“Will this injection make me catch infections more easily?” “I’ve heard about TB cases in patients on biologics — should I be worried?” These are among the most common questions I hear from patients in my rheumatology clinic, and they deserve honest, thorough answers. If you’re considering biologic therapy for conditions like rheumatoid arthritis, psoriasis, or inflammatory bowel disease, concerns about infection risk are completely valid — especially in India, which carries the world’s highest tuberculosis burden. This makes proper screening before starting treatment absolutely essential, not optional. Biologics work by targeting specific parts of your immune system, which is precisely why they’re so effective for autoimmune conditions. But this same mechanism can also lower your body’s defences against certain infections. The good news is that with proper screening, monitoring, and precautions, most patients can use these life-changing medications safely. As a DM Rheumatology specialist at NIMS Hospital Hyderabad, I’ve guided hundreds of patients through this process, balancing effective treatment with safety. In this guide, you will find answers to frequently asked questions about TB screening protocols, recognising warning signs of infection, understanding costs and assistance programs, and practical steps to protect yourself while on biologic therapy.
Why These Questions About Biologics and Infections Matter
When your doctor first mentions biologics, it’s natural to feel a mix of hope and worry. These powerful medicines can transform lives—controlling stubborn autoimmune conditions that haven’t responded to other treatments. But you’ve probably heard concerns about infections, and in India, those concerns carry special weight.
India carries the world’s highest tuberculosis (TB/क्षय रोग) burden. This isn’t just a statistic—it directly affects how we prescribe biologics. Before you start treatment costing anywhere from ₹15,000 to ₹1,50,000 per dose, thorough infection screening isn’t optional; it’s essential for your safety.
Your questions about infection risk aren’t signs of distrust or overthinking. They’re exactly what an informed patient should ask. Will I catch every cold? What about the TB my neighbour had? Can I visit my grandchildren safely? These worries deserve clear, honest answers.
**Key Point:** Being immunosuppressed doesn’t mean living in fear—it means being prepared, screened properly, and knowing which symptoms need immediate attention.
The good news? With proper screening, monitoring, and awareness, thousands of Indian patients safely benefit from biologics every year. Government schemes like PMJAY and manufacturer assistance programs can help manage costs, making safe treatment more accessible.
Let’s address your most pressing questions, starting with the fundamentals of how biologics affect your immune system.
What Are Biologics and Why Do They Increase Infection Risk?
Biologics are advanced medicines made from living cells that target specific parts of your immune system. Unlike older drugs that suppress immunity broadly, biologics block particular proteins — like TNF-alpha, interleukins, or B-cells — that drive inflammation (सूजन) in conditions like rheumatoid arthritis or psoriasis.
Think of your immune system as a security team protecting your body. Biologics are like removing specific guards who have become overactive and are attacking your own tissues. While this calms autoimmune attacks, it also creates gaps where infections — especially tuberculosis (TB) — can slip through undetected.
Why TB Risk Is Higher
TNF-alpha, blocked by many biologics, is crucial for keeping TB bacteria contained in your body. Without it, dormant TB (latent infection you may not know you have) can reactivate and spread.
**Important:** In India, where TB exposure is common, screening before starting biologics isn’t optional — it’s essential for your safety.
This is why your doctor will order specific tests before prescribing these medications.
Which Infections Should I Be Most Worried About While on Biologics?
Not all infections pose equal risk when you’re on biologics. Here are the key concerns:
Tuberculosis (TB/क्षय रोग) — The Primary Concern
India accounts for 27% of global TB cases. Biologics, especially TNF inhibitors, can reactivate dormant TB that you may not know you have. This is why TB screening before starting biologics is mandatory — not optional.
Other Serious Infections
• **Bacterial pneumonia** — lung infections that can progress rapidly
• **Skin infections** — cellulitis or abscesses requiring prompt treatment
• **Hepatitis B reactivation** — can flare dangerously if you’re a carrier
• **Fungal infections** — including oral thrush or deeper infections
• **Herpes zoster (शिंगल्स)** — painful reactivation of chickenpox virus
Why These Matter More Than Common Colds
Biologics target specific immune pathways that fight serious infections. A mild cold uses different defenses, so you’ll recover normally. But TB, pneumonia, and deep fungal infections require exactly the immune responses that biologics suppress.
