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

Abstract

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.

Keywords: COVID-19; healthcare seeking; impact; treatment; tuberculosis.

Figure 1

Geographic distribution of participants in the study. The geographic map of Tianjin, China was created using Epi Info (https://www.cdc.gov/epiinfo), with a dot density map to demonstrate district distribution of patient participants, overlaying a spot map to mark TB clinics, non-TB hospitals surveyed. : dot density by district according to home address of patients participated in the anonymous questionnaire. : the 12 TB clinics or designated hospital in the city. : the 45 non-TB hospitals were purposively selected in city and district levels, considering their report of presumable patients with TB in the previous years. : highlight the center of the city, which accounts for 1.4% of the city area and accommodates around one third of the city population.

Figure 2

(A) Epidemic curve of locally transmitted COVID-19 cases and key time points in Tianjin, China, 2020. a: 2020/1/24, the first-level response was initiated; intensive lockdown being implemented, such as community constraint and restriction of public traffic; the municipal TB designated hospital was repurposed to the COVID-19 hospital and suspended TB service. b: 2020/4/8, reopen of Wuhan city where the COVID-19 was firstly learnt. c: 2020/4/30, the response to COVID-19 was downgraded to second-level; when all sectors being gradually reopening. d: 2020/6/6, the response to COVID-19 was further downgraded to the third-level, when all sectors back to normalization under basic measures for COVID-19 control, such as mask wearing in public and COVID-19 testing with presumable symptoms. e: 2020/7/22, the municipal TB designated hospital gradually restored TB healthcare, meanwhile still served as the COVID-19 hospital (for imported COVID-19 cases). f: 2020/11/20, the municipal TB designated hospital again suspended TB healthcare. g: 2020/11/27, another hospital with specialty of infectious diseases was newly appointed as an interim TB designated hospital to complement the deficiency of TB service. First-level response to COVID-19. Second-level response to COVID-19. Third-level response to COVID-19. (B) Pulmonary TB report by month in Tianjin, China, in 2020, 2021 and 2022, compared with the average level in 2017–2019. (C) Epidemic curve of locally transmitted COVID-19 cases in Tianjin, China, in the three quarters in 2022.