New Delhi: India, with 2.4 million tuberculosis (TB) cases in 2019, has the most cases (27%) in the world. With attention focused on the COVID-19 pandemic, resources from government TB programmes around the world, including in India, have been diverted to the COVID-19 response, says Grania Brigden, director of The Union, a global organisation working on TB and other lung-related issues.
"I fear we can expect the number of "missing millions" in TB increasing again after all the work that has been done to find the missing cases of TB," Brigden says. She is referring to the millions of undiagnosed and untreated cases of TB in India and other countries.
Brigden, who has previously worked with the United Kingdom's National Health Services as a respiratory doctor and with Médecins Sans Frontières on antimicrobial resistance, spoke to IndiaSpend on how COVID-19 has impacted TB, what countries need to do to prevent and control TB, and why the focus on eliminating TB should not waver.
According to this year's Global TB Report, TB is still the "top infectious disease killer in the world", in spite of the COVID-19 pandemic. As many as 10 million people developed TB in 2019 and it killed 1.4 million. Why then, in all these years of working on the issue, have we never seen the kind of mobilisation for TB that we see for COVID-19?
In the past five years especially, we have seen far greater mobilisation and commitment to ending tuberculosis at all levels, with the ministerial summit in Moscow and the UN High Level meeting on TB in 2018. The global response to COVID-19, especially the race for a vaccine, probably has at least something to do with the fact that the novel coronavirus is impacting the wealthy developed world heavily. Neither SARS [Severe Acute Respiratory Syndrome], MERS [Middle East Respiratory Syndrome] or Ebola really touched people's lives in the west the way that COVID-19 has. This reality mirrors just why TB continues to be seen like the 'poorer cousin' among infectious diseases--it only affects poorer people in the developing world. Despite killing more people than any other infectious disease, outside of the high burden LMIC [low- and middle-income] countries, it remains out of sight and out of mind.
The threat of COVID-19 has revealed how exposed we are all to viruses and respiratory infections of this kind but also to other potential pandemics. People can see for themselves the social and economic devastation that a health issue like COVID-19 can produce. We need to seize the moment and urgently re-assess the importance of pandemic preparedness and addressing infectious diseases going forward. This means having serious conversations on why investing in the health of one's own citizens is part of that equation, and why part of the solution resides in ending the unnecessary suffering and death from preventable, treatable and curable diseases such as TB, regardless of where, or in whom, they happen.
What gains that TB made in the last few years have been lost by the global focus on COVID-19 this year?
The sudden focus on COVID-19 has had a significant negative impact on TB, potentially more than other diseases, because in many countries the COVID-19 response has been built on or has utilised the TB response. The two diseases, although not the same, have many similarities--airborne respiratory illnesses needing good infection prevention and control measures. This has meant that in many countries, including India, TB programmes have been "re-purposed" to support the COVID-19 response, using TB programme staff and facilities, which has meant that these services are not available for people with, or at risk of, TB. We have already seen early data showing that there have been significant drops in the number of people presenting with signs and symptoms of TB and less people starting treatment. I fear we can expect the number of "missing millions" in TB increasing again after all the work that has been done to find the missing cases of TB.
Also, services have been reduced to really focus on "core" activities, which means a lot of the work on TB prevention activities has been stopped, just when progress was being made in offering preventive treatment to people at risk of contracting TB. This is particularly worrying as TB/COVID-19 co-infection leads to worse outcomes for both diseases. So we must continue to scale up TB preventive treatment during the COVID-19 pandemic as it has a dual benefit--protecting people from TB, as well as from worse outcomes if they get COVID-19.
When next year's global TB report numbers are released, what do you expect to see on incidence, mortality and other parameters?
I fear these will all be going in the wrong direction.
Do you worry that money that was earmarked, or could have been used on TB science, testing, research or policy, now does not exist due to COVID-19?
It is unclear what impact COVID-19 will have on TB funding but the amount of investment into COVID research and programmatic management does lead to the fear regarding a reduction in investment in TB. Additionally, given the likely economic recession, that is predicted in the coming years, particularly in some of the countries that support TB research and programmes, there is likely to be less money available for TB funding.
The additional challenge is that a lot of recent funding calls have all been linked to COVID. This may be to TB's advantage--if funding is to support the COVID response, this could also be used to build capacity and strengthen the TB response with regard to access to diagnostic tools, infection control measures, contact tracing, screening for respiratory symptoms, as these are similar for both TB and COVID-19.
