BY MINAJ RANJITA SINGH
Minaj Ranjita Singh received her MA in May 2020 from Johns Hopkins SAIS studying International Development. She is also the social chair and alumni representative of the SAIS IDEV 2020 cohort.
Subject: Uninterrupted TB treatment during COVID 19 outbreak
Introduction:
India has the highest burden of Tuberculosis (TB) in the world, accounting for a quarter of the total number of cases. TB, which is a treatable disease, is the leading cause of death from infectious diseases worldwide. During these unprecedented times of the COVID-19[1] pandemic, immunocompromised patients are at high risk, especially in a country with high-density living conditions. This article provides recommendations to avoid disruptions in TB treatment in India due to the COVID-19 outbreak and response.
Background:
Tuberculosis is caused by mycobacterium tuberculosis,[i] which can be nefarious if it is resistant to multiple drugs, posing a significant threat to global health security. Broadly, it is divided into Drug Susceptible TB (DS-TB) and Drug Resistant TB (DR-TB); the latter one is responsible for locking generations into a cycle of poverty when not taken care of. In 2018, around 2.6 million people fell ill with TB in India with an incidence rate of 199 per 100,000 and 130 specifically for Multiple DR-TB.[ii] Although the death rate has decreased since 2000 from more than 700,000 to 449,000, it is still the 6th leading cause of death in India.[iii] The treatment of DS-TB is low cost and highly effective and it may give an additional 20 years of life to an individual in the middle of his/her productive life.[iv]Despite the low costs, the national TB budget is still under-resourced, with 80% of the budget (USD 583 million in 2019)[v] is domestically funded.
Both being respiratory infectious diseases, COVID-19[2] and TB have similar symptoms such as cough, fever and difficulty in breathing and are spread by close contact; however, TB is airborne whereas coronavirus’ mode of transmission is through droplets.[vi] Contact Tracing is an important part of reducing population level burden in both cases.[vii][viii] TB’s transmissibility varies from that of COVID-19; an individual who has a latent TB can’t infect another being,[ix] whereas an asymptomatic COVID patient can spread the virus. TB has a longer incubation period, and its onset in the body is far slower than COVID-19.[x] Experts have already predicted that COVID-19 will adversely affect all routine health services,[xi][xii] more so for TB prevention and treatment services because of the similarities in their healthcare capacity and training, which will result in redirected resources and personnel away from TB services. [xiii][xiv]
Current status:
TB treatment and care is dominated by the private healthcare sector in India which treats more than half of the country’s TB patients. [xv] This sector is largely fragmented and unregulated with difficulty in detection, testing and tracking diagnosed patients as data gathering is opaque and poor. Apart from this, inappropriate prescriptions by small chemists and health facilities have amplified the spread of DR-TB and these require longer, more expensive treatments.[xvi] Poor knowledge of the disease and the services provided by the government, paired with a desire for confidentiality and personalized care, drive individuals to seek care from the private sector.[xvii] However, poorly designed plans by unsupervised private sector can be dangerous leading to the spread of drug resistant TB[xviii] . For preventive purposes, a 100 years old vaccine called Bacillus Calmette Guérin (BCG) is provided to children under 5 years of age but the effects wear off after 15-20 years. In 2017, the Government of India announced the National Strategic Plan (NSP) to eliminate[3] TB by 2025 with a four-pronged approach to detect, treat, prevent and build strengthened policies and empowered institutions.[xix] Usually, one in four TB patients in India had to resort to ‘hardship financing’ by mortgaging/selling their private properties in order to pay for treatment.[xx] To eliminate this, the NSP stated the provision of social welfare schemes to the patients as one of its objectives.
