Even before Covid-19 became a pandemic, India was dealing with the world’s oldest epidemic, tuberculosis (TB), which affected 2.64 million Indians in 2019 and killed nearly 450,000 people in the country. That is over 1,000 plus TB deaths every single day, well before Covid entered the country.
Estimates suggest that the Covid pandemic could cause an additional 6.3 million tuberculosis cases globally between 2020 and 2025, with the most vulnerable populations, especially children, at risk. While the country aimed to eliminate TB by 2025 — five years ahead of the global target — the Covid pandemic reversed all the progress made towards elimination of TB. India contributed the biggest drop in TB case notifications last year, indicating that a large number of cases went undetected.
While 6.3 million TB infections were notified in 2019, the figure fell to 4.9 million last year. Reports suggest that this 1.4 million people did not receive treatment for TB in 2020, leading to 500,000 additional deaths in 2020, according to a WHO modelling.
About 41 per cent of all cases dropped in 2020 came from India. The risk of a tuberculosis infection turning into a disease has increased, while case notification has dropped in 2020 in India. TB clinics were not functioning because the healthcare workforce was redirected to fight Covid. All the advancement the country made in TB elimination pre-Covid has declined. Economic devastation leading to unemployment and lack of nutrition due to frequent lockdowns has further worsened the situation.
Integrating TB and Covid to augment India’s health outreach is the need of the hour to diminish the effect of the Covid crisis on TB. This can be achieved by increasing overall testing capacity, active screening, implementation of strategies for easy identification of TB hotspots, and ensuring uninterrupted drug supply for treatment through heedful planning of local and regional distribution and transportation which will especially help cater to the vulnerable populations who are at a high risk of suffering from adverse outcomes of TB.
India’s Central TB Division had already announced a rapid response plan to expand TB services and managed to mitigate some damage. A welcome move! With multiple waves of Covid raging across the country and the risk posed by new SARS-CoV-2 variants, the focus on TB services should not falter. Meeting the TB notification target is critical for India to eliminate the disease. Though the number of newly detected cases is still about 12 per cent less than pre-Covid, TB notifications have been on a steady rise for the past few months, according to the Nikshay database, a Web-enabled patient management system for TB control under the Union government’s National TB Elimination Program (NTEP).
We still need to gear up to reach the target of elimination. It is necessary to prioritise early diagnosis, isolation and treatment of TB patients so that they don’t become super-spreaders and secondary cases are avoided. Delayed TB diagnosis and treatment might substantially increase TB mortality.
Undernutrition hurts
Undernutrition and TB have an underlying relationship; it contributes to a staggering 55 per cent of the annual TB incidence in India. While India has shown tremendous increase in TB treatment between 2017 and 2019, we cannot eliminate TB if we ignore the connection between undernutrition and TB. Despite India’s economic growth, we have an alarming number of undernourished and food insecure people, especially children, women, tribal and other marginalised communities.
Addressing undernutrition in TB patients and their families require bringing them under social protection programs such as Targeted Public Distribution System and Integrated Child Development Scheme (ICDS) beyond the TB programme`s flagship Direct Benefit Transfer (DBT) Scheme.
The PDS system should focus on provision of subsidised protein-rich ingredients such as eggs, millets, lentils and legumes to address widespread malnutrition. The inter-related ministries such as Women and Child Development and Social Justice should work together with the Health Ministry in TB control by ensuring adequate nutritional status and food security for the beneficiaries.
Along with addressing the nutritional needs to accelerate progress toward ending tuberculosis, there is a need for sustained increase in investments in tuberculosis control services that are delivered as part of comprehensive primary health-care services and for strengthening health workforce capacity and health systems as part of overall efforts toward achieving universal health coverage in India.
As we observe World Tuberculosis Day on March 24, the theme — Invest to End TB. Save Lives — is apt to convey a sense of urgency. In our road towards recovery from the setbacks caused by Covid, it is paramount to make tuberculosis case detection a priority. The next few years will be crucial in the tuberculosis response and it is pertinent for all stakeholders including NTEP, Government of India’s inter-ministerial framework, multilateral agencies, corporates, CSOs, healthcare providers and the communities to achieve the agreed targets to end TB in India by 2025.
Lessons learnt in the battle against Covid can most definitely help in providing insights to fulfill the goal of eliminating TB. Tuberculosis is preventable and treatable and no one with tuberculosis should miss-out on the care they need.
The writer is Director-Health, World Vision India