**🚨 Seek immediate medical attention if you develop:** Fever above 101°F lasting more than 2 days, cough with blood, rapidly spreading skin redness, or severe fatigue with yellowing eyes.
Understanding which infections require vigilance leads us to the crucial first step: proper screening before you begin treatment.
Why Is TB Screening Mandatory Before Starting Biologics in India?
India carries the world’s highest tuberculosis burden, with nearly 28 lakh (2.8 million) new cases annually. This means many Indians harbour **latent TB** (सुप्त टीबी) — TB bacteria sleeping quietly in their bodies without causing symptoms or spread. You feel perfectly healthy, but the infection exists.
**Active TB** is different — it causes cough, fever, weight loss, and can spread to others.
Why Biologics Change This Risk
Biologics, especially TNF inhibitors like adalimumab and infliximab, work by suppressing parts of your immune system that normally keep latent TB contained. Without screening, starting these medications can “wake up” dormant bacteria, causing serious TB disease within weeks to months.
**Important:** TB screening is a safety checkpoint, not a barrier. Most patients clear screening smoothly and proceed to treatment without delays.
Think of it as checking your brakes before a long drive — a simple precaution that protects you throughout your treatment journey.
Let’s understand exactly what tests you’ll need and what results mean.
What Tests Are Done for TB Screening Before Biologics?
Before starting biologic therapy, your doctor will check for TB infection (टीबी संक्रमण) using a combination of tests. In India, where TB is common, thorough screening is essential.
Chest X-ray
This imaging test detects active TB in your lungs or signs of past infection. Cost: ₹200-₹500 at most centres.
Mantoux Test (TST)
A small amount of protein is injected under your skin. After 48-72 hours, your doctor measures any swelling. This indicates TB exposure but can give false results if you’ve received BCG vaccination. Cost: ₹100-₹300.
IGRA Blood Tests (QuantiFERON/T-SPOT)
These blood tests measure your immune response to TB bacteria and aren’t affected by BCG vaccination. They’re more specific but costlier—₹2,500-₹4,500 at private labs.
**Why both tests?** Your doctor may recommend TST and IGRA together because each can miss cases the other catches, especially in immunocompromised patients.
Understanding what happens if these tests reveal latent TB is your next important step.
What Happens If My TB Screening Is Positive?
A positive TB screening can feel alarming, but here’s the reassuring truth: **it doesn’t disqualify you from biologic therapy**. It simply means we take a careful, protective approach before starting treatment.
Understanding Your Result
A positive test usually indicates **latent TB** (सुप्त टीबी) — dormant bacteria in your body that aren’t causing active disease. In India, where TB exposure is common, many healthy people test positive without ever developing symptoms.
Treatment to Protect You
Your doctor will prescribe preventive therapy, typically:
• **Isoniazid** for 6-9 months, or
• **Shorter rifampicin-based regimens** (3-4 months)
These medications cost approximately ₹200-₹500 monthly and are highly effective at preventing TB reactivation.
When Can Biologics Begin?
Here’s the good news — **you don’t need to complete the entire TB treatment first**. Most rheumatologists safely start biologics after 1-2 months of consistent preventive therapy, once they confirm you’re tolerating the medication well.
**🚨 Contact your doctor immediately if** during preventive therapy you develop fever, persistent cough, night sweats, or unexplained weight loss — these may indicate active TB requiring evaluation.
With proper screening and prevention, thousands of Indian patients safely receive biologics every year. Next, let’s explore how we monitor for infections during your biologic treatment…
Do I Need Repeat TB Screening During Biologic Treatment?
Yes, repeat TB screening is essential while on biologics, especially in India where TB exposure risk remains high.
Recommended Surveillance Schedule
Most rheumatologists recommend:
• **Annual IGRA testing** (₹1,500-3,000) for patients on TNF inhibitors
• **Chest X-ray every 12-18 months** or if symptoms develop
• **Immediate testing** after known TB contact
Your doctor may increase frequency if you live in crowded areas, work in healthcare, or have household members with cough lasting over 2 weeks.
Warning Symptoms (चेतावनी के लक्षण)
**Seek immediate evaluation if you develop:** Persistent cough beyond 2 weeks, evening fever (शाम को बुखार), unexplained weight loss, night sweats, or fatigue — even if your last screening was normal.
