Retrospective Cohort Study of Effects of the COVID-19 Pandemic on Tuberculosis Notifications, Vietnam, 2020

Assessment of the impact of COVID-19 on tuberculosis care at a tertiary hospital: integrating lessons from COVID-19 learned

Introduction

During the COVID-19 pandemic outbreak in 2020 until 2023, healthcare resources dedicated to critical diseases, including respiratory conditions like Tuberculosis (TB), were significantly impacted worldwide. The Instituto Nacional de Enfermedades Respiratorias "Ismael Cosío Villegas" (INER), a leading tertiary-level hospital in Mexico City and a national reference center for respiratory diseases, was designated exclusively for COVID-19 patients during these years.

Methods

This report aims to assess the pandemic's impact on TB care at INER and propose strategies for improving TB management by integrating lessons learned from the pandemic. TB presumptive cases were reviewed between 2016-2023, covering pre-pandemic, pandemic, and post-period; the number of diagnosis tests performed and number of attending TB patients in the emergency areas, hospitalization, or outpatient consultation were analyzed. The mortality rate of patients during hospitalization was also examined.

Results

Our analysis revealed that during the pre-pandemic period (2016-2019), around 1,000 TB patient consultations were managed annually across outpatient and inpatient settings, and it drastically declined in 2020, a trend that persisted through 2021 and 2022. Survival of TB patients was affected, and disruption in TB care resulted in a decrease in TB diagnoses during the pandemic and increased mortality rates among hospitalized patients during the post-pandemic period. In response to the challenges posed by the pandemic, INER adopted innovative strategies such as telehealth services and reinforced human resources dedicated to respiratory pathologies. These efforts and enhanced diagnostic testing have strengthened the hospital's capacity to care for TB patients. The lessons learned during the pandemic have been pivotal in reshaping and improving the healthcare system's approach to managing TB in a tertiary care setting.

Effect of COVID-19 restriction measures on multidrug resistant tuberculosis case notifications and treatment outcomes at treatment centres in Uganda

BACKGROUND

Multidrug resistant tuberculosis (MDR-TB) is a global public health threat. In 2021, an incidence of 3.6% was reported among new TB patients, and 18% was reported among previously treated patients. The emergence of the COVID-19 pandemic impacted the health sector, although little is known about the effect of restrictive COVID-19 measures on MDR-TB case notifications and treatment outcomes in Uganda. This study aimed to assess the effect of COVID-19 restriction measures on MDR-TB case notifications and treatment outcomes at treatment centres in Uganda.

METHODS

This was a retrospective cohort study in which a total of 483 participants were enrolled-238 before (March 2018-February 2020) and 245 during (March 2020-February 2022) COVID-19 restrictions. The data were extracted from the Drug-Resistant Tuberculosis (DR-TB) Health Management Information System (HMIS), and patient charts, and census sampling was employed. Interrupted time series (ITSA) was used to compare MDR-TB case notifications and treatment outcomes.

RESULTS

Before the COVID-19 restrictions, the majority 58.0% were aged less than or equal to 38 years whereas during the restrictions, the majority 51.8% were aged greater than 38 years. A total of 238 cases of MDRTB were reported before, and 245 cases were reported during the restrictions. There was no immediate (β2; 0.134) or sustained (β3; 0.494) impact of COVID-19 restriction measures on monthly MDR-TB case notifications. The mean number of monthly MDR-TB notifications was similar for the 3-month period before (11.0 cases per month) and during (10.0 cases per month) the COVID-19 restrictions (p-value 0.661). The proportions of patients who achieved successful MDR-TB treatment before (81.5%) and during (81.7%) COVID-19 restriction was not significantly different (p- value < 0.001). During the COVID-19 restrictions, not being married (aPR 0.85, 95% CI: 0.74-0.97) and treatment delay greater than 7 days (aPR 0.87, 95% CI 0.78-0.96) were negatively associated with successful treatment outcomes.

CONCLUSION

Restrictive COVID-19 measures did not affect MDR-TB case notifications or treatment outcomes. Not being married and having a treatment delay greater than 7 days reduced the chances of a successful treatment outcome during COVID-19. The WHO and MoH should continue strengthening active case finding, contact screening and community engagement to consolidate MDR-TB control and management in preparation for similar future pandemics.

The impact of the COVID-19 pandemic on tuberculosis treatment outcomes in 49 high burden countries

BACKGROUND

The COVID-19 pandemic disrupted tuberculosis (TB) health services, including treatment support and access to drugs, as patients were not able to access health facilities. While the effect of this disruption on treatment outcomes has been studied in isolated treatment centres, cities and provinces, the impact of the pandemic on TB treatment outcomes at a country and regional level has not been evaluated.

