Tuberculosis

 Tuberculosis [TB] in the Covid 19 Pandemic

    Since time immemorial, tuberculosis [TB] has been a major cause of suffering and death. It is one of the oldest human diseases, with a history that predates humanity. TB has had a massive social and economic impact over the years, in addition to its medical implications. Each year, the WHO estimates that there are approximately 10.4 million new cases of tuberculosis and 1.8 million deaths from the disease. One-third of these new cases (approximately 3 million) are unknown to the health system, and many are not being treated properly. Tuberculosis is the world's leading cause of death among infectious diseases, claiming over 4000 lives every day.  

    As the world joins forces to combat the COVID-19 pandemic. It is critical to ensure that vital services and operations for dealing with long-standing health problems continue to protect the lives of people suffering from tuberculosis and other diseases or health conditions. We believe that losing sight of the unfinished business of tuberculosis control will jeopardise important milestones, gains, and ambitions, and that now, more than ever, is the time to care about TB. The COVID-19 pandemic has caused a rise in tuberculosis deaths for the first time in more than a decade. According to the World Health Organization's 2021 Global TB report, the COVID-19 pandemic has reversed years of global progress in combating tuberculosis, and TB deaths have increased for the first time in over a decade. More people died from tuberculosis in 2020, with far fewer people being diagnosed, treated, or given TB preventive treatment compared to 2019, and overall spending on essential TB services falling.

Overview of Covid 19 - The COVID-19 pandemic is potentially the greatest healthcare challenge of our time. The COVID-19 virus is a new pathogen that is highly contagious, spreads quickly, and has the potential to have massive health, economic, and societal consequences in any setting. Coronaviruses are a large family of viruses that can infect both animals and humans. Several coronaviruses are known to cause respiratory infections in humans, ranging from the common cold to more serious diseases like Middle East Respiratory Syndrome (MERS) and Severe Acute Respiratory Syndrome (SARS) (SARS). Rarely, animal coronaviruses can evolve, infect humans, and then spread between people, as seen with MERS and SARS.

    The Novel coronavirus disease (COVID-19) outbreak, which began in a seafood market in Wuhan, Hubei Province, China, in mid-December 2019, has now spread to 214 countries/territories/areas worldwide. On January 30, 2020, WHO (under International Health Regulations) declared this outbreak a "Public Health Emergency of International Concern" (PHEIC). On March 11, 2020, the World Health Organization declared COVID-19 a pandemic.

TB Facts - Tuberculosis (TB), the second deadliest infectious killer (after COVID-19), It is caused by bacteria (Mycobacterium tuberculosis), which most commonly affects the lungs. It can spread when people with tuberculosis expel bacteria into the air, such as when coughing. Each year, approximately 90% of those infected with tuberculosis (TB) live in 30 countries. Men accounted for 56 percent of all TB cases in 2020, adult women accounted for 33 percent, and children accounted for 11 percent. Many new cases of tuberculosis are caused by five risk factors: malnutrition, HIV infection, alcohol use disorders, smoking, and diabetes.

    The transmission of tuberculosis and COVID-19 is studied epidemiologically. While both tuberculosis and COVID-19 are spread through close contact between people, the exact mode of transmission differs, which explains some differences in infection control measures to mitigate the two conditions. People who inhale TB bacilli that remain suspended in the air in droplet nuclei for several hours after a TB patient coughs, sneezes, shouts, or sings can become infected. The size of these droplet nuclei plays an important role in determining their infectiousness. Their concentration decreases with ventilation and direct sunlight exposure.

    The main source of infection is people infected with the novel coronavirus. Close contact results in direct person-to-person transmission, primarily through respiratory droplets released when an infected person coughs, sneezes, or speaks. These droplets may also land on surfaces, where the virus can continue to replicate. Infection can also occur if a person comes into contact with an infected surface and then touches his or her eyes, nose, or mouth. Handwashing, along with respiratory precautions, is thus critical in the control of COVID-19.

Pathophysiology - The majority of COVID-19 patients have a respiratory tract infection caused by SARS-CoV-2 infection. They can, however, progress to a more severe and systemic disease in a small percentage of cases. Acute Respiratory Distress Syndrome (ARDS), sepsis and septic shock, multi-organ failure, including acute kidney injury and cardiac injury, characterise it. Autopsy findings in China and Europe revealed pulmonary vasculature endothelial damage, microvascular thrombosis, and haemorrhage.

    Clinically, COVID-19 symptoms can be similar to tuberculosis symptoms, such as fever, cough, and shortness of breath, but there is usually a difference in the rate at which the symptoms appear. The symptoms of COVID-19 are more likely to be recent. Patients with COVID-19 who sought treatment at various Covid facilities reported the following signs and symptoms: Fever, cough, fatigue, shortness of breath, expectoration, myalgia, rhinorrhea, sore throat, and diarrhoea Prior to the onset of respiratory symptoms, some people experience a loss of smell (anosmia) or a loss of taste (ageusia). Atypical symptoms such as fatigue, decreased alertness, decreased mobility, diarrhoea, loss of appetite, delirium, and absence of fever are more common in the elderly and immune-compromised patients. Children may not have complained about fever or coughing as frequently as adults. TB and COVID-19 symptoms can be similar, with cough, fever, shortness of breath, and malaise being common in both. Not only can this cause diagnostic confusion, but TB patients who are already stigmatised for coughing will be even more likely to be viewed with concern in the event of a pandemic, given the fear of COVID-19. As a result, people may be afraid to seek medical attention when they experience symptoms that are caused by tuberculosis.

