruti Jain is a Survivors Against TB Media Fellow. This story was covered as part of the Survivors Against TB Media Fellowship 2020, awarded to encourage evidence-based, empathetic reportage on important issues related to TB.