Covid-19 has disrupted life across India as we know it. Response to this pandemic has impacted other health services of which tuberculosis is the most significant. With similar clinical symptoms, TB and Covid-19 present a deadly mix for India’s health system. TB, though curable, remains India’s severest health crisis killing over 1,200 Indians daily with delays in diagnosis, treatment, access and possibly increased suffering, mental health issues for those affected.
The TB programme and its services have been badly hit in the Covid-19 pandemic. Our recent analysis of on-ground cases and reports reveal that both diagnosis and treatment are significantly affected.
Nonavailability of drugs
TB affected individuals, especially those suffering from pulmonary TB, are frightened of Covid-19 and are not visiting labs and hospitals for diagnosis. Those advised the crucial drug susceptibility testing are either not getting it done or the test is not happening easily. This is evident in the TB notifications for new cases have been falling consistently. Though India ordered bidirectional screening for TB and Covid, its implementation is not likely to be easy.
Patients affected by drug-sensitive and drug-resistant TB patients are also unable to access medicines putting the treatment in jeopardy and likely increasing in transmission. The lack of transportation has restricted the ability to access health centres. There have been reports of nonavailability of drugs in both the public and private sectors. Also, access to new drugs such as Bedaquiline and Delamanid is bound to reduce during this time leading to increased challenges for the treatment of multi-drug-resistant TB.
Also, without supportive supervision and other forms of monitoring and support in treatment patients motivation to continue toxic treatment. The worst affected are drug-resistant TB patients who are on regimens containing injections that have to be administered by health workers who are either unavailable or not easy to reach with limited transport facilities. The lack of access to health services has also brought up the issue of management of adverse drug reactions and comorbidities.
As a result of Covid-19, these challenges are bound to increase and impact patients’ ability to continue treatment. For instance, patients affected by mental health issues are three times more likely to stop or give up on treatment due to side effects. They are also less likely to delay seeking treatment. However, we have no procedure to diagnose or treat them in the care cascade right now.
Need to prioritise testing
India’s TB epidemic is not a biological challenge, it is a broader manifestation of numerous other factors. In this pandemic, charting a new course needs an understanding of these numerous factors and complexities by decision-makers in the context of both diseases. Where do we start?
India needs to prioritise testing. Fever and cough are symptoms of both TB and Covid-19, this commonality can be leveraged to encourage simultaneous screening and resume TB screening and diagnostic services in both public and private health sectors. Using the Xpert MTB/RIF TB test since this test is critical for early detection of drug-resistant TB in many settings. Active case finding within communities and in high-density geographies must be initiated for both TB and Covid-19, to actively find, isolate and treat cases.
India needs to address treatment challenge’s for ongoing and new patients both in the public and private sectors. TB patients should be provided with at least two to three months of supply of medications as a start. The TB programme must carefully track and forecast drug supplies, to avoid stock-outs. It is critical for TB programmes to switch to all oral regimens recommended by World Health Organization. Access to new and novel regimens must be increased in both the public but also the private sector through the creation of centres in the private sector across the country.
An important aspect would be to integrate social and mental health support aspects as an essential part of treatment. Implement a stigma mitigation strategy in communities and for affected individuals and families. An essential requirement is to build skills among the health force, to reduce stigma and provide better quality care – including mental health screening and support. Another important aspect is to institute mechanisms for peer support – in the form of virtual networks etc where patients can be connected to survivors.
Using telemedicine and adherence technologies and call centres to support TB patients may allow for frequent consultations but limited in-person visits to health centres. These should be multilingual, broad-based and easily accessible for all through multiple user-friendly platforms.
A collective response
Community-based care is a critical, felt-need in TB. Where facility-based TB services are not recommended or feasible, community capacity must be built to deliver community-based TB services that require profiling, training for assigned tasks and proper supervision.
India has one of the world’s largest and most diverse private sectors. According to the National Family Health Survey, over 60% of all Indian’s seek care in the private sector at some point or another. In the case of TB, this number remains reasonably high. The government needs to employ new and innovative strategies to engage and work with the private sector. Mobilising both public and private health sectors, including community-based groups in the collective Covid-19 and TB response.
The Covid-19 crisis is a wakeup call to the entire health system and how it disregards the needs of those fighting diseases like TB. If India ignores even one patient, not only do we risk their lives, we risk the spread of TB and Covid-19.
Chapal Mehra is a public health specialist who works extensively in the areas of infectious diseases like tuberculosis and HIV.