World TB Day: TB and COVID
COMMENT
"While India seems to be sailing unexpectedly well through the period of the "third COVID wave", the country needs to brace itself for a new possible and prolonged war with "COVID-related TB". While COVID may subside, TB is likely to continue to be the biggest infectious disease."
"The solution lies in taking over the entire responsibility of detecting and treating TB throughout the country exclusively by the government, as a vertical programme governed by an administratively and financially autonomous body, if necessary by creating a separate Ministry. It is important to be autonomous, as we all know too well how the game of governance – a game of handball between Ministries, Departments and Organisations – is played in our set up. It is to be autonomous because we know that many IAS officers 'become cogs in the wheels of complacency and acquiescence, turn lazy and cynical, and worse, lose their moral compass', in the present set up (https://timesofindia.indiatimes.com/blogs/toi-edit-page/has-ias-failed-the-nation-yes-and-its-not-all-politicians-fault-the-service-rewards-mediocrity-risk-aversion/ ). TB control is more of an administrative problem than a medical one -- easily accessible diagnostic tools are available, cost-free medicines are available."
-- Dr. T. Rama Prasad, Perundurai, India
(A more detailed comment and account on TB can be found in: https://drtramaprasad.blogspot.com/2017/04/tuberculosis-in-india_29.html and https://www.thehindu.com/opinion/open-page/a-bad-patch/article31069356.ece )
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Writer : T. Rama Prasad
Email ID : drtramaprasad@gmail.com
Submitted for : OPEN PAGE, THE HINDU
Date : February 23, 2023
TB or not TB – that’s the question !
“To be, or not to be, that is the question”
(from Hamlet, spoken by Hamlet)
March 24, World TB Day : The time has come to celebrate a monumental defeat. The time of hype … singing the same chorus in a different style … the annual rituals of rallies, speeches and seminars. Hackneyed gestures and lax efforts are commonplace. All the theatrical activity dissipates quickly, much like the fizzling out of the effervescence from a soda bottle. One who follows up these acts can visualize a great scenario of farcical dimensions. All this brouhaha is about a well-understood disease for which a cure is available free of cost and which remained uncontrolled for over half-a-century. The grand pronouncements and the rhetoric may never meet the reality.
Pronouncements
A commitment was pronounced at the UN high-level meeting on tuberculosis (TB) in 2018. Ending the TB epidemic by 2030 was one of the health targets of the United Nations Sustainable Development Goals (SDGs). While US$ 13 billion is needed annually for TB prevention, diagnosis, treatment and care to achieve the global target, funding in low and middle income countries (LMICs) that account for 98% of the TB cases falls far short of what is required – less than half (41%) of the global budget. There was an 8.7% decline in spending between 2019 and 2020, with TB funding going back to the level of 2016. India’s pronouncement has been more pleasing. Going through the India TB Report 2018 : Annual Status Report, one gains the impression that there is political will and a strong strategy to reach the goal of ending TB in India, much earlier, by 2025, in line with the National Health Policy, 2017.
Ground realities
It is perhaps poetic that an estimated 10.6 million people fell ill with TB in 2021, an increase of 4.5% from 2020, and 1.6 million people died in the year from TB worldwide. Globally, TB is the first leading infectious killer – a ‘durable’ killer, compared to the ‘short-time’ killer, COVID-19. TB is killing more people than ever before in history – 1,000 people every day in India alone, at present. This chronic mortality does not become news, whereas a death due to COVID-19 grabbed the headlines. Statistics of the World Health Organization (WHO) for India for 2021 gave an estimated incidence of 2,590,000 TB cases. When I entered the TB field half-a-century ago, I thought that it would be hard to find a case of TB in 2020s to show to medical students for teaching purpose.
Drug resistance
Multidrug-resistant TB (MDR-TB) remains a public health crisis and a health security threat even to people in well-developed countries. It arises out of irregular, inadequate and inefficient treatment. More than 40 years ago, when I wrote in the columns of The Hindu of April 28, 1977 that ‘development of drug resistance has far-reaching implications and if unchecked would make TB totally unmanageable, whatever be the means’, my senior colleague, who is no more now, commented that it was a ‘distilled pessimism’. But the Global Tuberculosis Report, 2019 of the WHO says India has the highest number of TB and drug-resistant TB cases in the world.
TB and COVID-19
The COVID-19 pandemic has complicated the scenario of TB globally. The WHO and the researchers are of the view that the recent worsening of the TB epidemic globally is likely to be associated with the pandemic. The causes may be varied: decreased attention to TB owing to the enormous focus on COVID-19; potential biological effects of the interaction between the two diseases –- a ‘Cursed Duet’. Studies revealed that people with ‘old healed lesions of TB’ who get infected with the ‘Covid virus’ suffer more from lung function impairment and poor quality of life. The risk of death due to TB is 1 to 3 times higher in COVID-19 patients. The two diseases may be mutually aggravating. A clearer picture would emerge only after the completion of the ongoing global study on TB and COVID-19 patients, coordinated by the Global Tuberculosis Network (GTN) and supported by the WHO. Ironically, TB has been insurmountable over a long period of time though it is preventable and curable, while COVID-19 is exiting after a short spell of three years though its prevention and cure are not yet clear. As it did with almost everything else, COVID-19 may upset the plans and targets set for elimination of TB.