METHODS

We used treatment outcomes for new and relapse TB cases reported to the World Health Organization (WHO) from 49 high TB, TB/HIV and drug-resistant TB burden countries from 2012 to 2019. We developed multinomial logistic regression models for trends in TB treatment success, failure, death and loss to follow up. We predicted TB treatment outcomes for 2020 and 2021, comparing these to observations, by computing ratios between observed and predicted probabilities. We aggregated these risk ratios (RR) for six WHO-defined regions using random-effects meta-analysis.

RESULTS

Across 49 countries and four TB treatment outcomes, 17 (out of 196) country-outcome pairs in 2020 and 21 in 2021 had evidence of systematic differences between observed and predicted TB treatment outcome probabilities. Regionally, only four (out of 24) region-outcome pairs had evidence of systematic differences in 2020 and four in 2021, where the European region accounted for four of these in total. Globally, there was evidence of systematic differences in treatment failure in both 2020 (RR: 1.14, 95%CI: 1.01-1.28, p = 0.0381) and 2021 (RR: 1.36, 95%CI: 1.03-1.78, p = 0.0277), deaths in 2020 (RR: 1.08, 95%CI: 1.03-1.13, p = 0.0010) and losses to follow up in 2020 (RR: 0.91, 95%CI: 0.86-0.97, p = 0.0059).

CONCLUSIONS

While for some countries and regions there were significant differences between observed and predicted treatment outcomes probabilities, there was insufficient evidence globally to identify systematic differences between observed and expected TB treatment outcome probabilities because of COVID-19-associated disruptions in general. However, larger numbers of treatment failures and deaths on treatment than expected were observed globally, suggesting a need for further investigation.

The global impact of COVID-19 on tuberculosis: A thematic scoping review, 2020-2023

BACKGROUND

This thematic scoping review of publications sought to understand the global impact of COVID-19 on tuberculosis (TB), interpret the scope of resonating themes, and offer policy recommendations to stimulate TB recovery and future pandemic preparedness.

DATA SOURCES

Publications were captured from three search engines, PubMed, EBSCO, and Google Scholar, and applicable websites written in English from January 1, 2020, to April 30, 2023.

STUDY SELECTION

Our scoping review was limited to publications detailing the impact of COVID-19 on TB. Original research, reviews, letters, and editorials describing the deleterious and harmful--yet sometimes positive--impact of COVID-19 (sole exposure) on TB (sole outcome) were included. The objective was to methodically categorize the impacts into themes through a comprehensive review of selected studies to provide significant health policy guidance.

DATA EXTRACTION

Two authors independently screened citations and full texts, while the third arbitrated when consensus was not met. All three performed data extraction.

DATA SYNTHESIS/RESULTS

Of 1,755 screened publications, 176 (10%) covering 39 countries over 41 months met the inclusion criteria. By independently using a data extraction instrument, the three authors identified ten principal themes from each publication. These themes were later finalized through a consensus decision. The themes encompassed TB's care cascade, patient-centered care, psychosocial issues, and health services: 1) case-finding and notification (n = 45; 26%); 2) diagnosis and laboratory systems (n = 19; 10.7%) 3) prevention, treatment, and care (n = 22; 12.2%); 4) telemedicine/telehealth (n = 12; 6.8%); 5) social determinants of health (n = 14; 8%); 6) airborne infection prevention and control (n = 8; 4.6%); 7) health system strengthening (n = 22; 13%); 8) mental health (n = 13; 7.4%); 9) stigma (n = 11; 6.3%); and 10) health education (n = 10; 5.7%).

LIMITATIONS

Heterogeneity of publications within themes.

CONCLUSIONS

We identified ten globally generalizable themes of COVID-19's impact on TB. The impact and lessons learned from the themed analysis propelled us to draft public health policy recommendations to direct evidence-informed guidance that strengthens comprehensive global responses, recovery for TB, and future airborne pandemic preparedness.

