COVID-19, Tuberculosis and the agenda to eliminate: Re-starting a focused elimination program for India

Tuberculosis (TB) is one of the most ancient diseases of mankind and one of the ten major causes of mortality worldwide. ^[1] TB along with Acquired Immune Deficiency Syndrome (AIDS) and malaria rank among the top three fatal infectious diseases which pose threat to global public health, especially in middle- and low-income countries. ^[2] India accounts for more than one-fourth of the world’s Tuberculosis (TB) cases which amounts to about 2.6 million cases out of 10 million cases worldwide.^[3] Considering INDIA TB Report 2020, 24.04 lakh patients were notified through NIKSHAY portal, an increase of 11% over last year, with 6.7 lakh patients being notified from the private sector aiming a success approach towards TB elimination.^[4] The concern is to know where we stand now in terms of Tuberculosis Notification and Management?

Unfortunately, as COVID 19 Pandemic hit the nation, a remarkable dent has been caused by it on the ongoing TB control activities across the country adversely affecting the routine programmatic activities like case-finding, initiation of treatment, follow-up and contact tracing. Anecdotal evidences suggest that in the country only 40-50% of TB cases have been registered as compared to the same period during last year.^[5] Many factors are responsible for reduced registration and reporting as health systems are extremely busy handling the pandemic and also, people are scared to access health services with the fear of contracting coronavirus infection. The National Tuberculosis Elimination Programme needs to develop a policy document, guidelines and robust supervision and monitoring tools for collection of sputum at microscopy centers with strict emphasis on implementation of infection control practices.^[5] A study conducted by A M Cronin et al in USA indicated transfer of TB resources for COVID-19 use (including personal protective equipment, housing, hospital beds, and isolation rooms) and concluded that the COVID-19 response is diverting resources from essential TB elimination activities.^[6] N Kwak et al conducted study in South Korea regarding the effect of COVID on Tuberculosis Notification and found significant reduction in TB Notifications with the surge of COVID 19.^[7] In the study conducted by V K Jain et al in India, considerable disruption in Tuberculosis service provisions were found both in the primary care and hospital settings due to various factors like lockdown, social distancing, isolation strategies and public health guidelines to prevent viral transmission which impacted the delivery of all aspects of Tuberculosis care.^[8] Therefore in order to control TB and to follow the road towards its elimination, strategies need to be modified and adapted which includes maintaining continuous supply of PPE and all necessary equipments, promoting home visits rather than hospital visits for DOTS and Sample collection and encouraging the health staff and community to be more vigilant than ever. The resources assigned for Tuberculosis care which has been diverted to COVID care needs to be look at utmost priority. One of the strategies taken by the Government of India has issued advice regarding the provision of TB medications to patients in the outpatient setting, stating that these patients should be provided with TB medications to last 1 month, and in exceptional circumstances 2-month supplies, to reduce the need for patients to attend clinics therefore reducing the risk of transmitting the disease. ^[9]

 The Coronavirus pandemic should be used as an excellent opportunity to create awareness about TB in the community since the social distancing along with the better hygiene practices may limit the spread of communicable diseases, most importantly Tuberculosis. ENGAGE-TB: Integrating community-based TB activities into the work of NGOs and other CSOs must be promoted on a greater scale with public health proficient NGOs leading the space instead of all-weather NGOs in the market rising with paid advertisements.

The app used for COVID-19 case tracing named ‘Aarogya Setu App’ should not affect the continuity of essential contact tracing applications (apps) used for people affected by tuberculosis and rather should be used to encourage the usage of same by the respective field staff. Though not much evident studies are present till date, it is believed that both of the infectious diseases may show synergistic impact on social and economic impact worldwide as both the diseases are expected to spread in overcrowded areas with poor and undernourished populations.^[10]

If the approach towards Tuberculosis Care and Control during COVID-19 Pandemic doesn’t change, it may lead to numerous Hidden, Untreated TB cases adding up to high risk cases for COVID-19 and increasing the case burden and fatality rate. Any delay in the treatment of TB patients would deteriorate their disease and hence more extensive management will be required, some may develop multidrug resistance and super infection by Coronavirus. Therefore continuous reporting, notifying, contact tracing, sputum sample reaching on time and treatment of tuberculosis should be also considered as utmost priority, mainly during the times of COVID-19 Pandemic.

REFERENCES:

1. Yadav J, Verma S, Chaudhary D, Jaiwal PK, Jaiwal R. Tuberculosis: Current Status, Diagnosis, Treatment and Development of Novel Vaccines. Curr Pharm Biotechnol. 2019; 20(6):446-458.
2. Singh R, Dwivedi SP, Gaharwar US, Meena R, Rajamani P, Prasad T. Recent updates on drug resistance in Mycobacterium tuberculosis. J Appl Microbiol. 2020; 128(6):1547-1567.
3. World Health Organization (WHO). Global TB Report 2019. https://www.who.int/tb/publications/global_report/en/. [Accessed on 10 Oct 2020].
4. TB REPORT 2020
5. COVID 19 AND NTEP
6. Cronin AM, Railey S, Fortune D, Wegener DH, Davis JB. Notes from the Field: Effects of the COVID-19 Response on Tuberculosis Prevention and Control Efforts—United States, March–April 2020. Morbidity and Mortality Weekly Report. 2020 Jul 24; 69(29):971.
7. Kwak N, Hwang SS, Yim JJ. Effect of COVID-19 on tuberculosis notification, South Korea. Emerging Infectious Diseases. 2020 Oct; 26 (10):2506.
8. Jain VK, Iyengar KP, Samy DA, Vaishya R. Tuberculosis in the era of COVID-19 in India. Diabetes & Metabolic Syndrome: Clinical Research & Reviews. 2020 Sep 1;14 (5):1439-43.
9. Government of India. Ministry of Health and Family Welfare (MOHFW) National Tuberculosis Elimination Program (NTEP). http://www.tbcindia.gov.in/.[Accessed on 12 Oct 2020].
10. Khurana AK, Aggarwal D. The (in)significance of TB and COVID-19 co-infection. Eur Respir J 2020; 56: 2002105 [https://doi.org/10.1183/13993003.02105-2020].

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