India’s tuberculosis endemic in the Covid-19 era

Nearly a year ago, India entered into a nationwide lockdown to arrest the spread of the Covid-19 pandemic. As we commemorate the year gone by, which roughly coincides with World Tuberculosis day today (the lockdown came into effect on March 25, 2020), it is relevant to apply the lessons learnt. According to a report in the European Respiratory Journal, tuberculosis (TB) has for years been the world's leading infectious disease killer, till it was overtaken by Covid-19 on April 1, 2020. India has long borne the highest global burden of TB, accounting for one-fourth of the world’s cases. In 2019, tuberculosis infected 2.64 million and killed nearly 450,000 Indians, a fact which should not be forgotten.

While India put up a brave fight, faring better than some of the most developed countries in its response to Covid-19, the pandemic pushed India’s healthcare system to its limits.

Multiple factors have stalled the progress made on eradicating TB during the Covid-19 period. With public and private healthcare players prioritising the containment of Covid-19, the impact on TB services was severe. Both qualitative and quantitative research on TB over the past year is scanty, with fewer reported cases, primarily due to travel and accessibility restrictions. Data collection and reporting was also impacted as resources were reallocated to address the pandemic. This was further compounded by patients’ reluctance to seek medical services due to the fear of catching the virus. Travel restrictions and loss of wages also added to the woes of the weaker sections of society who are more vulnerable to TB.

Funding was another major obstacle. Last year, worldwide funding for TB diagnosis, prevention, treatment, and care was only $6.5 billion, half of the $13-billion target previously agreed upon by the UN Political Declaration on TB. Treatment adherence was disrupted, thereby increasing the risk of a drug-resistant disease and mortality. In the first six months of the year, India saw a 25%-30% drop in TB case notifications according to a report by the World Health Organization.

While most medical services are focussed on addressing Covid-19, ensuring essential health services for TB patients needs to be prioritised as well. Keeping in mind the similarities of how TB and Covid-19 spreads, the learnings of the pandemic can be applied towards countering TB in a useful manner.

TB spreads through droplets of infected persons like Covid-19. Hence, physical distancing can reduce disease transmission here as well. Similarly, the practice of wearing masks by patients, caregivers or family members can prevent the spread of infection. Some of the practices followed due to pandemic have beneficial effects for TB.

With emphasis on diagnosis at the sign of the first symptoms, early detection and treatment can lead to better outcomes for TB patients. With rapid and precise results now available, the diagnosis can be delivered sooner. With wider awareness on contact tracing, TB cases can be tracked similarly and managed like Covid-19.

A report in The BMJ mentions that in September 2020, the National TB Elimination Programme (NTEP) announced a Rapid Response Plan to mitigate the impact of the Covid-19 pandemic on the TB epidemic and NTEP activities. The plan includes a bi-directional TB-Covid-19 screening, home-based sample collection and delivery of TB medicines, and modification of the DOTS (Directly Observed Treatment, Short-course, a treatment strategy) approach to include digital adherence technologies.

Keeping in mind the health and economic benefits of TB elimination, the government has set an ambitious target of a TB-free India by 2025, five years ahead of the UN's Sustainable Development Goals target. The government is already working on four main pillars in the healthcare space. It has made substantial progress in terms of prevention of illness and promotion of wellness, providing healthcare access to all, building health infrastructure, and expanding quality and quantity of healthcare professionals.

From a research perspective, while it is important to look into the development of drugs and curative treatments, it is also equally critical that funding organisations and policymakers prioritise operational research to effectively and efficiently tackle TB and its social determinants through the lens of the Covid-19 pandemic and associated economic slowdown. Having failed to eradicate TB for decades, the Covid-19 pandemic alertness and mobilisation of society, government and media can be used to facilitate TB goals effectively.

To truly eliminate TB from the country, we need to stand in solidarity. A collective will and commitment is required of all public and private stakeholders to work collaboratively for achieving holistic healthcare goals to keep TB under control. We must all join hands and work together to improve awareness and outcomes in diagnosis, prevention, treatment, and eventual elimination of TB. The way we have fought the pandemic, if the same will and determination is applied, together, we can eliminate TB before 2025.

Views are personal. The author is President and Head, India Region Formulations, Lupin Ltd.