The impact of the COVID-19 epidemic on tuberculosis control in China

Global Health Commodities Supply Chain in the Era of COVID-19 Pandemic: Challenges, Impacts, and Prospects: A Systematic Review

Background

The COVID-19 pandemic led to the most substantial health crisis in the 21st Century. This pandemic interrupted the supply of essential commodities for human beings. Among the essential commodities for human survival, disruption of the supply of essential health commodities has become a global concern.

Objective

The study aimed to systematically analyze published articles on the challenges, impacts, and prospects of the global health commodities' supply chain in the era of the COVID-19 pandemic.

Methods

A standard searching strategy was conducted in seven research databases to retrieve pertinent articles. Finally, 459 articles were retrieved for further screening, and only 13 articles were selected for final synthesis.

Results

Almost 38.5% of the studies targeted the supply chain of health commodities used to treat HIV, TB, and malaria. Lockdown policies, travel restrictions, lack of transportation, low manufacturing capacity, and rising costs were the significant challenges indicated for the supply interruption of essential health commodities and COVID-19 vaccines. Findings indicated that the supply interruption of essential health commodities leads to a devastating impact on global health.

Conclusion

Global medicine shortages due to the pandemic crisis can have a devastatingly harmful impact on patient outcomes and might result in a devastatingly long-lasting effect on the health of the world community. Supply-related challenges of the COVID-19 vaccine affect countries' ambitions for achieving herd immunity quickly. Monitoring the pandemic's effect on the health commodities' supply system and designing a short-term and long-term resilient health supply chain system that can cope with current and future health catastrophes is pivotal.

Analysis on time delay of tuberculosis among adolescents and young adults in Eastern China

Background

Tuberculosis (TB) is recognized as a significant global public health concern. Still, there remains a dearth of comprehensive evaluation regarding the specific indicators and their influencing factors of delay for adolescents and young adults.

Methods

All notified pulmonary TB (PTB) patients in Jiaxing City were collected between 2005 and 2022 from China's TB Information Management System. Logistic regression models were conducted to ascertain the factors that influenced patient and health system delays for PTB cases, respectively. Furthermore, the impact of the COVID-19 pandemic on local delays has been explored.

Results

From January 1, 2005 to December 31, 2022, a total of 5,282 PTB cases were notified in Jiaxing City, including 1,678 adolescents and 3,604 young adults. For patient delay, female (AOR: 1.18, 95%CI: 1.05-1.32), PTB complicated with extra-pulmonary TB (AOR: 1.70, 95% CI: 1.28-2.26), passive case finding (AOR: 1.46, 95% CI: 1.07-1.98) and retreatment (AOR: 1.52, 95% CI: 1.11-2.09) showed a higher risk of delay. For health system delay, minorities (AOR: 0.69, 95% CI: 0.53-0.90) and non-students (AOR: 0.83, 95% CI: 0.71-0.98) experienced a lower delay. Referral (AOR: 1.46, 95% CI: 1.29-1.65) had a higher health system delay compared with clinical consultation. Furthermore, county hospitals (AOR: 1.47, 95% CI: 1.32-1.65) and etiological positive results (AOR: 1.46, 95% CI: 1.30-1.63) were associated with comparatively high odds of patient delay. Contrarily, county hospitals (AOR: 0.88, 95% CI: 0.78-1.00) and etiological positive results (AOR: 0.67, 95% CI: 0.59-0.74) experienced a lower health system delay. Besides, the median of patient delay, health system delay, and total delay during the COVID-19 pandemic were significantly lower than that before.

Conclusion

In general, there has been a noteworthy decline in the notification rate of PTB among adolescents and young adults in Jiaxing City while the declining trend was not obvious in patient delay, health system delay, and total delay, respectively. It also found factors such as gender, case-finding method, and the hospital level might influence the times of seeking health care and diagnosis in health agencies. These findings will provide valuable insights for refining preventive and treatment strategies for TB among adolescents and young adults.

Toward tuberculosis elimination by understanding epidemiologic characteristics and risk factors in Hainan Province, China

BACKGROUND

The disease burden of tuberculosis (TB) was heavy in Hainan Province, China, and the information on transmission patterns was limited with few studies. This atudy aims to further explore the epidemiological characteristics and influencing factors of TB in Hainan Province, and thereby contribute valuable scientific evidences for TB elimination in Hainan Province.

METHODS

The TB notification data in Hainan Province from 2013 to 2022 were collected from the Chinese National Disease Control Information System Tuberculosis Surveillance System, along with socio-economic data. The spatial-temporal and population distributions were analyzed, and spatial autocorrelation analysis was conducted to explore TB notification rate clustering. In addition, the epidemiological characteristics of the cases among in-country migrants were described, and the delay pattern in seeking medical care was investigated. Finally, a geographically and temporally weighted regression (GTWR) model was adopted to analyze the relationship between TB notification rate and socio-economic indicators. The tailored control suggestions in different regions for TB elimination was provided by understanding epidemiological characteristics and risk factors obtained by GTWR.

RESULTS

From 2013 to 2022, 64,042 cases of TB were notified in Hainan Province. The estimated annual percentage change of TB notification rate in Hainan Province from 2013 to 2020 was - 6.88% [95% confidence interval (CI): - 5.30%, - 3.69%], with higher rates in central and southern regions. The majority of patients were males (76.33%) and farmers (67.80%). Cases among in-country migrants primarily originated from Sichuan (369 cases), Heilongjiang (267 cases), Hunan (236 cases), Guangdong (174 cases), and Guangxi (139 cases), accounting for 53%. The majority (98.83%) of TB cases were notified through passive case finding approaches, with delay in seeking care. The GTWR analysis showed that gross domestic product per capita, the number of medical institutions and health personnel per 10,000 people were main factors affecting the high TB notification rates in some regions in Hainan Province. Different regional tailored measures such as more TB specialized hospitals were proposed based on the characteristics of each region.

CONCLUSIONS

The notification rate of TB in Hainan Province has been declining overall but still remained high in central and southern regions. Particular attention should be paid to the prevalence of TB among males, farmers, and out-of-province migrant populations. The notification rate was also influenced by economic development and medical conditions, indicating the need of more TB specialized hospitals, active surveillance and other tailored prevention and control measures to promote the progress of TB elimination in Hainan Province.

Epidemiological characteristics of seven notifiable respiratory infectious diseases in the mainland of China: an analysis of national surveillance data from 2017 to 2021

BACKGROUND

Respiratory infectious diseases (RIDs) remain a pressing public health concern, posing a significant threat to the well-being and lives of individuals. This study delves into the incidence of seven primary RIDs during the period 2017-2021, aiming to gain deeper insights into their epidemiological characteristics for the purpose of enhancing control and prevention strategies.

METHODS

Data pertaining to seven notifiable RIDs, namely, seasonal influenza, pulmonary tuberculosis (PTB), mumps, scarlet fever, pertussis, rubella and measles, in the mainland of China between 2017 and 2021 were obtained from the National Notifiable Disease Reporting System (NNDRS). Joinpoint regression software was utilized to analyze temporal trends, while SaTScan software with a Poisson probability model was used to assess seasonal and spatial patterns.