-.- Dr. T. Rama Prasad
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“Incidentally, Dr. T. Rama Prasad holds the WORLD RECORD in medical journalism of authoring 28 articles related to COVID-19 which were published in a single monthly medical journal, THE ANTISEPTIC, in 30 months. This article titled ‘Yellow Nail Syndrome and COVID-19 …’ is one of them.”
An anecdote
During my childhood, one of my schoolmates had huge nails. Her name was Gowri. We nicknamed her as ‘Goru’ (meaning nail of a finger or toe in Telugu). They used to say that her huge nails caused a problem in her heart. It might be a case of ‘Digital Clubbing’ (abnormal nails) which occurs in some ‘Congenital Heart Diseases’. After one summer vacation, ‘Goru’ didn’t come back to the school. It was learnt that she died due to the nail / heart problem, and that heart surgery couldn’t be done as they didn’t have money to pay for it.
Perhaps, this incident prompted me to look at everyone’s nails from that time which might have led me to report the first case of ‘Yellow Nail Syndrome’ from India in 1980 and the first case in the world of ‘Yellow nails & Covid’ now in 2023. And perhaps, the death of ‘Goru’ due to inability to pay for the surgery motivated me to start my ‘PAY WHAT YOU CAN’ Clinic half-a-century ago. -- T. Rama Prasad
March 24, 2022
On this 'WORLD TB DAY', the unpalatable news that India witnessed a sharp19% rise in tuberculosis (TB) cases in 2021over the previous year, even as 64% of India's TB symptomatic population was not able to seek healthcare services between 2019 and 2021 due to Covid disruptions. We don't know how much of this rise has been due to Covid -- indirectly or directly (read my article titled "Covid and Tuberculosis" which is pasted below). There has been an increase by 11% of the death rate due toTB between 2019 and 2020. The prevalence of TB among Indians above the age of 15 is 312 cases per one lakh of population, more than double the global average of 127. The consternating findings come from the 'India TB Report 2022' and the 'National TB Prevalence Survey 2019-2021'. This survey is conducted six decades after the first survey in 1955-58. And now, whatever little progress that was made during the past few decades is set back by many decades. With Covid's 'support', TB is likely to rampage across the world, especially the vulnerable countries like India.
End of TB by 2025
The government has today on March 24, 2022 again committed to make India TB-free by 2025. If one goes through the 'India TB Report 2018 : Annual Status Report' (https://tbcindia.gov.in/showfile.php?lid=3314), one gains the impression that there is a committed political will and a strong programming strategy in place to reach the goal of ending TB in India by 2025, in line with the 'National Health Policy, 2017'. Every one concerned should work hard honestly to see that this new initiative would not end as a "TB Hatao" slogan. But, it seems that 2025 is too nearby to achieve that target. The year 2025 would tell us whether it is just a political promise. The 'national TB programme' couldn't do it in its existence of around half-a-century ! In my existence of over half-a-century in the field of TB, I fired many salvos against the policy makers of TB control, but they stuck to their guns. Many of them are no more today to witness the present appalling TB scenario. I don't talk much, the noise you hear is from my writings in media over half-a-century. Read a sample in the article pasted below, titled "A bad patch" ( https://www.thehindu.com/opinion/open-page/a-bad-patch/article31069356.ece ) and my blog article titled "Tuberculosis in India" ( https://drtramaprasad.blogspot.com/2017/04/tuberculosis-in-india_29.html ). TB has remained invincible and insurmountable.
A zillion-volt SHOCK
A decade ago, the authorities which kept on painting a rosy picture had a zillion-volt shock when a report released on the eve of World TB Day (2012) by the World Health Organization (WHO) stated that ‘India presents a dismal picture having the highest number of MDR-TB cases in South East Asia’.
India is now facing a tuberculosis crisis in terms of morbidity, mortality, magnitude and drug resistance which no earlier generation ever had to face. There are 2.8 million cases of which half-a-million may be harbouring drug-resistant bacilli. And 50 crores may be carrying 'latent TB infection'. Of late, one thousand persons have been dying every day in India due to TB. And we have been losing 2,240 billion rupees due to TB each year. Hence, it is imperative that policy makers, politicians in power and the public do some soul searching on the control of TB in India. Now more than ever, comprehensive and novel methods are to be employed to control TB with the same sincerity and urgency we are witnessing to combat COVID-19.
From the PAST to the PRESENT
Tuberculosis control is a quirky conundrum, plagued by an abundance of problems and no clear solutions. If the medical mess is about uncontrolled regimens of treatment, burgeoning drug resistance and flagrant violation or ignorance of treatment guidelines, it is also about bad infrastructure -- designed and executed poorly with absolutely no realistic foresight. That is exactly why any revision after revision of the control programme is making health officials lose sleep.
. COVID and TUBERCULOSIS .
RAMA PRASAD T.
Dr. T. Rama Prasad,
Formerly: Medical Superintendent (Special) of RTS & IRT Perundurai Medical College and Research Centre,
Perundurai, Tamil Nadu, India.
