Covid-19 pandemic has gripped the entire globe as the world populace has been held captive to the causative organism Coronavirus (SARS-CoV-2) since more than a year [1]. Since March 2020, India has undergone spectrums of complete and partial lockdowns in its different states [2]. Health systems have been consumed with Covid-19 disease management and it is distressing to watch the system fall apart [3]. Health resources and manpower have been diverted towards Covid-19 inpatients as the much-required frontline warriors. Community health resources have been immersed in Covid-19 related health education, behaviour change communication, prevention, early identification, tracing, testing, quarantine, home management, hospital transfers, data management, vaccinations, etc. National and sub national leaders including the top health officials and health agencies have been at the forefront fighting the virus war. Although this all-encompassing emphasis on a pandemic is indispensable, it has caused a disregard to the other prevalent critical health concerns of the communities. One such disease being overlooked due to the Covid-19 pandemic is Tuberculosis. The long-term silent pandemic of Tuberculosis has been quietly killing more than one person per minute in India for decades. This translates into more than thousand deaths per day due to Tuberculosis. Statistics make it the top ranked infectious disease killer in India before the emergence of Covid-19 [4,5]. 

During the last one year, many battles against the novel Corona virus have been won, however, the war is far from being over. The newer and multiple variants keep surfacing with higher infectivity and severity. This nature of the disease has not only made Covid-19 elimination a tough ask but also has a negative effect on Tuberculosis program, especially the notifications [4,6]. 

Status and Implications 

India has been the highest Tuberculosis burden country across the world. Total active cases are estimated to be about one crore [7]. Annually 27 lakh new TB cases occur in India with an incidence rate of 193 / per lakh of population. Annual newly diagnosed Tuberculosis cases contribute to more than a fourth (27%) of the global new TB estimates. TB case fatality ratio in India is 17% compared to the global ratio of 14%. Annually 4.6 lakhs deaths happen in India due to TB. The TB deaths in India contribute to about one third (29%) of global TB deaths. India not only ranks first in TB burden but is also number one in Multi drug resistant (MDR) – TB contributing 27% to the world burden. India is also one of the top ranked countries for dual HIV-TB infection burden. India has the highest numbers of healthcare workers getting infected with TB annually. A total of 22,314 healthcare workers were diagnosed with TB in 2019. India contributes about half (47%) of global healthcare workers infected with TB during a year [8]. 

WHO End TB strategy has laid down specific goals with timelines to be achieved in future. Three of these parameters are TB incidence rates, TB deaths and proportion of households facing catastrophic costs due to Tuberculosis. Each of this variable has a well-defined target for years 2020, 2025 and 2030. The goal was to reduce TB incidence to 25% by year 2020 and to 50% by 2025. Milestone for TB deaths reduction was 35% by year 2020 and 75% by 2025. As per target, no household affected by Tuberculosis must face catastrophic costs by year 2020. However, by 2019, globally, none of these targets had crossed midway mark of 2020 End TB goals [8].

In 2019, when Covid-19 pandemic hit the world, global accomplishments of TB targets had observed a 9% reduction in TB incidence rate (Compared to 25% target for 2020), 14% reduction in TB deaths (Compared to 35% target for 2020) and 49% reduction in households affected by TB facing catastrophic costs (Compared to target of 100% reduction by 2020). Targets’ achievement for India also lagged behind the goals as set through WHO End TB strategy. By 2019, India had achieved 11% reduction in TB incidence rates and 7.2% reduction in TB deaths as compared to year 2015. In India, 17% of Tuberculosis patients faced catastrophic financial burden due to Tuberculosis [8]. 

There has been a strong political will and intensified efforts to achieve Tuberculosis End TB targets to eliminate TB in India by 2025. Hence, the TB indicators have shown substantial improvement in previous years. Country not only accomplished reductions in TB incidence and TB deaths, but also boasted of improved notifications of Tuberculosis cases over prior few years. There was jump of 12% in the TB cases notification numbers from 2018 to 2019 [8-10]. 

It was at this epidemiological phase of TB, the exceptionally challenging Covid-19 pandemic affected the country and the globe. The pandemic further hushed the silent pandemic of Tuberculosis. Considerably deserved priority given to Tuberculosis control got pushed to the background. Many resources and facilities; both private and public, got earmarked for “Covid-19 only” patients. Non-Covid-19 facilities turned hesitant to treat patients due to fear and uncertainties surrounding Covid-19 infection. Reallocation of monetary, human and other resources was aimed to diminish and curb the Covid-19 waves. Diagnostic, preventive and curative services across the country got over-burdened and over whelmed with treating Covid-19 patients [11]. 