RESULTS

A total of 11,963,886 cases of the seven RIDs were reported during 2017-2021, and yielding a five-year average incidence rate of 170.73 per 100,000 individuals. Among these RIDs, seasonal influenza exhibited the highest average incidence rate (94.14 per 100,000), followed by PTB (55.52 per 100,000), mumps (15.16 per 100,000), scarlet fever (4.02 per 100,000), pertussis (1.10 per 100,000), rubella (0.59 per 100,000), and measles (0.21 per 100,000). Males experienced higher incidence rates across all seven RIDs. PTB incidence was notably elevated among farmers and individuals aged over 65, whereas the other RIDs primarily affected children and students under 15 years of age. The incidences of PTB and measles exhibited a declining trend from 2017 to 2021 (APC = -7.53%, P = 0.009; APC = -40.87%, P = 0.02), while the other five RIDs peaked in 2019. Concerning seasonal and spatial distribution, the seven RIDs displayed distinct characteristics, with variations observed for the same RIDs across different regions. The proportion of laboratory-confirmed cases fluctuated among the seven RIDs from 2017 to 2021, with measles and rubella exhibiting higher proportions and mumps and scarlet fever showing lower proportions.

CONCLUSIONS

The incidence of PTB and measles demonstrated a decrease in the mainland of China between 2017 and 2021, while the remaining five RIDs reached a peak in 2019. Overall, RIDs continue to pose a significant public health challenge. Urgent action is required to bolster capacity-building efforts and enhance control and prevention strategies for RIDs, taking into account regional disparities and epidemiological nuances. With the rapid advancement of high-tech solutions, the development and effective implementation of a digital/intelligent RIDs control and prevention system are imperative to facilitate precise surveillance, early warnings, and swift responses.

The lived experiences of tuberculosis survivors during the COVID-19 pandemic and government lockdown in South Africa: a qualitative analysis

BACKGROUND

Tuberculosis (TB) is a major health concern in South Africa, where prior to COVID-19 it was associated with more deaths than any other infectious disease. The COVID-19 pandemic disrupted gains made in the global response to TB, having a serious impact on the most vulnerable. COVID-19 and TB are both severe respiratory infections, where infection with one places individuals at increased risk for negative health outcomes for the other. Even after completing TB treatment, TB survivors remain economically vulnerable and continue to be negatively affected by TB.

METHODS

This cross-sectional qualitative study, which was part of a larger longitudinal study in South Africa, explored how TB survivors' experienced the COVID-19 pandemic and government restrictions. Participants were identified through purposive sampling and were recruited and interviewed at a large public hospital in Gauteng. Data were analyzed thematically, using a constructivist research paradigm and both inductive and deductive codebook development.

RESULTS

Participants (n = 11) were adults (24-74 years of age; more than half male or foreign nationals) who had successfully completed treatment for pulmonary TB in the past two years. Participants were generally found to be physically, socioeconomically, and emotionally vulnerable, with the COVID-19 pandemic exacerbating or causing a recurrence of many of the same stressors they had faced with TB. Coping strategies during COVID similarly mirrored those used during TB diagnosis and treatment, including social support, financial resources, distraction, spirituality, and inner strength.

CONCLUSIONS

Implications and suggestions for future directions include fostering and maintaining a strong network of social support for TB survivors.

The impact of the COVID-19 pandemic on TB diagnosis in the Brazilian prison population, 2020-2021

BACKGROUND: TB is an infectious disease with a worldwide impact. TB is closely associated with social and housing conditions, exerting a significant impact on the prison population, which is particularly susceptible to the disease. Evidence suggests that the COVID-19 pandemic has exacerbated social vulnerability. This study therefore aimed to analyse the impact of the pandemic on the diagnosis of new cases of TB in the Brazilian prison population in the years 2020 and 2021.METHODS: This is an ecological study involving cases of TB recorded in the prison population of Brazil from 2015 to 2021. Data were collected from the Brazil's Information System for Notifiable Diseases.RESULTS: The incidence of TB in the prison population in Brazil fell from 1,005.9/100,000 population between 2015 and 2019 to 852.3/100,000 population between 2020 and 2021. In 2021, there was a deficit of 539 cases (-7.6%) compared to what was expected for the year. In 2020, there was a 10% reduction in TB diagnoses in January and February, reaching 3.8% in March. A negative percentage was observed in most of the subsequent months. In 2021, the year began with a 21.6% decline in January, returning to positive values only in August and September.CONCLUSION: The first years of the COVID-19 pandemic resulted in underdiagnosis of TB in the Brazilian prison population.

Immediate and long-term changes in infectious diseases in China at the "First-level-response", "Normalized-control" and "Dynamic-COVID-zero" stages from 2020 to 2022: a multistage interrupted-time-series-analysis

BACKGROUND

From January 2020 to December 2022, China implemented "First-level-response", "Normalized-control" and "Dynamic-COVID-zero" to block the COVID-19 epidemic; however, the immediate and long-term impact of three strategies on other infectious diseases and the difference in their impact is currently unknown. We aim to provide a more comprehensive understanding of the impact of non-pharmacological interventions (NPIs) on infectious diseases in China.

METHODS

We collected data on the monthly case count of infectious diseases in China from January 2015 to July 2022. After considering long-term trends using the Cox-Stuart test, we performed the two ratio Z tests to preliminary analyze the impact of three strategies on infectious diseases. Next, we used a multistage interrupted-time-series analysis fitted by the Poisson regression to evaluate and compare the immediate and long-term impact of three strategies on infectious diseases in China.

RESULTS

Compared to before COVID-19, the incidence of almost all infectious diseases decreased immediately at stages 1, 2, and 3; meanwhile, the slope in the incidence of many infectious diseases also decreased at the three stages. However, the slope in the incidence of all sexually transmitted diseases increased at stage 1, the slope in the incidence of all gastrointestinal infectious diseases increased at stage 2, and the slope in the incidence of some diseases such as pertussis, influenza, and brucellosis increased at stage 3. The immediate and long-term limiting effects of "Normalized-control" on respiratory-transmitted diseases were weaker than "First-level-response" and the long-term limiting effects of "Dynamic-COVID-zero" on pertussis, influenza, and hydatid disease were weaker than "Normalized-control".

CONCLUSIONS

Three COVID-19 control strategies in China have immediate and long-term limiting effects on many infectious diseases, but there are differences in their limiting effects. Evidence from this study shows that pertussis, influenza, brucellosis, and hydatid disease began to recover at stage 3, and relaxation of NPIs may lead to the resurgence of respiratory-transmitted diseases and vector-borne diseases.

Excess deaths among adults in the state of Santa Catarina: an ecological study during the COVID-19 pandemic, Brazil, 2020-2021

OBJECTIVE

to estimate excess deaths during the COVID-19 pandemic in the state of Santa Catarina and its macro-regions, Brazil, 2020-2021.

METHODS

this was an ecological study, using data from the Mortality Information System; excess deaths in adults were calculated by the difference between the observed number of deaths and expected number of deaths, taking into account the average of deaths that occurred between 2015 and 2019; the variables "macro-region of residence", "quarter", "month", "sex" and "age group" were analyzed; data were analyzed in a descriptive manner.

RESULTS

a total of 6,315 excess deaths in 2020 and 17,391 in 2021, mostly in males (57.4%) and those aged 60 years and older (74.0%); macro-regions and periods with the greatest excess deaths were those in which there were most deaths due to COVID-19; the greatest excess deaths occurred in March 2021 (n = 4,207), with a progressive decrease until the end of the year.

CONCLUSION

there were excess deaths in the state of Santa Catarina and in all its macro-regions during the COVID-19 pandemic.