Understanding what happens if you test positive helps you prepare for treatment adjustments.
Which Biologics Carry the Highest Infection Risk?
Not all biologics carry the same infection risk. Understanding these differences helps you appreciate why your rheumatologist recommends specific medications for your situation.
TNF Inhibitors (infliximab, adalimumab, etanercept)
These carry the highest TB reactivation risk — critical in India where latent TB is common. Among them, etanercept has slightly lower TB risk than infliximab or adalimumab. Cost ranges from ₹15,000-₹45,000 per dose, with biosimilars offering 30-40% savings.
Rituximab
Increases risk of respiratory infections and can lower immunoglobulin levels over time, particularly concerning if you already have low antibody levels.
Tocilizumab
Uniquely masks fever (बुखार) — you might have a serious infection without typical warning signs.
JAK Inhibitors
Associated with higher shingles (herpes zoster) risk; vaccination before starting is recommended.
**Key Point:** Your rheumatologist selects biologics based on YOUR specific risk profile — disease type, TB status, infection history, and budget constraints.
Now let’s explore exactly what screening happens before you start any biologic therapy.
Can I Take Vaccines While on Biologics?
Yes, but the type of vaccine matters greatly. Biologics suppress parts of your immune system, which affects how safely you can receive certain vaccines.
Safe Vaccines (Inactivated/Non-Live)
These contain killed viruses or just pieces of germs—your weakened immune system can handle them safely:
• **Flu shot** (injectable, not nasal spray)
• **COVID-19 vaccines** (Covishield, Covaxin, Corbevax)
• **Pneumococcal vaccine** (prevents pneumonia—highly recommended)
• **Hepatitis B**
• **Tdap** (tetanus, diphtheria, pertussis)
Vaccines to Avoid (Live Vaccines)
These contain weakened but living germs that could cause infection in immunosuppressed patients:
• **MMR** (measles, mumps, rubella)
• **Varicella** (chickenpox/छोटी माता)
• **BCG** (tuberculosis—important in Indian context)
• **Oral polio drops**
• **Nasal flu spray**
**Best Practice:** Complete all recommended vaccinations—especially pneumococcal and annual flu shots—at least 2-4 weeks *before* starting biologics. This gives your immune system time to build protection while it’s still functioning fully.
⚠️ **Contact your doctor immediately** if you’ve accidentally received a live vaccine while on biologics, or if a household member receives oral polio vaccine (they can shed the virus).
Understanding vaccination timing helps protect you—but knowing when to seek emergency care is equally vital…
What Should I Do If I Get an Infection While on Biologics?
If you develop signs of infection while on biologics—such as fever (बुखार), persistent cough, painful urination, or unusual fatigue—contact your rheumatologist promptly. Don’t panic, but don’t ignore symptoms either.
Should I Stop My Biologic?
**Never stop your biologic without consulting your doctor first.** In many mild infections (like a simple cold), continuing treatment is safe. For moderate-to-severe infections, your rheumatologist may temporarily hold the biologic until you recover. Stopping abruptly without guidance can trigger disease flares, complicating your recovery further.
When to Seek Immediate Care
**Urgent warning:** Seek emergency care for high fever (>101°F) lasting more than 2 days, difficulty breathing, blood in cough or urine, severe headache with neck stiffness, or rapidly spreading skin redness. These may indicate serious infections requiring hospitalization.
Keep your rheumatologist’s contact number accessible, and inform any treating doctor that you’re on immunosuppressants.
Understanding when routine monitoring is needed helps you stay protected between appointments.
Are Biosimilars as Safe as Original Biologics Regarding Infections?
Biosimilars (जैवसमान दवाएं) are near-identical copies of original biologic medicines. In India, biosimilars must pass rigorous testing by CDSCO (our drug regulatory authority) to prove they work the same way and carry equivalent safety profiles—including infection risks.
**The key point:** A properly approved biosimilar of rituximab or adalimumab carries the same TB risk and requires the same screening as the original brand. Your infection precautions don’t change based on whether you’re receiving the original or biosimilar version.
Why This Matters for Indian Patients
Biosimilars cost 30-40% less than originator biologics, making treatment accessible to more patients. For example, biosimilar adalimumab may cost ₹12,000-₹15,000 per dose versus ₹25,000+ for the original—significant savings over months of treatment.
