Hidden Hepatitis Infections Pose Challenge To TB Elimination, Study Finds; Researchers Call For Integrated Screening

As India intensifies efforts to eliminate tuberculosis (TB), a new study has drawn attention to another largely overlooked public health challenge — viral hepatitis. Researchers have found that a significant proportion of TB patients are also infected with hepatitis B and hepatitis C viruses, co-infections that can complicate treatment, increase the risk of liver injury and adversely affect treatment outcomes.

The systematic review and meta-analysis, published in the Indian Journal of Medical Research, estimates that around one in every 10 TB patients in India is infected with hepatitis B, while 6% are co-infected with hepatitis C. Among TB patients living with HIV, hepatitis B prevalence rises to 17%, highlighting a particularly vulnerable group.

The study, conducted by researchers Dr. Arohi Chauhan, Dr. Abhinav Sinha, Dr. Yogesh Patel, Dr. Pankaj Nimavat, Dr. Sandeep Chauhan, and Dr. Sanghamitra Pati from the South Asian Institute of Health Promotion, the Indian Council of Medical Research (ICMR), the WHO National TB Elimination Programme Technical Support Network and other institutions, analysed data from 11 studies involving 4,502 TB patients across India.

Lead author Dr. Sanghamitra Pati said the findings underscore the need to integrate hepatitis screening and management within India's National TB Elimination Programme (NTEP), noting that these co-infections have remained under-recognised despite their important implications for patient care.

India accounts for more than a quarter of the global TB burden and also carries a substantial burden of chronic viral hepatitis. While both diseases are major public health concerns individually, their coexistence creates unique clinical and programmatic challenges.

Unlike TB, which primarily affects the lungs, hepatitis B and hepatitis C damage the liver. This becomes particularly significant because several first-line anti-TB medicines are potentially hepatotoxic. Patients with underlying chronic hepatitis are therefore more susceptible to drug-induced liver injury, treatment interruption, treatment modification and poorer outcomes.

The review titled, ‘Viral hepatitis co-infections with tuberculosis in India: A systematic review and meta-analysis,’ found that hepatitis B prevalence among TB patients is considerably higher than estimates reported for the general Indian population. Likewise, hepatitis C prevalence among TB patients was substantially higher than in the wider community. The burden was particularly high in studies from southern and western India.

The researchers observed that TB-hepatitis co-infection demands repeated liver function monitoring, additional diagnostic investigations and closer clinical supervision throughout treatment. Without integrated services, these patients are more likely to experience fragmented care, delayed diagnosis and interruptions in therapy.

The burden is even greater among patients with HIV and drug-resistant TB. Hepatitis B prevalence was estimated at 17% among TB-HIV co-infected patients and 11% among patients with drug-resistant TB.

The authors described this overlap as a "syndemic infectious complex", where multiple infectious diseases interact to worsen clinical outcomes and increase treatment complexity. They also noted that hepatitis medicines may interact with anti-TB drugs, while chronic liver disease can impair nutrition and immunity, both of which are essential for recovery from TB.

The review fills an important evidence gap by providing India-specific estimates of hepatitis B and hepatitis C among TB patients. Earlier regional analyses had pooled data from several South-East Asian countries and often failed to distinguish chronic hepatitis present before TB treatment from liver injury caused by anti-TB medicines.

Although the authors acknowledged that only 11 eligible Indian studies were available and that evidence on long-term treatment outcomes and the cost-effectiveness of routine hepatitis screening remains limited, they concluded that the available evidence supports closer integration of hepatitis services into TB care. They recommended considering routine hepatitis B and hepatitis C screening at the time of TB diagnosis, alongside systematic liver function monitoring and coordinated management of co-infected patients.

Commenting on the findings, Dr. Anuj K Bhatnagar, Doctor of Medicine- Tuberculosis and Respiratory Diseases; Consultant & Head , Department of Chest & Tuberculosis at Rajan Babu Institute for Pulmonary Medicine, who was not part of the study, highlights the need for greater attention to hepatitis B and hepatitis C among TB patients because liver disease can complicate TB treatment and adversely affect outcomes.

He noted that baseline liver function abnormalities are not uncommon among TB patients, with nearly 18% showing elevated liver enzymes before or during treatment. Under existing standard operating procedures, patients with deranged liver function are routinely evaluated for underlying hepatitis B and C infections.

"The study raises an important question. If we were to undertake routine screening of all TB patients for hepatitis B and C, similar to the existing screening for HIV and diabetes, we would obtain a much clearer estimate of the true burden of TB-hepatitis co-infection in the country," he said.

Dr. Bhatnagar pointed out that, unlike HIV and diabetes, where bidirectional screening is already recommended because of the established association with TB, there is currently no programme-based recommendation for routine hepatitis screening among all TB patients.

Patients with hepatitis co-infection are more likely to require modifications in anti-TB treatment because several first-line TB medicines can affect the liver. They are also at greater risk of adverse drug reactions, poor nutritional status, treatment interruption, relapse and recurrent infections.

"These patients constitute a vulnerable subgroup. Identifying them early allows physicians to monitor them more closely, individualise treatment and minimise complications," he said.

"The objective is not simply to treat TB but to cure it successfully with the fewest complications. If clinicians know at the outset which patients have hepatitis B or C, they can devote additional attention to those who are more likely to develop treatment-related problems," he explained.

Dr. Bhatnagar said the study should encourage policymakers to examine the feasibility of incorporating hepatitis screening into TB care.

Echoing similar views, Dr. Sumit Anand, Senior Medical Officer and Respiratory Physician, Dept of Medicine, Swami Dayanand Hospital under the Delhi Government, said the importance of the study extends well beyond documenting the prevalence of co-infection.

"Patients with underlying chronic viral hepatitis have reduced hepatic reserve and are therefore more susceptible to hepatotoxicity during anti-TB treatment. Such liver injury may necessitate interruption or modification of therapy, potentially compromising treatment success and increasing the risk of relapse or drug resistance," Dr. Anand explained.

Agreeing with Dr. Bhatnagar’s observation, he said the higher prevalence of hepatitis B among TB patients with HIV and drug-resistant TB further strengthens the case for integrated management of these vulnerable groups. While data on hepatitis C among drug-resistant TB patients remain limited, the availability of highly effective direct-acting antiviral therapy makes early diagnosis particularly valuable.

According to Dr. Anand, one of the strengths of the review is that it provides India-specific pooled estimates using a systematic methodology, although its findings should be interpreted in light of the relatively small number of studies, predominance of hospital-based data, regional variations and limited long-term follow-up.

He added that whether universal hepatitis screening should become national policy would depend on epidemiology, cost-effectiveness and programme feasibility.

"The encouraging message is that both diseases are now treatable. TB is curable, and Hepatitis C can be cured in more than 95% of patients with modern antiviral therapy. Early diagnosis, careful liver monitoring and coordinated management between TB and hepatology services can significantly improve patient outcomes while supporting India’s goal of TB elimination," said Dr. Anand.