Tuberculosis guidelines during Covid -19
Epidemic in the time of Pandemic
Dr Ajay Shankar,
JR, Respiratory medicine,
MMIMSR

Progress till lockdown
• Millenium development goals to Sustainable Development Goal
• End TB by 2025- 5yrs ahead of SDG
• Programme renamed as NTEP
• Active screening
• Public private partership
• Rapid increase in TB Notifications
• “Missing million TB cases” 24 lakh cases of 27lakh TB cases notified in 2019

Covid-19 will set fight against TB back
by at least 5 years
• Imminent disaster of Pandemic VS Long running Palgue

Challenges and stratergies to manage
TB during Covid-19
• Diagnosis of new active cases- 78% drop during lockdown
• OP setting challenges
• Community TB challenges
• Contact tracing applications
• Monitoring and supply of ATT
• Covid 19 testing and TB

Challenges contd..
• Covid -19 and TB disease
• Lockdown effects during covid-19 Pandemic
• PPE concerns
• Personal safety of HCW’s
• Effect on TB immunization program
• Economic consequence of Covid-19 Pandemic

COVID-19. Tuberculosis

Tuberculosis in the era of COVID-19 in India Vijay Kumar Jain a, *, Karthikeyan P. Iyengar b, David Ananth Samy b, Raju Vaishya c

Covid -19 And TB disease
• Early evidence suggest pateints with latent TB and
established disease have an increased risk of SARS-CoV 2
infection and predisposition to develop severe Covid-19
pneumonia
• Prevelance of Tb among Covid found to be 0.37 -4.47% in
different studies

Concurrent infection of SARS CoV and
TB
• Worser Prognosis
• 2.1 fold increased risk of severe COVID-19 Disease
• Prexisting lung damage
• If clinical picture Atypical test for both
• Special care to High risk patients- HIV, DM, Malnutrition

Guidance Note on Bi-Directional TB-COVID
Screening of TB among ILI/SARI cases
• A- Bi-Directional TB-COVID Screening
• B- TB Screening for ILI cases
• C- TB Screening for SARI cases

Bi- Directinal TB-Covid Screening
• For Diagnosed TB Patients
• All newly diagnosed and on treatment should be tested

• TB Screening for Covid Positive Patients
• 4-Symptom Complex
• Cough > 2 weeks
• Fever greater than two weeks
• Significant unexplained Weight loss
• Night Sweats
• History of contact with TB Patient
• History of Tb and Symptomatic

Intensive management of TB-COVID
co-morbid patients
• Link TB service faciities with COVID Isolation facilities
• Covid Screening updated in NIkshay Portal

TB Screening For ILI cases
• ILI with 4 symptom complex
• History of contact with TB
• History of TB
• ILI symptoms > 10 days

Diagnostic Algorithm

TB screening for SARI case
• SARI with 4 symptom complex
• History of Contact with TB case
• History of SARI symptoms > 10 days

Diagnostic Algorithm for SARI case

Rapid response Plan sept 2020
• Bidirectional TB-COVID screening
• Restore diagnostic facility diverted for covid
• Introduce lung health concept
• Replace smear microscopy by NAAT testing
• Home sample collection in Red zones
• Infection control, cough etiquette, mask use

Contd..
• Contact tracing and area mapping
• Migrant Stratergy
• Private sector involvement- IMA, IAP, ICS, FOGSI- professional medical bodies informed
about mandatory notification , free drugs and diagnosis.
• Modified DOT- TB SAMPARK, tele consultation
• Monthly supply of TB drugs with option of home delivery

Contd..
• Use Isolation facilty for DSTB DRTB
• Airborne infection control in OPD’s and IPDs
• Triaging at entry points
• TB ID cards for better mobility
• Single window system

*Covid-19
*Tuberculosis

Conclusion
• Global health is not a Zero-sum Game, we need to urgently tackle the
coronavirus pandemic and simultaneously deal with other existing health
priorities, we don’t need to pick one.
• Now that we have witnessed how easily one infectious killer can affect millions,
we should realize that TB is and will always be a major problem for us all.
• The very same urgency and actions we are taking against covid -19 are needed
against TB.

Long Covid
• The Battle ahead

Long Covid
• Currently no delineated consensus definition for the condition
• Long covid
• Post-covid syndrome
• Post acute COVID-19 syndrome
• Long haulers

NICE Definition
• Presence of signs and symptoms that develop during od following an
Infection consistent with Covid -19 which continues for 12 weeks or more
and are not explained by an alternate diagnosis.
• This includes both ongoing symptomatic covid-19 (4-12wks) and post Covid
syndrome (12 weeks or more)

hashtag disease
The Tweet that started it

Key literatures
• Huang, Jan 2021, cohoty study. 6month consequence
• Chopra, Nov 2020, Observational cohort, 60 days outcome
• Carvalho Schneider, Oct 2020, non critical COVID 19 follow up after 2months
• Carfi, July 2020, persistent symptoms in acute covid
• Halpin, July 2020, cross sectional study, post discharge symptoms and rehabilitation
needs
• Tenforde, July 2020, telephone interview study, delayed return to usual health

6-month consequences of COVID-19 in patients discharged
from hospital: a cohort study (Huang, January 2021).
Overall, in this large cohort study of 1,733 patients with COVID-19 assessed 6 months after
discharge, most patients exhibited at least one symptom, particularly fatigue or muscle
weakness, sleep difficulties, and anxiety or depression. More severely ill patients had
increased risk of pulmonary diffusion abnormality, fatigue or muscle weakness, and anxiety or
depression. The seropositivity and titers of the neutralizing antibodies were significantly lower
than at acute phase.