**Patient Tip:** Don’t hesitate to discuss biosimilar options with your doctor. Lower cost doesn’t mean lower safety standards or reduced effectiveness.
Beyond safety equivalence, understanding how biologics actually increase infection risk helps you stay vigilant during treatment.
How Can I Reduce My Infection Risk While on Biologics?
Living well on biologics means taking sensible precautions without becoming fearful. Think of it as being careful, not restricted.
Daily Habits That Matter
**Hand hygiene** is your strongest defence—wash hands thoroughly before eating and after being in public spaces. Carry an alcohol-based sanitiser (₹50-150) when soap isn’t available.
**Food safety**: Avoid street food during initial treatment months, ensure meat is well-cooked, and drink filtered or boiled water. Wash fruits and vegetables thoroughly.
**Dental care**: Brush twice daily and get dental check-ups every 6 months—mouth infections can spread when immunity is lower.
Monsoon-Specific Precautions (मानसून में सावधानियां)
India’s monsoon brings unique challenges:
• Avoid wading through stagnant water (leptospirosis risk)
• Use mosquito repellents and nets (dengue, malaria prevention)
• Don’t consume cut fruits from vendors
• Keep wounds covered and dry
Balancing Caution with Normal Life
You don’t need to isolate yourself. Continue working, socialising, and enjoying life. During disease outbreaks (flu season, COVID waves), wear masks in crowded places like local trains or markets. Skip large gatherings only when community transmission is high.
**See your doctor urgently if**: Any wound becomes red, swollen, or produces pus; fever persists beyond 2 days; or you develop cough with breathlessness.
Knowing when to contact your rheumatologist—and what symptoms need immediate attention—is equally important for your safety.
Do Steroids and Other Immunosuppressants Add to Infection Risk?
Yes, combining biologics with steroids (स्टेरॉयड), methotrexate, or other DMARDs does increase infection risk compared to using any single medication alone. This is called “cumulative immunosuppression” — each medication slightly lowers your immune defenses, and together, the effect adds up.
This is precisely why your rheumatologist works to taper steroid doses once biologics start working — often reducing from higher doses to below 7.5 mg prednisolone daily, or stopping entirely when possible.
Why Combinations Are Still Used
Despite the added risk, these combinations often control disease better than single drugs, preventing joint damage and organ complications. The key is careful monitoring — regular blood tests, infection screening, and prompt reporting of fever or unusual symptoms.
**Contact your doctor immediately** if you develop fever above 100.4°F, persistent cough, or painful urination while on combination therapy.
With proper precautions, most patients safely manage these regimens for years, which brings us to what monitoring schedule you should expect.
What About Hepatitis B and C Screening Before Biologics?
Hepatitis B and C are viral infections affecting the liver (यकृत). Before starting biologics—especially rituximab or TNF inhibitors like infliximab and adalimumab—your doctor will test for these viruses through simple blood tests (HBsAg, anti-HBc, anti-HCV).
Why This Matters
Biologics can “wake up” a dormant hepatitis B virus hiding in your liver, causing sudden, severe liver damage called reactivation. This risk is highest with rituximab but exists with other biologics too.
Preventive Steps
If you test positive for hepatitis B (even past infection), you’ll likely need preventive antiviral tablets like tenofovir or entecavir (₹300-800/month) throughout biologic therapy. If you’re non-immune, hepatitis B vaccination is recommended before starting treatment.
**🚨 Alert your doctor immediately** if you develop yellowing of eyes/skin (पीलिया), dark urine, or severe fatigue during biologic therapy.
With hepatitis screening complete, let’s explore how to monitor for infections during ongoing treatment.
Is It Safe to Travel While on Biologics?
Travelling on biologics requires extra planning, but most trips are safe with preparation.
Before You Travel
Discuss your destination with your doctor 6-8 weeks ahead. Some travel vaccines (like yellow fever) use live viruses and are unsafe on biologics. Your doctor may adjust your dose timing around travel dates.
Carrying Medications
Keep biologics in a cooling bag during transit. Carry a doctor’s letter explaining your medication need—this helps at airport security and customs. Always pack medicines in hand luggage (हाथ का सामान), never checked bags.