Presently: Director of ‘PAY WHAT YOU CAN’ Clinic, Perundurai, Erode District, TN – 638052. drtramaprasad@gmail.com WhatsApp +91 98427 20393 BLOG https://drtramaprasad.blogspot.com
WEBSITE www.rama-scribbles.in Twitter @DrRamaprasadt Facebook T Rama Prasad
Telegram Dr T Rama Prasad
`
A MONTHLY JOURNAL OF MEDICINE AND SURGERYSN
Vol. 118 No. 12 December 2021 ISSN 0003 5998
Indexed in IndMED Email: admin@theantiseptic.in www.theantiseptic.in
. COVID and TUBERCULOSIS .
. COVID and TUBERCULOSIS .
RAMA PRASAD T.
Dr. T. Rama Prasad,
Formerly: Medical Superintendent (Special) of RTS & IRT Perundurai Medical College and Research Centre, Perundurai, Tamil Nadu.
Presently: Director of ‘PAY WHAT YOU CAN’ Clinic, Perundurai, Erode District, TN – 638052.
Specially Contributed to “The Antiseptic” Vol. 118, No. 12
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“Science like life, feeds on its own decay. New facts burst old rules; then newly divined conceptions bind old and new together into a reconciling law.”
-- William James
ABSTRACT
True to this quote, an unanticipated association between the two distinctly different diseases is discerned. At the beginning of the Covid pandemic, the old disease of antiquity, tuberculosis, and the new disease of modernity, COVID-19, were scientifically thought not to have a common thread; but the emergence of new facts have bound them together. The commonalities of the two diseases and the imperatives of a common approach to control both the diseases are briefly discussed in this paper with the knowledge available around mid-November 2021. In this context of the seemingly unending catastrophe caused by these two monstrous diseases, let’s hope for that stroke of serendipity which may facilitate control of both the diseases by a common approach.
Key words: COVID-19, Tuberculosis, National Tuberculosis Control Programme, WHO Global Tuberculosis Programme, Coinfection of Covid and tuberculosis, Covid control, COVID-TB
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Introduction
There are two main pathogens / diseases responsible for death due to infection in the world at present -- SARS-CoV-2 / COVID-19 (Covid) and Mycobacterium tuberculosis / tuberculosis (TB). In early 2020, when the disastrous and devastating Covid was spreading like wildfire, we didn’t have an inkling of its deadly association with the smouldering scourge, TB. Now, it is known that the coinfection of Covid in TB patients had accelerated both the diseases, leading even to death. A parallel epidemic of TB may add fuel to the fire. It is not yet clear as to how exactly this happens. This is a dangerous grey area which is to be navigated with utmost caution as the two diseases seem to be mutually aggravating.
Both the diseases spread through air, affect mostly the lungs and have similar symptoms. However, Covid spreads and kills fast while TB is indolent and a slow performer, deadly though. Though TB had been the deadliest infectious disease in the world, it had not been in focus as it had not been a dramatic killer like Covid. Some details about ‘Tuberculosis in India’ are in my articles published on my blog and in The Hindu which are in the cited references.1,2
We could not satisfactorily control TB though we have specific drugs to treat; we could not control Covid due to lack of specific drugs (Molnupiravir and Paxlovid are in the pipeline). The impact of Covid on TB problem (which could not be controlled yet, and riddled with problems of drug-resistance) may become humongous in the long term even as Covid may be contained in the near future, for the simple reason that effective vaccines are being made for Covid while none exists against TB in adults (BCG vaccine protects only to some extent against development of some forms of TB in children). It is unfortunate that an effective vaccine against TB couldn’t be developed though the disease has been with the humanity for a very long time – it can be traced to the prehistoric ages (the remains of Pleistocene bison in Wyoming gives evidence of presence of TB over 17,000 years ago). And the cause for the disease was identified around one-and-a-half centuries ago (Robert Koch announced the discovery of the causative bacillus on March 24, 1882). In stark contrast, the expected time of 10 years to produce a vaccine for a coronavirus is ‘compressed’ into 10 months in the case of Covid !3
Covid and TB camaraderie
Covid and TB have such significant ‘syndemic’ characters that the two coinfections may be referred to by the term “COVID-TB”. TB used to cause “slow death”, but now onwards the “COVID-TB” may cause “fast-slow” death ! The new combination of the diseases is data-deficient as Covid robbed all the attention during the past two years to the negligence of all other diseases.
A scientific study has evaluated the correlation of host-expression with SARS-CoV-2 and interaction of 26 proteins of SARS-CoV-2 with 332 human proteins.4 It was found that Mycobacterium tuberculosis that causes TB shares most of the host protein interaction partners (same interactome) with SARS-CoV-2 which is of utmost importance as both the infections have high affinity towards lung tissues. Lung is commonly involved in most of the cases of COVID-TB. Both the pathogens may induce immunomodulation disorders leading to an unbalanced inflammatory response which can worsen the course of both the diseases.