TB case reportings witnessed a sudden decline in end of March 2020. There was 60% reduction in TB notifications immediately after the first lockdown with restrictions of movements affecting people’s health seeking behaviour [8]. The notifications remained low throughout 2020 and only 18.05 lakhs cases were notified as compared to an expected estimate of 29.9 lakhs notifications for the year 2020. Hence, approximately, 12 lakh TB cases have been missed in 2020 due to the Covid-19 pandemic [12]. This drop in notifications was seen in both public and private sector. Disruption in the TB notification and TB services has not been limited to India alone. Worldwide, the Tuberculosis program has been affected [8,13,14]. 

In India, it is estimated that additional five lakh TB cases over next five years will be piled onto the pre-existing high burden of Tuberculosis in the country [13]. The stressed health systems and resources diverted to manage Covid-19 positive patients have caused decreased new TB case registrations and lack of treatment adherence in already diagnosed TB patients. There is a high likelihood that this non-compliance to stringent TB drug regime is going to lead to increased MDR TB over coming years [15]. Surge in MDR TB will escalate the TB mortality rates and add to the financial burdens on families. Health expenditure of a TB patient is increased by approximately Rs 3300 per month despite free medications under the Government sponsored Nation al TB elimination program (NTEP). This expense is largely due to travel and nutrition. The average cost for MDR TB treatment in India is mammoth amount of Rs 4.8 lakhs. This includes hospitalizations, procedures, interventions and expensive antibiotics [16]. Thus, an increased burden of MDR TB cases will affect an individual as well as burden the country’s health system [8]. 

Having similar symptoms (Cough, fever) as Covid-19, TB diagnosis is likely to be delayed or completely missed. This increases the risk of communicability of Tuberculosis in the community [17]. One infective Tuberculosis patient is able to spread the infection to 10-15 people. Modelling studies have forecasted that high-burden countries such as India will observe 20% increased deaths due to Tuberculosis over 5 years compared with if there was no Covid-19 pandemic [18]. Disruption of routine immunization services for children due to the pandemic are likely to further accentuate TB burden and mortality [19].

Way Forward

In India, under NTEP (National TB Elimination program), Rapid response plan was initiated in September 2020 to mitigate the Covid-19 impact on Tuberculosis detection and treatment [20]. Central TB Division of the country issued another advisory on 6^th April, 2021 to mitigate the impact of rising Covid-19 cases on the TB program so as to meet the WHO End TB targets for 2025. 

The plan and advisory include: [21]

• Ensuring continuity in TB services, 

• Bi-directional TB-Covid-19 screening, 

• Uninterrupted laboratory services for both Covid-19 and Tuberculosis, 

• Rapid molecular testing instead of the traditional sputum smear examinations, 

• Emphasised new case finding through home sample collection, 

• Home delivery of TB medicines 

• Modified DOTS strategy utilizing digital technologies to ensure treatment adherence. 

The multipronged new approaches as per the rapid response plan and the Govt. of India advisory must be re-emphasised to ensure that they are not side-lined due to the explosive second wave and expected future waves of Covid-19. It is recommended to track the missing millions of 2020 due to Covid-19 pandemic and initiate appropriate treatment at the earliest. Treatment adherence through digital reminders and home delivery of medications must be mandated to prevent MDR TB exploding in the country in the approaching years. Government has established a massive communication and media campaign for bringing awareness about Covid-19 and its vaccination. It will be helpful to utilize the aforesaid resources to bring awareness about prevention of TB, importance of early diagnosis & treatment and medication compliance. TB data management could be merged with daily data review of Covid-19 with tantamount importance [22]. Mobile apps have been developed for TB and Covid-19. Launching and popularising a dual disease mobile app for TB and Covid-19 could be effective. This would be an opportunity to prevent TB and Covid -19 together due to similar mode of spread. 

India must utilize this opportunity to build a robust health system enabled to address and withstand unexpected demands without compromising regular healthcare services ²². The reduced TB budgets during the year 2020-21 may need to be reconsidered in future so as to continue the progress made in TB control over the previous five years [23]. 

The expected surge in TB cases in near future must be dealt with intensified measures to achieve “End TB” goals. 

1. United Nations News. “COVID’s Grip Keeps World in ‘Perilous Situation’.” United Nations, May 2021, https://news.un.org/en/story/2021/05/1091632.

2. Zee News. “Lockdown Anniversary: How COVID-19 Brought Lives to a Standstill in India.” Zee News, May 2021, https://zeenews.india.com/india/lockdown-anniversary-how-covid-19-brought-lives-to-a-standstill-in-india-2349998.html.

3. Outlook. “Heartbreaking to See COVID-19 Crisis Utterly Overwhelm India’s Health Systems: US Lawmakers.” Outlook, May 2021, https://www.outlookindia.com/newsscroll/heartbreaking-to-see-Covid-19-crisis-utterly-overwhelm-indias-health-systems-us-lawmakers/2074574.

4. Khetrapal, S., and R. Bhatia. “Impact of COVID-19 Pandemic on Health System and Sustainable Development Goal 3.” Indian Journal of Medical Research, vol. 151, no. 5, 2020, pp. 395–399. https://doi.org/10.4103/ijmr.IJMR_1920_20.