Sixty-Day Outcomes Among Patients
Hospitalized With COVID-19 (Chopra,
November 2020).
• Overall, in this observational cohort of patients hospitalized with COVID-19 in Michigan,
nearly 1 in 3 patients died during hospitalization or within 60 days of discharge. For most
patients who survived, ongoing morbidity, including the inability to return to normal activities,
physical and emotional symptoms, and financial loss, was common, confirming that the toll of
COVID-19 extends well beyond hospitalization.

Follow-up of adults with non-critical COVID-19
two months after symptoms' onset (Carvalho-
Schneider, October 2020).
• Overall, in this descriptive clinical follow-up study of 150 non-critical patients with COVID-19,
two-thirds of adults experienced persistent symptoms up to 2 months after symptom onset,
primarily anosmia/ageusia, dyspnea or asthenia.

Post-discharge persistent symptoms and health-related
quality of life after hospitalization for COVID-19 (Garrigues,
August 2020).
• Overall, in this study of patients with COVID-19 discharged from the hospital
and interviewed over 3 months post diagnosis, the majority of patients
experienced continued symptoms, most commonly including fatigue and
dyspnea.

Persistent symptoms in patients after acute COVID-19
(Carfi, July 2020).
Patient population:
• Overall, in this study of patients with COVID-19 discharged from the hospital with SARS-CoV-2
RNA clearance by RT-PCR and interviewed approximately 2 months after diagnosis, the
majority of patients experienced continued symptoms, with the most common symptoms being
fatigue and dyspnea.

Post-discharge symptoms and rehabilitation needs in survivors of COVID-19
infection: A cross-sectional evaluation (Halpin, July 2020).
• Overall, in this study of patients with COVID-19 discharged from the hospital at least 4
weeks prior to study enrollment, the majority of patients experienced continued symptoms,
with the most common symptoms being fatigue and dyspnea.

Symptom duration and risk factors for delayed return to usual health among outpatients with
COVID-19 in a multi-state health care systems network — United States, March–June 2020
(Tenforde, July 2020).
• Overall, in this study of patients who were diagnosed with COVID-19 in the outpatient
setting, primarily had mild disease and were interviewed a median of 16 days post
diagnosis, the majority had continued symptoms. The most common symptoms
included cough and fatigue.

National Institute for Health Research (NIHR) suggests that Long Covid may be made up of 4
phenotypes
•Post-intensive care
•Post-viral fatigue
•Permanent organ damage
•Long-term COVID

Long COVID Symptoms
Long COVID can include a range of different signs and symptoms
across body systems including, but not limited to:
pulmonary, cardiovascular, gastrointestinal, reproductive,
genitourinary, endocrine, renal, dermatologic, musculoskeletal,
neurological, neuropsychiatric, immunological, ophthalmic, and
audiological.

Respiratory and Cardiovascular symptoms
• Breathlessness
• Cough
• Chest tightness
• Chest pain
• Palpitations

Generalised symptoms
• Fatigue
• Fever
• Pain

Neurological symptoms
• Cognitive impairment ('brain fog', loss of concentration or memory issues)
• Headache
• Sleep disturbance
• Peripheral neuropathy symptoms (pins and needles and numbness)
• Dizziness
• Delirium (in older populations)

Gastrointestinal symptoms
• Abdominal pain
• Nausea
• Diarrhoea
• Anorexia and reduced appetite (in older populations)
Dermatological
• Skin rashes

Musculoskeletal symptoms
• Joint pain
• Muscle pain
Psychological/psychiatric symptoms
• Symptoms of depression
• Symptoms of anxiety

Ear, nose and throat symptoms
• Tinnitus
• Earache
• Sore throat
• Dizziness
• Loss of taste and/or smell

Pathological Process
• Viral persistence
• Continued hyperactive immune response
• Cellular metabolic dysfunction
• Auto antibodies
• Neurological dysfunction
• Neuroimmunology
• Organ Impairment- Cardiac Impairment.

Mast Cell Activation Syndrome
• The prevalence of MCAS is similar to that of severe cases within the Covid-19-infected population.
Much of Covid-19's hyperinflammation is concordant with manners of inflammation which MC
activation can drive. Drugs with activity against MCs or their mediators have preliminarily been
observed to be helpful in Covid-19 patients.
• Hyperinflammatory cytokine storms in many severely symptomatic Covid-19 patients may be rooted
in an atypical response to SARS-CoV-2 by the dysfunctional MCs of MCAS rather than a normal
response by normal MCs. If proven, this theory has significant therapeutic and prognostic
implications.

Management of Long Covid
• Management of covid-19 after the first three weeks is currently based on limited evidence
• Approximately 10% of people experience prolonged illness after covid-19
• Many such patients recover spontaneously (if slowly) with holistic support, rest, symptomatic treatment, and gradual increase in activity
• Home pulse oximetry can be helpful in monitoring breathlessness
• Indications for specialist assessment include clinical concern along with respiratory, cardiac, or neurological symptoms that are new,
persistent, or progressive

4 point management of MCAS
➢Diet
➢Supplements
➢Anti Histamines
➢Mast Cell Stabilizers

Diet
• Low Histamine Diet
• Preserved meats such as smoked or cured meat, aged cheeses, fermented foods, and alcohol.
Cocoa, certain nuts, avocado, banana, shellfish, tomatoes, citrus fruits, legumes, and
strawberries are other foods high in naturally-occurring histamines.
• In general, avoid packaged or canned products and turn to fresh foods. Histamine levels in
foods can increase as they age, so it’s always ideal to cook fresh food daily when you’re battling
histamine.

Supplements
• Vitamin C
• Vitamin D
• Zinc
• Niacin
• Selenium
• Manganese

Anti histamines

Mast Cell Stabilizers

The ABCDEF of covid long care

Thank You