We still do not know whether manifestations of COVID-TB are directly due to the pathogens or a dysregulated immune system. The pulmonary alveoli are like the battleground for both Covid and TB though TB surreptitiously affects the lungs without alerting immune systems much, while Covid aggressively promotes immunopathology and damages tissues through pyroptosis. The long-term trajectory of these effects remains unknown, as does the probability of success of interventions to subdue the problem. This combo may severely affect ‘high-TB-burden’ countries in Africa, South America and Southeast Asia. This is akin to the association of TB with the ‘human immunodeficiency virus’ (HIV) which resulted in a deadly syndemic of global proportions in the mid-20th century. SARS-CoV-2 infection is also seen as a nosocomial infection in TB cases.
According to the Centers for Disease Control and Prevention of the US, TB patients are at a greater risk for severe forms of COVID-19. COVID-19 coinfection in TB patients was found to accelerate the disease course of both the diseases which may lead to death. A study of meta-analysis of COVID-TB concluded that a moderate level of evidence suggests that people with COVID-TB are 2.21 and 2.27 times more likely to die or develop severe disease, respectively, than COVID-19 patients.5 The most common comorbidities among COVID-TB patients were diabetes (24.36%), hypertension (17.95%), HIV infection (6.41%), hepatitis (3.85%), epilepsy (3.85%) and cancer (2.56). Furthermore, when infected with Covid, old healed TB lesions may get activated, and the people of ‘latent TB infection’ (LTBI) may develop active TB. Hence it is imperative that appropriate precautions and preparation of the health systems to tackle the impending burden of the coinfection are to be planned well. Past experience with SARS and MERS-CoV has shown that adverse effects of TB occurred during and after the infectious phase of the diseases. Notwithstanding our experience with similar viruses in the past, we are still groping in the dark corridors of the ominous and looming pandemic.
Commonalities
Covid and TB have more commonalities than differences. Firstly, both are infectious diseases that spread through air through aerosols or droplets that come out while coughing or sneezing. Secondly, both have conspicuously similar symptoms like cough, chest cold, fever, breathlessness, fatigue and loss of appetite which may lead to mistakes in diagnosis (rarely though, both may produce symptoms of any system in the body – even only loss of smell or just headache in Covid; or only chronic swellings in the neck or just vague pain in the abdomen in TB, for example). Thirdly, lungs are affected in most of the cases of COVID-TB, and the radiological images of lungs may also have some commonalities and superimpositions that may confuse clinicians. And, the two diseases share the same social determinants and some comorbidities which make the diseases more formidable. Moreover, one should be aware that many other bacterial and viral diseases which affect lungs may have the same commonalties.
Covid effect on TB control
While documentation on the subject of the two coexisting diseases is very limited, experience points to poorer outcomes of treatment in the cases affected by both Covid and TB. Reported data on the TB cases during the past two years may present a false picture of control over TB as many of the TB patients didn’t go for regular check-up and as many suffering from some mild symptoms didn’t approach any doctor due to Covid restrictions, ‘lockdowns’ and deputation of TB staff to Covid-related departments. So, the COVID-TB has become a neglected paradigm resulting, perhaps, in worsening of the TB scenario in India and development of more drug-resistance. The pandemic is threatening efforts to control TB. The WHO has estimated that 6.3 million additional new TB cases and an additional 1.4 million TB deaths will be registered between 2020 and 2025 as a consequence of lockdowns and restrictions.
Being a pathogen highly adapted to coexist and thrive among the humanity, the TB bacillus has ‘latently’ (not causing disease or symptoms) infected two billion people.23 Normally, about a fraction of 10% of the ‘latent TB infection’(LTBI) turns into active TB disease in a lifetime. With the convergence of COVID and TB, this percentage may rise to 50% as it was with the HIV and TB combo. As such, the consequences of the Covid pandemic pose serious challenges to TB control programmes.
The fire rages on
In Venezuela, there was a decrease in the number of the tests done for TB to the extent of 90% in the second quarter of 2020. The lockdowns in Sierra Leone in Africa caused a drop of 75% in the case load of TB in April 2020. It doesn’t mean that the TB burden got reduced by 75% ; people just couldn’t approach the medical facilities which were busy handling Covid. The 75% of the cases would have had disrupted treatment and developed drug resistance. This might be the scenario in other developing countries too. This is the impact of all the attention being focussed on Covid. Once all the Covid restrictions are lifted, the huge submerged TB would emerge to the surface along with the known and unknown comorbid effects of Covid, and thus the fire rages on.
Covid conundrum
The World Health Organization (WHO) had declared COVID-19 as a “Public Health Emergency of International Concern” on January 30, 2020, and as a pandemic on March 11, 2020. The first case of COVID-19 in the world was reported on December 31, 2019 in China, and the first one in India on January 31, 2020. A huge volume of knowledge about Covid had accumulated over the past two years, but much of it is patchy and inconclusive, right from its origin to treatment. A little of it may be found in my 14 articles published over the previous 14 months on subjects related to Covid in The Antiseptic, a journal of Medicine and Surgery, and in Health, a journal devoted to healthful living.5,6,7,8,9,10,11,12,13, 14,15,16,17,18 And some sequential information may be found on my blog.3
Globally, as of November 13, 2021, 250 million cases and 5 million deaths were recorded in 216 countries in the past two years since COVID-19 wrecked the definition of the word ‘normal’ and ravaged lives and livelihoods of millions. The World Bank estimated that around 120 million people have been pushed into extreme poverty and that millions are hanging between gloom and doom.
