Burden of TB during COVID-19 pandemic-single center experience

To the Editor, COVID-19 pandemic has impacted tuberculosis (TB) diagnosis, surveillance and management due to lock down, hesitancy in visiting hospitals due to fear of contracting SARS-COV-2, healthcare workforce shortage due to over-helming cases and lab burdened with testing for SARS-COV-2.[1] We looked at the burden of TB during COVID-19 pandemic in our institution and specific risk factors for TB during this period. A retrospective observational study by electronic medical record review was done in a 750 bedded quaternary centre in Kerala, South India, between January 2020–2022. Number of cases reported through NIKSHAY, the web enabled patient management system for TB control under the National Tuberculosis Elimination Programme (NTEP), during this period were noted and compared with previous years’ hospital and national data. Clinical and radiological features, associated with COVID-19 infection and comorbidities were looked at. During the study period 293 cases of TB were newly diagnosed of which 117 were diagnosed in 2020 and 176 in 2021. The trend in cases notified revealed that there was >50% drop in cases during 2020 as compared to 2018 and 2019 [Figure 1]. The nadir in case numbers was between March and June 2020 which was similar to national data and was during the period of lockdown in the country.[2,3] The cases gradually increased during later part of 2020 and in 2021 [Figure 2]. Majority were men (62%); 6.14% belonged to paediatric age group. Extrapulmonary TB (EPTB) was noted in 63%. The common comorbidities noted were diabetes mellitus (64%), chronic kidney disease (28%) and systemic hypertension (28%). Fifteen patients (5.12%) had TB diagnosed either concurrently (1%) or within 4 weeks (4.09%) of COVID-19 infection. Twelve of these cases were microbiologically confirmed TB; 3 were probable TB of which 2 cases were diagnosed as pleural TB based on the pleural fluid analysis and 1 was diagnosed as lymph node TB by histopathology. Among the 15 patients, one half had pulmonary TB; among the EPTB, lymph node TB (28.3%) was the commonest. Among those with TB and recent COVID-19 infection, 72% had received steroids.Figure 1: Monthly data of newly detected TB cases in numbers over the yearsFigure 2: TB cases repoted to Nikshay before and during COVID pandemicTo summarize, the number of TB cases reported during COVID-19 pandemic was low and least during lockdown period and is similar to national data, suggesting that delay in approaching healthcare could be a reason. Majority of patients who had TB post COVID-19 had history of steroid use for COVID-19 infection suggesting that steroids could be a risk factor for opportunistic infections like TB. This is of importance as India is a TB endemic country. Steroid use for COVID 19 should be as per guidelines and those exposed to steroids and other immune suppression should be closely followed up for opportunistic infections such as TB. Enhancing TB surveillance by integrating TB and COVID-19 diagnosis by bi-directional testing as recommended by the Ministry of Health and Family Welfare in India is the need of the hour for early diagnosis of TB during pandemic.[4] Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.