key: cord-328267-tk0zc8il authors: Liu, Qiao; Lu, Peng; Shen, Ye; Li, Changwei; Wang, Jianming; Zhu, Limei; Lu, Wei; Martinez, Leonardo title: Collateral Impact of the Covid-19 Pandemic on Tuberculosis Control in Jiangsu Province, China date: 2020-08-28 journal: Clin Infect Dis DOI: 10.1093/cid/ciaa1289 sha: doc_id: 328267 cord_uid: tk0zc8il The Covid-19 pandemic may impede global tuberculosis elimination goals. In Jiangsu Province, China, tuberculosis notifications dropped 52% in 2020 compared to 2015–2019. Treatment completion and screening for drug resistance decreased continuously in 2020. Urgent attention must be paid to tuberculosis control efforts during and after the Covid-19 pandemic. The tuberculosis burden in China has seen dramatic reductions in the past three decades. 1, 2 Between 1990 and 2010, there was a 65% and 48% decrease in the prevalence of smear-and bacteriologically-positive tuberculosis throughout China. 2 These reductions represent hundreds of thousands of saved lives over the time-period and maintaining these gains in the tuberculosis burden are essential to make goals of tuberculosis elimination by 2035 set by global health organizations. 3 The Covid-19 pandemic has the potential to substantially impact disease control for a range of diseases. Considerable increases in hospitalizations due to Covid-19 may overload health systems. For example, in the most heavily impacted regions of Italy, the national healthcare service was on the verge of collapse. 4, 5 Additionally, health care workers have become sick or are repurposed to control of Covid-19 and laboratories are de-prioritized diagnosis of tuberculosis (and other diseases) concentrating on Covid-19 diagnosis. There is a concern that, due to health care shortfalls and fear of contracting Covid-19, individuals will not seek medical attention when needed. In 2001, the SARS epidemic caused a short downfall in tuberculosis case notifications, later regressing to pre-epidemic levels. 6 Recent studies have documented substantial decreases in secondary diseases including myocardial infarctions and strokes. 7, 8 In addition, decreases in immunization rates and HIV testing have been reported in some settings. [9] [10] The impact of the Covid-19 pandemic on disease control for tuberculosis at a population-level is not well known. [11] [12] [13] To address this knowledge gap, we investigated several markers of tuberculosis control in Jiangsu Province, China, covering a population of approximately 80 million inhabitants. We compared tuberculosis case notifications, tuberculosis treatment outcomes, and diagnostic screening for multidrug resistance (MDR) among tuberculosis patients from 2015-2020 before and after the Covid-19 pandemic began in China. A c c e p t e d M a n u s c r i p t Tuberculosis is a reportable disease in China and all persons with tuberculosis are managed through the Tuberculosis Management Information System of Jiangsu province. Due to this, patient diagnoses can be tracked at a city-and provincial-level over time. We included weekly data from January 2015 to the end of May 2020. We concentrated our analysis on annual markers reported to the World Health Organization including the absolute number of tuberculosis notifications, notification rate, and tuberculosis treatment success rate. 3 Other measures were also analyzed to measure laboratory capacity and screening for multi-drug resistant (MDR) tuberculosis. We calculated the proportion of persons in which treatment previously failed; iii) sputum smear positive tuberculosis patients that were close contacts of MDR-tuberculosis patients; iv) a previous relapse event; or v) new tuberculosis patients who remained smear positive two months into anti-tuberculosis treatment. We compared weekly tuberculosis notifications between 2015-2019 with 2020 levels. We also assessed indicators before and after provincial-wide quarantine (January 24, 2020) and when 90% of businesses were re-opened at the provincial-level (March 27, 2020). We stratified our results at the city-level to investigate whether our results were modified by a certain location in the province. We A c c e p t e d M a n u s c r i p t Discussion This is the first data from China reporting the potential indirect impact on tuberculosis control of the Covid-19 pandemic. We found a substantial reduction, in excess of 50%, in tuberculosis notifications in 2020 compared to 2015-2019. There is substantial concern that the Covid-19 pandemic may impede global tuberculosis elimination goals by 2035 and our results suggest that tuberculosis control may be severely impacted, at least temporarily. Tuberculosis treatment outcomes and diagnostic screening for MDR among tuberculosis patients was also reduced in 2020 indicating that health care access may have reduced or health professionals may have been unavailable in dealing with tuberculosis control after being redirected to Covid-19 control efforts. Vigilance, reprioritization of tuberculosis control practices, and sustained funding and resources for drug resistant screening, diagnoses, and promoting treatment adherence must be immediately conducted in endemic settings to mitigate the damage to tuberculosis control suggested by these results. The decreased number of tuberculosis notifications in 2020 likely suggests lower tuberculosis patient case detection in the province. Social distancing interventions, which took place in much of China, may impact Mycobacterium tuberculosis transmission as well as health care access. Interventions, such as quarantine and social distancing, may have influenced tuberculosis notification numbers by reducing transmission. However, the long incubation period of tuberculosis 14 suggests that massscale interventions would not have shown immediate effects as seen in this study. In addition, reductions in treatment completion and MDR screening during this time period suggest that both deterred health care seeking and community disease management are likely drivers of these trends. A decrease in tuberculosis case notifications in 2020 has also been seen in other recent findings from settings outside of China. 