With COVID19 caseload bringing about an unprecedented stress on India’s health infrastructure, other deadly infectious diseases seem to have lost the attention they need.  

News reports indicate that there has been an increase in the cases of tuberculosis (TB) infection ever since the COVID19 pandemic started in India in March, last year. But because of the pandemic and the lockdown, TB notification in India has dropped by 46 per cent between 2019 and 2020, as reflected in the data from Nikshay portal, under the National Tuberculosis Elimination Programme, Ministry of Health and Family Welfare. 

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Both COVID19 and tuberculosis (TB) primarily target the same organ of the body — the lungs. Though COVID19 is caused by a coronavirus known as SARS-CoV-2, TB is caused by a bacterium called Mycobacterium tuberculosis.

According to the World Health Organization (WHO), tuberculosis and COVID-19 are both infectious diseases that attack primarily the lungs. Both diseases have similar symptoms such as cough, fever and difficulty breathing. TB, however, has a longer incubation period with a slower onset of disease. Incubation period refers to the time gap between contracting an infection and experiencing its symptoms.

“While experience on COVID-19 infection in TB patients remains limited, it is anticipated that people ill with both TB and COVID-19 may have poorer treatment outcomes, especially if TB treatment is interrupted,” warns the WHO.

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Is there a direct link between COVID19 and tuberculosis?

An infection of a person’s lungs by COVID19 doesn’t necessarily mean that tuberculosis infection will soon take over but a decline in the general immunity of the patient makes her/him vulnerable for other infections like TB. 

The higher numbers of TB cases can also be attributed to the disruption of the health services for the patients due to the havoc wreaked by the COVID19 pandemic.

A September 2020 article published in BMJ Journals  states that there was a sharp decline in the vaccination of children against TB in India as the medical infrastructure was hugely concentrated on containing and treating COVID19. 

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“In March 2020, over 260,000 fewer children [in India] received the BCG vaccine that provides protection against childhood TB than in January 2020. The decline in April was even sharper—just half as many children received the BCG vaccine in April 2020 as in January 2020,” the article mentioned.

How tuberculosis is especially dangerous for COVID patients

The Union Health Ministry, in September, 2020, in  its notes on the screening of COVID19 andTB, mentioned that the prevalence of TB among COVID19 patients has been found to be 0.37 per cent to 4.47 per cent in different studies. 

Also Read: Tuberculosis and coronavirus: Challenges of managing an epidemic within a pandemic

It also stated that history of active as well as latent TB is an important risk factor for SARS-CoV-2 infection. “This not only results in increased susceptibility, but also rapid and severe symptom development and disease progression with poor outcomes,” it stated.

In its suggestion, the health ministry also stated that there must be a ‘bidirectional screening’ of all the COVID and TB patients:

COVID screening for diagnosed TB patients: All newly diagnosed TB patients or those currently on treatment should be tested for COVID-19. Based on the result of COVID-19 test, further management would be undertaken as per the health ministry’s guidelines. Even upon diagnosis of COVID, treatment of TB should continue uninterrupted. 

TB screening for COVID positive patients: All COVID-19 cases should be screened for TB symptoms using the four-symptom complex (Cough for more than two weeks, persistent fever for more than two weeks, significant weight loss, night sweats), history of contact with TB cases, history of TB.

Potential impact of COVID19 on tuberculosis

The reputed medical journal The Lancet, published a research paper on November 1, last year stating that the disruption in the treatment of TB patients due to COVID19 can have potentially long term effects.

“If lockdown-related disruptions cause a temporary 50% reduction in TB transmission, we estimated that a 3-month suspension of TB services, followed by 10 months to restore to normal, would cause, over the next 5 years, an additional 1·19 million TB cases and 361,000 TB deaths in India, 24,700 TB cases and 12,500 deaths in Kenya, and 4,350 cases and 1,340 deaths in Ukraine,” it estimated.

From the finding of the research, it was interpreted that lockdown-related disruptions can cause long-lasting increases in TB burden.

“But these negative effects can be mitigated with rapid restoration of TB services, and targeted interventions that are implemented as soon as restrictions are lifted,” The Lancet noted.

Meanwhile, as per the Stop TB Partnership’s media brief released in March this year, since March 2020, the COVID-19 pandemic has severely disrupted TB responses in low- and middle-income countries, stalling and reversing years of progress made against TB. In 2020, COVID-19 overtook TB globally as the most common cause of death from an infectious disease, but in low- and middle-income countries, TB deaths remain far higher than those from COVID-19.

As the number of people vaccinated against COVID-19 grows, the number of COVID-19 deaths decrease while TB will continue to kill roughly 4000 people globally every day, warned Stop TB Partnership.

Delay in diagnosis of tuberculosis leading to surge in cases

Meanwhile, due to the disruption of the TB treatment and the prolonged incubation period of the infection, doctors claim that many of the cases that are emerging now are the ones that were not detected during the COVID19 pandemic.

Ajith Bhasker, a Kozhikode-based pulmonologist has been quoted as saying in a news report that routine TB detection had taken a back seat during the COVID19 pandemic.

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“TB is a disease which progresses slowly and people may relate their symptoms such as cough and fever to be part of the seasonal illness and ignore it,” he said.

“When these people are hospitalised with COVID, the patches that show up in lung X-rays are assumed to be those due to COVID. Thus many of the TB cases which are now surfacing are cases which we failed to pick up earlier from the community,” Bhasker added.

Tuberculosis in India

Before COVID19 became a global pandemic, India was already dealing with tuberculosis (TB)—which affected 2.64 million Indians in 2019 and killed nearly 450 000 people in the country, as per the data published in the ‘India TB Report 2020’ by the Union Health Ministry. 

The data, in other words, mean that India witnessed over 1,000 TB deaths every single day, well before COVID-19 entered the picture.

Integrated approach for prevention and care of COVID-19 and TB patients:

Implement massive community and primary health care level screening. People with a cough and fever should be tested for both TB and COVID19.

Mobilise, create, develop and support networks of TB survivors and TB communities.

Implement airborne infection prevention and control measures in all health care units and in congregation settings. 

Implement real-time surveillance data with early warning systems for data-driven and agile public-health decision making.