Poor infection control, slow recovery: Dual TB-Covid-19 load hits states

It has been two months since Kenchamma, 48, started on tuberculosis (TB) medication under the government programme in Tumkur, Karnataka but recovery has been slow. "She is still not well--feels nauseous, exhausted and weak," said her son, Ashok Kumar.

Kenchamma had both TB and Covid-19, a debilitating combination that makes recovery from either disease hard, doctors said.

Preliminary studies in India show a 0.37% to 4% prevalence of TB among Covid-19 patients while 1.14% of the TB patients screened for Covid-19 were diagnosed with the disease, until October 2020, per an emailed response from India's central TB division. In all, India has had over 10.3 million Covid-19 cases until January 14, 2021 and over 2.4 million TB cases in 2019.

"Tuberculosis is associated with a 2.1-fold increased risk of severe Covid-19 disease," noted India's TB elimination programme, while releasing a guideline on testing TB patients for Covid-19 in September 2020. The guidelines suggested TB screening for all patients of Covid-19, influenza-like illnesses (ILI) and Severe Acute Respiratory Infection (SARI). It also suggested a TB test for any Covid-19 patient who shows symptoms, had contact with a TB patient or had TB previously.

Kenchamma's dual diagnosis and her treatment were swift but in some states, 'bi-directional' screening and testing for TB and Covid-19 began at different points in the pandemic and in some states, it has yet to be fully implemented, our reporting showed. The challenges include staff shortages--exacerbated by diversion of TB staff towards Covid-19 response--and special safety requirements for collecting and testing samples from Covid-19 patients, we learned from the TB programme staff, patient groups and experts we interviewed.

Why co-infection diagnosis is important

Under the guidelines of the Ministry of Health and Family Welfare, all new and existing TB patients are to be tested for Covid-19 and their treatment decided on the basis of test results. All Covid-19 patients too should be screened for symptoms of TB. Those who have a cough and/or fever for over two weeks, significant weight loss and night sweats or a history of contact with a TB patient or a history of TB, should be offered a test--chest X-Ray or sputum test.

TB and Covid-19 co-infections need timely diagnosis as both diseases have similar symptoms, impact the same body parts and burden the respiratory system, experts said. Covid-19 can be lethal for TB patients whose lung capacity is already compromised.

Active as well as latent TB is a risk factor for contracting Covid-19, said officials at India's central TB division. TB patients also tend to have co-morbid conditions, such as malnutrition, diabetes, smoking and HIV that increase their vulnerability to Covid-19, the Central TB Division said.

"Just because one of the two diseases has been diagnosed doesn't mean that you could ignore the other if the symptoms are indicative. It could have an adverse reaction," said Santosh Gupta, Uttar Pradesh's state TB officer.

In Mumbai, anyone who comes to a public hospital is tested for Covid-19 through an antigen test, said Blessina Kumar of Touched by TB, an NGO for people affected by TB. But Kumar cautioned against making Covid-19 tests mandatory for everyone coming for a TB test. "TB staff have already been diverted for Covid-19", and this could further burden the system, she explained.

Kenchamma was admitted to the general hospital in Tumkur when her body temperature spiked to 105 degrees Fahrenheit, her son said. She also had a cough. She was tested twice to confirm Covid-19 and her sputum sample was taken the same day for a TB test along with blood, urine and stool samples. "We don't know how she caught either disease," said Kumar.

It took nine days for Kenchamma to test negative for Covid-19 but she will continue to be treated for TB till April--a six-month course of two TB medicines. The dual infection will impact her more--cause weight loss and weakness, for example--than a single disease, said Sanath Kumar, Tumkur's district TB officer.

Between April and November 1, 2020, Karnataka had screened 29,352 TB patients and tested 11,313 (38.5%) of those for Covid-19 based on their symptoms. Of these, 348 patients (3%) were found positive for Covid-19 and provided treatment, as per the data provided by the Karnataka TB programme.

States follow different protocols

Kerala has been implementing bi-directional testing for Covid-19 and TB since May and continues to do so, its TB officer Sunil Kumar told IndiaSpend: It tests Covid-19 patients for TB if they have vulnerabilities such as diabetes, or other long-term symptoms such as a persistent cough. And they test a TB patient for Covid-19 in case of symptoms of the latter. Kumar did not provide data on patients with TB/Covid-19 co-infection.

Uttar Pradesh is also implementing the guidelines, said state TB officer Gupta, but did not provide any data. "It is challenging to do all these [sample] collections with the necessary precautions for Covid-19 but we have instructed all districts to do it," he said.

