Global rise in tuberculosis worries health experts

Temporary immunosuppressive effects of COVID, use of steroids, among other factors, behind spike

The rise in tuberculosis (TB) cases in India and globally has become a matter of concern for health experts. 

They claim COVID infections lead to an increase in the incidence of TB. The temporary immunosuppressive effects of COVID, lung damage, and the steroids used to treat the virus have lead to the reactivation of either previous infection or latent TB or the development of new TB.

Meanwhile, health experts have welcomed the patent of wonder drug Bedaquiline coming to an end in July, which they say will allow pharma companies to make a generic version that is affordable.

Mid-day, in its June 25, 2020 report ‘Experts warns of tuberculosis outbreak amidst COVID-19 pandemic’, highlighted how thousands of migrant workers had to quit taking their multidrug resistant (MDR) TB medicines midway due to the lockdown, increasing the spread of the disease to remote villages.

Dr Wiqar Shaikh, professor of medicine, Grant Medical College and Sir JJ Group of Hospitals, explained that TB is a common disease worldwide. Dr Shaikh said that the TB-causing bacteria, mycobacterium tuberculosis was discovered by Robert Koch, who was the director of the Royal Prussian Institute for Infectious Diseases in Germany. For his discovery, Koch was awarded the Nobel Prize in 1905. Dr Shaikh added that although the bacteria was discovered in 1882, TB has been around in the world for approximately 3 million years. He also highlighted the association of Koch with his institution (Grant Medical College) where the latter worked on the cholera-causing organism, Vibrio cholera.

Alarming numbers

Dr Shaikh stated that according to the World Health Organisation, there were 10.6 million cases of TB worldwide in 2022. The National TB Prevalence Survey of 2022 said that there were a total of almost 26 lakh TB cases in India in 2022, or 316 cases per lakh population, a jump of 19 per cent from the previous year. Indeed, as per the WHO Global TB Report of 2022, India is considered a high TB country and more than 26 per cent of TB cases in the world are from India.

Dr Shaikh said that in the world, almost 13 lakh people died of TB in 2022 and five lakh were Indians. Delhi is considered the TB capital of India, and last year the incidence of TB in Delhi was 737 cases per one lakh of the population, which is much higher than the national average.

The severe MDR TB affects about 1.24 lakh Indians, an average of nine cases per one lakh people. Dr Shaikh explained that the two tests used to determine MDR TB were the GeneXpert and the MGIT tests. The latter GeneXpert determines whether the patient is resistant to Rifampicin, the first-line drug used in the treatment of TB. The former test determines whether TB bacteria will grow in an MGIT tube in the presence of TB drugs. If the bacteria grow, MDR TB is confirmed.

Ramp up testing

Dr Shaikh added that the common drugs used to treat MDR TB were Bedaquiline, Pretomanid, Delamanid and Terizidone. Bedaquiline, he explained, was one of the earliest MDR drugs and was discovered by Koen Andries at Janssen Pharmaceuticals, now part of Johnson & Johnson. The company will be losing its patent on Bedaquiline and one can expect cheaper versions to come out in India. Dr Shaikh lamented the fact that the TB Alliance, the largest TB organisation in the world, has virtually no presence in India.

He said that people are not aware of when to obtain medical assistance when they get symptoms suspected to be TB.

Dr Shaikh also suggested that to bring TB under control in India, we need to ramp up testing and ensure widespread availability of drugs, particularly in rural areas, and also have health personnel frequently visit homes to detect and treat cases.

COVID and TB

Dr Ketan Vagholkar, professor of Surgery at Dy Patil Medical College, said, "There has been a surge in the incidence of TB during and after the pandemic. Diagnosis of TB during the pandemic was difficult and invariably delayed, causing disseminated TB. Difficulty in securing anti-TB medication during the pandemic added to the problems. This led to complications and drug-resistant TB.”

