World TB day: A grim reminder on urgent steps to reverse the setback for India’s major killer disease

COVID-19 has taken a heavy toll on tuberculosis or TB in India. In a disease that sees one TB patient die every minute, the under-reporting of cases triggered by the lost contacts during the lockdown months last year and the social distancing compulsions apart from the movement of healthcare and community-based workers on the ground away from TB care to COVID, has all combined to pose a serious challenge and experts feel it is now imperative for India to not just focus on recovering the lost ground but to also innovatively try and hasten up the process of new case detection.

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Numbing Numbers

TB has always been an area of concern for India, not just for the sheer numbers involved but also because of the nature of disease, which is contagious and left untreated can lead to serious illness and death. Typically, one TB patient, can potentially infect 10 to 15 others in year and in a country of India’s size there is much to worry about. “In terms of absolute numbers, we are about 18 per cent of the world population but have about 27 per cent of world TB cases making India number one globally in terms of TB cases and deaths due to TB,” says Dr K S Sachdeva, the former deputy director general, Central TB Division at the National TB Elimination Programme and a highly regarded voice in TB care.

Part of the reason for the high numbers in India has also to do with its large population. It sees around 26 lakh new TB cases every year. “While we may be number one in terms of cases but India is at number 38 globally in terms of new cases seen per lakh population. In India it is 193 cases per lakh population as against much higher rates in other countries such as Afghanistan, some African countries, Indonesia and others.

Ask him about the setback on account of COVID and he says: “In the entire year, the setback was 25 per cent and therefore as compared to 24 lakh cases detected and put on treatment in 2019, it was down to little over 18 lakh in 2020 though the fall was much higher during the lockdown months but it picked up subsequently to close the year with around 25 per cent dip in case detection.”

More Deaths

Agrees, Dr Hemant D Shewade, Senior Operational Research Fellow, The Union, an international scientific NGO focussed on tuberculosis and lung disease. His study of the impact of COVID on TB care in India are quite revealing. Explaining, he says, “in a review paper co-authored by me and published in the Indian Journal of Tuberculosis last December, using the WHO (World Health Organisation) methodology for India, a 20 per cent increase in the number of deaths was estimated on account of under-reporting that happened in 2020.” Referring to the estimates made for India and what their findings suggested, he says, “as against 450,000 deaths per year for India, we estimate this to increase to 540,000 deaths due to under detection of TB.” This is huge and as we can gather translates to roughly about 1400 deaths per day or as bad as one every minute in India due to TB.

Dr Shewade says this has taken India back to 2014-15. “So, in a sense, it has reversed all the gains it had made in the last five years.” And there is more to worry as he points out: “Sadly, even as I speak now, the TB services across the country have not returned back to normal.” He says, “the TB detection fell by about 25 per cent in 2020 meaning if there were 100 patients were diagnosed in 2019, only 75 were diagnosed in 2020 with the remaining staying undiagnosed with some eventually dying because those who do not take the treatment have a 40 to 80 per cent chance of dying leading to higher estimates of deaths due to TB now.”

Setting The Clock Back

The priority now, he says, is to focus all energies “to get the TB services back to normal – the pre-COVID-19 levels – and this includes getting the TB testing at the PHCs (Public Health Centres) back to the pre-COVID-19 levels, ramping up case findings, detecting severely ill TB patients. All with a single motive to try and stop the deaths.” He says “much like how in the case of COVID where severe cases are referred to a hospital and mild cases confined to quarantine at home, we need to have a similar urgency in treating to severely ill patients.”

Currently, there is DOT (Directly Observed Therapy), which is ambulatory care under the supervision of a community member (community DOT – Asha (Accredited Social Health Activist) worker or an anganwadi worker (a community-based frontline worker) or any other community member) or even a family member (family DOT). But, Dr Shewade, says, “we need to screen these patients for severe illness at the diagnosis stage – and immediately have them shifted to inpatient care in hospitals because most of the TB deaths happen within one or two months of treatment. Once these severely ill patients recover, they can continue ambulatory DOT at their residence. Those who are not severely ill can undergo the routine ambulatory DOT right from the beginning of treatment.

Hope In Despair

Dr Sachdeva however, while also pointing out that the detection was down by about 25 per cent, reminds that “you will see a resurgence if you do not reach out to patients and therefore tracing and treatment have a crucial role.” On the setback due to COVID, he however feels, the lost ground may not be a five year setback as is made out by globally used modelling methods. “I do not quite buy this theory because there have been some positive spin-offs from COVID that may have unwittingly helped TB care,” he says and explains: “While we are hypothesising at the moment, it may be worth nothing that there may have been a cut in transmission rate by 20 per cent on account of several factors. After all, TB patients too were wearing masks and observing social distancing and not travelling in crowded public transport. Then, the testing has got a boost with much more widespread rapid molecular testing machines, which based on the cartridges used, could be deployed for COVID testing also. These are against the low sensitivity sputum smear microscopy testing used earlier for TB.” With the higher sensitivity of the molecular testing, Dr Sachdeva says, there is now scope for additional case detection. He says, “while TB requires six months of treatment and is a highly infectious disease, what has also helped now is a greater sensitivity among people towards lung diseases with heightened awareness towards cough and the testing required and the need to approach a healthcare provider. All in all, therefore the setback may be more by about three years.”

Dr Sachdeva remains hopeful and feels, “we can cover the lost ground and still be able to reach the goal set for elimination of TB by 2025.” For this, he points to some measures that were put in place pre-COVID but could be strengthened now. “For instance, the increased coverage of TB preventive therapy that was put in place and goes beyond the current focus on only the high risk groups such as those that are HIV positive and children under five years age to now even reaching out to contacts of TB patients across age groups. This will need strengthening. That apart, he says, the other measure is population-level vulnerability mapping and screening for TB. Like reaching each and every household and enquiring on the health history and based on that assess the risk of TB for that population and track and monitor on a regular basis. These, he says, were started before the pandemic and will now need to be expedited and strengthened.”