15, 16 In Nigeria, there was a 35% and 34% decrease in the number of presumptive and active tuberculosis notifications from January to May 2020 15 while, in South Korea, tuberculosis notifications decreased by 24% in 2020 compared to prior years. 16 Tuberculosis notifications and diagnoses must continue to be monitored in settings that have seen this reduction. The finding that screening for drug resistance among tuberculosis patients has reduced by 15-17% has important implications to the tuberculosis epidemic in China. This is likely to lead to community transmission of drug resistance at a critical time when sustained tuberculosis control efforts in China has resulted in significant improvement in tuberculosis burden. 1, 2 Reductions in MDR screening are likely due to de-prioritization of tuberculosis testing and diagnoses in laboratories which have been A c c e p t e d M a n u s c r i p t re-directed to Covid-19 testing. Drug resistant screening among tuberculosis patients was altered from 2015-2020 and this may have impacted our results; however, since GeneXpert became available to all counties in the province in 2020, we would've expected an increase, rather than a decrease, in screening uptake of tuberculosis patients for drug resistance if the Covid-19 pandemic had not occurred. Monitoring drug resistant tuberculosis trends in late 2020, 2021, and 2022 will be critical to understanding whether this decrease in testing leads to population-wide increases in drugresistance. Our analysis suggests that collateral effects of the Covid-19 pandemic on tuberculosis control are substantial, with a reduction of 36%-52% in tuberculosis notifications in 2020 compared to 2015-2019. Substantial decreases were also seen in patient treatment success and screening for MDR among new and high-risk tuberculosis patients. These findings suggest health care seeking and management are largely responsible for tese trends. Urgent attention must be paid to tuberculosis control efforts 13, 17 to mitigate further impact of the Covid-19 pandemic on tuberculosis morbidity and mortality. A c c e p t e d M a n u s c r i p t NOTES Acknowledgement: The research was considered part of routine public health surveillance and, due to this, was considered exempt from ethical approval. All data was de-identified prior to use and identifying information was not available. Qiao Liu, Wei Lu, Limei Zhu, and Leonardo Martinez conceived the study. Qiao Liu, Peng Lu, Wei Lu, and Limei Zhu collected the data. Leonardo Martinez analyzed the data and made the first draft of the manuscript. Limei Zhu, Wei Lu, and Jianming Wang participated in the study design. All authors assisted in data interpretation. All authors read and edited the drafted manuscript for important intellectual content. All authors have read and approved the final manuscript. The funders of the study had no role in study design, data collection, data analysis, data interpretation, or writing of the report. The corresponding author had access to all the data in the study and had final responsibility for the decision to submit for publication. The corresponding author had full access to all the data in the study and had final responsibility for the decision to submit for publication. The effect of tuberculosis control in China Tuberculosis prevalence in China, 1990-2010; a longitudinal analysis of national survey data The Italian health system and the COVID-19 challenge Indications for healthcare surge capacity in European countries facing an exponential increase in coronavirus disease (COVID-19) cases Lowered tuberculosis notifications and deterred health care seeking during the SARS epidemic in Hong Kong Collateral effect of Covid-19 on stroke evaluation in the United States The Covid-19 Pandemic and the Incidence of Acute Myocardial Infarction Impact of COVID-19 lockdown on routine immunisation in Karachi, Pakistan. The Lancet Global Health Impact of the COVID-19 Pandemic on HIV Testing and Assisted Partner Notification Services Impact of COVID-19 on tuberculosis control in China Anticipating the impact of the COVID-19 pandemic on TB patients and TB control programmes Tackling two pandemics: a plea on World Tuberculosis Day. The Lancet Respiratory Medicine Lifetime risks, incubation period, and serial interval of tuberculosis Impact of COVID-19 on TB care: experiences of a treatment centre in Nigeria Effect of COVID-19 on Tuberculosis Notification, South Korea COVID-19, tuberculosis, and poverty: preventing a perfect storm A c c e p t e d M a n u s c r i p t A c c e p t e d M a n u s c r i p t