Diagnosis - Accurate diagnostic tests are required for both tuberculosis and COVID-19. The tests for the two conditions are distinct, and both should be made available to people who have respiratory symptoms that are similar to those of the two diseases. An early diagnosis of both tuberculosis and COVID-19 is critical in the care of people who are at risk of adverse outcomes, including death. Older age, as well as certain comorbidities such as diabetes and chronic obstructive pulmonary disease, increase the likelihood of severe COVID-19 and the need for intensive care and mechanical ventilation. These risk factors are also poor prognostic indicators in tuberculosis. If TB patients have lung damage from previous tuberculosis sequelae or chronic obstructive pulmonary disease, they may develop a more severe illness if infected with COVID-19.

    Covid 19 treatment is symptomatic and supportive. The advantage for tuberculosis is that we do have effective treatments, including for drug-resistant forms of the disease. We also have treatments for the early stages of tuberculosis infection that can keep a person from becoming ill with the disease. The programme offers a standardised treatment regimen comprised of multiple anti-tuberculosis drugs. Typically, a drug regimen consists of a two to six month intensive phase followed by a four to one and a half year continuation phase. The programme provides various treatment regimens based on the nature of antimicrobial resistance to the disease. Depending on the pattern of drug resistance, a number of regimens comprised of a combination of 13 drugs are available for drug-resistant cases.

    Social Stigma - Tuberculosis stigmatization exists in many settings, but it is particularly prevalent in the community and workplace. COVID-19 is likely to cause it to rise and become perplexed. Fear is linked to stigma, and fear of COVID-19 will grow. This has already occurred in cases that have been primarily imported, with stigma directed not only at the affected patients, but also at their caregivers and family. This is also true for healthcare workers who are likely to be dealing with both COVID-19 and TB. India's Predicament According to one study in India, 15% of women with tuberculosis (equivalent to 100,000 women per year in the country) face rejection from their families. Before COVID-19 became a worldwide pandemic, India was dealing with a much older epidemic: tuberculosis. In fact, no country has a greater TB burden than India, which accounts for one-quarter of the world's 10 million TB cases and 1.4 million TB deaths each year. In 2019, 2.64 million Indians were affected, and nearly 450 000 people were killed in the country. That amounted to over 1000 TB deaths per day before COVID-19 entered the picture.

    Prevention is essential. Several characteristics of this virus make prevention difficult, including non-specific disease features, infectivity even before the onset of symptoms during the incubation period, transmission from asymptomatic people, and a long incubation period. Vaccines have saved more lives, reduced disability, and alleviated suffering than any other medical discovery or intervention. A vaccine aids the body's immune system in recognising and combating pathogens such as viruses or bacteria, thereby protecting us from the diseases they cause. Vaccines protect against more than 25 diseases, including measles, polio, tetanus, diphtheria, meningitis, influenza, tetanus, typhoid, and cervical cancer.

    There are reasons to be optimistic as the COVID-19 pandemic enters its third year. Vaccines, for starters, are lowering the number of deaths, at least in countries where vaccination is widely available. Second, there is mounting evidence that the most recent variant, Omicron, causes less severe disease than previous variants. COVID-19 can cause a variety of complications, including pneumonia, respiratory failure, blood clots, stroke, and heart attack, all of which can be fatal. Furthermore, the majority of those who die after contracting COVID-19 have one or more comorbidities.

How to safeguard yourself and others against COVID-19 variants?

1. Maintain a minimum distance of one metre between yourself and others.

2. Cover your mouth and nose with a well-fitting mask.

3. Open the windows.

4. Cough or sneeze into a tissue or a bent elbow.

5. Hands should be washed frequently.

6. Getting vaccinated may save your life.

7. COVID-19 vaccines offer effective protection against serious illness, hospitalisation, and death.

    A look at the history of tuberculosis reveals that it took humans thousands of years to identify the causative organism, and another 60 years to develop an effective treatment. Toward the end of the twentieth century, the twin disasters of HIV and tuberculosis, as well as multidrug-resistant tuberculosis [MDR-TB], appeared to be on the verge of destroying humanity. Tuberculosis has always been with us, only surfacing now and then to make us wiser.

Dr. Rajendra Nanavare

Chest physician Group of TB hospitals Sewri Mumbai.

Editorial manager Indian journal of Tuberculosis. Teacher, Lecturer and Examiner for Post graduate (post MBBS) Diploma and fellowship in Chest and TB. Tropical medicine and internal medicine College of physicians and surgeons Parel Mumbai.