Due to COVID-19, the Prime Minister of India announced a 21-day lockdown of the nation on 24th of March 2020. The many years of capacity building by Indian Government and international donors for TB treatment, prevention and control will now act as a support system for responding to the current global health threat. According to experts, many potential TB patients are scared to go to the hospital because of the fear of being mistaken as a COVID-19 patient since the symptoms are similar. In addition, there was a huge drop in TB reporting (approximately 80%) in the first month of the lockdown.[xxi] During this time, it is important to make sure that there is no interruption in the treatment of TB patients. A circular by the Central TB Division, Ministry of Health and Family Welfare, Government of India, instructed all public health care facilities to disburse a one-month supply of drugs to the patients. [xxii] This raises an important concern for patients who seek care under private health facilities. Another circular extends its treatment and support for all patients (private and public). [xxiii]
Challenges and Recommendations:
Along with the ongoing interventions which demonstrate the much-needed ambition and intent, care must be taken so that TB treatment is not compromised. Although the routine footfalls in the Outpatient Department will reduce with the lock-down, it is very crucial to make sure that no service delivery sites should be closed. Those already on treatment should have continuous supervision through Directly Observed Treatment, short course (DOTS) providers at the local health facility. For those who are recently diagnosed with TB, health workers or nurses should be allowed to initiate the treatment in the case of DS-TB. This policy intervention is present in Brazil and South Africa and has proven to be very helpful.[xxiv] If there is a dearth of experienced medical professionals, resident doctors/ medical students should be taught technical expertise. All the existing call centers those were dedicated helplines for TB patients now are contacted for conducting COVID response. To maintain the flow of this service and ensure that the call centers are not overwhelmed, the Mumbai and Gurgaon call centers in India should recruit additional personnel who can be trained to help. Similarly, due to the diversion of resources, this pandemic could result in serious disruptions of payments (such as cash transfers) and social benefits (such as the provision of dry rations) to TB patients. This could be mitigated by automated payments and hiring more local delivery personnel. Apart from providing clinical services and proper treatment options, it is equally important for a comprehensive health plan to compensate for economic and health losses caused by the disease.
During this time, to reduce opportunities for transmission of sars-cov-2, community-based care should be strongly preferred over hospital treatment unless the conditions are very serious. For both public sector and private sector patients, adhering to the treatment such as remembering pills is an issue, which can be solved by appointing a buddy[4] who can help remember the medicine and track the dosage. Before lockdown, social health workers monitored their progress but these front line workers have been moved to tackle COVID-19. With the lockdown, volunteers could be trained to communicate, counsel and monitor the patients via the use of digital technologies (such as WhatsApp, zoom, or other tools) wherever possible, thus providing a low-cost adherence support mechanism.[xxv] With the lockdown, last-mile delivery of medication to the doorstep of the patients or any other accessible location nearby can provide uninterrupted service. This last-mile delivery model is implemented by a non-governmental organization called Operation ASHA,[xxvi] which has taken a financially pragmatic approach to treat TB patients in the world’s most remote locales.
Lastly, advocacy is critical to make sure TB treatments are uninterrupted with the right doctor administering the correct combination of drugs. As the information about the novel coronavirus is widespread, there should be baseline preparedness programs to spread awareness about TB. This can be done at school levels by assignments of informing the students about the dangers and cure for TB and at community levels in rural areas by local health providers. Although there is sufficient media presence, reporting fails to adequately cover the facilities provided by the public programs and does not make an effort to destigmatize the disease.
Conclusion:
As diagnosed TB carriers can infect others, and lead to the deaths of people who could have otherwise been treated, it is vital to take maximum measures to avoid another health crisis in India. Strengthening capacity by engaging more local health personnel, increasing the use of technology, regulating unsupervised private healthcare and balancing the distribution of resources among COVID-19 and TB should be given importance. As no stone is left unturned during the COVID-19 pandemic, being a preventable and curable disease, TB can be eliminated with community ownership and changing behavioral practices.
Footnotes
[1] Coronavirus Disease 2019
[2] The facts and evidence for coronavirus and COVID are still under research and continuously evolving
[3] should be less than 1 case of TB for a population of a million people
[4] Medecins sans Frontieres in Mumbai came up with the concept of buddies for individual counselling https://www.msfindia.in/mumbai-new-life-new-tuberculosis-drugs/
Endnotes
[i] https://www.who.int/features/qa/08/en/
[ii] World Health Organization. Global tuberculosis report 2019.
[iii] http://www.healthdata.org/india
[iv] https://www.eiu.com/graphics/marketing/pdf/its-time-to-end-drug-resistant-tuberculosis-full-report.pdf
[v] World Health Organization. Global tuberculosis report 2019.