Domestic Travel During Monsoon
Monsoon season increases waterborne and mosquito-borne infections. If travelling to rural areas or flood-prone regions, take extra precautions—boil drinking water, use mosquito repellents, and avoid street food.
**Before Travel:** Save contact details of a rheumatologist or immunologist at your destination. In emergencies, reach out to NIMS Hyderabad or AIIMS Delhi for teleconsultation guidance.
Finding Care Abroad
Research hospitals with immunology services before departure. Carry copies of your latest blood reports and TB screening results.
Understanding what symptoms need urgent attention helps you act quickly, whether at home or away.
When to See a Rheumatologist: Warning Signs You Shouldn’t Ignore
If you’re on biologics or other immunosuppressants, knowing when to seek help quickly can prevent serious complications. Here’s your clear guide to warning signs and what to do.
Red-Flag Symptoms That Need Urgent Attention
**Seek medical care within 24-48 hours if you experience:**
– Fever (बुखार) above 100.4°F (38°C) lasting more than 2 days
– Unexplained weight loss (वज़न कम होना) — losing 3-4 kg without trying
– Night sweats (रात को पसीना) that soak your clothes
– Cough lasting more than 2 weeks, especially with blood-tinged sputum
– Skin infections, wounds, or cuts that aren’t healing after a week
– Painful blistering rash on one side of your body (possible shingles/हर्पीज़)
Emergency Room vs. Clinic Visit
Go to the ER immediately if you have:
• High fever with confusion, difficulty breathing, or chest pain
• Spreading skin redness with fever (possible cellulitis)
• Any hospitalization-level illness while on biologics
A clinic appointment within 1-2 days is appropriate for:
• Low-grade fever without other alarming symptoms
• Minor infections that aren’t spreading
• New but stable symptoms you want evaluated
Emergency Contact Protocol
Keep these ready at all times: 1. Your rheumatologist’s emergency number 2. Name and dose of your biologic medication 3. Nearest hospital with infectious disease services
**Patient Tip:** Before starting biologics, ask your doctor: “What symptoms should make me call you immediately?” Save this list on your phone.
Understanding these warning signs empowers you to act decisively—now let’s address the most common questions patients have about biologics and infection risk.
Further Resources and Patient Support
Helpful Resources for Your Journey
Immunodoc Educational Materials
Access free, doctor-verified guides on biologics, TB screening, and infection prevention at Immunodoc.in. All content is reviewed by Indian specialists and updated regularly.
Insurance and Coverage
Check IRDAI guidelines for biologic coverage under your health policy. PMJAY (Ayushman Bharat) may cover treatment at empaneled hospitals—ask your hospital’s help desk.
Patient Assistance Programs
Most biologic manufacturers offer support programs reducing costs by 20-50%. Your rheumatologist or hospital pharmacist can guide you through applications.
Support Communities
Connect with autoimmune condition support groups (सहायता समूह) through hospitals or verified online platforms for shared experiences.
**Key Tip:** Always verify health information with your rheumatology team before making treatment decisions.
Your care team remains your most valuable resource throughout treatment.
Key Points for Patients
- TB screening is mandatory before starting any biologic therapy in India – never skip this step
- Not all infections mean you must stop biologics; contact your rheumatologist before making changes
- Vaccinations should ideally be completed 2-4 weeks before starting biologics – live vaccines are contraindicated during treatment
- Indian patients face unique infection risks due to endemic TB; regular monitoring every 6-12 months is essential
- Early reporting of fever, cough, or unusual symptoms can prevent serious complications
For Healthcare Professionals
This article was authored by Dr. Keerthivardhan, DM Rheumatology, NIMS Hospital, Hyderabad. India has the world’s highest TB burden, making pre-biologic screening non-negotiable. Biologics cost ₹15,000-₹1,50,000 per dose depending on the molecule, with biosimilars offering 30-40% cost savings. Government schemes like PMJAY may partially cover biologic therapy at empaneled hospitals, and patient assistance programs from manufacturers can help reduce out-of-pocket expenses. For clinical guidelines, refer to ACR, EULAR, and Indian Rheumatology Association (IRA) resources.
Reviewed by Dr. Keerthivardhan, DM Rheumatology · NIMS Hospital, Hyderabad. Last reviewed: April 2026. This article is for educational purposes only and does not replace professional medical advice. Always consult your doctor before changing your treatment.