But TB is not all linked to COVID and therefore we need to ensure that there remains funding dedicated to TB. We already know that we are getting less than half the amount of investment needed to achieve the END TB targets. We not only need to maintain current funding but also increase it, which will be difficult with so much extra investment in COVID-19.
In India, machines used to test for TB, such as TrueNat and CBNAT machines, have been diverted to test for COVID-19. Could this affect TB diagnosis in India, given the systemic struggles India already had, before COVID-19, to test and treat for TB?
This is a real concern. These tests can not only tell if someone has TB, they also include testing for drug resistance which is important to ensure that we are offering the right treatments to people with TB. However, there is a real opportunity to strengthen TB diagnosis. Given the investment in COVID-19, if the investment is given to increase the number of these platforms available, this will strengthen the TB programme and TB diagnostic infrastructure in the long term. We also need to ensure that the sample transportation system is strengthened.
The other benefit is that if these platforms can run tests for both TB and COVID-19, it will allow for bi-directional screening--anyone presenting with cough or fever (regardless of duration) is tested for TB and COVID-19. In high burden countries, like India, this could really help finding the missing millions with TB. This will need political will and strong advocacy but we need to see the synergies where they exist and ensure that interest and investment in COVID-19 leaves a lasting legacy and ensures that the initial negative impact of COVID-19 on TB is reversed.
The Indian government has recommended bi-directional TB and COVID-19 testing. Is this a good idea that will help detect more TB cases? Or, will combining COVID-19 and TB testing lead to fewer people choosing to get tested because of stigma around the diseases? Could this also lead to a shortage of diagnostic capacity?
Bi-directional screening has many advantages but the stigma issue is an important consideration. However, now more than ever, we need to ensure that we are messaging that COVID-19 and TB are respiratory infections and can affect anyone. Stigma is a friend of COVID-19 and TB. Stigma helps them spread so we must bring all we have learnt in TB with regards to stigma reduction and ensure that people who have respiratory symptoms know that they can access diagnostic services in a supportive environment without stigma. By fighting stigma, we are fighting TB and COVID-19.
Over the years, TB notification [the official term for registering TB patients with the government] in India has doubled from 1.4 million in 2013 to 2.4 million in 2019. But India also has the largest number of TB patients in the world. Still, 46% fewer TB cases were notified in India between March and June 2020 compared to 2019. What are your specific notes for India's TB situation, during and post this pandemic? What is India doing right on TB? What does India need to change?
A recent paper in the Indian Journal of Tuberculosis, "The potential impact of the COVID-19 response related lockdown on TB incidence and mortality in India" by Anurag Bhargava, of the Department of Medicine at Yenepoya Medical College in Mangaluru, and Hemant Deepak Shewade of The Union, showed a 59% reduction in TB case detection between March 25 and May 19, 2020. This may result in an estimated additional 87,711 TB deaths in 2020.
To prevent this from happening, TB services need to be restored to pre-COVID levels as soon as possible and active case-finding activities accelerated to detect the missed patients and put them on treatment. Regarding restoration of TB services, anecdotal evidence and notification data still suggests that India is not back to pre-COVID TB detection levels.
The review article highlighted proposed other steps needed to reduce TB rates, especially considering the worsening impoverishment associated with the lockdown. Poverty and poor nutrition is a risk factor for TB and therefore consideration should be given to rations, including pulses utilising public distribution systems, and direct cash transfers to those most at risk, pending restoration of livelihoods. This is beyond the direct reach of the TB programme but will have a positive effect on the fight to end TB in India.
The Union is supporting operational research in some states of India detecting severe TB at notification, given that we are concerned that the period of reduced detection of TB will mean that we will see more advanced cases of TB as we try to catch up. This work aims to identify those at the highest risk of death early and provide them with appropriate care.
We should not change the timeline to eliminate TB because of COVID-19. We should in fact double down on our efforts to end TB. What the COVID-19 response has shown is that there are mechanisms and political will to eradicate a killer respiratory pathogen and we need to take this energy from the multisectorial national response and ensure that it is brought to TB. The urgency to stop people dying from a preventable, curable illness [TB] has never been greater. I hope that governments and funders see the importance of health and ensure that investment in health and health systems continues. This will benefit TB and for India, the effort to defeat COVID-19 turns into an effort to defeat two deadly respiratory illnesses: TB and COVID-19.
(Bhuyan is a special correspondent at IndiaSpend.)
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