Commentary

Why India must tackle the double burden of COVID-19 and TB urgently

For millions of TB patients, the post-COVID-19 world will not be ‘back to normal’ unless treatment for the other silent epidemic is prioritised, say Geetha Vani Rayasam* and Anshu Bhardwaj**.

doi:10.1038/nindia.2021.67 Published online 11 May 2021

Healthcare volunteers queue up to take tuberculosis samples to microscopy centres.

© Sanjay Baid/EPA-EFE/Shutterstock

As healthcare professionals, scientists and governments around the world focus their energies on arresting COVID-19, attention to another grave health crisis — Tuberculosis (TB) — has been eclipsed. World TB Day on 24 March 2021, came amidst a grim reminder that the post-pandemic world will not be the same for TB patients if enough resources are not diverted back to TB research and care.

When the pandemic struck, four countries — India, Indonesia, the Philippines and South Africa accounting for 44% of the world’s TB cases — showed a significant drop in reported case numbers between January to June 2020. WHO estimates that if TB remained undiagnosed in 25 to 50% lesser people in these 3 months, anywhere between 0.2 to 0.4 million people would have died due to the disease.

In 2020 alone, 1.4 million fewer people received TB care as compared to 2019. This makes for around 20% less people globally and almost 25% less in India receiving TB care.

The World Health Organization’s ‘End TB’ strategy, which aims at reducing TB deaths by 95% between 2015 and 2035, has been hit hard by COVID-19. The long-term effects of the pandemic on global TB elimination targets will only become clearer with time. Meanwhile, the WHO recommends that while governments mount an effective and rapid response to COVID-19, they must ensure that TB services are maintained

Importantly, the WHO also points out that people with both TB and COVID-19 may have poorer treatment outcomes if TB treatment is interrupted. Given the lockdowns and the tremendous strain on the health services during the pandemic, it is challenging to ensure appropriate care and services especially for multidrug-resistant (MDR) and extensively drug-resistant (XDR) TB patients.

Like elsewhere during COVID-19, TB services were disrupted1 in India, which accounts for the highest number of cases globally (26% in 2019). WHO has revealed that at least a million people across the globe could not receive TB treatment in 2020 marking a huge setback for national TB control programmes. Estimates point to 500,000 deaths from TB in the last year2, 3

India’s Central TB Division announced a rapid response plan to expand TB services and managed to mitigate some damage, though the number of newly detected cases is still about 12% less than pre-COVID3.  With the second wave now raging across the country and the risk posed by new SARS-CoV-2 variants, the focus on TB services should not falter.

Vaccine lessons from COVID-19

Interestingly, both TB and COVID-19 are infectious diseases primarily affecting the lungs. The former is caused by a bacteria Mycobacterium tuberculosis (Mtb) and the latter by the coronavirus SARS-CoV-2. Both diseases have similar symptoms such as cough, fever and difficulty in breathing.

While the quest for TB vaccines beyond BCG has been on for a long time, multiple vaccines have been developed for SARS-CoV-2 within a year – a feat unimaginable for any other disease till now. There are multiple reasons behind the lack of effective vaccines for TB (beyond BCG), but the primary reason is that Mtb is a complex pathogen and has co-evolved within humans for thousands of years, learning to evade the host’s immunity. On the other hand, vaccines for COVID-19 were developed at a really fast pace due to the massive impact the virus had on humankind.

TB experts in India increasingly feel that despite decades of research and development, TB vaccines, short-duration drugs or point of care diagnostics have not made much headway. At a recent discussion on World TB Day around disruptive ideas and critical strategic gaps in TB research, experts also pointed out that non-invasive diagnostics would be the game changer in surveillance and rapid control of infection.

Despite the complexity of TB infection, the disease can be addressed with the collective efforts of the scientific and healthcare communities, just as in case of COVID-19. Existing approaches, including standard of care for TB, need to be challenged, since current approaches offer only incremental success not enough for India to reach the ambitious 2025 End TB target.

COVID-19 has spotlighted mRNA vaccines, which can be the next step for TB vaccines and therapeutics. COVID-19 diagnostics, especially collection and processing of samples for rapid surveillance, have seen many innovations that can be harnessed for TB diagnostics. India’s ability to conduct clinical trials at warp speed for vaccines or therapeutics during COVID-19 bodes well for TB. 

Handling a double whammy

A mobile clinic for active TB case surveillance in Arunachal Pradesh, India.

© GoAP

These new technology platforms, disruptive ideas and data-driven holistic approaches must be attempted boldly for TB. Digital tracing apps, use of masks, importance of surveillance and epidemiology are some of the other key learnings from COVID-19 that can serve the objective of TB elimination well, if adopted and utilised at the same pace. Significantly, in India, people are now being given a month’s supply of TB drugs to decrease visits to health centers, and health workers are monitoring the drug usage on video calls. Measures such as these along with TB centres testing people for both COVID-19 and TB will go a long way in handling both the crises simultaneously2.

COVID-19 has also demonstrated the need to support investment in research and development in the public sector, collaborations between academia and industry and engagement of all stakeholders, including the public. These approaches will help address other infections, which are leading to an ever-increasing rate of antimicrobial resistance throughout the world.

The Lancet Global Health Commission delineates the urgent need for investment in high-quality health systems pointing out that poor-quality care is a bigger killer than insufficient access to care4. COVID-19 has exposed the fragile nature of the current health care systems in India and worldwide and calls for an immediate course correction. In addition to the strengthening of the health care infrastructure, patient-centered services are needed for achieving better TB control5.

The complex nature of disease manifestation and increasing rate of antimicrobial resistance calls for urgent action based on learnings from the COVID-19 pandemic. Moreover, the overburdening of the health care system by COVID-19 alongside the adverse economic impact is going to pose a formidable challenge for management of TB.

If we do not refocus attention on TB, it has the ominous potential of becoming a bigger pandemic than COVID-19.

(*Senior Principal Scientist & Head of Science Communication & Dissemination at CSIR, New Delhi. **Principal Scientist, CSIR-Institute of Microbial Technology, Chandigarh, India.)


References

1. Shrinivasan, R. et al. India’s syndemic of tuberculosis and COVID-19. BMJ Glob. Health 5, e003979 (2020).

2. Roberts, L. How COVID hurt the fight against other dangerous diseases. Nature 592, 502–504 (2021).

3. Three million COVID deaths is a grim milestone. Nature 592, 488 (2021).

4. Kruk, M. E. et al. Introducing The Lancet Global Health Commission on High-Quality Health Systems in the SDG Era. Lancet Glob. Health 5, e480–e481 (2017).

5. Reid, M. J. A. et al. Building a tuberculosis-free world: The Lancet Commission on tuberculosis. Lancet 393, 1331–1384 (2019).