The lived experiences of Tuberculosis survivors during the COVID-19 pandemic and government lockdown in South Africa: a qualitative analysis

Background Tuberculosis (TB) is a major health concern in South Africa, where prior to COVID-19 it was associated with more deaths than any other infectious disease. The COVID-19 pandemic disrupted gains made in the global response to TB, having a serious impact on the most vulnerable. COVID-19 and TB are both severe respiratory infections, where infection with the one place individuals at increased risk for negative health outcomes for the other. Even after completing TB treatment, TB survivors remain economically vulnerable and continue to be negatively affected by TB. Methods This cross-sectional qualitative study, which was part of a larger longitudinal study in South Africa, explored how TB survivors' experienced the COVID-19 pandemic and government restrictions. Participants were identified through purposive sampling and were recruited and interviewed at a large public hospital in Gauteng. Data were analyzed thematically, using a constructivist research paradigm and both inductive and deductive codebook development. Results Participants (n = 11) were adults (24-74 years of age; more than half male or foreign nationals) who had successfully completed treatment for pulmonary TB in the past two years. Participants were generally found to be physically, socioeconomically, and emotionally vulnerable, with the COVID-19 pandemic exacerbating or causing a recurrence of many of the same stressors they had faced with TB. Coping strategies during COVID similarly mirrored those used during TB diagnosis and treatment, including social support, financial resources, distraction, spirituality, and inner strength. Conclusions Implications and suggestions for future directions include fostering and maintaining a strong network of social support for TB survivors.

Immediate and long-term changes in the epidemiology, infection spectrum, and clinical characteristics of viral and bacterial respiratory infections in Western China after the COVID-19 outbreak: a modeling study

BACKGROUND

The impact of COVID-19 on the epidemiology, clinical characteristics, and infection spectrum of viral and bacterial respiratory infections in Western China is unknown.

METHODS

We conducted an interrupted time series analysis based on surveillance of acute respiratory infections (ARI) in Western China to supplement the available data.

RESULTS

The positive rates of influenza virus, Streptococcus pneumoniae, and viral and bacterial coinfections decreased, but parainfluenza virus, respiratory syncytial virus, human adenovirus, human rhinovirus, human bocavirus, non-typeable Haemophilus influenzae, Mycoplasma pneumoniae, and Chlamydia pneumoniae infections increased after the onset of the COVID-19 epidemic. The positive rate for viral infection in outpatients and children aged <5 years increased, but the positive rates of bacterial infection and viral and bacterial coinfections decreased, and the proportion patients with clinical symptoms of ARI decreased after the onset of the COVID-19 epidemic. Non-pharmacological interventions reduced the positive rates of viral and bacterial infections in the short term but did not have a long-term limiting effect. Moreover, the proportion of ARI patients with severe clinical symptoms (dyspnea and pleural effusion) increased in the short term after COVID-19, but in the long-term, it decreased.

CONCLUSIONS

The epidemiology, clinical characteristics, and infection spectrum of viral and bacterial infections in Western China have changed, and children will be a high-risk group for ARI after the COVID-19 epidemic. In addition, the reluctance of ARI patients with mild clinical symptoms to seek medical care after COVID-19 should be considered. In the post-COVID-19 era, we need to strengthen the surveillance of respiratory pathogens.

Patient, Diagnosis, and Treatment Delays Among Tuberculosis Patients Before and During COVID-19 Epidemic - China, 2018-2022

What is already known about this topic?

The coronavirus disease (COVID-19) pandemic could have a damaging impact on access to tuberculosis (TB) diagnosis and treatment.

What is added by this report?

The overall delay experienced by TB patients during the COVID-19 pandemic has shown a modest decrease in comparison to the period before the pandemic. Notably, higher patient delays were observed among agricultural workers and those identified through passive case-finding methods. Furthermore, the patient delay in eastern regions was shorter compared to western and central regions.

What are the implications for public health practice?

The observed increase in patient delay in 2022 should be of concern for ongoing TB control efforts. Health education and active screening initiatives must be enhanced and broadened among high-risk populations and regions characterized by extended patient delays.

The Impact of COVID-19 on Tuberculosis Program Performance in the Kingdom of Lesotho

Background: As tuberculosis (TB) is an airborne disease requiring multi-month therapy, systems of TB detection and care were profoundly impacted by the COVID-19 pandemic. The worsening economic situation, including income, food, and housing insecurity, impacted the social conditions in which TB—already a leading killer in resource-limited settings—thrives. This study assesses the impact of COVID-19 on TB detection and treatment in Lesotho. Methods: We used routine program data from 78 health facilities in Lesotho. We created time series models from July 2018 to March 2021 to quantify COVID-19-related disruptions to TB program indicators: outpatient visits; presumptive, diagnosed, treated, and HIV co-infected cases; and treatment outcomes including successful (cured and completed) and unsuccessful (death and treatment outcome unknown). Results: We observed a significant decline in cumulative outpatient visits (−37.4%, 95% prediction interval [PI]: −40.1%, −28.7%) and new TB cases diagnosed (−38.7%, 95%PI: −47.2%, −28.4%) during the pandemic, as well as TB-HIV co-infections (−67.0%, 95%PI: −72.6%, −60.0%). However, we observed no difference in treatment success (−2.1%, 95%PI: −17.0%, 15.8%). Conclusions: TB case detection in Lesotho fell during the COVID-19 pandemic, likely related to the uptake of overall health services. However, treatment success rates did not change, indicating a strong health system and the success of local strategies to maintain treatment programs.

Impact of COVID-19 Pandemic on Tuberculosis Preventive Services and Their Post-Pandemic Recovery Strategies: A Rapid Review of Literature

BACKGROUND

Coronavirus disease 2019 (COVID-19) pandemic has disrupted tuberculosis (TB) care and prevention around the world. The aim of this study is to review literature on the impact of COVID-19 on TB preventive services and discuss their policy options during and after the pandemic.

METHODS

We conducted a rapid review of scientific literature on the impact of COVID-19 on TB preventive services and their recovery strategies. After conducting a line-by-line open coding, their codes were applied in the descriptive theme building process, which was guided by the End TB strategy. TB preventive measures were selected and classified into five analytical categories: 1) vaccination against TB, 2) detection and treatment of latent TB infection (LTBI), 3) screening and diagnostics, 4) active case finding and contact tracing, and 5) surveillance.

RESULTS

We identified 93 articles, of which 65 were research articles. During the pandemic, we observed decrease in Bacillus Calmette-Guérin (BCG) coverage, TB diagnostic services, case finding activities, and LTBI management. TB case detection was declined, which was not resumed to the pre-pandemic level after loosening the lock-down. Several recommendations were highlighted: 1) secure BCG stocks and its supply chains, 2) consider catch-up activities of routine immunization and LTBI screening, 3) maintain minimal TB health services, infection prevention and control, and surveillance, 4) leverage laboratory capacity and contact tracing mechanisms, 5) consider simultaneous testing for TB and COVID-19, and 6) Incorporate digital health technologies.

CONCLUSIONS

Our findings and lessons learnt from the pandemic can aid in the development of future national TB control program.

Trends in respiratory diseases before and after the COVID-19 pandemic in China from 2010 to 2021

BACKGROUND

The ongoing benefits of coronavirus disease 2019 (COVID-19) nonpharmaceutical interventions (NPIs) for respiratory infectious diseases in China are still unclear. We aimed to explore the changes in seven respiratory infectious diseases before, during, and after COVID-19 in China from 2010 to 2021.

METHODS

The monthly case numbers of seven respiratory infectious diseases were extracted to construct autoregressive integrated moving average (ARIMA) models. Eight indicators of NPIs were chosen from the COVID-19 Government Response Tracker system. The monthly case numbers of the respiratory diseases and the eight indicators were used to establish the Multivariable generalized linear model (GLM) to calculate the incidence rate ratios (IRRs).

RESULTS

Compared with the year 2019, the percentage changes in 2020 and 2021 were all below 100% ranging from 3.81 to 84.71%. Pertussis and Scarlet fever started to increase in 2021 compared with 2020, with a percentage change of 183.46 and 171.49%. The ARIMA model showed a good fit, and the predicted data fitted well with the actual data from 2010 to 2019, but the predicted data was bigger than the actual number in 2020 and 2021. All eight indicators could negatively affect the incidence of respiratory diseases. The seven respiratory diseases were significantly reduced during the COVID-19 pandemic in 2020 and 2021 compared with 2019, with significant estimated IRRs ranging from 0.06 to 0.85. In the GLM using data for the year 2020 and 2021, the IRRs were not significant after adjusting for the eight indicators in multivariate analysis.