[vi]https://www.paho.org/en/news/20-3-2020-tuberculosis-and-covid-19-what-health-workers-and-authorities-need-know
[vii]https://www.kff.org/coronavirus-policy-watch/is-contact-tracing-getting-enough-attention-in-u-s-coronavirus-response/
[viii] Kasaie, Parastu, Jason R. Andrews, W. David Kelton, and David W. Dowdy. "Timing of tuberculosis transmission and the impact of household contact tracing. An agent-based simulation model." American journal of respiratory and critical care medicine 189, no. 7 (2014): 845-852.
[ix] World Health Organization. (2018). Latent tuberculosis infection: updated and consolidated guidelines for programmatic management (No. WHO/CDS/TB/2018.4). World Health Organization.
[x] https://www.who.int/tb/COVID_19considerations_tuberculosis_services.pdf
[xi]https://www.who.int/news-room/detail/30-03-2020-who-releases-guidelines-to-help-countries-maintain-essential-health-services-during-the-covid-19-pandemic
[xii]https://www.dph.illinois.gov/topics-services/diseases-and-conditions/diseases-a-z-list/coronavirus/health-care-providers
[xiii] https://www.washingtonpost.com/world/hiv-tuberculosis-coronavirus-high-risk-africa-south asia/2020/04/08/78820db6-737d-11ea-ad9b-254ec99993bc_story.html
[xiv] http://www.stoptb.org/news/stories/2020/ns20_014.html
[xv] Arinaminpathy, Nimalan, Deepak Batra, Sunil Khaparde, Thongsuanmung Vualnam, Nilesh Maheshwari, Lokesh Sharma, Sreenivas A. Nair, and Puneet Dewan. "The number of privately treated tuberculosis cases in India: an estimation from drug sales data." The Lancet Infectious Diseases 16, no. 11 (2016): 1255-1260.
[xvi] Claiborne, Anne B., Rita S. Guenther, Rebecca A. English, and Steve Olson, eds. Facing the Reality of Drug-Resistant Tuberculosis in India: Challenges and Potential Solutions: Summary of a Joint Workshop by the Institute of Medicine, the Indian National Science Academy, and the Indian Council of Medical Research. National Academies Press, 2012.
[xvii] Arinaminpathy, Nimalan, Deepak Batra, Sunil Khaparde, Thongsuanmung Vualnam, Nilesh Maheshwari, Lokesh Sharma, Sreenivas A. Nair, and Puneet Dewan. "The number of privately treated tuberculosis cases in India: an estimation from drug sales data." The Lancet Infectious Diseases 16, no. 11 (2016): 1255-1260.
[xviii] Kwan, Ada, Benjamin Daniels, Vaibhav Saria, Srinath Satyanarayana, Ramnath Subbaraman, Andrew McDowell, Sofi Bergkvist et al. "Variations in the Quality of Tuberculosis Care in Urban India." (2018).
[xix] https://tbcindia.gov.in/WriteReadData/National%20Strategic%20Plan%202017-25.pdf
[xx] Yadav, Jeetendra, Denny John, and Geetha Menon. "Out of pocket expenditure on tuberculosis in India: Do households face hardship financing?." Indian Journal of Tuberculosis 66, no. 4 (2019): 448-460.
[xxi] https://indianexpress.com/article/india/tuberculosis-cases-drop-amid-lockdown-coronavirus-covid-19-6368736/
[xxii] https://tbcindia.gov.in/WriteReadData/26032020DONTEPAdvisory.pdf
[xxiii] https://tbcindia.gov.in/WriteReadData/26032020DONTEPAdvisory.pdf
[xxiv] World Health Organization. (2019). Global tuberculosis report 2019. World Health Organization.
[xxv] Krafft, Caroline, and Paul Glewwe. "Education Perspective Paper: Benefits and Costs of the Education Targets for the Post-2015 Development Agenda." Copenhagen Consensus Center Post-2015 Consensus Series (2014).
[xxvi] Singh, Sakshi, and Sandeep Kumar. "Tuberculosis in India: Road to elimination." International journal of preventive medicine 10 (2019).
PHOTO CREDIT: Free use image from Canva Pro.