India had 34 million cases with 0.46 million deaths. Right now, in November 2021, the Indian government is on tenterhooks about the expected ‘Third Covid Wave’ while people, in general are off the hook, and are letting their guard down with the declining trend of the Covid cases – just around 10,000 on November 6, 2021 and just as much as in February 2021 before the ‘Second Covid Wave’ disastrously pushed up the number to around 4,00,000 a day in April 2021 ! Though the pall of fear has dimmed, the timing of the ‘second wave’ should not be forgotten.
At the same time, it is intriguing and perplexing to note that there have been alarming surges of cases in Russia, Europe, the US and Singapore where health facilities and Covid vaccine coverage had been excellent. No new variants of significant presence have been reported, after the Delta / Delta Plus. Two years on, several lacunae in the knowledge and understanding of Covid still exist.19,22,20,24,23 India’s fortunes are to be watched over the next two months which are crucial and critical. If something worse than the Delta (whose world tour started in India) evolves, the world would – Heaven forbid -- be back to the drawing board.
Tragedy of tuberculosis
While much of the world population including children knows about the ‘kill power’ of the new disease, Covid, curiously, not many know that the old disease, TB has been killing overwhelmingly over decades and is less preventable than Covid. TB is killing more people than ever before in history -- 1,000 people every day in India at present ! And, though poverty and TB have a mutually reinforcing relationship, the wealthy are also affected by TB as the disease spreads through air, and as even an aristocrat can’t have private air though he may have a private jet aeroplane. Dubbed as “Ebola with wings,” TB flies freely from place to place. Kamala Nehru, Mohammed Ali Jinnah, Srinivasa Ramanujan, Lennec, Lady Roosevelt, John Keats, Shelly and a host of other celebrities succumbed to TB !
The Global Tuberculosis Report, 2019 of the WHO says India has the highest number of TB and ‘multidrug-resistant tuberculosis’ (MDR-TB) cases in the world. On the eve of World TB Day in 2012, a report released by the WHO stated that India presents a dismal picture having the highest number of MDR-TB cases in South East Asia. Ignominiously, this is the situation despite the operation of a grand National Tuberculosis Control Programme (NTCP) for over half-a-century, since 1962.1, 2 The programme has been a theoretically very sound one based on robust scientific studies and conceived under the guidance of international health bodies. As it didn’t yield the expected results, it was revised (RNTCP) periodically (1993 to 1998) to cover deficiencies discovered under field conditions and even included‘Public Private Partnership’ (PPP) and incentives for patients and doctors as well.
More than 44 years ago, I wrote in the columns of The Hindu of April 28, 1977 that “… development of drug resistance, which is a result of inadequate and irregular treatment mostly, has far-reaching implications and if unchecked would make tuberculosis totally unmanageable by the present methods in course of time, whatever be the means. Irregular and inadequate treatment keeps the patient often alive, suffering and infective to disseminate drug-resistant organisms into the environment …” 1,2 Experts of that time derisively dismissed off my comments as pessimistic utterances. They are no more here today to know that the chances of controlling TB are more bleak now due to the partnership of the old bacillus with the new virus ! And the number of ‘multi-drug-resistant TB’ cases in India in 2018 is a shocking half million (1,30,000 in 2015), topping the world, and ticking the ‘India’s TB Time Bomb’.
The phantom menace
Again, when Covid started its journey in India (when there were just 500 Covid cases and 10 deaths in India !), I wrote in a special article published in The Hindu of March 15, 2020 that “…I find that there is less guarantee of a cure now than a few decades ago, notwithstanding the availability of more drugs. There were tools, but we didn’t use them properly. And now it seems that TB has become insurmountable and invincible, notwithstanding the introduction of drugs such as Bedaquiline, Linezolid and Pretomanid. TB is killing more people than ever before in history – 1,000 people every day in India, at present. This chronic mortality does not become news, whereas one case of COVID-19 grabs the headlines. On World TB Day on March 24, we mourn the thousand deaths every day while going through the annual rituals of rallies, speeches and seminars. Hackneyed gestures and lax efforts are commonplace. One who follows up these acts can visualize a great scenario of farcical dimensions. The grand pronouncements and the rhetoric may never meet the reality. Why all this annual hype – singing the same chorus in a different style ? …” 2
Much as we dislike grumbling about the efficiency of the control measures, the horrendous facts leave us with no choice but to package our message in a bundle of barbed wire.24 India should take pride in its unicorns but simultaneously raise the bar. We missed the chance to puff up our chest with the pride of elimination of TB. And thus, we landed in the medical quagmire.
The infamous history
The history of the TB control programme since it was founded in 1962 is checkered and its track record triggers mocking. According to the 'Global Report of 2017', the estimated incidence of TB in India is 2.8 million, accounting for a quarter of the world's TB cases. Various new initiatives and policy changes have been made since 2017 for early detection, better treatment, more cooperation and positive outcome. Government of India has set the highly ambitious goal of ending TB in India by 2025, through 'National Strategic Plan (NSP) 2017-2025, in line with 'National Health Policy 2017'. This is 5 years ahead of the target of 'Sustainable Development Goals', and 10 years ahead of the 'End-TB target' of the WHO. Now, the Covid seems to have upended the plans.