CONCLUSION

Our study demonstrated the incidence of the seven respiratory diseases decreased rapidly during the COVID-19 pandemic in 2020 and 2021. At the end of 2021, we did see a rising trend for the seven respiratory diseases compared to the year 2020 when the NPIs relaxed in China, but the rising trend was not significant after adjusting for the NPIs indicators. Our study showed that NPIs have an effect on respiratory diseases, but Relaxation of NPIs might lead to the resurgence of respiratory diseases.

Diagnosis and Treatment Pathway of MDR/RR-TB in Taizhou, Zhejiang Province, China

This study aims to understand MDR/RR-TB patients' experience from seeking TB-related health care to diagnosis and treatment completion, as well as the social determinants with the waiting time for DST and treatment, pre-treatment attrition, and treatment outcome based on a retrospective cohort study. Univariate and multi-variate logistic regressions were used to analyze the associated factors. The median time of waiting time for DST and treatment was 24.00 and 30.00 days, respectively. Non-residential patients (aOR: 2.89, 95% CI: 1.14-7.70), registered before 2018 (aOR: 19.93, 95% CI: 8.99-48.51), first visited a county-level hospital (aOR: 4.65, 95% CI: 1.08-21.67), sputum smear-negative (aOR: 3.54, 95% CI: 1.28-10.16), and comorbid with pneumoconiosis (aOR: 7.10, 95% CI: 1.23-47.98) had a longer DST delay. The pre-treatment attrition was 26.9% (82/305). Elderly, non-residential patients and patients registered before 2018 were more likely to refuse MDR/RR treatment. However, in housekeeping/unemployment and farmer/fisherman, recurrent patients tended to take therapeutic measures actively. The successful treatment rate was 62.1% (105/169). Elderly, comorbidity with diabetes and sputum smear conversion time >1 month may lead to poorer outcomes. Immediate interventions should be taken to smooth diagnosis and treatment pathways and improve the social protections further so as to encourage patients to cooperate with the treatment actively.

Influence of COVID-19 for delaying the diagnosis and treatment of pulmonary tuberculosis-Tianjin, China

Background

The COVID-19 pandemic has disrupted the diagnosis, treatment, and care for tuberculosis (TB). Delays in seeking TB care may result in increased community transmission and unfavorable treatment outcomes. We sought to understand the influence of the COVID-19 pandemic on the proportion of patients with TB who delayed seeking the diagnosis and care for TB and explore the reasons for their postponement.

Methods

We surveyed a representative sample of outpatients treated for pulmonary TB from June to November 2020 using an anonymous standardized questionnaire. Multivariable logistic regression was used to calculate adjusted odds ratios (aOR) and 95% confidence intervals (CIs) of factors associated with the postponement of TB care. We used routinely collected surveillance data to assess trends of TB reports before and after the emergence of COVID-19 (2017-2019 vs. 2020-2022) in Tianjin, China.

Results

Among 358 participants who were diagnosed with pulmonary TB during the COVID-19 response, 61 (17%) postponed seeking TB diagnosis due to COVID-19, with 39 (64%) citing fear as the primary reason. Female sex (aOR:2.0; 95% CI: 1.1-3.7), previous antituberculosis treatment (aOR:3.2; 95%CI: 1.4-7.6), and TB diagnosis during the first-level response (aOR = 3.2, 1.7-6.2) were associated with the postponement. Among all 518 participants receiving antituberculosis treatment, 57 (11%) had postponed their regular healthcare visits due to COVID-19, 175 (34%) received no treatment supervision, and 32 (6%) experienced treatment interruption. Compared to 2017-2019, reported pulmonary TB declined by 36.8% during the first-level response to COVID-19, 23.5% during the second-level response, 14% during the third-level response in 2020, and 4.3% in 2021.

Conclusion

The COVID-19 response reduced the number of people who sought and received diagnosis, treatment, and care for TB in Tianjin, China. Integrative programs to ensure access and continuity of TB services should be considered and dual testing for SARS-CoV-2 and M. tuberculosis may facilitate finding cases.

The Effect of the COVID-19 Pandemic on Pulmonary Tuberculosis Control in the Selected Upazila Health Complexes of Dhaka Division, Bangladesh

Despite the enormous disruption of tuberculosis (TB) services reported globally, Bangladesh’s impact is not well documented. We aimed to assess the effect of the COVID-19 pandemic on the TB control program in Bangladesh from patients’ and service providers’ perspectives. We conducted a cross-sectional study from November–December 2021 at six conveniently selected Upazila Health Complexes (UHC) of the Dhaka division, Bangladesh. We conducted face-to-face interviews among 180 pulmonary TB service recipients and all TB service providers working in the selected UHC. We also reviewed TB registries from each UHC. All data were summarized using descriptive statistics tools. We found a 31% reduction in presumptive TB cases during 2021 compared to 2020. Other TB services, such as testing, were reduced by 16–36% during the same period. Service receivers reported a lack of transportation (95%), and a lack of adequate human resources (89%) as critical barriers to receiving and providing TB service, respectively. The findings of our study showed substantial interruption of TB service delivery during the COVID-19 pandemic, threatening the recent progress and pushback from achieving the 2035 End TB targets. Early mitigation of TB service delivery through adopting remote follow-ups using digital health technology and integrating COVID-19 and TB screening is essential for the continuity of essential TB services and achieving global TB targets.

The Impact of the COVID-19 Pandemic on Tuberculosis Case Notification and Treatment Outcomes in Eswatini

Objectives: We investigated the impact of COVID-19 on tuberculosis (TB) case notification and treatment outcomes in Eswatini.

Methods: A comparative retrospective cohort study was conducted using TB data from eight facilities. An interrupted time series analysis, using segmented Poisson regression was done to assess the impact of COVID-19 on TB case notification comparing period before (December 2018-February 2020, n = 1,560) and during the pandemic (March 2020–May 2021, n = 840). Case notification was defined as number of TB cases registered in the TB treatment register. Treatment outcomes was result assigned to patients at the end of treatment according to WHO rules.

Results: There was a significant decrease in TB case notification (IRR 0.71, 95% CI: 0.60–0.83) and a significant increase in death rate among registrants during the pandemic (21.3%) compared to pre-pandemic (10.8%, p < 0.01). Logistic regression indicated higher odds of unfavorable outcomes (death, lost-to-follow-up, and not evaluated) during the pandemic than pre-pandemic (aOR 2.91, 95% CI: 2.17–3.89).

Conclusion: COVID-19 negatively impacted TB services in Eswatini. Eswatini should invest in strategies to safe-guard the health system against similar pandemics.

Tuberculosis among Ambulatory People Living with HIV in Guangxi Province, China: A Longitudinal Study

BACKGROUND

This study aims to determine the prevalence of TB among ambulatory people living with HIV in Guangxi Province, which experienced the biggest HIV epidemic in China.

METHODS

We undertook a longitudinal study in five HIV/AIDS designated hospitals randomly selected from Guangxi Province; all newly diagnosed HIV/AIDS outpatients from 2019 to 2021 were screened for TB and interviewed with a questionnaire.

RESULTS

A total of 4539 HIV/AIDS outpatients were enrolled, with 2886 (63.6%) men and 1653 (26.4%) women. The prevalence of TB/HIV coinfection was 0.8%, with a clear downward trend from 1.3% in 2019 to 0.4% in 2021 (p = 0.0011). The prevalence of LTBI was 24.3%, with no significant differences from 2019 to 2021. The percentages of AIDS, comorbidity, nine symptoms and abnormal chest X-ray of TB were higher than those of the other PLWH.

