IN FOCUSSING ON COVID-19, FIGHT AGAINST ANOTHER SILENT PANDEMIC MUST NOT BE EASED

The alarming rate at which tuberculosis continues to strike death, technically it is no less deadly than CoViD-19, says RAJENDRA T NANAVARE on the Doctor’s Day.


Tuberculosis (TB) has been a major cause of suffering and death since times immemorial. Thought to be one of the oldest human diseases, the history of TB is as old as mankind. Over the years, not only the medical implications but also the social and economic impact of TB has been enormous. The World Health Organization (WHO) estimates that there are about 10.4 million new cases and 1.8 million deaths from TB each year. One-third of these new cases (about 3 million) remain unknown, and many are not receiving proper treatment. Tuberculosis is the world’s biggest killer among infectious diseases, claiming more than 4000 lives each day.

As the world comes together to tackle the CoViD-19 pandemic, it is important to ensure that essential services and operations for dealing with long-standing health problems continue to protect the lives of people with TB and other diseases or health conditions. To lose sight of the unfinished business of tuberculosis control will jeopardize important milestones, gains and ambitions, and we believe that now more than ever is the time to care about TB.

Tuberculosis and CoViD-19 both attack human lungs


Epidemiologically the transmission of TB and CoViD-19:

While both TB and CoViD-19 spread by close contact between people, the exact mode of transmission differs, explaining some differences in infection control measured to mitigate the two conditions. TB bacilli remain suspended in the air in droplet nuclei for several hours after a TB patient coughs, sneezes, shouts, or sings, and people who inhale them can get infected. The size of these droplet nuclei is a key factor determining their infectiousness. Their concentration decreases with ventilation and exposure to direct sunlight.

CoViD-19 transmission has primarily been attributed to the direct breathing of droplets expelled by someone with CoViD-19 (people may be infectious before clinical features become apparent). Droplets produced by coughing, sneezing, exhaling and speaking may land on objects and surfaces, and contacts can get infected with CoViD-19 by touching them and then touching their eyes, nose or mouth. Handwashing, in addition to respiratory precautions, are thus important in the control of CoViD-19. Hospital procedures that generate aerosols predispose to infection of both conditions and should only be conducted within recommended safeguards.

The data regarding CoViD-19 are changing daily. While the number of deaths due to CoViD-19 are increasing., about 1.5 million people died from TB in 2018 and, of this total, over 250,000 were HIV positive. This relates to more than 4,000 deaths a day due to TB.

Thus, TB is technically deadlier than CoViD-19, though one must consider the diseases vis-a-vis other risk factors like age, HIV status, quality of body’s immune systems, etc. People with active, untreated TB are far more likely to die than even the highest projected mortality estimates for CoViD-19, making it critical to address prevention and treatment options for TB. The co-infection of TB and CoViD-19 is still being discussed, but there is the possibility both could exacerbate the natural symptoms of the other and have negative impacts on a person’s health.

Clinically the symptoms of CoViD-19 can be similar to those of TB, with fever, cough and shortness of breath among other symptoms, but there is usually a difference in the speed with which the symptoms starts aggravating. CoViD-19 symptoms are likely to be of more recent onset.

Accurate diagnostic tests are essential for both TB and CoViD-19. Tests for the two conditions are different and both should be made available for individuals with respiratory symptoms, which may be similar for the two diseases. An early diagnosis of both TB and CoViD-19 is important in the care of people who are vulnerable to unfavorable outcomes, including death. Older age and certain comorbidities like diabetes mellitus and chronic obstructive pulmonary disease increase the likelihood of severe CoViD-19 and the necessity for intensive care and mechanical ventilation. These risk factors are also poor factors in TB. TB patients who have lung damage from past tuberculosis sequelae or chronic obstructive pulmonary disease may suffer from more severe illness if they are infected with CoViD-19.

Treatment of CoViD-19 is symptomatic and supportive. The advantage for TB is that we do have treatments that work, including for drug-resistant forms of TB. We also have treatments for the TB infection stage to prevent a person from becoming unwell with TB.

Tuberculosis Stigmatization:

This is a problem in many settings, though more so in community. It is likely to rise and be confounded by CoViD-19. Stigma is associated with fear, and fear of CoViD-19 will increase. This has already been seen in the cases primarily imported—with stigmatization being directed not only at the affected patients but also their care takers and family. This applies equally to healthcare workers who are likely to be managing both CoViD-19 and TB. The 2020 World TB Day had an emphasis on de-stigmatizing TB, but we should be de-stigmatizing any infectious disease. People do not go around spreading disease deliberately within their communities. As such, there is the need for stronger community engagement, including families and community-based groups being enabled to act as advocates.

The symptoms of TB and CoViD-19 can be similar. For example cough, fever, breathlessness and malaise being common in both. Not only can this create diagnostic confusion, but TB patients who are already stigmatized for coughing will be even more likely to be viewed with concern in Lower Middle Income Countries (LMICs), given the fear of CoViD-19. This could result in people being afraid to present to healthcare services when they have such symptoms that in fact result from TB. Negative social consequences, such as stigma, are a particular problem for women in some societies, restricting options for marriage and employment and even leading to divorce. A study in India indicated that 15% of women with tuberculosis (equivalent to 1,00,000 women per year nationally) faced rejection by their families.

A look at the history of TB reveals that it took thousands of years for humans to identify the causative organism, another 60 years to arrive at effective treatment. Towards the end of the twentieth century, the twin disaster of HIV and TB and multidrug-resistant tuberculosis (MDR-TB) seem to be on the verge of threatening to ruin the mankind. Tuberculosis has always been with us, only revealing itself every now and then and making us wiser.


RAJENDRA T NANAVARE is Chest physician & Chairperson DRTB center, Bedaquilin at GTB hospital, Mumbai, Ex-Pharmcovigilance in Drug Safety Monitoring committee for Bedaquilin at I.C.M.R and Ex-Consultant for international union against tuberculosis and lung diseases. He is also postgraduate teacher for Chest & TB in College of Physicians and Surgeons, Mumbai. He can be reached at docrajn1203@gmail.com


Opinions expressed in this article are of the author’s and do not represent the policy of The Edition. The writers are solely responsible for any claim arising out of the contents of their articles.

Tags: #Covid19 #Coronavirus #Tuberculosis #Destigmatization #HIV