India accounts for the highest TB burden globally; 27 percent of the cases are detected in India. If we have learnt anything from COVID-19, it is that prevention and caution are better than the cure
While the COVID-19 pandemic has gained prominence and disrupted health services in India, an endemic, tuberculosis (TB), also a primarily airborne disease, has silently spread its tentacles.
India accounts for the highest TB burden globally; 27 percent of the cases are detected in India. If we have learnt anything from COVID-19 , it is that prevention and caution are better than the cure. Then why are our TB programs hesitant to include preventative steps against TB?
While India has shown a tremendous increase in TB treatment between 2017 and 2019 (+35 percent), we cannot eliminate TB if we ignore the bidirectional link between undernutrition and TB. Despite India’s economic growth, we have an alarming number of undernourished and food insecure people, especially children, women, tribal and other communities who are financially marginalised. Undernutrition and TB have a causal relationship, it contributes to a staggering 55 percent of the annual TB incidence in India.
Even though malnutrition and undernutrition are considered synonyms, they are different. Malnutrition refers to an unbalanced diet, including excessive eating, while undernutrition, a deficiency of nutrients is subsumed under malnutrition.
Undernutrition pushes TB patients into a vicious cycle,it accelerates the progress of disease and leads to worse treatment outcomes once TB has developed. The catabolic effect of TB medicine results in weight loss and wasting, worsening malnutrition, which can be detrimental and even fatal. To break free of this cycle, the TB-affected and infected population need support for optimum nutrition.
However, the deadly combination of malnutrition and TB is often under-recognised or ignored.
Ignorance is lethal
A report from Chhattisgarh that observed 1695 adult pulmonary TB patients reveals that half of the men had weight less than 42 kilos while women were less than 34 kilos! Such malnutrition aggravates severe forms of TB that can have lethal, long-term implications such as the risk of severe disease, death, drug toxicity, drug malabsorption and worse, a higher risk of TB relapse after completing therapy.
In India, about 3,42,000 children are infected by TB, yearly; accounting for 31 percent of the global burden and 13 percent of the overall TB burden in the country; 40,000 children succumb to it every year. During our field visits in Madhya Pradesh, we have observed that a majority of severe acute malnourished (SAM) children have active TB. Their futures look bleak as they will be affected severely, if not fatally.
Pregnant women suffering from TB can be adversely affected, along with the foetus, neonate, and their children with short and long-term implications. The effects can range from repeated reproductive failure, foetal ill-health, preterm delivery, and TB of the new-borns and infants, which leads to high maternal and perinatal morbidity and mortality.
The cost of ignorance is high
Currently, the Indian government spends approximately Rs 13,500 to treat a TB patient, including general health service costs. This increases by 37 times, to Rs 5 lakh, to treat a case of Multi-drug-resistant (MDR)-TB! It makes financial sense for the government to focus on successfully treating TB patients, control progress of TB to MDR-TB and prevent further transmission.
While nutrition can help accomplish these goals, health departments ignore nutrition because it is seen as a welfare tool, not prevention. Secondly, the budgets only focus on medication, so nutrition uptake is termed ‘unaffordable’ even though a protein-rich food basket for a patient costs between Rs 13,000-15,000 per year.
While the government may argue that they provide Rs 500 direct cash benefit for TB patients’ nutritional needs under the Nikshay Poshan Yojana (NPY), how can poor patients afford a WHO-recommended protein-rich diet, especially with the increasing food prices? A recent study discovered that even after state-sponsored support, 50 percent families of TB patients face catastrophic costs as they struggle to meet the patient’s nutritional and other medical needs, pushing them further towards poverty and TB.
In Madhya Pradesh, after distributing protein-rich food baskets to TB patients for over a year, we have seen remarkable results:95 percent patients are TB-free and gained weight! Most of them have re-joined work too. This goes to prove that for a TB-free India, we need to consider interventions and support on multiple levels – prevention, treatment and rehabilitation.
Inequality of diseases
Since the pandemic, most human and economic health resources were re-allocated due to the high priority of COVID-19 . This has caused severe disruption in diagnosing and treating several health conditions, including TB, a more significant threat for the country. This has dramatically affected important outpatient activities and community-based TB disease prevention and health promotion programs.
While 6.3 million TB infections were notified in 2019, the figure fell to 4.9 million last year. Reports suggest that this 1.4 million people did not receive treatment for TB in 2020, leading to 500,000 additional deaths in 2020, according to a WHO modelling.
To control TB spread, it is necessary to prioritise early diagnosis, isolation, and treatment of TB patients so that they don’t become super-spreaders and secondary cases are avoided. However, the disruption of TB programs for the highly vulnerable populations such as poor, marginalised people and restrictions to personal mobility combined with diagnosis delay have negatively impacted vulnerable populations and increased household transmission.
Further, the similarities between TB and COVID-19 symptoms have hindered the detection of TB, leading to misdiagnosis, which we suspect will have an impact on community transmission.
Solutions
Addressing undernutrition requires considering TB patients and their families under social protection programs such as India’s Targeted Public Distribution System (TPDS). The TPDS system should focus on including protein-rich ingredients such as millets, lentils, eggs and meats to address malnutrition and diseases.
The inter-related ministries such as Women and Child Development and Family Welfare should work together with the health ministry in the TB control programs to ensure nutrition and food adequacy of the common beneficiaries.
Local-level administrations should keep appropriate budgets for nutritional provisions in annual projects after estimating the region’s annual TB notification, need for additional nutritional support, and content and cost of food baskets.
Screening for TB should be mandatory at all health camps to ensure that identified TB patients are supported by the Nutritional Rehabilitation Centres (NRCs) to work on nutritional deficiencies.
Through our projects in MP, ChildFund has seen the benefits of community-based programs to educate families on links between nutrition and TB, hygiene practices and counselling. We have also used CSR funds successfully for nutritional support to TB patients. This can be further explored, especially in piloting new strategies for a specific defined population, e.g., urban slum population, certain tribal areas etc.
Perhaps the country’s goal to make India TB-free by 2025 is aspirational, but if we start paying attention, we can beat this disease in the next decade by ensuring that malnutrition is addressed.
Pratibha Pandey, is senior health specialist, ChildFund India.