CONCLUSION

The prevalence of TB among ambulatory people with HIV in Guangxi Province was 14 times higher than the general population, and the annual declined TB prevalence indicated the effectiveness of TB and HIV control and prevention over recent years. The findings proved that symptom screening was insufficient for TB diagnosis and highlighted the importance of systematic TB screening at every visit to a health facility.

Clinical Outcomes of Individuals with COVID-19 and Tuberculosis during the Pre-Vaccination Period of the Pandemic: A Systematic Review

Background: Tuberculosis, like COVID-19, is most often a pulmonary disease. The COVID-19 pandemic has severely disrupted tuberculosis services in myriad ways: health facility closures, lockdowns, travel bans, overwhelmed healthcare systems, restricted export of antituberculous drugs, etc. The effects of the shared risk on outcomes of the two diseases is not known, particularly for the first year of the pandemic, during the period before COVID-19 vaccines became widely available. Objective: We embarked on a systematic review to elucidate the consequences of tuberculosis on COVID-19 outcomes and of COVID-19 on tuberculosis outcomes during the pre-vaccination period of the pandemic. Methods: The systematic review protocol is registered in PROSPERO. We conducted an initial search of PubMed, Embase, Web of Science, WHO coronavirus database, medRxiv, bioRxiv, preprints.org, and Google Scholar using terms relating to COVID-19 and tuberculosis. We selected cohort and case–control studies for extraction and assessed quality with the Newcastle-Ottawa scale. Results and Conclusion: We identified 2108 unique abstracts published between December 2019 and January 2021. We extracted data from 18 studies from 8 countries. A total of 650,317 persons had a diagnosis of COVID-19, and 4179 had a diagnosis of current or prior tuberculosis. We explored links between tuberculosis and COVID-19 incidence, mortality, and other adverse outcomes. Nine studies reported on mortality and 13 on other adverse outcomes; results on the association between tuberculosis and COVID-19 mortality/adverse outcomes were heterogenous. Tuberculosis outcomes were not fully available in any studies, due to short follow-up (maximum of 3 months after COVID-19 diagnosis), so the effects of COVID-19 on tuberculosis outcomes could not be assessed. Much of the rapid influx of literature on tuberculosis and COVID-19 during this period was published on preprint servers, and therefore not peer-reviewed. It offered limited examination of the effect of tuberculosis on COVID-19 outcomes and even less on the effect of COVID-19 on tuberculosis treatment outcomes.

Tuberculosis in an Aging World

Tuberculosis (TB) is one of the leading causes of death due to its being an infectious disease, caused by the airborne pathogen Mycobacterium tuberculosis (M.tb). Approximately one-fourth of the world’s population is infected with latent M.tb, and TB is considered a global threat killing over 4000 people every day. The risk of TB susceptibility and mortality is significantly increased in individuals aged 65 and older, confirming that the elderly represent one of the largest reservoirs for M.tb infection. The elderly population faces many challenges that increase their risk of developing respiratory diseases, including TB. The challenges the elderly face in this regard include the following: decreased lung function, immuno-senescence, inflammaging, adverse drug effects, low tolerance to anti-TB drugs, lack of suitable diagnoses/interventions, and age-associated comorbidities. In order to find new therapeutic strategies to maintain lung homeostasis and resistance to respiratory infections as we age, it is necessary to understand the molecular and cellular mechanisms behind natural lung aging. This review focuses primarily on why the elderly are more susceptible to TB disease and death, with a focus on pulmonary function and comorbidities.

Age-Specific Pulmonary Tuberculosis Notification Rates - China, 2008-2018

What is already known about this topic?

The incidence of tuberculosis (TB) was declining in China but has plateaued in recent years.

What is added by this report?

Notifications of pulmonary TB declined by 27.7% between 2008 and 2018, with an average crude decline of 3.4% per year and an average age-adjusted decline of 4.3% per year. Notifications decreased faster among older people, but slower in western China; the combination of trends led to an inflection in 2016 in the overall notification trend from decreasing to stable.

What are the implications for public health practice?

Population ageing and geographic disparities slowed tuberculosis control progress in China. Enhanced, targeted, and proactive responses are recommended to achieve the End TB targets.

Heterogeneous impact of Covid-19 response on tuberculosis burden by age group

Apart from the incidence and mortality caused by it, Coronavirus disease (COVID-19) has had a significant impact on other diseases. This study aimed to estimate the influences of COVID-19 pandemic on the incidence of tuberculosis (TB) and the number of TB-associated deaths in Republic of Korea. A dynamic compartment model incorporating age-structure was developed for studying TB transmission and progression using the Korean population data. After calibration with notification of incidence data from South Korea, the TB burden over 6 years (2020-2025) was predicted under the nine different scenarios. Under the scenario of strong social distancing and low-level health service disruption, new TB cases were reduced by 761 after 1 year in comparison to the baseline. However, in the elderly population, social distancing had little impact on TB incidence. On the other hand, the number of TB-related deaths mainly depends on the level of health service disruption for TB care. It was predicted that with a high degree of health service disruption, the number of TB-related deaths would increase up to 155 in 1 year and 80 percent of the TB-related deaths would be in the elderly population. The decrease of tuberculosis incidence is significantly affected by social distancing, which is owing to reduction of contacts. The impact of health service disruption is dominant on TB-related deaths, which occurs mainly in the elderly. It suggests that it is important to monitor TB-related deaths by COVID-19 because the TB burden of the elderly is high in the Republic of Korea.

COVID-19-related healthcare impacts: an uncontrolled, segmented time-series analysis of tuberculosis diagnosis services in Mozambique, 2017-2020

Introduction

Currently, COVID-19 dominates the public health agenda and poses a permanent threat, leading to health systems’ exhaustion and unprecedented service disruption. Primary healthcare services, including tuberculosis services, are at increased risk of facing severe disruptions, particularly in low-income and middle-income countries. Indeed, corroborating model-based forecasts, there is increasing evidence of the COVID-19 pandemic’s negative impact on tuberculosis case detection.

Methods

Applying a segmented time-series analysis, we assessed the effects of COVID-19-related measures on tuberculosis diagnosis service across districts in Mozambique. Ministry health information system data were used from the first quarter of 2017 to the end of 2020. The model, performed under the Bayesian premises, was estimated as a negative binomial with random effects for districts and provinces.

Results

A total of 154 districts were followed for 16 consecutive quarters. Together, these districts reported 96 182 cases of all forms of tuberculosis in 2020. At baseline (first quarter of 2017), Mozambique had an estimated incidence rate of 283 (95% CI 200 to 406) tuberculosis cases per 100 000 people and this increased at a 5% annual rate through the end of 2019. We estimated that 17 147 new tuberculosis cases were potentially missed 9 months after COVID-19 onset, resulting in a 15.1% (95% CI 5.9 to 24.0) relative loss in 2020. The greatest impact was observed in the southern region at 40.0% (95% CI 30.1 to 49.0) and among men at 15% (95% CI 4.0 to 25.0). The incidence of pulmonary tuberculosis increased at an average rate of 6.6% annually; however, an abrupt drop (15%) was also observed immediately after COVID-19 onset in March 2020.

Conclusion

The most significant impact of the state of emergency was observed between April and June 2020, the quarter after COVID-19 onset. Encouragingly, by the end of 2020, clear signs of health system recovery were visible despite the initial shock.

