In India, simultaneously fighting tuberculosis and COVID-19 could save millions of lives
COVID-19 and tuberculosis are both respiratory illnesses that can be addressed with similar strategies and resources.
With COVID-19, our lives are no longer the same. The pandemic has overshadowed other health issues and reversed the progress made over decades in our fight against other diseases, including tuberculosis (TB). In India, despite sustained and aggressive nation-wide interventions, this deadly disease continues to haunt the population with one of the world’s highest TB infection rates.
Under the National TB Elimination Program, the country has successfully treated over 20 million patients since 1997. Efforts have been afoot to further reduce the TB burden, but the COVID-19 pandemic has created serious obstacles.
However, rather than being an obstacle, the pandemic should be seen as an opportunity to simultaneously combat COVID-19 and TB, in order to avert millions of deaths.
The respiratory route is the primary mode of transmission for both infections. Interrupting it will stop the spread of both. In addition, global strategies to control COVID-19 and TB have common key elements: early detection, diagnosis, contact tracing, and case management. Both ailments also require a whole-of-society approach and active community engagement for implementing simple, doable, evidence-based and affordable non-pharmaceutical interventions.
The National TB Elimination Program is a good place to start this process in India. It has demonstrated the strong involvement of civil society and community leadership in prevention and management of TB. This can be used to curb the spread of COVID-19 through community outreach that seeks to reduce close contact and promote use of non-pharmaceutical interventions (e.g. respiratory hygiene) in communities, public transport and overcrowded houses.
The program has also been instrumental in finding active TB cases. This can be expanded to include COVID-19 by strengthening the surveillance for influenza-like illness. The unification of surveillance activity for communicable diseases with similar modes of transmission is prudent, efficient, productive, and cost-effective.
This success can also be attributed to the involvement/engagement of the private sector, including use of the TB notification and patient management system 'NIKSHAY.' This IT-based platform can be strengthened to integrating notifications and responses to COVID-19. The strategies for COVID-19 can be synchronized with TB’s four strategic pillars of "Detect – Treat – Prevent – Build."
India has scaled up diagnostic facilities by making highly effective tests available throughout the country. This has helped to make sure more people are diagnosed, receive proper medical treatment and thus reduce transmission of infection.
One of these tests, the cartridge-based nucleic acid amplification test, is rapid, highly sensitive, specific, and also detects resistance against recommended antituberculosis drugs. This system has also been extensively used during the COVID-19 pandemic, demonstrating the possibility of cross-use and integration of this system for diagnosis of other infectious diseases. With minor modifications it has the potential to become an affordable and reliable diagnostic aid across the spectrum of infectious diseases.
The pandemic should be seen as an opportunity to simultaneously combat COVID-19 and TB, in order to avert millions of deaths.
The other, TrueNat®, is a chip-based, portable reverse transcription polymerase chain reaction (RT-PCR) machine that is the fastest available test for COVID-19. It also has the potential to become an important diagnostic tool for multiple infectious diseases.
These tests can be made more effective by strengthening diagnostic outreach in the community with well-defined referral mechanisms.
Using the same facilities for testing TB and COVID-19, with possible expansion and strengthening, can help in successful reductions of both diseases. India has, in a remarkably short period of 6 months, scaled testing capacity for COVID-19 from the initial 15 testing laboratories to more than 1750 labs across the country. TB detection services can benefit immensely from this feasible, affordable and quality service network-based delivery model.
Prime Minister Narendra Modi has launched the Tuberculosis Free India Campaign (TB Mukt Bharat), presenting his vision to eliminate TB from India by 2025. Similar leadership has been shown in managing the pandemic. India even allocated about $10 million to the COVID-19 Emergency Fund for fighting the pandemic in the neighboring countries in South Asia. The pandemic response can benefit from adopting best practices in India’s TB program, including telemedicine, doorstep delivery of drugs, insurance coverage, improved logistics, private sector partnerships and other benefits to community and frontline health workers.
The COVID-19 response has put the focus on public health interventions like social distancing, use of masks, cough etiquette, and hand hygiene. Continuing these steps will help in preventing new infections of TB as well. In the long term, strengthening efforts on providing properly ventilated houses to the poor contributes to the prevention of all respiratory infections. Initiatives such as the 30-second coronavirus mobile phone ring tone produced in India can be also be used to promote control of TB and other infectious diseases.
Managing the COVID-19 outbreak can help end tuberculosis in India in other ways as well. A major challenge in TB elimination continues to be “missing cases”. Sustained awareness amongst communities on various facets of TB – including the lethal consequences of late diagnosis and incomplete treatment of TB, will encourage people to seek health services more quickly. A strong network of diagnostic laboratories – on the pattern of COVID-19 labs, is needed to confirm the diagnosis and provide appropriate treatment.
Lessons learnt from pandemic should also include integrated training on related ailments. The disease dynamics and management of TB and COVID--19 can be communicated simultaneously to medical professionals and the public to ensure uniformity and better compliance. Other diseases can also be easily integrated into these training modules or platforms for broader upgrading of skills and efficient use of training resources.
Across the world, enormous technical and financial resources are being invested into fighting the COVID-19 pandemic. Most of these are fortifying existing public health services and skills in managing cases and implementing effective measures for infection prevention and control. It will be prudent to sustain these achievements and use them to provide a swift response to future epidemics or pandemics as well as improved health services, especially those pertaining to respiratory infections.