Rhetoric and reality
Fostering undue complacency among the public through utterances of rhetoric of achievements did more harm than good. The magnitude of the TB problem does not attract anybody’s attention as TB disables and kills slowlyquite unlike Covid, Ebola or tsunami. The WHO declared TB a “Global Health Emergency” in 1993. And in 2006, the “Stop TB Partnership Development” and the “Global Plan to End TB” aimed to save 14 million lives between their launch and 2015. It was a costed plan and a roadmap for a concerted response to TB. On September 26, 2018, the United Nations (UN) held its first-ever high-level meeting on TB. Apart from the “UN Political Declaration on TB”, there are examples of high-level rhetoric and leadership on multisector accountability which include “Presidential or Head of State” and “End TB”/ “Race to End TB” initiatives, and formalized mechanisms for the engagement and accountability of stakeholders in various countries including India.
A number of targets were set, but not achieved in reality. One of the targets is to end TB epidemic in the world by 2030. Political will is the need of the hour, not verbiage, promises and pronouncements. Given the state of pusillanimous global leadership, the partnership of Covid and TB would, for a long time, haunt the poorer countries where TB had been rampant. The past is frequently the prologue in geopolitics. The leaders need to clear the phantoms from their heads and grasp reality.23 One leader even declared that Covid vaccines turn people into crocodiles and mired down his country in the mud of Covid.21
Humongous task
By 2022, US $ 13 billion is needed annually for TB prevention, diagnosis, treatment and care to achieve the global target agreed at the UN high-level meeting on TB in 2018. India has been losing 2,240 billion rupees due to TB each year. The WHO estimated that every year, worldwide, around 10 million people fall sick with TB which is one of the top 10 causes of mortality globally – around 1.5 million people die of TB each year. And it is estimated that worldwide 1.7 billion people (around one-quarter of the world population) are infected (not sick or infectious) with TB bacilli who are at risk of developing active TB. Ergo, TB is a much bigger liability than Covid as TB problem would be persistent (due to lack of a vaccine for adults) and as Covid is likely to be controlled in near future through vaccinations and drugs like Molnupiravirand Paxlovid. India’s proclaimed target (pre-Covid plan) is to eliminate TB from India by 2025. But now with the added adverse effects by Covid, the ambitious target may have to be revised drastically. Going by the past experiences, those who are responsible to control the diseases may weave a fig leaf out of the co-infection of ‘COVID-TB’.
Double whammy
With such a huge TB problem on our back, we are to face now the double-headed dragon of Covid and TB. Failure to control this is a certain health risk to the entire world both in terms of TB drug-resistance and Covid mutations. There had been an alarming disruption of TB treatment for about the past two years due to lockdowns and diversion of the concerned TB staff to handle the Covid problem which would result in increased drug-resistance. Secondly, coinfection of the TB patients by the Covid virus is most likely to worsen the scenario which would have a humongous economic impact both at individual and national level, apart from stressing the health services. The situation seems to be very scary with no vaccine for TB in sight. The confusion is confounded by the difficulties in diagnosis, as the symptoms and the pulmonary radiological findings may be similar and overlapping which may lead to wrong treatment.
BCG and Indian Immunity
What has bacterial TB vaccine to do with viral COVID-19 ? Bacillus Calmette Guerin (BCG) vaccine comprises of one kind of live but weakened (attenuated) tuberculosis bacilli usually given to infants to protect them against some forms (like miliary and meningeal) of TB. Most surprising is the assumption that BCG vaccination might have protected the countries where BCG vaccination is in general use - protection from COVID-19, though BCG is meant for protection against tuberculosis. The assumption arises out of scientific studies (New York Institute of Technology, USA). In a study (University of Texas, Houston) covering 178 countries, it is found that death rates due to COVID-19 are lower by a factor of 10 in countries that had a strong BCG vaccination regimens. It is found that morbidity and mortality due to COVID-19 are high in countries where BCG vaccination is not in practice universally (Spain, Italy, France, USA, etc.). The COVID-19 didn't affect much the countries where BCG vaccination is given soon after birth universally since a very long time (India, Japan, etc.). Death rates due to COVID-19 are low even when infection rates are moderate in Malaysia, Ireland, the Czech Republic, the Slovak Republic, Hungary, Costa Rica, India and many other nations which have strong BCG programmes.
BCG vaccination significantly increases the secretion of pro-inflammatory cytokines, specifically IL-1B which has been shown to play a vital role in 'antiviral immunity' - 'trained immunity'.20 And, BCG vaccination has been reported to offer broad spectrum protection against respiratory infections. Thus, the BCG protection might influence the morbidity and mortality due to COVID-19 by protecting people from co-occurring infections and sepsis which ultimately kill (https://doi.org/co.1101/2020.03.24.20042973).
Most of the Indians had BCG which may confer immunity against many bacteria and viruses. Hence, perhaps, the death rate due to COVID-19 is low in India. Almost all the Indians were given BCG vaccination (from 1948 onwards) soon after birth to prevent some forms of TB. Indians seem to be lucky that they may have some immunity against coronavirus also, unexpectedly.