Study on the Influencing Factors of Knowledge, Attitudes and Practice About Tuberculosis Among Freshmen in Jiangsu, China: A Cross-Sectional Study

Background

Adolescents aged from 19 to 22 are the main high-risk population of pulmonary tuberculosis (PTB). This study aimed to understand the current status of knowledge, attitudes and practices (KAP) about TB among freshmen from Jiangsu colleges and universities. Analyze its influencing factors and explore the interrelationships of KAP. This provides a basis for building a reversing mechanism for health education on tuberculosis prevention and treatment in middle and high schools.

Methods

A multistage randomly was used to select freshmen to conduct this online survey. The χ ² test was used to compare the rates. Construct linear regression model, logistic regression model, decision tree model and random forest model, use grid search to adjust the parameters of the model, and use multiple models to explore the influencing factors of the overall awareness rate of students' core knowledge of tuberculosis.

Results

A total of 6980 freshmen in colleges and universities were investigated. The total awareness rate was 89.02%, and the awareness rate of all core knowledge about TB was 58.94%. It is characterized by general demographic data, and all core knowledge is known as a label to establish a model, based on the f1- of the four models The score believes that the random forest model has the best fitting effect, and the ranking of the influencing factors included in the model is school type (0.72) >father's education (0.15) >family monthly income (0.03) >mother's education, gender, region (0.02); a structural equation model is established, and the modified knowledge and attitude path coefficient is 0.29 (P<0.05); the attitude and behavior path coefficient is 0.64 (P<0.05).

Conclusion

The total awareness rate of core knowledge of Jiangsu college freshmen reaches the national requirements, but the overall awareness rate is low. It is necessary to strengthen the health education of tuberculosis for those with identified risk factors.

COVID-19 Pandemic and Tuberculosis Control: A Narrative Review

Background

The world is currently struggling with the COVID-19pandemic. Measures to control the COVID-19 pandemic have affected other health problems and diseases, including tuberculosis (TB) and its control. The present narrative review aimed at reviewing published literature on the impact of the COVID-19 pandemic on TB control.

Materials and Methods

English language databases, including PubMed, ISI, Scopus, and Google Scholar, were searched using the keywords "Tuberculosis, COVID-19, and Coronavirus" to find relevant articles.

Results

Problems and limitations in financial and human resources, as well as medical and laboratory services caused by the COVID-19 pandemic, contribute to the reduction in the number of newly diagnosed patients with TB. More effort in identifying patients with TB is of great importance, and if the global number of newly diagnosed patients with TB decreases by 25% for three consecutive months due to the COVID-19 pandemic, the TB mortality rate will increase by 13%. An increase in the TB mortality rate means the failure of TB control programs to reach the targets of the Global End TB Strategy.

Conclusion

According to the latest statistics released by the Ministry of Health, the incidence of TB in Iran has not yet reached fewer than 100 cases per million population. On the other hand, being a neighbor with countries with a high risk of TB is a serious threat to Iran. Therefore, further effort to control TB during the COVID-19 pandemic is particularly important.

The burden of COVID-19 pandemic on tuberculosis detection: a single-center study

Background

Since being declared a global pandemic, Coronavirus disease 2019 (COVID-19) took over healthcare providers and researchers’ interest. However, other epidemic diseases, including tuberculosis (TB), are still a health issue that aggravate under the umbrella of health facilities exhaustion. This study aims to evaluate the impact of the COVID-19 pandemic on tuberculosis management.

Methods

A retrospective analysis of the quarterly reports issued by a tuberculosis management unit from 2017 to June 2021, including data of 12 subunits. The changes in pulmonary and extrapulmonary tuberculosis incidence trends (new + relapsed cases) throughout the 4 years were reported. The quarterly changed percentages in cases numbers along 2020 and first half of 2021 was compared with that of the same periods in 2019.

Results

Incidence of extrapulmonary tuberculosis was higher than pulmonary tuberculosis throughout the 4 year study periods (7.69 vs. 4.49, 9.44 vs. 4.33, 7.75 vs. 3.58, and 7.82 vs. 2.94/100.000 population, respectively) with a noticeable decline in the incidence of pulmonary TB during 2020. The second quarter of 2020 showed the lowest tuberculosis incidence rate with a 41.6% decline in the total number of diagnosed cases while 2nd quarter of 2021 showed 21.2% decline. During 2020, only 4 cases of multidrug-resistant TB were reported (compared to an average of 8 cases of MDR-TB yearly before the COVID-19 era).

Conclusion

There was a noticeable drop in tuberculosis case detection during the COVID-19 pandemic. The lockdown, started in Egypt by the end of March 2020, could contribute to the marked drop in the second quarter. However, a steady partial decline was continued during the first half of 2021, which foretells a growing problem.

Effect of COVID-19 lockdown on the pathway of care and treatment outcome among patients with tuberculosis in a rural part of northern India: a community-based study

Objectives: The coronavirus disease 2019 (COVID-19) pandemic affected routine healthcare services across all spectra, and tuberculosis (TB) care under the National Tuberculosis Elimination Program have been affected the most. However, evidence available at the community level is minimal. The clinical features, care cascade pathway, and treatment outcomes of TB patients pre- and during/post-COVID-19 pandemic lockdown in a rural community health block in northern India were assessed and compared.

Materials and Methods: This was a retrospective cohort study that included all patients diagnosed with TB and initiated treatment under programmatic settings between January 1 and June 30, 2020, in a rural TB unit in northern India. The periods from January 1 to March 23 and March 24 to June 30 were marked as pre-lockdown and during/post-lockdown, respectively.

Results: A total of 103 patients were diagnosed and treated for TB during the study period. A significantly higher proportion of pulmonary TB cases were reported during/post-lockdown (43, 82.7%) compared to that pre-lockdown (32, 62.7%), and a higher diagnostic delay was noted during/post-lockdown (35, 81.4%). Through adjusted analysis, patients diagnosed during/post-lockdown period (adjusted risk ratio [aRR], 0.85; 95% confidence interval [CI], 0.73–0.98) and previously treated (aRR, 0.77; 95% CI, 0.60–0.995) had significantly lower favorable treatment outcomes.

Conclusions: The symptom and disease (pulmonary/extrapulmonary) pattern have changed during/post-lockdown. The care cascade delays are still high among TB patients, irrespective of the lockdown status. Lockdown had a significant adverse impact on the outcomes of TB treatment.

Evidence of TB Services at Primary Healthcare Level during COVID-19: A Scoping Review

Tuberculosis (TB) is still a major public health concern, despite the availability of preventative and curative therapies. Significant progress has been made in the past decade towards its control. However, the emergence of the novel coronavirus disease 2019 (COVID-19) has disrupted numerous essential health services, including those for TB. This scoping review maps the available evidence on TB services at the primary healthcare (PHC) level during the COVID-19 period. A comprehensive literature search was conducted in PubMed, Web of Science, Medline OVID, Medline EBSCO, and Scopus. A total of 820 articles were retrieved from the databases and 21 met the eligibility criteria and were used for data extraction. The emerging themes were the effect of the COVID-19 pandemic on TB services, patient and provider experiences, recommendations for TB services during the COVID-19 period, and the implementation of the recommendations. The review found that the mitigation strategies, as well as fear and stigma experienced at the start of the COVID-19 pandemic may have led to TB cases potentially going undetected, which may threaten TB treatment outcomes. Therefore, efforts must be directed at finding these missing cases and ensuring that PHC facilities are equipped to adequately diagnose and treat them.

