Tuberculosis is a deadly disease – but it can’t take all the blame. When people have access to healthcare centres providing high-quality TB treatment at a low cost, to doctors, nurses and healthcare workers who counsel them of the importance of completing treatment, to a nutritious diet, and to people who understood their fear and trepidation, TB can be chased away in 6-8 months.
We need to remember these conditions instead of thinking of TB as a necessarily fatal affliction, and giving up trying to eradicate it from India. India has the largest number of people with TB among all the world’s countries – 2.69 million – and nearly 450,000 die every year (or 1,250 in a day). Almost 40% of the population is at risk for developing the disease, due to conditions including low/lowered immunity and malnutrition.
As the world is grappling with the COVID-19 pandemic, we need to remember TB for several reasons, not just for the large number of people it affects.
A robust, functional health system can manage a large TB burden. The National Strategic Plan (NSP) for TB, earlier known as the Revised National Tuberculosis Control Programme, is one of the largest programmes of its kind in the world as well as is considered to be one of the most successful health programmes of the nation.
NSP depends on a massive network of primary health centres (PHCs) that also double up as the most used TB treatment units: they diagnose the disease and are responsible for overseeing and ensuring treatment. The PHCs are also an Achilles heel of sorts. TheMany of their units around the country have been neglected for many years and have become increasingly dysfunctional. They don’t have drugs and other supplies available, and are often missing doctors, nurses and other staff – all despite significant investment in infrastructure and drug availability. There are also concerns regarding the providers’ knowledge of the diagnosis and treatment for TB, especially in rural areas.
The findings of the first ever systematic review of TB care in the country agree with the status of public health systems: 27% of missing TB patients globally were housed in India, and only 45% of all TB patients were found to complete treatment. While more TB patients seek treatment from the private sector, the number of patients treated as well as the outcome of treatment are both not well known.
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TB is closely linked to poverty. The disease thrives in slums and other overcrowded settlements with poorly ventilated rooms. The disease preferentially affects (poor) populations working in hazardous occupations: mining, construction, stone-grinding, etc. So if it combines with malnutrition, a vicious cycle is born: malnutrition is a risk factor for progression of latent TB infection to active TB. Malnutrition also increases the risk of severe disease, poor tolerance of drugs and relapse after cure. TB in turn causes weight loss and worsens nutritional status.
Our own data speaks of this: from December 2018 to June 2019, 110 TB patients were enrolled for treatment across five of our Amrit Clinics in the rural tribal areas of south Rajasthan. Of these, 61% were identified with severe thinness (BMI < 16.5), 35% had mild to moderate thinness (BMI 16.01-18.49), and only 7% were found to be normally nourished (BMI 18.5-24.99) or even overweight. The mean BMI was 15.7 among men and 14.9 among women – both within the range of ‘severe thinness’.
India launched a nutrition support scheme for TB patients in 2018 that assured them a cash transfer of Rs 500 per month for the duration of treatment. Notwithstanding the amount of extra nutrition Rs 500 per month stands for, the scheme was a much-needed and welcome step. Nutrition support and higher weight gain has been shown to reduce mortality and improve bodily functions. Sadly, even this small support has fizzed out; our experience in rural Udaipur suggests that for the last many months, patients have stopped receiving this cash transfer.
Revisiting TB diagnostics
The last decade has witnessed a revolution in TB diagnostics. We now have tests that are faster, more sensitive and also detect multi-drug resistance. While the Cartridge Based Nucleic Acid Amplification Test is increasingly being used in the country, our experience from Udaipur shows that there are not enough machines or laboratory technicians, added to which are frequent shortages of supplies specially cartridges. In this scenario, prompt diagnosis and start of treatment is denied to a large number of patients. These gaps need to be addressed on a priority to limit the emergence and spread of drug-resistance TB.
Finally, India’s issues with TB have implications for COVID-19 as well. We have yet to learn how the TB patients will respond to COVID-19 but the underlying lung damage and malnutrition may place them at a higher risk of severe pulmonary disease. More importantly however, the lockdowns are bound to worsen the livelihoods, food availability and access to treatment for TB patients. The preoccupation of India’s infrastructure, policy and administrators with the pandemic is only going to divert more attention away from TB.
March 24 marks the day on which Robert Koch announced the discovery of the bacteria that causes TB, 138 years ago. Today is a sober reminder to the public health community to revisit at the disease and renew our efforts to ensure prompt diagnosis, better management and nutrition support for TB patients. As the WHO has said, ‘it’s time to end TB’ – even in the times of the coronavirus.