How COVID-19 has hit India’s fight against TB

The pandemic has impacted access to diagnosis and treatment of tuberculosis in India.

A doctor examines a tuberculosis patient in Guwahati on March 24, 2018. | Photo Credit: Anupam Nath/AP

It is slowly becoming apparent that the COVID-19 pandemic, which first hit India in early 2020, has had devastating and long-lasting effects on the nation’s ability to achieve its tuberculosis goals.

The pandemic, followed by lockdowns and large-scale migrations of various populations, has continued to impact access to diagnosis as well as treatment of TB in India, according to the World Health Organisation’s Global Tuberculosis Report 2022, released on October 27, 2022.

“Progress made in the years up to 2019 has slowed, stalled or reversed, and global tuberculosis targets are off track,” said the report. There were 21.4 lakh notified cases of TB in India in 2021, which is 18 per cent higher than in 2020. Globally, there was a drop of 18 per cent in the number of reported cases between 2019 and 2020, the report revealed.

The Ministry of Health and Family Welfare, however, attributed the increased number of notified cases to the fact that India successfully offset the “disruptions” caused by COVID-19 through critical interventions in 2020 and 2021.

The WHO report pointed out that while the incidence of the disease has decreased by 18 per cent from five years ago—it was 256 cases per lakh population in 2015, and in 2021, it was 210 cases per lakh population—TB deaths in India have increased by 6.6 per cent in the same five-year period. The report highlighted the significant influence that nutrition and undernourishment play in this scenario.

Early detection is crucial

Drug-resistant TB (DR-TB) is a rare strain of the disease that occurs when the bacteria become resistant to the drugs generally used to treat the disease. DR-TB is more expensive and complicated to treat. The WHO report said that the burden of drug-resistant TB had increased by 3 per cent between 2020 and 2021 globally.

The bacteria that cause TB in the lungs and throat can be transmitted from person to person through the air but do not remain contagious after the first few weeks of treatment. TB often affects the lungs but it can also harm the brain, kidneys, lymph nodes, or spine. Although it is typically treatable and curable, it could cause eventual death if not properly treated.

A healthcare professional looks at the X-ray of a tuberculosis patient at Kashmir’s chest diseases hospital, in Srinagar in 2015. | Photo Credit: Nissar Ahmad

According to the WHO report, microbiological detection of TB at an initial stage is key to treatment. The report noted: “The microbiological detection of TB is critical because it allows people to be correctly diagnosed, is necessary to test for drug resistance, and ensures that the most effective treatment regimen can be selected as early as possible.”

Dalbeer Singh, who started the Global Coalition Against TB in 2012, years after he recovered from DR-TB and a close call with death, works closely with the government to come up with solutions to TB-related issues. He believes a multi-sectoral approach is important for the eradication of tuberculosis.

“TB is deeply connected to socio-economic conditions such as poverty, pollution, stigma, and malnutrition. Medication alone cannot treat the disease. That is why India is not able to eradicate the disease completely,” he said.

The hunt for TB vaccine

While most of us are familiar with the Bacillus Calmette-Guérin (BCG) vaccine, which has been administered to newborns for more than a century, a new TB vaccine called MTBVAC is being developed by Hyderabad-based Bharat Biotech and Biofabri, a Spanish biopharmaceutical company, for distribution in 70 nations with a high incidence of the illness. If successful, it will begin phase 3 clinical trials in South Africa, Senegal, and Madagascar this year and replace the BCG, which is reportedly ineffective in preventing pulmonary TB in adults, who, together with adolescents, are the main carriers of the disease.

More deaths than HIV

The United Nations’ sustainable development objectives call for eradicating TB in India by 2030. In 2018, Prime Minister Narendra Modi launched the “Tuberculosis Free India” campaign to eliminate the disease by 2025, five years ahead of the UN target. Health experts, however, consider this goal difficult given the ground realities.

Bharat Jayram Venkat, an anthropologist at the University of California, Los Angeles (UCLA), believes that given how the disease has changed over time, evolving into drug-resistant strains, the government is mistaken in its efforts to eradicate the illness.

“Tuberculosis has been around for thousands of years. Ever since antibiotics for TB were developed, governments have created goals to eliminate the disease. It hasn’t happened because drugs alone cannot cure a disease like this. The standards of living have to go up. There needs to be much more focus on socio-economic factors such as dignified work, good labour conditions, ventilation at home and sanitation,” he observed.

To reduce the chances of drug-resistant TB, he said, all patients should not be put on the same standard medication. The author of At the Limits of Cure, Venkat has drawn on historical and anthropological studies to trace the disease in India. He spent decades on research, and what started out as a study on HIV turned into a book on TB, as he found that more people were dying from TB, a curable disease, than from HIV, an incurable one.

As the WHO report noted, in 2021, 1.4 million deaths worldwide were officially attributed to tuberculosis, more than double the number of deaths attributed to HIV/AIDS (0.65 million). The COVID-19 pandemic has exacerbated TB mortality far more than HIV/AIDS-related deaths, which actually decreased between 2019 and 2021.

India, referred to as the TB capital of the world, sees over 2 lakh TB-related deaths a year, making it the country with the highest burden of the disease globally. This is not surprising, given the country’s dense population, poverty, and the large majority of people living in overcrowded, unsanitary conditions.

Marginalised and impoverished communities are obviously more vulnerable to death by tuberculosis. In August this year, the Centre identified 75 tribal districts for focused interventions. Then there is the issue of stigma. Women diagnosed with TB in rural areas cannot get married or are divorced, shunned, and isolated.

Even though the government’s Revised National TB Control Programmefor free diagnosis and treatment, run since 1997, is recognised as the world’s largest and fastest expanding TB control programme, the disease remains a personal and social crisis in the country. The pandemic has only made it worse.