Ensuring Continuity of Tuberculosis Care during Social Distancing through Integrated Active Case Finding at COVID-19 Vaccination Events in Vietnam: A Cohort Study

COVID-19 significantly disrupted tuberculosis (TB) services in Vietnam. In response, the National TB Program (NTP) integrated TB screening using mobile chest X-rays into COVID-19 vaccination events. This prospective cohort study evaluated the integrated model's yield, treatment outcomes, and costs. We further fitted regressions to identify risk factors and conduct interrupted time-series analyses in the study area, Vietnam's eight economic regions, and at the national level. At 115 events, we conducted 48,758 X-ray screens and detected 174 individuals with TB. We linked 89.7% to care, while 92.9% successfully completed treatment. The mean costs per person diagnosed with TB was $547. TB risk factors included male sex (aOR = 6.44, p < 0.001), age of 45-59 years (aOR = 1.81, p = 0.006) and ≥60 years (aOR = 1.99, p = 0.002), a history of TB (aOR = 7.96, p < 0.001), prior exposure to TB (aOR = 3.90, p = 0.001), and symptomatic presentation (aOR = 2.75, p < 0.001). There was a significant decline in TB notifications during the Delta wave and significant increases immediately after lockdowns were lifted (IRR(γ1) = 5.00; 95%CI: (2.86, 8.73); p < 0.001) with a continuous upward trend thereafter (IRR(γ2) = 1.39; 95%CI: (1.22, 1.38); p < 0.001). Similar patterns were observed at the national level and in all regions but the northeast region. The NTP's swift actions and policy decisions ensured continuity of care and led to the rapid recovery of TB notifications, which may serve as blueprint for future pandemics.

Drug-Resistant Tuberculosis and COVID-19: A Scoping Review on a New Threat to Antimicrobial Resistance

OBJECTIVE

To assess the impact of COVID-19 on the morbidity and mortality associated with drug-resistant tuberculosis (DR-TB).

METHODS

A comprehensive review of articles published in international databases since December 2019 was conducted. The findings are presented in a narrative format, supplemented with tables, diagrams, and a map created using ArcGIS software.

RESULTS

Thirty-five studies were selected, highlighting the significant consequences of COVID-19 on TB and DR-TB treatment progress. Four main thematic areas were identified: Clinical and epidemiological aspects of the interaction between COVID-19 and DR-TB; Management of physical resources and the team; Challenges and circumstances; Perspectives and possibilities.

CONCLUSIONS

This study revealed that the COVID-19 pandemic significantly negatively impacted the control of long-standing diseases like TB, particularly in the context of morbidity and mortality related to DR-TB.

The impact of COVID-19 pandemic on reported tuberculosis incidence and mortality in China: An interrupted time series analysis

Background

The reported number of cases and deaths from common infectious diseases can change during major public health crises. We explored whether the coronavirus disease 2019 (COVID-19) had an impact on tuberculosis (TB) incidence and mortality in China based on routinely reported TB data.

Methods

We used TB data used from the monthly national notifiable infectious disease reports in China from January 2015 to January 2023. Based on an interrupted time series (ITS) design, we applied Poisson and negative binomial regression models to assess the changes of reported TB incidence and mortality before and during the COVID-19 pandemic.

Results

We found a significant and immediate decrease in the levels of both reported TB incidence (relative risk (RR) = 0.887; 95% confidence interval (CI) = 0.810-0.973) and mortality (RR = 0.448; 95% CI = 0.351-0.572) at the start of COVID-19 outbreak. During the pandemic, the slope of reported incidence decreased significantly (RR = 0.994; 95% CI = 0.989-0.999), while the slope of reported mortality increased sharply (RR = 1.032; 95% CI = 1.022-1.041) owing to an abrupt rise in reported mortality after January 2022.

Conclusions

Both TB incidence and mortality decreased immediately at the start of the COVID-19 pandemic. Over a longer period, the COVID-19 pandemic had contributed to a sustained and more significant decrease in reported incidence, and a delayed but sharp increase in reported mortality.

The effect of the Covid-19 pandemic on Tuberculosis (TB) case notification in Ogun State, Nigeria

Introduction

COVID-19 pandemic has resulted in disruptions in delivery of Tuberculosis services especially, in resource-limited settings. Provisional data by the WHO from 84 countries indicates that about 1.4 million fewer people received care for tuberculosis in 2020 than in 2019. This study assessed the effect of COVID-19 pandemic on tuberculosis case notification rates in Ogun state, Nigeria.

Methods

A retrospective review of presumptive TB and diagnosed TB cases that were notified in 2019 and 2020. Analysis was done using Epi-info version 7.2.3.1. Level of statistical significance was p < 0.05.

Results

A total of 3102 and 3326 confirmed cases were reported in 2019 and 2020 respectively with an increase of 7.2%. There was significant decline in total number of cases notified in Q2, 2020 compared to 2019 (p=0.001) with a significant increase in proportion of TB cases notified by private facilities from 11.65% in 2019 to 20.27% in 2020.

Conclusion

Total TB cases notified in Ogun state increased during the covid-19 pandemic. There was significant decline in TB cases during the lockdown but an increase in proportion of TB cases notified by private facilities demonstrating that private facilities can withstand disruptions to TB case notifications due to the Covid-19 pandemic.

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.