Changes in notifiable infectious disease incidence in China during the COVID-19 pandemic

Nationwide nonpharmaceutical interventions (NPIs) have been effective at mitigating the spread of the novel coronavirus disease (COVID-19), but their broad impact on other diseases remains under-investigated. Here we report an ecological analysis comparing the incidence of 31 major notifiable infectious diseases in China in 2020 to the average level during 2014-2019, controlling for temporal phases defined by NPI intensity levels. Respiratory diseases and gastrointestinal or enteroviral diseases declined more than sexually transmitted or bloodborne diseases and vector-borne or zoonotic diseases. Early pandemic phases with more stringent NPIs were associated with greater reductions in disease incidence. Non-respiratory diseases, such as hand, foot and mouth disease, rebounded substantially towards the end of the year 2020 as the NPIs were relaxed. Statistical modeling analyses confirm that strong NPIs were associated with a broad mitigation effect on communicable diseases, but resurgence of non-respiratory diseases should be expected when the NPIs, especially restrictions of human movement and gathering, become less stringent.

Impact of COVID-19 on non-COVID intensive care unit service utilization, case mix and outcomes: A registry-based analysis from India

Background: Coronavirus disease 2019 (COVID-19) has been responsible for over 3.4 million deaths globally and over 25 million cases in India. As part of the response, India imposed a nation-wide lockdown and prioritized COVID-19 care in hospitals and intensive care units (ICUs). Leveraging data from the Indian Registry of IntenSive care, we sought to understand the impact of the COVID-19 pandemic on critical care service utilization, case-mix, and clinical outcomes in non-COVID ICUs.  Methods: We included all consecutive patients admitted between 1 st October 2019 and 27 th September 2020. Data were extracted from the registry database and included patients admitted to the non-COVID or general ICUs at each of the sites. Outcomes included measures of resource-availability, utilisation, case-mix, acuity, and demand for ICU beds. We used a Mann-Whitney test to compare the pre-pandemic period (October 2019 - February 2020) to the pandemic period (March-September 2020). In addition, we also compared the period of intense lockdown (March-May 31 st 2020) with the pre-pandemic period. Results: There were 3424 patient encounters in the pre-pandemic period and 3524 encounters in the pandemic period. Comparing these periods, weekly admissions declined (median [Q1 Q3] 160 [145,168] to 113 [98.5,134]; p<0.001); unit turnover declined (median [Q1 Q3] 12.1 [11.32,13] to 8.58 [7.24,10], p<0.001), and APACHE II score increased (median [Q1 Q3] 19 [19,20] to 21 [20,22] ; p<0.001). Unadjusted ICU mortality increased (9.3% to 11.7%, p=0.015) and the length of ICU stay was similar (median [Q1 Q3] 2.11 [2, 2] vs. 2.24 [2, 3] days; p=0.151). Conclusion: Our registry-based analysis of the impact of COVID-19 on non-COVID critical care demonstrates significant disruptions to healthcare utilization during the pandemic and an increase in the severity of illness.

Disruptions in maternal and child health service utilization during COVID-19: analysis from eight sub-Saharan African countries

The coronavirus-19 pandemic and its secondary effects threaten the continuity of essential health services delivery, which may lead to worsened population health and a protracted public health crisis. We quantify such disruptions, focusing on maternal and child health, in eight sub-Saharan countries. Service volumes are extracted from administrative systems for 63 954 facilities in eight countries: Cameroon, Democratic Republic of Congo, Liberia, Malawi, Mali, Nigeria, Sierra Leone and Somalia. Using an interrupted time series design and an ordinary least squares regression model with facility-level fixed effects, we analyze data from January 2018 to February 2020 to predict what service utilization levels would have been in March-July 2020 in the absence of the pandemic, accounting for both secular trends and seasonality. Estimates of disruption are derived by comparing the predicted and observed service utilization levels during the pandemic period. All countries experienced service disruptions for at least 1 month, but the magnitude and duration of the disruptions vary. Outpatient consultations and child vaccinations were the most commonly affected services and fell by the largest margins. We estimate a cumulative shortfall of 5 149 491 outpatient consultations and 328 961 third-dose pentavalent vaccinations during the 5 months in these eight countries. Decreases in maternal health service utilization are less generalized, although significant declines in institutional deliveries, antenatal care and postnatal care were detected in some countries. There is a need to better understand the factors determining the magnitude and duration of such disruptions in order to design interventions that would respond to the shortfall in care. Service delivery modifications need to be both highly contextualized and integrated as a core component of future epidemic response and planning.

The Epidemiological Characteristics of Pulmonary Tuberculosis - Kashgar Prefecture, Xinjiang Uygur Autonomous Region, China, 2011-2020

Introduction: National Notifiable Disease Reporting System (NNDRS) plays an important role in the early detection and control of tuberculosis (TB) in China. This study analyzed the epidemiological characteristics of pulmonary tuberculosis (PTB) in Kashgar Prefecture, Xinjiang Uygur Autnomous Region, China from 2011 to 2020 to provide a scientific basis for developing TB control strategies and measures in Kashgar.

Methods:The data were collected from the NNDRS, which included the geographical distribution, age, sex, occupation, and pathogenic classification of reported PTB cases in 12 counties/cities of Kashgar Prefecture from 2011 to 2020. Descriptive statistics were used to describe the characteristic of PTB epidemic in Kashgar.

Results: There were 189,416 PTB cases reported during 2011–2020, with a mean annual PTB case notification rate (CNR) of 451.29/100,000. A rising trend in the rate of reported PTB between 2011 and 2017 (χ²_trend=26.09, P<0.01) and a declining trend between 2018 and 2020 (χ²_trend=314.44, P<0.01) were observed. The months with the highest reported number of PTB cases were March to May and November to December. The mean annual rate of reported PTB was 451.88/100,000 for males and 450.67/100,000 for females. In addition, 19.76% of patients were bacteriologically-confirmed (Bac+) cases (37,425/189,416), and the mean annual Bac+ CNR was 89.17/100,000, rising from 64.76/100,000 in 2011 to 139.12/100,000 in 2020 (χ²_trend=74.44, P<0.01).

Conclusions: The CNR of reported PTB in Kashgar showed a significant declining trend in the past three years. Males, elderly population, winter and spring, and farmers as an occupation were the main factors associated with high incidence of tuberculosis in Kashgar. Targeted prevention and treatment of TB should be strengthened in key groups in this region.

The Impact of COVID-19 on Tuberculosis Patients' Behavior of Seeking Medical Care - China, 2020

What is already known on this topic?

The coronavirus disease 2019 (COVID-19) pandemic has disrupted the tuberculosis (TB) service system. However, the impact on TB patients in China remains unknown.

What is added by this report?

This report firstly addressed the impact of COVID-19 on TB patients in China. About half of TB patients did not revisit the hospital due to personal reasons. The reasons for irregular medication and postponing or cancelling examination after full treatment course were different.

What are the implications for public health practice?

Health education and risk communication should be strengthened for better TB patient management and treatment adherence, especially in light of the COVID-19 pandemic.

Impact of COVID-19 on non-COVID intensive care unit service utilization, case mix and outcomes: A registry-based analysis from India

Background: Coronavirus disease 2019 (COVID-19) has been responsible for over 3.4 million deaths globally and over 25 million cases in India. As part of the response, India imposed a nation-wide lockdown and prioritized COVID-19 care in hospitals and intensive care units (ICUs). Leveraging data from the Indian Registry of IntenSive care, we sought to understand the impact of the COVID-19 pandemic on critical care service utilization, case-mix, and clinical outcomes in non-COVID ICUs.  Methods: We included all consecutive patients admitted between 1 st October 2019 and 27 th September 2020. Data were extracted from the registry database and included patients admitted to the non-COVID or general ICUs at each of the sites. Outcomes included measures of resource-availability, utilisation, case-mix, acuity, and demand for ICU beds. We used a Mann-Whitney test to compare the pre-pandemic period (October 2019 - February 2020) to the pandemic period (March-September 2020). In addition, we also compared the period of intense lockdown (March-May 31 st 2020) with the pre-pandemic period. Results: There were 3424 patient encounters in the pre-pandemic period and 3524 encounters in the pandemic period. Comparing these periods, weekly admissions declined (median [Q1 Q3] 160 [145,168] to 113 [98.5,134]; p=0.00002); unit turnover declined (median [Q1 Q3] 12.1 [11.32,13] to 8.58 [7.24,10], p<0.00001), and APACHE II score increased (median [Q1 Q3] 19 [19,20] to 21 [20,22] ; p<0.00001). Unadjusted ICU mortality increased (9.3% to 11.7%, p=0.01519) and the length of ICU stay was similar (median [Q1 Q3] 2.11 [2, 2] vs. 2.24 [2, 3] days; p=0.15096). Conclusion: Our registry-based analysis of the impact of COVID-19 on non-COVID critical care demonstrates significant disruptions to healthcare utilization during the pandemic and an increase in the severity of illness.

