COVID-19 and its Effects on Occurrence of New Tuberculosis Cases

SUMMARY The lockdown due to COVID-19 has affected the world in many adverse ways. In India, it has caused worsening of poverty, increased rate of undernutrition, and probably underdetection of tuberculosis (TB) in the country. In country like India, where TB is strongly associated with poor socioeconomic status, these developments may have serious implications for TB progression. There is a fear that the post-COVID after effects has potential to reverse the gains made in the fight against TB over the past 5 years. It was found that there was almost 40% fall in new TB cases during initial 2 months of lockdown. However, there are no data from private institute. The study was conducted to find how the COVID-19 has affected the incidence of new TB cases in a private hospital. COVID-19 has affected the diagnosis of TB cases due to various reasons. Our analysis showed no significant difference among total number of patients visiting our outpatient in the year of 2020 compared to year of 2019 (P = 0.230). There was no statistically significant difference found in new TB cases (P = 0.243) as well as total GeneXpert samples sent (P = 0.230). SHORT COMMUNICATION India is one of the countries with highest burden of TB cases and deaths globally. It will be right to say that to end TB in the world; it is necessary to end TB in India. India accounts for more than a quarter of the world's 10 million estimated cases and 449,700 of the worlds estimated 1.3 million TB-related deaths.[1] Amrita Institute of Medical Sciences (AIMS), India, achieves the target of reducing TB incidence by 80% and TB deaths by 90% by 2025, 5 years before the global deadline in 2030.[1] As other countries of the world, India also had been affected badly with novel coronavirus (COVID-19) infection.[2,3] As a part of precautionary measures, to prevent spread of the COVID-19 pandemic in India, a nationwide lockdown for 68 days (March 26 to May 31, 2020) was implemented with phase-wise unlocking starting June 01, 2020.[4] It is estimated that the COVID-19 response-related lockdown may lead to an economic crisis which may double the percentage of people living below poverty and indirectly exacerbate food insecurity. The most common risk factor for TB is poverty and undernutrition.[5] The lockdown had also disrupted TB services. These developments may have serious implications for TB progression and transmission in India.[4] COVID-19 has caused two major setbacks which may affect TB epidemiology. Lockdown has caused worsening of poverty and underdetection of active TB. We did the current study to find whether it has actually caused the same effect on active case finding or not. As per published data, there was a 59% decrease in TB case detection in India, over a period of 8 weeks of lockdown (March 25 to May 19, 2020) as compared to the level of detection 8 weeks before the lockdown (January 29 to March 24, 2020).[4] This can be attributed to decrease number of patients visiting hospital. The decrease in TB case detection was 62% when compared to the level 1 year before (March 25 to May 19, 2019). This was calculated based on notification data extracted on June 11, 2020, from the NIKSHAY website (a case-based electronic TB notification system of India's National TB elimination Program). The private sector in the southern Indian state of Kerala follows the standards of TB care in India.[6] The AIMS, a private tertiary care hospital in Kerala, ensures 100% TB notification, as reported previously.[7] We were curious to know what happened to the TB patients diagnosed in this hospital. We studied the incidence of TB cases in year 2019 January to September and compared that with corresponding months in January-September 2020. The details are shown in Table 1. There was no significant difference in M: F ratio, even though a total number of cases were low in 2020 compared to 2019 [Figure 1].Table 1: Month-wise distribution of coronavirus disease-19 cases in the years of 2019 and 2020Figure 1: A bar diagram showing monthly distribution of new cases of tuberculosis in the year 2019–2020We found that the detection of new TB cases in our hospital in pre-lockdown months of January to March 2020 was quite similar to that of 2019 [Table 1]. In the month of March, the percentage of cases was almost 89% to that of 2019. After 25th March, there was a nationwide lockdown and Kerala was also part of it. We saw drastic fall of new cases in the month of April. A total of new cases of TB in April 2020 were 8 while it was 18 cases in April 2019. There was slight surge in new TB cases in months of May and June. However, since the month of July, the new TB cases came down. It was 26% less in the month of September when compared with corresponding month of the year 2019. We calculated P value for the difference in the incidence of cases in both groups, and we could not find any statistically significant difference among new TB cases; total outpatient (OP) cases and GeneXpert samples sent during the period of January–September, 2019–2020 [Table 2].Table 2: P value of difference between 2019 and 2020 tuberculosis incidencesDue to pandemic, priorities of health-care system shifted toward COVID-19 which had an adverse impact on TB diagnosis, treatment, and prevention.[8] A reduction in new TB cases in our hospital can be attributed to restricted movement due to lack of public transportation or fear of traveling to health facilities during lockdown. The reduction in TB detection may lead to increased transmission among community. It will be interesting to see how it affects the incidence in later months. There is a danger of increased mortality due to lack of timely initiations of treatment.[9] The WHO has circulated an information note on TB and COVID-19 emphasizing the need to avoid disruption of TB services during the COVID-19 pandemic.[10] CONCLUSION After marginal rise in TB cases in months of May to July 2020, the number of new cases of TB diagnosed in our hospital has significantly reduced gradually. In September 2020, the incidence of TB in our OP was only 28% to that of the last year. There was no statistically significant difference found between new TB cases; total OP cases and GeneXpert samples sent during March to September 2020, when compared with that of 2019. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.