Now, TB test recommended for COVID-19 patients in case of persisting cough

The latest clinical management guidelines by the national taskforce on the novel coronavirus disease (COVID-19) have advised positive patients to undergo a tuberculosis (TB) test if cough persists for more than two-three weeks.

The updated guidelines came from the Indian Council of Medical Research (ICMR) and the All India Institute of Medical Sciences (AIIMS) released January 17, 2022, have also listed active TB as a COVID-19 co-morbid condition.

The Indian government’s TB division had already advised bi-directional screening for TB in COVID-19 patients and vice-versa after the first wave in 2020. Prior to this, bi-directional screening was already underway for TB-diabetes and TB-HIV.

India was the first country to make this move after the pandemic hit, Shibu Vijayan, global TB technical director at PATH, a team of global innovators working towards achieving health equity, told Down To Earth.

“In the first two waves, the government had issued guidelines to look for TB infections in post-COVID patients. Once the SARS-CoV-2 virus infects you, it pulls down your immune system which could result in latent TB turning into an active infection,” Vijayan said.

India is a high TB burden country. Hence, there’s a high infection rate as well. If we’re not actively looking for TB cases, we might miss it and therefore trigger another transmission chain.

TB is an endemic disease in India, home to a quarter of the world’s total cases. Every third person has latent TB bacteria in their body, according to experts.

The second COVID-19 wave that hit India in early 2021 saw an indiscriminate use of steroids. This misstep in treatment, coupled with the use of immunosuppressive drugs, has the potential to trigger a latent presence of bacteria to turn into an active infection.

Symptoms of a COVID-19-TB co-infection include fever, cough, dyspnea, weight loss and fatigue.

According to a study published in Frontiers in Medicine last August, “older age, complications including hypertension, hepatitis, cancer, symptoms of dyspnea at admission, CT imaging features of bilateral lesions, infiltrates, tree in bud, and higher leucocyte count may be predictors for poor prognosis of COVID-TB patients.”

The study added that COVID-19-TB patients were 2.21 times more likely to die and 2.7 times more likely to develop severe disease than COVID-19 patients.

TB case determination came down as resources were redirected to handle the pandemic. DTE had earlier reported that India was on its way to miss the TB case notification target for 2021:

India contributed the biggest drop in case notifications last year, indicating that a large number of cases went undetected. About 41 per cent of all cases dropped in 2020 came from India.

The Modi government set an ambitious target to eradicate TB by 2025 — five years ahead of the global goal set by the World Health Organization (WHO). Experts argue this could be a good opportunity to ramp up case detection as the end goal nears.

The absolute percentage of those succumbing to the disease has risen to five-seven per cent now, up from one-two per cent during pre-COVID times.

It is clear that reported deaths among TB patients have gone up since the pandemic began. This is a proxy indicator that TB patients are getting diagnosed late.

This is a trend that has been recorded globally as well. According to WHO’s 2021 Global TB Report, deaths grew for the first time in over a decade. An estimated 1.5 million people died of TB in 2020. The figures are set to be even higher for 2021 and 2022.

Therefore, the new guidelines have been touted as a good opportunity by experts to increase detection of both COVID-19 and TB.

Some experts have cautioned that several TB patients who were under treatment can no longer be tracked.

“Thousands of patients under TB treatment are missing now. Most of them have either migrated back home or changed locations due to the pandemic. It is possible that many must have relapsed and could be transmitting further,” Rajiv Bajaj, Bihar Voluntary Health Association, Patna, told DTE.

Bajaj warned of an impending massive TB epidemic made worse by the high chances of drug resistance. He said the government came up with this step keeping all of these things in mind. “They are trying to play catch up with the spread of TB,” he added.

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