Reduced access to TB care contributes to more deaths in 2021

On the eve of World Tuberculosis Day, a report from the Brihanmumbai Municipal Corporation (BMC) revealed that Mumbai recorded more tuberculosis (TB) deaths in 2021 than the previous three years

Mumbai On the eve of World Tuberculosis Day, a report from the Brihanmumbai Municipal Corporation (BMC) revealed that Mumbai recorded more tuberculosis (TB) deaths in 2021 than the previous three years.

Collated for four years, the civic body’s data shows that Mumbai registered 1,917 TB deaths last year as against 1,352 in 2020, 1,478 in 2019 and 1,471 in 2018. (Hindustan Times)

Collated for four years, the civic body’s data shows that Mumbai registered 1,917 TB deaths last year as against 1,352 in 2020, 1,478 in 2019 and 1,471 in 2018. This year, till March 21, the civic body recorded 204 deaths.

The uptick in the number of TB deaths is a reflection of the World Health Organisation’s (WHO) 2021 Global Tuberculosis Report, which stated that for the first time in over a decade, TB deaths have increased because of reduced access to TB care due to the pandemic.

However, BMC officials said that death of TB patients solely from the disease reduced during the pandemic and many deaths may be attributed to Covid and/or respiratory failure, cardiovascular disease, HIV and such.

Dr Pranita Tipre, TB Head, BMC, said that deaths are collaborated deaths which also include other causes of death. “The civic body has an online registry of TB patients on which the death toll is updated. If any TB patient has succumbed due to other medical reasons, the portal will still show it as a TB death. Also, in the last two years, TB patients have contracted Covid infection and have succumbed to it, but it is written as TB deaths.”

Tipre added, “The civic body’s death audit committee will analyse these numbers. The death may not have been because of TB.”

But medical experts and health activists chose to differ with the civic body’s rationale for the rise in TB deaths in the city.

Dr Lancelot Pinto, pulmonary medicine specialist, PD Hinduja Hospital, Mahim, said, “There was an overall reluctance to approach the healthcare system due to lockdowns, and stigma associated with respiratory symptoms. In addition, over half of all patients with TB approach the private sector for their initial diagnosis and treatment, and it is plausible that economic hardships, diversion of healthcare workforce to Covid, difficulty accessing resources without mandatory RT-PCR reports, all contributed to delayed health-seeking, and consequently, delays in treatment initiation, resulting in deaths.” He added that the lack of adequate treatment of comorbid conditions such as diabetes, also associated with treatment outcomes in TB, could have contributed as well to the rise in deaths.

Ganesh Acharya, a TB survivor/TB-HIV activist, said that with the pandemic waning, it is time for the government to concentrate on TB, which is deadlier than Covid. He said that the number of new TB cases and deaths should be higher than what BMC figures reveal.

“TB deaths that are now recorded are all complex cases. We have more TB patients dying that are perhaps not getting reported,” he said.

Acharya emphasised on the need for early screening for infectious diseases. “There is still a huge amount of stigma attached to TB. People are scared to approach healthcare. We need to remove that stigma and encourage people for early screening, diagnosis and treatment. Door-to-door may not help us much,” he said.

Dr Vikas Oswal, who heads the TB programme at Shatabadi Hospital in Chembur, said in the pandemic, healthcare for TB patients was compromised. “All chest physicians were busy with Covid. There are many migrant TB patients in Mumbai who left for their native places with many not having enough stock of medicines. That led to defaulting on medications,” he said.

Dr Rajendra Nanavare, pulmonologist and ex-medical superintendent of BMC’s Sewri TB Hospital, said, “We had patients who had stopped taking medicines. They stopped coming to the hospital because there was a lockdown and there were travel restrictions etc. There was also a fear of getting Covid.”

Apart from TB deaths going up, the number of new TB cases, which saw a dip in 2020 with the start of the pandemic, also went up. New TB cases detected in Mumbai in 2020 were 43,464, out of which 4,367 were multidrug resistant (MDR) TB and 200 were Extensively drug-resistant (XDR) TB. In 2021, the city reported 58,840 new cases, out of which 5,909 were MDR TB and 126 were XDR-TB. Before the pandemic, in 2019, the city saw 60,597 new cases, of which 5,673 were MDR-TB and 794 were XDR TB.

MDR TB is caused by TB bacteria that are resistant to at least isoniazid and rifampin, the two most potent TB drugs. These drugs are used to treat all persons with TB disease. XDR TB is a rare type of multidrug-resistant tuberculosis (MDR TB) that is resistant to isoniazid and rifampin, plus any fluoroquinolone and at least one of three injectable second-line drugs (i.e., amikacin, kanamycin, or capreomycin).

Acharya said there is also a rise in primary infection of MDR-TB and XDR-TB , which is cause of concern. “In the pandemic, people were forced to stay indoors. The immune system of many got affected. While there was a rise in primary infection of MDR-TB and XDR-TB, there are high chances of these numbers going up,” he said.