He added, “COVID itself leads to an increase in the incidence of TB. The temporary immunosuppressive effects of infection. lung damage and the steroids used to treat COVID-19 have played a direct role in immunosuppression, leading to the reactivation of either previous infection or latent TB or the development of new TB. Diagnosis is a big challenge as there is a significant overlap of pulmonary or respiratory symptoms, especially between long COVID and its variants and pulmonary TB. Patients with comorbidities had a very bad prognosis. It is necessary that citizens experiencing unremitting pulmonary symptoms meticulously follow up with their physician, especially the elderly and those suffering from comorbidities such as diabetes.”

TB re-emerging in city

Dr Subhash Hira, professor of global health at the University of Washington-Seattle and former Vice-Chair of the Global Fund-Geneva’s technical board whose experts successfully led the global control of infectious diseases, said, “About one-quarter of the world's population of 8 billion is infected with TB mycobacteria. But only a small proportion of those infected get sick. People with weakened immune systems eg HIV/AIDS, malnutrition, anaemia, chronic illnesses etc are at much greater risk of falling ill from TB. A person living with HIV is about ten times more likely to develop active TB in his or her lifetime. Many services were disrupted by the pandemic in 2020-22 but its impact on the TB control programme has been particularly severe. This is the first time in several years that an upward trend has been reported in the number of people developing both TB and MDR TB. Epidemiologists have attributed this trend to the pandemic."

He added, "There was under-reporting or under-diagnosis of ill persons or poor laboratory testing for TB leading to ‘missed TB cases’. There has been a decline in the global budget for TB diagnosis and control expenditures from US$6 billion in 2019 to $5.4 billion in 2021; almost half of the required annual budget of $13 billion. Since the outbreak of COVID-19 in 2020, the prevalent cases of TB in the world have doubled to 45 million cases: thus the global spending per case of TB has reduced to $130 per year, which is about R10,000, far less than the optimum requirement, which should have $260 per year per patient.”

Dr Hira stated that though the number of new TB cases dropped in 2020 and the restrictions in mass movements and universal usage of masks did reduce significant community transmission of TB, the later trend of work-from-home increased the vulnerability of home-bound women to TB and it is the number of new women and male TB patients are the same.” 

Testing is overlooked at times

Dr Santosh Bansode, emergency medicine specialist, said that because health professionals are concentrating on diagnosing COVID, testing for TB is overlooked sometimes. “Any patient with a cough that lasts more than three weeks should be screened for TB. Weight loss and general weakness are seen later. In pulmonary TB, we see fever along with cough. Anyone who has a prolonged cough and experiences weakness, weight loss and reduced appetite should be tested for TB. The public should be made aware of doses and length of treatment and encouraged to complete the course of treatment. TB can be fully cured if diagnosed at an early stage and complete treatment is taken. So early diagnosis is very important and TB symptoms should not be missed and testing and screening should be done as early as possible.”

Wonder drug patent almost over

Bedaquiline, which costs approximately R35,000, will cost to a few hundred rupees now that its patent is ending, according to Dr Hira.

“If the cost of Bedaquiline goes down, more people can use it. The government should provide this drug free of cost to poor patients with routine TB medicines in case of MDR TB on the advice of a doctor. In diseases like TB, poor people develop drug resistance if they discontinue or fail to complete the treatment due to any reason,” said Dr Bansode.

Scene in the rest of the world

According to Dr Hira, “In 2022, the top eight countries that have two-thirds of TB cases are India (28 per cent), Indonesia (9.2 per cent), China (7.4 per cent), the Philippines (7 per cent), Pakistan (5.8 per cent), Nigeria (4.4 per cent), Bangladesh (3.6 per cent) and the Democratic Republic of the Congo (2.9 per cent). There are several major challenges to global TB elimination by 2030; these include a rise in MDR-TB to 4.5 lakh new cases in 2021.”

Box: Rise in new TB cases*

*as stated by Dr Subhash Hira

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