Until August, the Karnataka state programme was screening cases of Covid-19, ILI and SARI for TB, as per the guidelines. But as Covid-19 cases grew, this became unfeasible, said Rameshchandra Reddy, the Karnataka state TB officer, in December 2020. The state is still trying to screen all TB patients for Covid-19, which is easier as all TB patients come under the government programme. In the case of Covid-19, the TB programme has to coordinate with other departments which is a challenge, experts said.

Mizoram started implementing the guidelines in December 2020, the state's TB-HIV coordinator, J. Rinkimi, told IndiaSpend. All districts in the state have been notified that Covid-19 patients should be screened for TB seven days after they test negative, and if they have symptoms, be tested for it. The state does not test ILI and SARI patients, but are now planning for it, Rinkimi added.

How pandemic affected TB reporting

For years, India has been unable to accurately count its TB patients--missing many of those who are treated in the private sector or misdiagnosing them. But now fewer TB cases are being missed by the government. But the pandemic and the ensuing lockdown pushed TB notifications down to 1.7 million in 2020--only 59% of the nearly 3-million target India had set at the start of the year and 74% of the cases reported in 2019. This puts more undiagnosed patients at risk and increases the chance of the infection spreading.

In Mizoram, the lockdown made it hard for the TB programme staff to reach interior areas and few people came to clinics, said Rinkimi. "The number [of TB notifications] as compared to previous years is not good."

"Roughly, about 70% of the National TB Elimination Programme's molecular diagnostic capabilities and 80% of HR was temporarily diverted for Covid-19 response across the country," the central TB division said in its emailed response.

"We all know that the last 10 months have seen treatment interruptions, hindered availability of drugs, shrinking supply of diagnostic tests, delays in diagnosis, interrupted supply chains, diversion of manufacturing capacity and imposition of physical barriers for patients who must travel to distant clinics to pick up the medications," Union health minister Harsh Vardhan said of the pandemic's effect on TB at an event in November 2020.

Even before Covid-19, the TB mission had been short-staffed across departments.

The central TB division is asking states to fill vacancies and with the onset of Covid-19, states have understood the importance of timely recruitment of staff, a consultant with the central TB division said.

Problems on the ground

The TB programme does not have the kind of infection control methods and special training needed to collect samples and test for Covid-19, said Kumar of Touched by TB. "The plan is okay but there are a lot of problems on the ground," she said of the government's guidelines on bi-directional testing.

An advisor to Karnataka's TB programme agreed--the TB programme staff are not trained to collect sputum samples from Covid-19 patients or those who might be suspected to have Covid-19, because it would require special infection control methods like PPE etc. and the sample would have to be tested in a lab that is prepared to handle these samples, the advisor said. "It is a challenge for health workers and health technicians."

"See, we need safety cabinets for Covid-19 testing but in many districts these are not available so it is very dangerous for our staff," said Rinkimi of Mizoram. To make this easier, general hospitals should inform the district TB centre of any such [Covid-19] cases and help in sputum collection, she said.

Improving TB case notifications

To mitigate the impact of Covid-19 on TB, the government recommended bi-directional TB-Covid-19 screening, screening among ILI and SARI cases, intensifying of private sector engagement, and redeployment of the repurposed TB programme staff and machines that had been diverted to Covid-19 diagnosis, health minister Vardhan had said at the November press conference.

Since September 2020, with the pandemic having plateaued, diagnostics and staff are gradually being redeployed for the TB programme, the central TB division told IndiaSpend. In Karnataka, where all TB staff were engaged in Covid-19 response at one stage, 50% were back on TB-related duty by early December 2020, state TB officer Reddy said.

Although the central TB division said that bi-directional screening had resulted in significant TB case detection and should continue, Rinkimi of Mizoram sounded doubtful: "I don't know if this will help increase the TB notifications much. Perhaps in some cases. But not much… We had one case of co-infection in June/July but there are very few such cases."

States are trying other ways of finding missing TB cases too. Karnataka focused on an active case-finding programme in December 2020 to screen vulnerable populations, especially in old age homes and prisons, for TB, Reddy said. Karnataka's state TB programme usually conducts active case-finding sessions twice a year, but Covid-19 ruled that out until December 2020. "This time the target is to screen 1 crore population," he said.

Among the payoffs from the country's Covid-19 response, the central TB division counts the infection control measures put in place, especially in hospitals, as well as the ramped up molecular diagnostic capacities that would decentralise TB diagnosis and distribute it across the country. "Behavioural changes acquired during the pandemic such as cough hygiene, use of masks, [and] social distancing, when sustained, will further contribute to reducing transmission of respiratory illness along with TB," the central TB division said in its email respose.