Combating TB: Lessons from COVID-19 – Explained, pointwise

Introduction

March 24 is observed as the World Tuberculosis day. The day is designed to build public awareness about the global epidemic of tuberculosis and efforts to eliminate the disease. It is a preventable and curable disease, but it continues to impact the lives and development of millions of children and adolescents. As per World Health Organization (WHO), children and young adolescents aged under 15 years represent about 11% of all people with TB globally. Experts suggest that replicating the strategies used to manage COVID-19 could prove beneficial in combating TB and limiting its prevalence and magnitude.

What is Tuberculosis (TB)?

Tuberculosis (TB) is an infectious airborne bacterial disease caused by Mycobacterium tuberculosis. It most commonly affects the lungs but can also damage other parts of the body.

Types of TB-related conditions: (a) Latent TB: The bacteria remain in the body in an inactive state. They cause no symptoms and are not contagious, but they can become active; (b) Active TB: The bacteria do cause symptoms and can be transmitted to others; (c) Multi Drug resistant (MDR) TB: It is caused by an organism that is resistant to at least isoniazid and rifampin, the two most potent first line TB drugs. These drugs are used to treat all persons with TB disease; (d) Extensively drug-resistant TB: It is resistant to both first- and second-line drugs due to drug misuse and mismanagement. It is a more serious condition than MDR TB. Its symptoms usually include a cough (sometimes blood-tinged), weight loss, night sweats and fever. Patients with active symptoms require a long course of treatment involving multiple antibiotics.

What is the current status of TB?

In the decade between 2010-20, 1.5-2 million individuals died every year because of tuberculosis. TB disproportionately affects people in low-income nations, the poor and the vulnerable. According to WHO’s Global TB report 2021, with 25.9 lakh TB cases, India is home to 25% of the global tuberculosis cases. 

India has reported more than 20% decline in case notifications. The country reported 18 lakh tuberculosis cases in 2020 as compared to 24 lakh in 2019. The fall not due to reduced cases of the disease but due to under-reporting. Fear of COVID lockdowns and economic stress discouraged people from visiting medical facilities to notify of the disease and to get treatment.

What are the causes behind high occurrence of TB in India?

Poverty: A majority of TB patients in India get affected due to undernourishment. Poverty impacts their accessibility to food and ability to get treated which makes them more susceptible to occurrence and continuance of TB.

Bad Habits: Over a hundred million Indians smoke tobacco — a strong risk factor for both developing TB, and dying from it. A strong addiction towards it induces the person to consume tobacco even during the TB treatment which makes it difficult to cure.

Underreporting: One of the major factors of TB prevalence in India is under-reporting of TB cases. This leaves the risk of spreading TB to other healthy individuals. Inaccurate estimates of the tuberculosis burden in India between 2000-2015, has led the World Health Organization (WHO) to seriously underestimate the TB epidemic.

Social Attitude: Patients often hesitate to seek treatment or deny their condition altogether for fear of social discrimination and stigmatisation. Moreover, even after being diagnosed, they fail to complete their treatment resulting in development of multi drug resistance.

Many other issues like human resource shortage, payment delays, procurement delays and drug stock-outs add to prevalence of TB. 

What steps have been taken for combating TB?

National Strategic Plan for TB elimination (2017-25): It plans to provide incentives to private providers for following the standard protocols for diagnosis and treatment as well as for notifying the government of cases. Further, patients referred to the government will receive a cash transfer to compensate them for the direct and indirect costs of undergoing treatment and as an incentive to complete treatment.

Nikshay: It is an online tuberculosis reporting system for medical practitioners and clinical establishments that aims to increase the reporting of tuberculosis, especially from the private sector.

TB-free India Campaign: It was launched to take the activities under the National Strategic Plan for TB Elimination forward in a mission mode for ending the epidemic by 2025.

Currently, two vaccines VPM (Vakzine Projekt Management) 1002 and MIP (Mycobacterium Indicus Pranii) have been developed and identified for TB, and are under Phase-3 clinical trial.

Bacille Calmette-Guérin (BCG) vaccine is presently the sole vaccine available for the prevention of Tuberculosis (TB). However, its efficacy is very less in countries on or near the equator like India, Kenya and Malawi, where the burden of TB is higher.

What are the similarities between TB and COVID-19?

Both are transmissible and airborne infections. 

Both are more likely to spread in crowded settings, and harm people with immuno-compromising conditions.

Both have impacted a huge number of people across the globe and can be controlled with collective efforts.

How has the arrival of COVID-19 caused a surge in cases of TB?

Lack of Testing: Before the Covid pandemic, it was assumed that a third of all individuals with TB were undiagnosed, and were likely spreading the disease in their communities. In the past two years, case detection has dropped, suggesting that the proportion of such ‘missing cases’ is likely to have increased. 

Fear and Stigma: Lockdowns, the fear of healthcare establishments and the stigma associated with respiratory symptoms have possibly contributed to the increase in “missing cases”. 

Accessibility issue: For those diagnosed, access to medicines has not been easy during the Pandemic. 

Shortage of Personnel: The redirection of human resources within the health system during the three Covid waves has left TB facilities understaffed leading to poorer quality and delayed care.

Historical Evidence: Studies have suggested that Covid may trigger pathways leading to reactivation of dormant TB bacilli. Historically, turmoil in society (such as wars), food insecurity, poverty and malnutrition have resulted in surges in the incidence of TB. 

Source: BMJ Journal of Global Health

How can the lessons learnt from managing COVID-19 be used in combating TB?

Test, treat and track has been a strategy successfully employed for managing COVID-19. There is a need to aggressively scale up testing with innovative strategies such as active surveillance, bidirectional screening for respiratory tract infections using the most sensitive molecular diagnostics, and contact tracing. 

The biggest victory against COVID-19 has been the speed with which vaccines were developed, scaled up and deployed. The same approach must be replicated for tuberculosis; lobbying for funding from governments and industry to develop a successful vaccine for TB.

During COVID-19, there was a high degree of emphasis on sensitizing people and inducing them to behave in COVID appropriate manner. This involved ventilation of indoor spaces, voluntary masking and avoidance of crowded places. We need to ensure similar behavior from TB patients to reduce the spread. 

What more should be done towards combating TB?

First, India needs to triple the funding not just for TB but for health, nutrition and preventive services. It needs to actively invest on a similar scale as done during the COVID-19. For instance, the amount of money spent by governments for research and development in the first 11 months of the COVID-19 pandemic was 162 times the corresponding amount spent on TB in 2020.

Second, the country needs to invest in state-of-the-art technologies, build capacity, expand its health workforce and strengthen its primary care facilities. 

Third, there is also a need to consider telemedicine and remote support as important aspects of health services that could play a pivotal role in early detection and treatment.

Fourth, the government must ensure that social security programmes are duly implemented. They work towards prevention of modifiable risk factors like malnutrition, poverty etc. This would possibly pay richer dividends than an exclusive focus on ‘medicalising’ the disease.

Fifth, the government must build an open and collaborative forum where all stakeholders, especially affected communities and independent experts, take a lead role.

Conclusion

It’s time to acknowledge the magnitude of the disease, and work harder at offering individuals equitable healthcare access and resources that the disease warrants. Collective effort is desired at local, national and international level to attain SDG 3.3 which aims to end the epidemics of AIDS, tuberculosis, malaria and neglected tropical diseases by 2030.

Source: Indian Express