Surge in cases appears imminent because of delayed TB diagnoses and treatments during pandemic
Worldwide focus on the novel SARS-CoV-2 reversed momentum that was halting an age-old killer. Tuberculosis (TB) remains the world's most-lethal infectious disease after COVID-19, and, according to an infectious disease expert at the University of Colorado Anschutz Medical Campus, health experts had planned to end the TB epidemic by 2035.
Those hopes have been pushed back between five to 12 years, experts believe. "We are trying our best (to reach the 2035 target), but because of COVID, now most of those hopes are lost," said Aakriti Pandita, MD, assistant professor of medicine at the University of Colorado School of Medicine.
"I think we were on track to some extent … in the next couple of years to at least decrease it," Pandita said of tuberculosis, which killed over 1.5 million people in 2020. In the meantime, TB deaths are surging.
Pandita, a survivor of both COVID-19 and TB, brings a patient's perspective to both diseases. She became the fourth case of COVID - and first healthcare worker - infected in Rhode Island in early 2020. She came down with TB in 2015 when she was a second-year resident at SUNY Upstate (N.Y.) Medical University Program. With COVID, it took 12 days to get diagnosed. With TB, it took 12 months.
'Grand masquerader'
Pandita said TB is known as the "grand masquerader" because of its ability to mimic other diseases.
Tuberculosis, a bacterium that most commonly infects the lungs but can strike anywhere in the body, attacked Pandita's spine, making it especially difficult to diagnose. At the time, not much was known about spinal TB and Pandita received not only the wrong treatment regimen, but drugs that worsened her condition.
TB Has a Tendency to Become Drug Resistant Of the many insidious aspects of tuberculosis, perhaps the worst is its tendency to become resistant to drugs the longer it goes unchecked.
Drug-resistant TB is the most-feared diagnosis, Aakriti Pandita, MD, said. "With TB, it's another reason it's so crucial and time-sensitive to receive a diagnosis as early as possible."
Treatment often requires four or five drugs and over the span of many months - if not a year or two, she said. "This makes it difficult to treat if resistance develops, especially since we don't have a ton of drugs available due to poor funding in TB." |
Now, Pandita is researching what happens to COVID patients who get TB, and vice versa, to see what the combination does to individuals. Is their disease worse? Will they have increased mortality? Does COVID activate latent TB? Pandita said one-third of the world population carries the latent bacterium.
She's keeping a close eye on the TB incidence rate. It took an unusual dip at the start of the COVID pandemic - 18% internationally and 19.4% in the United States.
Pandita said worldwide reporting of TB cases declined during the pandemic due to lockdowns, social distancing and COVID's disruption of the healthcare system. At the start of the pandemic, newly diagnosed TB patients had their treatments delayed, she said, allowing infections to worsen in a significant percentage of cases.
Meanwhile, collections of sputum, used to diagnose TB in the lungs, decreased sharply during the pandemic, allowing infections to progress without medical interventions and thereby increasing severity.
As the pandemic wore on and people returned to somewhat regular healthcare routines, many physicians began to see atypical cases of TB. "Because of COVID, we saw very unusual TB cases, or patients who presented very late in their clinical course and had substantial damage because of that," Pandita said. "It presented late and they were much sicker."
Bracing for a TB surge
Because of the delayed TB diagnoses and treatments during the pandemic, TB experts are bracing for a surge of the disease, which, due to improved diagnostics and treatments, had been targeted for global control within 15 years.
The illness dates back 3,000 years in India and more than 2,000 in China. TB caused an estimated 25% deaths in Europe from the 17th to 19th centuries.
"Worldwide experts are now concerned that deaths from TB are beginning to rise. Unless we act now, we'll see a rising number of TB cases and an increasing number of deaths in the next couple years," Pandita said. "It just takes that long to see the effects from COVID."
Much of the data at this point is early and anecdotal, but if trends persist, Centers for Disease Control and Prevention data from 2022 through 2025 will offer a hint of the overall case increase.
Colorado is a low-incidence TB state, with just 66 TB patients in 2019. Pandita said TB progress in Colorado has been static since 2012. To achieve a target elimination rate, the state would need to drop to below five or six cases a year.
Path to becoming an advocate
Pandita grew up in India and often experienced curfews and lockdowns during medical school in Kashmir, a volatile and disputed region divided between India and Pakistan.
Later, after her medical residency in upstate New York, Pandita secured a fellowship in infectious disease at Brown University in Rhode Island.
In early 2020, she traveled to Colorado where she became an attending physician later that year. Her husband joined her from California where he worked as a radiologist. Pandita still doesn't know how or where she caught COVID in February 2020 - quite possibly from air travel.
She wasn't hospitalized but recovery was difficult with the isolation and fever. Her experience with TB was much worse. It took a year to get diagnosed and another to recover. "My family got disrupted - they had to come from India to take care of me. I was in pain for a long time," she said.
Pandita joined We Are TB, a survivor group in the United States. Because of TB's lethality and easy transmission, the disease remains stigmatized, she said. Pandita is now a sought-after speaker on TB. She has spoken to Congressional panels advocating more research funding (it has languished for TB) and improved clinical care.
"As physicians, we can do a lot when it comes to policy change and acting on a larger scale," she said. "There are a lot of problems with TB - be it research, clinical aspects and even the patient care aspects of it. It's a very old kind of system (treatment- and research-wise). It's very patriarchal in a way."
'Human rights around it'
Often times, she said, patients don't know their rights when it comes to care. "There are a lot of inequities with TB," Pandita said. "With COVID, we saw less-privileged patients coming from poorer, vulnerable communities that were most affected. It's the same with TB. … There are a lot of human rights around it."
During her fellowship, Pandita traveled to India to work with tuberculosis patients. "I got decent treatment (for my case), but in India I saw the worst of the worst cases - patients who'd had back pain for three, four, five years before being diagnosed," she said. "I saw much more morbidity, and patients who couldn't care for themselves because they lacked money. Just the damage that delayed diagnosis did to them."
Pandita said it will require strong and focused political will to finally eliminate TB, and it surprises her that the message still needs to be underscored. Tuberculosis is, after all, still atop the pyramid of infectious disease killers.
"With infectious diseases in general, we tend to think they're not our problem," she said. "Infections spread. And if they are in one corner of the world, they will affect the whole world."
