Caring for TB patients in the time of Coronavirus

— By Dr KK Aggarwal

India continues to have the highest burden of both TB and drug-resistant TB in the world. India launched a TB Free India Campaign on March 13, 2018 at the Delhi End TB Summit and has set 2025 as the deadline of eliminating TB from the country.

Today, with much of the global focus, including resources, being shifted towards Covid-19, other diseases such as TB run the danger of being relegated to the background.

But, can we afford to do so? Not, if we are to meet the deadline, which is five years before the global target of 2030.

There are lessons to be learnt from Covid-19. Covid-19 has in a way shown us the path to control the TB burden in the country. Prevention is the key and this is what will bring us closer to our goal of making India TB-free.

Both Covid-19 and TB can have similar symptoms such as cough, fever and difficulty breathing. Do not ignore any patient with cough. The WHO recommends that tests for both conditions should be made available for individuals with respiratory symptoms.

TB is an airborne infection which spreads via droplet nuclei (< 5 µ in size) released into the air when the infected person coughs, sneezes, sings or even talks. Covid-19, though not yet known to be air-borne, spreads by large droplets (< 5 µ in size).

Open TB cases are infectious and just being within close proximity of an infected person may expose a person to the risk of acquiring the infection. The risk of disease transmission is particularly high in overcrowded conditions. Anybody could be harboring the infection and therefore could be the source of infection, which could also be Covid-19.

Measures must be put in place to limit disease transmission; protective measures such as basic infection prevention and control, hand hygiene, cough etiquette are common to both.

All household and close contacts of patients with infectious TB should be traced and tested and treated with a full course of ATT if found positive for TB. This also includes people living with HIV and other people at risk with lowered immunity or living in crowded settings. These groups are also at high risk of Covid-19. And if infected, they are at risk of developing severe disease.

Contact tracing interrupts the chain of transmission of the disease by early diagnosis of cases as well as timely and complete treatment.

All TB patients, especially active and drug-resistant cases, should be isolated or self-quarantined for 14 days.

The CDC has defined the “minimum period of isolation of the patient – pulmonary tuberculosis (also includes mediastinal, laryngeal, pleural, or miliary). Until bacteriologically negative based on three appropriately collected and processed sputum smears that are collected in eight – 24 hour intervals (one of which should be an early morning specimen), and/or until 14 days after the initiation of appropriate effective chemotherapy, provided therapy is continued as prescribed, and there is demonstration of clinical improvement (i.e., decreasing cough, reduced fever, resolving lung infiltrates, or AFB smears showing decreasing numbers of organisms.” (Available at: https://www.cdc.gov/tb/programs/laws/menu/isolation.htm)

Every case of TB should be notified and diligently followed up during the course of its treatment. Public awareness at grass root level must be created to the scale similar to Covid-19.

Social distancing, adopted as preventive measure for Covid-19 may interrupt treatment of TB. The government must act to ensure availability of anti-tuberculosis treatment.

TB is a treatable condition. But, any disruption in treatment can result in drug-resistant TB.

The WHO has published an information note to assist national TB programs and health personnel to urgently maintain continuity of essential services (prevention, diagnosis, treatment and care) for people affected with TB during the COVID-19 pandemic. It has cautioned that during the Covid-19 pandemic, adequate stocks of TB medicines should be provided to all patients to take home to ensure treatment completion without having to visit treatment centers unnecessarily to collect medicines.

Following this call from the WHO, the government has said that it has enough drugs to last until March 2021 and India’s TB patients will not be affected. Drugs will be issued for a month in advance so that patients have enough medicines with them even case of a lockdown (https://www.indiaspend.com/covid19-could-disrupt-tb-drug-supply-hitting-those-most-vulnerable-to-the-virus/, March 24, 2020).

The government has now allowed doorstep delivery of essential medicines during the 21-day national lockdown vide a notification dated 26th March, “…in exercise of the powers conferred by Section 26B of the Drugs and Cosmetics Act, 1940 (23 of 1940), the Central Government hereby directs that in case any person holding a license in Form-20 or Form-21 under the Drugs and Cosmetics Rules, 1945 to sell, stock or exhibit or offer for sale, or distribute drugs by retail, intends to sell any drug including the drugs specified in Schedule H except narcotics, psychotropics and controlled substances as defined in the Narcotic Drugs and Psychotropic Substances Act, 1985 (61 of 1985) and the drugs as specified in Schedule H1 & Schedule X to the said rules, by retail with doorstep delivery of the drug, the licensee can sell such drugs subject to the condition that any such sale of a drug specified in Schedule H shall be based on receipt of prescription physically or through e-mail…”

(https://www.mohfw.gov.in/pdf/Doorstepdelivery26B.pdf )

((The writer is President, CMAAO, HCFI and Past national President IMA))