India’s syndemic of tuberculosis and COVID-19

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Rukmini Shrinivasan, Saurabh Rane, Madhukar Pai

Before COVID-19 became a global pandemic, India was dealing with another, much older epidemic—tuberculosis (TB)—which affected 2.64 million Indians in 2019 and killed nearly 450 000 people in the country. That is over 1000 TB deaths every single day, well before COVID-19 entered the picture. In fact, no country has a higher TB burden than India, which accounts for a quarter of the 10 million global TB cases and 1.4 million TB deaths each year.

Even before the pandemic, the cascade of TB care in India has been leaky, with long diagnostic delays, complex care pathways, poor quality of TB care in public as well as private health sectors and high TB case fatality.

While the COVID-19 pandemic did not escalate in India until May 2020, by early November, India has reported over 8 million cases of COVID-19, with over 125 000 deaths. As the pandemic continues to escalate, the healthcare system is falling apart under the stress. India’s economy (GDP) contracted by 24% in the April–June period in 2020.

While the public health system is collapsing under the stress of the growing COVID-19 caseload, the private healthcare system is becoming expensive and challenging to access.9 In both sectors, non-Covid-19 conditions are getting little attention.

When India went into a stringent lockdown on March 25, anecdotal evidence suggested that citizens were having difficulty accessing routine health services.10 A large part of the health administrative machinery had to be diverted in identifying and containing COVID-19 cases, many hospitals were designated as ‘COVID-19 only’ and others restricted routine services for fear of an infected patient causing an outbreak.

Additionally, the complete closure of public and most private transport made travel to health facilities difficult, and horror stories of patients with chronic conditions dying before they could make it to a doctor emerged in the media. Hundreds of thousands of migrants were forced to walk hundreds of miles back to their homes, and they received little by way of medical care. Tests, medicine refills and medical consultations are essential activities for patients but were severely disrupted due to lack of transportation, lockdown measures and an overwhelmed health system.

Large-scale disruption of TB and general health services

Official data on the extent of health service disruptions have been harder to come by. The National Health Mission’s Health Management Information System (NHM-HMIS),12 an administrative database, aims to collect and publish updated data from over 250 000 health facilities across the country nearly daily. The majority of the NHM-HMIS reporting facilities are in rural areas and are government-run, and their services range from immunisations and the distribution of contraceptives to the treatment of cancer, including all age groups, and both communicable and non-communicable disease treatment.

After the data for March 2020, summarised in an Indian newspaper in late April,10 the NHM-HMIS reported no new data for the next 3 months. In late August, data for April, May and June finally became available, and it laid bare a worrying disruption of all health services.11 In particular, the data show serious disruption in access to the prevention, monitoring and treatment of TB, India’s biggest infectious disease killer.

In March 2020, over 260 000 fewer children received the BCG vaccine that provides protection against childhood TB than in January 2020 (figure 1). The decline in April was even sharper—just half as many children received the BCG vaccine in April 2020 as in January 2020. These declines were also evident when the numbers are compared with the same months of the previous year. In May, there was some evidence of an improvement, but the numbers for both May and June were a long way from those earlier in the year or in previous years.