5. Mint. “Primary Healthcare to Take a Back Seat in COVID-19 Battle.” LiveMint, May 2021, https://www.livemint.com/news/india/primary-healthcare-to-take-a-back-seat-in-covid-battle-11586981129624.html.

6. Financial Express. “India Not a Country to Lose Courage, We Will Fight and Win: PM Modi on War against Coronavirus.” Financial Express, May 2021, https://www.financialexpress.com/india-news/india-not-a-country-to-lose-courage-we-will-fight-and-win-pm-modi-on-war-against-coronavirus/2251920/.

7. Indian Express. “Lessons from COVID-19 Pandemic Must Be Deployed to Control Tuberculosis.” The Indian Express, May 2021, https://indianexpress.com/article/opinion/columns/coronavirus-covid-19-cases-tuberulosis-cases-in-india-7194807/.

8. World Health Organization. Global Tuberculosis Report 2020. WHO, 2020, https://www.who.int/teams/global-tuberculosis-programme/tb-reports/global-tuberculosis-report-2020.

9. Ministry of Health and Family Welfare. National Tuberculosis Elimination Programme (NTEP): Annual TB Report 2020. Government of India, 2020, www.tbcindia.gov.in.

10. Pai, M. et al. “India’s Plan to Eliminate Tuberculosis by 2025: Converting Rhetoric into Reality.” BMJ Global Health, vol. 2, 2017, e000326. https://doi.org/10.1136/bmjgh-2017-000326.

11. The Tribune India. “Non-COVID-19 Patients Can’t Be Left in the Lurch.” The Tribune, May 2021, https://www.tribuneindia.com/news/comment/non-covid-patients-cant-be-left-in-the-lurch-83557.

12. Ministry of Health and Family Welfare. National Tuberculosis Elimination Programme (NTEP): Annual TB Report 2021. Government of India, 2021, www.tbcindia.gov.in.

13. The Print. “Govt Says There Could Be 5 Lakh More TB Cases, 1.5 Lakh More Deaths as COVID-19 Hits Services.” The Print, May 2021, https://theprint.in/health/govt-says-there-could-be-5-lakh-more-tb-cases-1-5-lakh-more-deaths-as-covid-hits-services/498346/.

14. Huang, F. et al. “The Impact of the COVID-19 Epidemic on Tuberculosis Control in China.” The Lancet Regional Health – Western Pacific, vol. 3, October 2020. https://doi.org/10.1016/j.lanwpc.2020.100032.

15. Rumende, C.M. “Risk Factors for Multidrug-Resistant Tuberculosis.” Acta Medica Indonesiana, vol. 50, no. 1, 2018, pp. 1–2.

16. Mullerpattan, J.B. et al. “Catastrophic Costs of Treating Drug-Resistant TB Patients in a Tertiary Care Hospital in India.” Indian Journal of Tuberculosis, vol. 66, no. 1, 2019, pp. 87–91. https://doi.org/10.1016/j.ijtb.2018.04.011.

17. World Health Organization. Global Tuberculosis Programme: Our Response to COVID-19. WHO, 2020, https://www.who.int/teams/global-tuberculosis-programme/covid-19.

18. Hogan, A.B. et al. “Potential Impact of the COVID-19 Pandemic on HIV, Tuberculosis, and Malaria in Low-Income and Middle-Income Countries: A Modelling Study.” The Lancet Global Health, vol. 8, no. 9, 2020, pp. e1132–e1141. https://doi.org/10.1016/S2214-109X(20)30288-6.

19. European Pharmaceutical Review. “Dealing with Immunisation during the COVID-19 Pandemic: India’s Experience.” European Pharmaceutical Review, May 2021, https://www.europeanpharmaceuticalreview.com/article/119520/dealing-with-immunisation-during-the-covid-19-pandemic-indias-experience/.

20. Shrinivasan, R. et al. “India’s Syndemic of Tuberculosis and COVID-19.” BMJ Global Health, vol. 5, no. 11, 2020, e003979. https://doi.org/10.1136/bmjgh-2020-003979.

21. Ministry of Health and Family Welfare. Advisory to Mitigate the Impact of Acute Rise of COVID-19 Cases on the Tuberculosis Programme (NTEP) in the Country. Government of India, May 2021, https://www.tbcindia.gov.in/showfile.php?lid=3598.

22. Bhatia, R., and P. Abraham. “Lessons Learnt during the First 100 Days of COVID-19 Pandemic in India.” Indian Journal of Medical Research, vol. 151, no. 5, 2020, pp. 387–391. https://doi.org/10.4103/ijmr.IJMR_1925_20.

23. The Hindu. “TB Notifications Register Fall due to Pandemic Disruptions.” The Hindu, May 2021, https://www.thehindu.com/news/national/tb-notifications-register-fall-due-to-pandemic-disruptions/article34153456.ece.