World Tuberculosis Day 2022: India at the cusp of TB implosion, time to bring focus back on TB

The devastating pandemic since 2020 has reversed the gains achieved in the fight against Tuberculosis. The last two years, perhaps, were some of the worst years for millions of TB patients across the world, many of whom had lost access to the healthcare system as the entire global public health infrastructure was focused on fighting the deadly Covid-19 virus.

In India, the National TB Elimination Program (NTEP), which is the government’s public health initiative that organises anti-Tuberculosis efforts, faced a severe crisis when most of its resources were diverted to fight the Covid-19 pandemic. The TB mitigation efforts faced a colossal blow between 2020 and now, and therefore we need to have the TB conversation. More so today, as today is World Tuberculosis Day. The day is observed to raise public awareness about the devastating health effects of TB along with its social, psychological and economic implications.

The global public health infrastructure was so focused on Covid-19 that the fight for TB took a beating also in terms of the financial investments to fight the disease. That is why this World Tuberculosis Day’s theme is “Invest to End TB. Save Lives”. It is investment and investment alone that can help accelerate the end of the TB epidemic.

According to the World Health Organisation, TB continues to remain one of the world’s deadliest infectious killers. It is estimated that everyday, over 4100 people die of TB in the world and nearly 28,000 people fall ill because of it. As per the Global TB report 2021, the estimated incidence of all forms of TB in India for the year 2020 was 188 per 100,000 population. The total number of incident TB patients notified during 2021 was 19,33,381, which was 19 per cent higher than that of 2020 that stood at 16,28,161. In 2020 alone, India accounted for 26% of the incident TB cases globally.

In the last one year as the pandemic was tiding down, the Thane municipal corporation noticed an increase in TB diagnosis among those in the age group of 15-36 years. Most of these were drug-resistant TB cases. Like Thane, in many other parts of the country, during the last two years there has been an increase in TB diagnosis among the younger age groups. If reports are to be believed, the numbers and statistics in most studies related to TB during the pandemic could just be the tip of the iceberg as many cases have gone unreported and undetected because of Covid-19.

The numbers related to mortality due to TB is also very alarming. According to reports, the estimated mortality rate among all forms of TB was 37 per 100,000 people in 2020. As per the Global TB report 2021, there has been a slight increase in the mortality rate due to all forms of TB between 2019 and 2020 by 11% in India. Reports suggest that the estimated deaths from all forms of TB, excluding HIV, for 2020 was 4.93 lakhs In India, which was 13% higher than the 2019 figures.

Covid and TB have similar initial presentations, hence, patients ignore the symptoms for prolonged periods. If a patient requires steroids during Covid therapy, there is a possibility of reactivation of latent TB into active TB. The inter-connecting relation between some Covid cases to TB is such that during the pandemic, the government revised Covid guidelines and included people suffering from TB into the high-risk category of patients developing severe Covid-19 infection. This serves as a reminder about how devastating TB could be, even more, when combined with covid and without doubt fighting Tuberculosis is one of the biggest public health challenges in the world today.

But early detection and timely intervention could be the magic solution to bringing down the numbers of incidence rates of TB and limiting the progression and transmission of the disease to a great degree. As we have already seen in the case of Covid-19, timely development of the vaccination helped the spread and the containment of the virus to a large extent. Similar work has been done in the case of TB too, but with limited success.

As far as TB is concerned, a single shot of BCG vaccine is expected to provide lifetime immunity against the disease, but the vaccine still has limited efficacy in preventing pulmonary Tuberculosis in adults and adolescents. Both these categories of people are known to be the super-spreaders of the disease. Currently, there are very few vaccine candidates in discussion related to TB. But their efficacies are yet to be proven. One of the vaccines being tested to prevent Tuberculosis of the lungs is Immuvac, which was developed to prevent leprosy. Immuvac, also known as Mycobacterium Indicus Pranii displays antigens similar to both the leprosy and the TB bacterium.

The other vaccine candidate is VPM1002, a recombinant BCG that is the most widely used vaccine globally. This new vaccine developed by Germany has the genetic code of the BCG but is edited in a way that leads to better availability of the TB antigens, thus training the immune system to effectively fight Tuberculosis. In short, when it comes to vaccines, we don’t have effective vaccines yet. The vaccines currently being developed are also for specific categories of people, such as those at high risk for TB.

Even though research into TB vaccines is a step in the right direction, for now, the mainstay of the elimination programme is early detection of new cases, testing for drug resistance and aggressive treatment of the disease. We need to also focus on the point of care testing of TB. Tests such as CBNAAT and TrueNat are more sensitive than microscopy, and they can also detect whether the TB is drug-resistant. In fact, we have to make these tests the first line of diagnosis across the country.

I treated a patient who was 29-years-old and was diagnosed with continuous cough and fever for about 20 days. His younger brother was diagnosed with TB and received treatment from a government centre. Before coming to me, the patient had visited multiple doctors who had prescribed him different regimens of antibiotics. When his case was presented to me, he had already had his chest x-ray ready, which was suggestive of TB, but his sputum test was negative. We carefully worked on him over the next five days, and he was diagnosed with drug-resistant Tuberculosis. Drug-resistant TB is a condition when the bacteria becomes resistant to the drugs used by the patient to fight TB, which means that the drug can no longer kill the TB bacteria.

Four years later, he is fully cured and is able to have a normal family life. This case study shows why active search for latent cases and active screening of family members is important. This also emphasises the deployment of molecular testing, which is also now available at all district-level hospitals.

It is very important to know about the precautionary measures that can prevent the spread of TB to a large extent. The first step is to ensure that children less than five years of age in your household are vaccinated with the BCG vaccine. The BCG vaccine can effectively prevent TB by 80% for 15 years, but its efficacy in people over the age of 35 is a matter of concern.

Early diagnosis and timely intervention is by far the most effective way to prevent the spread of Tuberculosis. It is proven that a person with infectious Tuberculosis can infect up to 10 to 15 other people per year. But if the same patient is put on a TB treatment procedure, within two weeks, he can reach a stage where he will no longer be able to cause infections.

TB awareness, TB outreach, TB testing, TB contact tracing can all help fight the disease. But in the absence of investments, the global fight against TB will not see fruition. The World Health Organisation has called for urgent investments to fight TB and save millions of lives globally. India, too is at the cusp of a TB implosion. It’s time we bring the much-needed focus back on TB and save lives.

Dr Kirti Sabnis is an Infectious Disease consultant doctor with Fortis Hospital, Mumbai. With several years of experience in the areas of Tuberculosis, treatment of Infectious Diseases, HIV treatment, Venereal Diseases, Dr Kirti Sabnis has also been at the forefront of the battle against Covid-19.