India needs pulmonary rehabilitation in primary healthcare centres to combat post-tuberculosis lung sequelae: experts

Tuberculosis (TB) remains a significant global health concern, with 1.25 million deaths reported in 2023, according to the World Health Organization. India bears a substantial burden, accounting for 26% of global TB cases and 26% of TB-related deaths.

According to the Indian Journal of Respiratory Care (2022) and studies by The Lancet journal, many TB survivors continue to suffer from long-term lung damage, including fibrosis (scarring of lung tissue that reduces elasticity and impairs breathing), cavitation (formation of hollow spaces in the lungs due to tissue destruction), and airflow obstruction, despite completing their treatment.

These post-TB complications often lead to chronic respiratory impairment, reduced quality of life, and economic hardships due to lost wages and ongoing medical expenses. Hence, this calls for a renewed focus on comprehensive care, including palliative care and rehabilitation. The second UN high-level meeting on TB in 2023 made commitments to address these long-term consequences of TB, recognising the critical need for post-TB care.

The WHO, through its End TB Strategy, aims to eradicate TB by 2030, and India’s National Tuberculosis Elimination Programme (NTEP) has laid out post-TB follow-up guidelines to diagnose and manage complications. However, the practical implementation of these guidelines remains inconsistent, leaving many survivors without access to proper rehabilitation.

What is pulmonary rehabilitation and its status in India ?

According to the American Thoracic Society (ATS) and the European Respiratory Society (ERS), pulmonary rehabilitation (PR) is a multidisciplinary intervention designed to improve both the physical and emotional well-being of patients with chronic respiratory diseases. It is widely recognised as one of the most cost-effective treatments for improving lung function and overall quality of life. The Indian Journal of Respiratory Care identifies PR as the most effective and evidence-based tool to manage post-TB sequelae, helping to prevent further morbidity and mortality while improving patient outcomes.

According to Sanjeev Nair, professor of respiratory medicine, Government Medical College, Thiruvananthapuram, PR encompasses various aspects, including physical exercise, breathing techniques, medication adherence, psychosocial support, nutritional counselling, oxygen therapy, smoking cessation, and occupational rehabilitation.

Physical exercise plays a crucial role, incorporating upper and lower limb strengthening, treadmill exercises, and respiratory muscle training to enhance lung function. Additionally, breathing exercises such as diaphragmatic and pursed-lip breathing are essential in managing airflow limitations.

Ensuring continued medication adherence is another key component, as many post-TB patients struggle with proper drug intake, which can lead to further health complications. Psychological support is also integral, as TB survivors often experience anxiety and depression due to stigma and the long-term effects of the disease. Nutritional support helps strengthen immunity, while oxygen therapy benefits those with severe lung damage. Occupational rehabilitation programs, such as those at Tambaram Sanatorium, train survivors in vocational skills, allowing them to regain financial independence.

Dr. Nair points out that India currently lacks dedicated PR centres, with the Vallabhbhai Patel Chest Institute (VPCI), University of Delhi, Delhi, India being one of the few institutions offering structured programs. The Indian government has designated the Rajan Babu Institute in Delhi to focus on PR and Tambaram Sanatorium in Chennai for palliative TB care, but these initiatives remain under expert review and have yet to be fully implemented.

Early detection in controlling post-TB lung sequelae

Shibu Vijayan, chief medical officer, Global Health , Cure.ai, emphasises that pulmonary rehabilitation in India is still in a research phase rather than an implementation phase. He highlights the importance of early detection in controlling lung sequelae and stresses that this requires greater attention in both global and national TB care strategies. While there have been efforts to develop guidelines, many hospitals have yet to implement structured rehabilitation programs.

Dr. Vijayan points out that sequential X-rays and pulmonary function tests are critical diagnostic tools to assess structural lung damage post-TB treatment. He explains that the focus has now shifted to X-ray-based follow-ups, which allow healthcare providers to monitor lung damage more effectively. The government of India recommends a two-year follow-up for TB survivors, which includes baseline X-rays, intensive treatment X-rays, and pulmonary function testing. However, adherence to this protocol remains inconsistent across healthcare facilities. “Strengthening early detection methods and ensuring the widespread implementation of X-ray-based follow-ups could significantly improve long-term outcomes for TB survivors,” he says.

According to Dr. Nair, early detection can prevent further infection. Especially because studies, including one he was part of in Ernakulam, found that 25% of TB patients tracked had died within seven years. It is crucial to diagnose the lung damages early as it can otherwise lead to Chronic Obstructive Pulmonary Disease (COPD), ongoing lung obstruction, and abnormalities that impair daily activities.

Community concerns

Ganesh Acharya, TB survivor and activist, points out the ground realities of inadequate post-TB care facilities in hospitals across India. He emphasises that patients often struggle to find specialised care and are forced to seek out pulmonologists and TB specialists on their own.

Having battled TB for years, Acharya continues to suffer from asthma attacks, which frequently force him to take breaks from his career. He explains that post-TB care needs to be implemented like active TB treatmentas survivors remain vulnerable to complications and reinfection. “We need structured care, not just for treatment but for recovery,” he says. Due to his TB-related health issues, he underwent lung surgery, which further revealed the challenges of accessing quality post-TB medical support.

Acharya criticises the gap between policy and implementation, noting that while post-TB and palliative care are widely discussed, patients often struggle to find these services in practice.

Expanding post-TB care access

A major challenge is that TB care in India is largely decentralised, with treatment provided at primary healthcare centres that lack rehabilitation facilities. As a result, access to PR remains limited, especially in rural areas.

To improve post-TB care, Dr. Nair stresses the importance of expanding PR to primary healthcare centres, ensuring accessibility for all TB survivors. Kerala’s (Step wise approach to Airway Diseases) SWAAS programmeserves as a model for integrating COPD and TB care at the primary level. The programme provides mini spirometers for lung function assessments, supplies essential medications locally, and train nurses and healthcare workers to guide patients in breathing exercises and nutrition. Additionally, the involvement of local government bodies (panchayats) ensure continued financial and social support for TB survivors.

Experts urge that by adopting and scaling up PR models like these, starting from primary care centres, India can bridge the gap in post-TB care, reduce mortality rates, and enhance the overall well-being of TB survivors.