It may be interesting to know that more than 40 years ago (in 1979), there was a raging controversy about giving BCG vaccine in India, in view of a robust study which found BCG not to be beneficial in protecting against TB. At that point of time, in the context of this study and the controversy about continuing BCG, a premium medical journal, The Antiseptic wrote an editorial mentioning opinions of some leading experts in the field (including me) who supported continuance of BCG. In the editorial (Vol. 76, No. 12, December 1979), the journal mentioned my view as: “Dr. T. Rama Prasad of the Perundurai Sanatorium says that without conducting similar studies at various places in the country it would be a disservice if any doctor pronounces to the public that BCG is ‘useless’ or ‘harmful’.”
The way forward
Addressing both Covid and TB simultaneously and integrating control programmes of both the diseases would be the key to contain these diseases in the long term. A comprehensive plan to stop these two mutually aggravating diseases is to be put in place. During the past two years (2020 and 2021), a huge chunk of TB patients didn’t or couldn’t go to TB clinics for review or collection of drugs due to ‘Covid restrictions’; and so, their disease might have advanced and the TB bacilli might have gained dangerous drug-resistance due to irregular and inadequate treatment. Such bacilli in turn spread the disease exponentially in the communities, especially of ‘TB endemic’ countries like India, Indonesia and China.
The double-headed dragon, COVID-TB, is a potential threat to the humanity which if unchecked would lead to untold misery, especially in poorer countries. The duo has many similarities which make a common approach advantageous in controlling both the diseases. Considering the many commonalities between COVID-19 and TB (in the clinical presentation diagnostic methods, epidemiological characteristics, transmission of the diseases, preventive measures and the control strategies) a common control programme for both the diseases would be desirable. It should be easy and practicable, as the Covid control measures are fundamentally based on the same strategy as for TB (early detection, contact tracing, prevention of the spread and treatment of the case). Even the underlying risk factors for poor outcomes are also common (like diabetes, old age and other lung diseases).
Moreover, in many countries, a well-established control programme for TB is already in existence. The same infrastructure of men and materials, with a little modification, could be utilised for Covid and TB straight away, cutting down the costs and facilitating a smooth take off. Integration of control programmes for Covid and TB would automatically and advantageously lead to more detection of TB in the population. Every COVID-19 case is to be screened for TB in all ‘high-TB-burden’ countries like India. Similar integration of programmes for HIV and TB in Ecuador and some other countries yielded very gratifying results. It is paramount that a vertical common programme for Covid and TB, governed by an administratively and financially autonomous body, if necessary by creating a separate Ministry, is developed.1
This is an opportunity given by the pandemic to screen more people for TB, especially in the low and middle income countries where most of the TB burden is present. In the frenetic pandemic activity, TB has been a neglected paradigm. Ergo, not much is known about the magnitude of this dual problem. As more and more cases are detected, we have to learn on the go about this portentously gloomy situation. Even in the case of the ‘India’s second wave’, it was not known until the end that ‘Delta’ variant was mostly responsible for the disaster. After a decade from now, it might be said that TB had been the cause for sustenance of Covid !
The uncertainty in the field of Covid is such that, on November 9, 2021, French health authorities advised against use of the ‘mRNA Moderna Covid vaccine’ (which is rated as one of the two best vaccines in the world, the other being the ‘mRNA Pfizer Covid vaccine’) for people under 30, after a nation-wide study confirmed a slight risk of myocarditis and pericarditis associated with mRNA vaccines. The very next day, German health authorities issued the same advisory for their country based on findings of Germany’s Federal Institute for Vaccines and Biomedicines. Curiously, the ‘Pfizer Covid vaccine’ of the same mRNA platform didn’t have this axe fallen on it. Another example of our poverty of knowledge is the tremendous surge in October-November 2021 in Europe as well as Asia even while there is the expert opinion that the pandemic is entering an endemic stage. The claptrap has only been growing.19
Right task at Right time
Controlling the unrelenting spread of TB is an urgent matter, as urgent as for Covid. If we don’t nip it in the bud, it would grow into unmanageable dimensions just as what happened to the laidback India during the ‘second wave’. In February 2021, just as now in November 2021, there were only around 10,000 cases per day. And so, India went on to indulge in ‘meetings and melas’ only to witness a spike of 4,00,000 cases a day in April 2021. If people relax that way now, the new ‘longer-lasting Covid cum TB wave’ would – God forbid – kill poorer countries where most of the TB is present. Let India handle the right task at the right time. Let’s remember the following quote of Chanakya, the iconic Indian intellectual who authored the ancient Indian treatise, Arthashastra:
