Tuberculosis and COVID-19 in India- double trouble!

Tuberculosis (TB) still continues to be endemic in various regions of the world and is one of the leading causes of mortality in India. The global health crisis due to novel coronavirus SARS-CoV-2 outbreak has presented the world with a war which we need to fight on multiple fronts. TB disease management requires multi-prong interventions of surveillance, clinical assessment, testing, contact tracing, confirmation of diagnosis with supervised or in- supervised treatment regimens for effective eradication. India accounts for more than one- fourth of the world's Tuberculosis (TB) cases. This amounts to about 2.6 million cases out of 10 million cases worldwide. One third of the global drug-resistant TB cases are in India, according to the World Health Organisation (WHO). Hence as we confront challenges due to COVID-19, national programmes to combat TB need to be actively engaged ensuring an effective, rapid response to COVID-19 whilst maintaining TB services. The following challenges and strategies need to be addressed to confront these dual diseases together.

Drop in diagnosis of new TB cases and access to facilities

‘Lockdown’, self-isolation, quarantine, containment strategies introduced by Government of India to prevent the spread of novel coronavirus -SARS-CoV-2 has led to a 78% drop in the diagnosis of new TB cases in April 2020 compared to the same month in 2019 according to Central Tuberculosis Division Nikshay portal. Closure of out-patient departments (OPD) at various hospitals, refusal of treatment by numerous hospitals, difficulty in reaching Direct Observed Therapy programme (DOTS) centres has heightened the complexity of management of TB during the COVID-19 pandemic. Multi-month dispensing to ensure uninterrupted treatment for TB patients supported by the Government of India, National Tuberculosis Elimination Program (NTEP) will go a long way reducing hardships with acceleration of community TB programs.

Role of Telemedicine

The need to avoid face to face consultations during the COVID -19 pandemic to reduce the risk of viral transmission has been acknowledged. However, expansion of telemedicine facilities such as e-Sanjeevani, a Government of India, integrated telemedicine initiative can fill the vacuum left due to lack of OPD facilities and will limit the need of hospital visits. Smartphone technology applications can be expanded to play a key role in assessment, monitoring, contact tracing and remote management of TB patients as it is being undertaken for COVID-19 disease in the current pandemic.

TB and COVID-19 testing

Though the mode of transmission differs slightly, both TB and COVID-19 spread by close contact between people. COVID-19 and TB have similar clinical features and presentations. Concurrent infection of SARS-CoV-2 and mycobacterium tuberculosis (TB) can occur during the current COVID-19 pandemic and as such damage caused by pre-existing TB infection can predispose the patient to develop COVID -19 as well. Simultaneous testing for both TB and COVID-19 should be performed on atypical presentation of symptoms in patients and high index of suspicion will facilitate concurrent management.

Conclusion

COVID-19 and Tuberculosis has spelled double trouble for India. There is a concern that as efforts are diverted to fight the emergent COVID-19 health crisis, there is delay in the treatment of TB patients and that there may be a surge in number of TB patients once the lockdown restrictions are lifted. Response to COVID-19 pandemic should be run simultaneously and not affect the continuity of essential TB national programs.

Conflicts of interest

The authors have none to declare.