Coronavirus affects India’s tuberculosis care

Annie Banerji, Reuters

When India’s strict coronavirus lockdown left migrant worker Brijesh jobless overnight, he had to make a quick decision — leave for his home village or wait to collect his tuberculosis medicine.

With no public transport to get to the local tuberculosis (TB) centre, he decided to pack up and head to his home more than 1,100 kms away in eastern Bihar state.

“Everything was shut. There was no guarantee that I would get my medicines,” said the 44-year-old, who had been working as a scrap dealer on the outskirts of Delhi.

“I had little savings and worried about feeding my wife and daughter. So I panicked and left,” he told the Thomson Reuters Foundation by phone from his village in Darbhanga district.

Brijesh, who declined to give his full name fearing being identified as someone with TB — which still brings stigma and discrimination — was not alone in his struggle in India, home to the world’s highest number of TB cases.

Data from the World Health Organization shows about 10 million people fell ill with TB in 2018 with 1.5 million deaths. India accounted for 27% of new cases and nearly 450,000 deaths.

The nearly 70-day national lockdown enforced in India in late March left millions of TB sufferers with little to no access to crucial drugs, doctors and follow-up treatments.

Health experts have raised concerns that the pandemic has overwhelmed India’s precarious healthcare system, with most medical personnel and services pushed into the fight against COVID-19 while placing TB care on the back-burner.

Although restrictions have eased since June, people have remained too scared to go to medical facilities or been turned away for reasons ranging from staff shortage to confusion over COVID-19 and TB diagnoses.

Symptoms for both include coughing, sometimes with mucus, chest pains, weakness and fever.

“A month or two into the pandemic and TB services were in complete disarray,” said Chapal Mehra, of the advocacy group Survivors Against TB.

“This pandemic is a wake-up call that our healthcare systems are not set up adequately and unable to withstand a crisis.”

India’s coronavirus outbreak is the third worst in the world behind the United States and Brazil, with nearly 2.4 million confirmed cases and more than 47,000 deaths by mid-August, according to a tally by the Johns Hopkins University.

Its impact on TB care has been immediate — under-detection of a disease that is exacerbated by undernourishment, according to the health ministry.

The government’s TB programme showed registration of new cases between January and June this year dropped by more than 25% compared with the same period in 2019.

Under-detection could result in an additional estimated 87,711 TB deaths in 2020, according to a review article co-authored by the International Union Against Tuberculosis and Lung Disease published last month.

Health experts worry this could derail India’s plan to eliminate the disease by 2025 — five years ahead of the global target.

But Kuldeep Singh Sachdeva, head of the government’s Central TB Division, said while the pandemic has had a “palpable impact” on TB care, it was unlikely to affect the deadline.

He said new behaviours adopted in the wake of COVID-19, such as wearing masks and social distancing, could help reduce TB, which is spread through coughs and sneezes.

He also said that the government had anticipated a decrease in TB notifications due to the lockdown.

“We will be able to cover that dip in coming months,” he said. He said health services had resumed and his department was pushing combined testing for both TB and COVID-19, with about 50,000 done so far.

Authorities have also ramped up awareness campaigns on TB and assessment calls with state officials, and provided helplines for people facing diagnosis or treatment trouble.

Sachdeva said patients who had started treatment pre-lockdown had drugs delivered to their doors.

Janender, who declined to give his full name, said although he did not get medicines at home, he had no problems with his treatment during the pandemic. “Once a month I stock up on my medicines. It has been seamless,” said the 26-year-old, who was diagnosed in December, as he waited for a check-up at a New Delhi hospital.

Manju Devi, 32, however, had to restart her medication after she failed to pick them up for two weeks during the lockdown.

“There was no transport on the road and the police were beating those venturing out,” said her husband Ram Chela from Lakhimpur Kheri of northern Uttar Pradesh state.

The lockdown not only restricted movement, but pushed millions into hunger and poverty as they lost jobs.

In response India promised free food, including 5 kgs (11 lbs) rice or wheat and lentils, to 800 million people. But economists and campaigners said few of those in need are registered with the federal food welfare scheme, or have the documents needed to secure benefits.

Dr. Hemant Deepak Shewade, who co-authored The Union article, said the lockdown may double levels of poverty and exacerbate food insecurity in India, where undernutrition in adults accounts for up to 44% of TB cases. Although the government provides 500 rupees ($7) as nutritional support to registered TB patients, Shewade urged the transfer of 7,500 rupees and more grains to the poorest, and a boost in rural jobs to improve diets.

“The current amount of rations ... covers only half of the calorie requirements,” he said.

While TB services gradually pick up, health experts were concerned that people were still reluctant to visit local facilities. “People are not coming to the public health facilities because there is deep stigma attached to COVID-19 and TB — it’s like a double stigma,” said Subrat Mohanty, head of Project Axshya, a civil society initiative that supports the government’s TB programme to detect and diagnose cases.

He said the project, which is funded by The Global Fund to Fight Aids, Tuberculosis and Malaria, stopped between April and June, so there were no door-to-door case findings, sputum tests or health camps. With lack of access to healthcare, harsh side effects of a cocktail of drugs and isolation, patients can develop mental health problems, including anxiety and depression, said Mehra of Survivors Against TB. “Basically motivation to continue medication becomes zero,” he said.

That was the case for Brijesh too.

He was initially relieved to stop his nine month course of medication that he said made him cranky, drowsy and nauseated.

But without treatment for nearly three months, he said he worried about transmitting the disease to his family or becoming multi drug-resistant — a major public health crisis in India.

He said it had been impossible to get drugs since his village was one of the worst-affected in this year’s floods. “I’m just scared now. If I go to a hospital, I can catch (the coronavirus). If I don’t my TB will get worse. What if I die?” he said.