Impact of COVID-19 Pandemic on Pre-Treatment Delays, Detection, and Clinical Characteristics of Tuberculosis Patients in Ningxia Hui Autonomous Region, China

Background: To contain the pandemic of COVID-19, China has implemented a series of public health interventions that impacted the tuberculosis control substantially, but these impacts may vary greatly depending on the severity of the local COVID-19 epidemic. The impact of COVID-19 on TB control in Ningxia Hui Autonomous Region is little known. Methods: Based on the national TB Information Management System (TBIMS), this study accessed the actual impact of COVID-19 on TB by comparing TB notifications, pre-treatment delays, and clinical characteristics of TB cases between 2020 COVID-19 period and 2017-2019 baseline. The data were divided into three periods based on the response started to fight against COVID-19 in Ningxia Hui Autonomous Region, including the control period (10 weeks before the pandemic), intensive period (10 weeks during the Ningxia Hui Autonomous Region lockdown), and regular (10 additional weeks after Ningxia Hui Autonomous Region reopen). Results: TB notification dropped sharply in the first week of the intensive period but took significantly longer to return to the previous level in 2020 compared with the 2017-2019 baseline. Totally, the TB notification rates decreased by more than 60% in the intensive period of COVID-19 compared with the average level of 2017-2019. The sputum smear-positive rate of TB patients diagnosed in intensive period of COVID-19 was significantly higher than that in the corresponding periods of 2017-2019 (P < 0.001). The rate of cavity on X-ray inspection of TB cases diagnosed in the intensive period of COVID-19 was significantly higher than that in period 2 of 2017-2019 (23.5 vs. 15.4%, P = 0.004). The patients' delay in the intensive period was significantly longer than that before the pandemic (P = 0.047). Conclusions: The TB notification in Ningxia was impacted dramatically by the pandemic of COVID-19. To compensate for the large numbers of missed diagnosis as well as delayed diagnosis during the intensive period of COVID-19, an urgent restoration of normal TB services, and further emphasis on enhanced active case finding and scale-up of household contact tracing and screening for TB-related symptoms or manifestation, will be essential.

Timing the SARS-CoV-2 index case in Hubei province

Understanding when severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) emerged is critical to evaluating our current approach to monitoring novel zoonotic pathogens and understanding the failure of early containment and mitigation efforts for COVID-19. We used a coalescent framework to combine retrospective molecular clock inference with forward epidemiological simulations to determine how long SARS-CoV-2 could have circulated before the time of the most recent common ancestor of all sequenced SARS-CoV-2 genomes. Our results define the period between mid-October and mid-November 2019 as the plausible interval when the first case of SARS-CoV-2 emerged in Hubei province, China. By characterizing the likely dynamics of the virus before it was discovered, we show that more than two-thirds of SARS-CoV-2-like zoonotic events would be self-limited, dying out without igniting a pandemic. Our findings highlight the shortcomings of zoonosis surveillance approaches for detecting highly contagious pathogens with moderate mortality rates.

Health Facilities and Treatment Service Models of the National Tuberculosis Program - China, 2010-2020

What is already known about this topic?

A new tuberculosis (TB) treatment service model called "trinity model" has been adopted in China since 2010 but the implementation coverage is still unknown.

What is added by this report?

In 2020, more than one-third (36.5%) of health facilities diagnosed less than 100 TB cases, about one-fourth (25.5%) diagnosed 100 to 200 cases, and 94 health facilities diagnosed more than 800 cases. Among 2,960 county-level TB management areas, 157 (5.3%) counties were dominated by CDCs, 364 (12.3%) were dominated by TB/infectious diseases-specific hospitals, 370 (12.5%) independent TB dispensaries (or chronic disease stations), and 2,069 (69.9%) general hospitals.

What are the implications for public health practice?

The National TB Program (NTP) needs to explore more suitable treatment reimbursement mechanisms and help treatment facilities build an efficient referral system to provide quality treatment services for TB patients.

Recovering from the Impact of the Covid-19 Pandemic and Accelerating to Achieving the United Nations General Assembly Tuberculosis Targets

In 2020, the novel COVID-19 pandemic replaced TB as the world’s top cause of death from an infectious disease. The October 21, 2020 the UN Secretary-General report on progress towards implementation of the UNHLM political declaration on TB stresses that although high-level commitments and targets had galvanized global and national progress towards ending TB, urgent and more ambitious investments and actions were required, especially in lieu of the COVID-19 pandemic where associated public health measures and travel restrictions, have disrupted health services universally. The report sets out 10 priority recommendations to get the world on track to reach agreed targets by 2022. Political commitment is more critical than ever. COVID-19 diagnostic and vaccination health services need to be aligned to TB services with active early case finding in communities, engaging the private sector care providers and mitigation of fear and stigma. Healthcare staff and community workers and leaders need to be provided with COVID-19 vaccination and personal protective equipment. The UNHLM declaration committed to mobilize 15 billion USD per annum for TB, of which 13 billion USD is for TB care and 2 billion USD per annum for TB R&D. The Global Fund needs to increase funding for TB. Learning from the unprecedented speed of COVID-19 vaccine development, fastracking development and evaluation of TB vaccines is essential. World leaders need to urgently address and reverse the socio-economic consequences of the COVID-19 pandemic and these will determine to what extent they will impact on achieving TB targets.

TB and COVID - Public and private health sectors adapt to a new reality

Health systems across the world have been baffled by the COVID19 pandemic. Tuberculosis (TB) care and prevention especially in high burden countries has faced disruption to their routine services. Though these setbacks were predicted by many modelling studies, reports and surveys from the field convey the hard reality faced by the TB services. However, health systems have not given up and have become resilient by adapting interesting strategies to overcome these obstacles. The private health sector has also stepped up to the occasion by supporting national TB programs through innovative approaches. The scientific community has laid down several evidence-based recommendations to help TB programs get back on track. Its time to unite these forces to not just overcome the challenge posed by the pandemic but also to build a more resilient health system.

Timing the SARS-CoV-2 Index Case in Hubei Province

Understanding when SARS-CoV-2 emerged is critical to evaluating our current approach to monitoring novel zoonotic pathogens and understanding the failure of early containment and mitigation efforts for COVID-19. We employed a coalescent framework to combine retrospective molecular clock inference with forward epidemiological simulations to determine how long SARS-CoV-2 could have circulated prior to the time of the most recent common ancestor. Our results define the period between mid-October and mid-November 2019 as the plausible interval when the first case of SARS-CoV-2 emerged in Hubei province. By characterizing the likely dynamics of the virus before it was discovered, we show that over two-thirds of SARS-CoV-2-like zoonotic events would be self-limited, dying out without igniting a pandemic. Our findings highlight the shortcomings of zoonosis surveillance approaches for detecting highly contagious pathogens with moderate mortality rates.