“If the right task is not accomplished at the right time, then time itself wrecks the chances of success.” -- Chanakya
REFERENCES
1. https://drtramaprasad.blogspot.com/2017/04/tuberculosis-in-india_29.html
2. https://www.thehindu.com/opinion/open-page/a-bad-patch/article31069356.ece
3. https://drtramaprasad.blogspot.com/2020/06/coronavirus-covid-19-sars-cov-2_43.html
4. https://www.nature.com/articles/s41586-020-2286-9
5. https://www.frontiersin.org/articles/10.3389/fmed.2021.657006/full
6. Rama Prasad, T. Disastrous Second Covid Wave in India. The Antiseptic. 2021 June; Vol.118; No.6; P: 20-27; Indexed in IndMED – www.antiseptic.in
7. Rama Prasad, T. Is the “Lockdown Medicine” too toxic ? The Antiseptic. 2020 October; Vol. 117; No. 10; P: 13-15; Indexed in IndMED – www.theantiseptic.in
8. Rama Prasad, T. Covid Variants. The Antiseptic. 2021 May; Vol.118; No.5; P: 11-14; Indexed in IndMED -- www.theantiseptic.in
9. Rama Prasad, T., Versha Rajeev. The Conundrum of COVID-19 Vaccines. The Antiseptic. 2021 January; Vol.118; No.1; P: 10-17; Indexed in IndMED – www.theantiseptic.in
10. Rama Prasad, T. Covishield or Covaxin ? The Antiseptic. 2021 April; Vol. 118; No. 4; P: 12-16; Indexed in IndMED – www.theantiseptic.in
11. Rama Prasad, T., Versha Rajeev. Antiseptics, Disinfectants and COVID-19. The Antiseptic. 2020 November; Vol.117; No.11; P: 26-28; Indexed in IndMED – www.antiseptic.in
12. Rama Prasad, T. 40+15 Hypoxia Test in COVID-19. The Antiseptic. 2020 December; Vol. 117; No. 12; P: 13-17; Indexed in IndMED – www.antiseptic.in
13. Rama Prasad, T. Mucormycosis and COVID-19 in India. The Antiseptic. 2021 July; Vol.118; No.7; P: 21-26; Indexed in IndMED -- www.antiseptic.in
14. Rama Prasad, T. Vagaries of India’s Covid Vaccination Policy. The Antiseptic. 2021 August; Vol.118; No.8; P: 10-16; Indexed in IndMED – www.antiseptic.in
15. Rama Prasad, T., Versha Rajeev. Tea and Covid. Health. 2020 October; Vol.98; No.10; P: 4-6.
16. Versha Rajeev., Rama Prasad, T. Fear and Covid. Health. 2020 November; Vol.98; No.11; P:31-32
17. Rama Prasad, T. India’s Third Covid Wave. The Antiseptic. 2021 September; Vol.118; No.9; P: 14-20; Indexed in IndMED – www.antiseptic.in
18. Rama Prasad, T. Covid, Children and Schools. The Antiseptic. 2021 October; Vol.118; No.10; P: 08-18; Indexed in IndMED -- www.antiseptic.in
19. Rama Prasad, T. The Science and Nonsense around COVID. The Antiseptic, 2021 November; Vol. 118; No. 11; P: 8-14; Indexed in IndMED -- www.antiseptic.in
20. https://drtramaprasad.blogspot.com/2020/
21. Rama Prasad, T., Versha Rajeev. https://drtramaprasad.blogspot.com/2017/04/covid-crocodiles.html
22. https://drtramaprasad.blogspot.com/2017/04/hydroxychloroquine-hcq-and-coronavirus_29.html
23. https://drtramaprasad.blogspot.com/2017/04/corona-and-charles-darwin.html
24. https://drtramaprasad.blogspot.com/2017/04/modern-medicine-good-bad-and-ugly_30.html
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COVID-TB is a double-headed dragon, doubly lethal.
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Some more writings, presentations, papers and comments related to TUBERCULOSIS by Dr. T. Rama Prasad:
1. Drug Resistance in Tuberculosis - Journal of the Indian Medical
Association, Vol. 64, pp. 264-267, 1975.
2. Childhood Tuberculosis - Part I - The Antiseptic, Vol. 76, pp. 449-504,1979
3. Childhood Tuberculosis - Part II - The Antiseptic, Vol. 76. pp. 567-574, 1979
4. Short-course Chemotherapy - The recent Advances in the Treatment
of Respiratory Tuberculosis - Current Medical Practice, Vol.24,
pp. 41-46, 1980.
5. Drugs in the treatment of Tuberculosis - The Antiseptic,
Vol. 75, p.678, 1978
6. Chemotherapy of Tuberculosis - The Antiseptic, Vol. 76, p.248, 1979.
7. Streptomycin in Tuberculosis - The Antiseptic, Vol. 76, p.516, 1979.
8. How effective is the TB control programme ? (Special Article) -
The Hindu, Vol.100, No. 274, p.8, 1977.
9. Five years Plans and TB Control Programme (Special Article) -
The Hindu, Vol.101, No. 275,
10. National Tuberculosis Control Programme - views presented,
on invitation by theTuberculosis Association of India, at the 32nd
National Conference on Tuberculosis and Chest Diseases, 1977.
12. Correlation between Geomagnetic Activity and Haemoptysis -
paper presented at the II Tamil Nadu State Conference on Tuberculosis
& Chest Diseases, 1980.
13. Hundreds of published writings in the lay press which can’t be listed here due to space constraints.
“COVID is adding fuel to the fire of TB.”
-- Dr. T. Rama Prasad
"While India seems to be sailing unexpectedly well through the period of the "third COVID wave", the country needs to brace itself for a new possible and prolonged war with "COVID-related TB". While COVID may subside, TB is likely to continue to be the biggest infectious disease."
-- Dr. T. Rama Prasad, Perundurai, India.
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