“A war has a victor, but a pandemic has only the vanquished”.
-Laura Spinney, Pale Rider: The Spanish flu of 1918 and how it changed the world
On April 1, 2020, a novel virus SARS-CoV-2, which had only just been described, overtook an ancient bacteria, tuberculosis or TB, as the leading infectious cause of death. On this day, mortality from COVID-19 exceeded the daily toll of 5,000 deaths from TB. Suddenly the 1.5 million or so deaths annually from TB paled into insignificance when compared to the 2.5 million annual mortality from COVID-19.
Let’s examine the looming impact and synergies of these two airborne diseases: One as old as human civilisation, and the other unknown till a year ago. It is now clear that patients with TB are more prone to COVID and if they do contract the disease their need for hospitalisation and ICU is higher, so is the mortality rate of such patients, whose lungs are already weak. The huge TB patient population of India is thus a vulnerable one, and if patients with latent TB are also at higher risk from TB, as some experts feel they are, then the alarm should be ringing as 40 per cent of all Indians are believed to be latently infected.
These airborne diseases affect the same population. Perhaps it is no coincidence that diabetes, overcrowding, poverty and air pollution are amongst the most common bio-social determinants of not just TB, as we have long known, but also of COVID-19 as we have only just discovered. It is projected that the COVID pandemic has already pushed an additional 100 million below the poverty line: A population which will then be more vulnerable to the ravages of TB as well.
The world’s largest and longest lockdown, abruptly enforced by PM Modi spelt misery for this country’s huge TB population. Suddenly patients found it impossible to access TB services and large numbers of them dropped off the radar. TB notifications declined dramatically which means these patients “disappeared” without access to diagnosis or treatment for the many months of the lockdown.
TB is a disease that is very unforgiving of irregularities in follow up or treatment and we are only now seeing large rebounds in the numbers of patients, many of whom have developed drug resistant (MDR or XDR) TB due to irregular visits to DOTS centres. This applies to private clinics as well. We published findings from our very busy TB clinics at the Hinduja hospital, and found that footfalls of TB patients had fallen by two-third compared to the 2019 levels.
The path to successful TB diagnosis and cure is a long and winding road at the best of times, with nine months to two years of uninterrupted treatment being the norm. The hurdles posed by COVID proved insurmountable and sadly many patients gave up the race. Scared to leave their houses, lacking the transport to reach TB centres, the woes of these patients multiplied with drug stock-outs and shortages of TB. Colleagues at the Imperial hospital, London, estimated that each month of lockdown in India resulted in an additional 40,000 cases annually, adding up to a total of 150,000 increase in TB deaths over the next 5 years. Even BCG vaccination rates suffered. In March 2020, 260,000 fewer infants received BCG vaccine than in January of the same year, whilst in April, 1 million fewer children were vaccinated.
Economic and nutrition packages that had been promised to poorer TB patients also took a hit as did services for the HIV-affected. All these directly and indirectly added another level of complexity to the suffering of our Indian TB patients. Sadly, the collateral damage from COVID on TB is long lasting and runs deep. It threatens to set back by many years the fragile recent gains made by India’s National TB programme (NTP).
Every crisis it is said, is an opportunity in disguise, and telemedicine helped us reach out to our most difficult XDR-TB patients. At the Hinduja hospital, we guided several of these patients through the difficult days of the lockdown by allowing us to monitor their tests, compliance, and drug treatment remotely, guiding them across the stormy seas they had to navigate. Seventy per cent of our patients, when later polled, said they would prefer such video consultation with the resultant saving in time, transport, and cost on a permanent basis — clearly a pragmatic option to consider as the pandemic refuses to abate.
This crisis is, therefore, also an opportunity to reimagine TB care. To reinvest in our underfunded and overburdened paradigms of TB care, which are already beginning to look dated and uninspired. “What if we tackled TB like we tackled COVID” is the question public health experts should ask. Already one advantage is apparent to us all: Masks have become the new norm, and our TB patients are thus less destigmatised and less likely to transmit infection in crowded communities. What if we leveraged the lakhs of community workers currently helping with COVID contact tracing to also actively seek out TB suspects and help in their early diagnosis and enrolment in TB DOTS clinics? And, why stop there? Let us follow this up with investing and fast-tracking the TB drug and vaccine pipeline which currently runs in such a trickle. It is scandalous that TB has a single vaccine which is a century old whilst 12 COVID vaccines, discovered at breathtaking scientific speed, are already in deployment across the globe with over 70 in Phase 3 trials and 175 in pre clinical stages. We need to ask ourselves: if this crisis cannot build our collective resolve and spur us to action, what will?
This article first appeared in the print edition on March 27, 2021 under the title ‘The bacteria and the virus’. Udwadia, a leading TB Expert, is at the Hinduja Hospital in Mumbai; Mehra is a Public Health Specialist.