Effect of COVID-19 pandemic on tuberculosis notification.

To The Editor

With the emergence of COVID-19 as a pandemic in January 2020, India has witnessed two waves of the pandemic. The second wave was worse in terms of magnitude and severity of disease, bearing severe constraints to the overburdened healthcare system. COVID Pandemic has affected all walks of life but its impact has been profound on the vulnerable groups such as Tuberculosis (TB) Patients. The TB Programme in India was renamed in 2019 as National TB Elimination Programme (NTEP) with a mission to end TB by 2025 i.e, five years ahead of Sustainable Development Goals. Intensive measures were taken in 2018, 2019 and early parts of 2020 to improve TB case finding in public as well as private sector due to which India had made significant progress towards the goal of Ending TB till 24th March, 2020 when the nation-wide lockdown affected all the key strategic interventions resulting in decline in TB case notification.

India witnessed the first decline in TB notification in 2020 which was closely associated with the rise in COVID cases and subsequent lockdown across the country (Fig. 1 ). Modelling studies to understand the potential effect of the COVID-19 response on TB epidemiology has been published by Stop TB Partnership indicates that for every month of Lockdown, 2,32,665 excess Cases and 71,290 Deaths will be added in India.

Fig. 1

Total notified TB cases from India over 2018–2021 [Source: Nikshay Dashboard].

A similar pattern is evident again this year in 2021 during the second wave where we see a sharp decline in the notification of TB cases. May 2021 has witnessed the lowest number of TB cases reported cumulatively across India in the past 3 years (Fig. 1).

There are always two sides of the coin. A positive thought could be that there is an actual decline in the number of TB Patients. COVID appropriate behaviour is not only helpful in tackling the Pandemic but mask, hand hygiene, social distancing has led to a major behavioural shift in Indian population which could be a potential factor in limiting the spread of Tuberculosis during the Pandemic leading to an actual decline in number of TB Patients.

However, the other side of the coin is there is only a decline in the notification of TB cases. There are several potential factors (like closure of health facilities, fear of contracting COVID in Healthcare Centres, TB Care Providers involved in COVID activities, Patients stranded in different locations, non-availability of transport services and restricted movement, COVID-19 and TB coinfection, use of NTEP labs for COVID-19 testing) which could have led to the decline in the notification of TB cases.

It is extremely important to tackle this unfavourable trend. Suggested solutions include TB-COVID Bidirectional screening and research, contact tracing of all notified TB cases, doorstep collection of samples wherever required, continued services at laboratories for providing both TB & COVID services along with continuous drug supply of anti-tubercular therapy. The social norms of following COVID appropriate behaviour while continuing TB services is the need of the hour.

A learning lesson which can also be identified from Fig. 1 is that due to intensified efforts of TB Care workers & strong commitment towards TB Elimination, India was successfully able to reach the pre-COVID level of notified cases by the end of 2020. The second wave in 2021 has created a similar challenge, but with the added advantage of lessons learnt from managing TB Cases during a similar situation last year. It is not hard to imagine that with all the steps taken to mitigate the impact of COVID-19 on Tuberculosis, India can not only achieve the pre-COVID level of notified cases but even beyond that!

Conflicts of interest

The authors have none to declare.