Impact of COVID-19 Pandemic on the Tuberculosis Case Findings of India: Exploration of the Magnitude of the Threats as Well as the Available Opportunity to Mitigate the Threats

Abhijit Dey1*, Arista Lahiri2, Sweety Suman Jha3 and Arup Kumar Chakrabartty4 1Medical Consultant, WHO-RNTCP Technical Support Network, Kolkata, India 2Senior Resident, Department of Community Medicine, College of Medicine and Sagore Dutta Hospital, Kolkata, India 3Junior Resident, Department of Preventive and Social Medicine, All India Institute of Hygiene and Public Health, Kolkata, India 4Honorary Secretary, Health Vision and Research, Kolkata, India


Introduction
The COVID-19 pandemic is straining health systems worldwide. The rapidly increasing demand on health facilities and health care workers threatens to leave some health systems overstretched and unable to operate effectively. The World Health Organization recommended that countries should identify essential services that will be prioritized in their efforts to maintain continuity of service delivery [1]. Impact of COVID-19 Pandemic on the Tuberculosis Case Findings of India: Exploration of the Magnitude of the Threats as Well as the Available Opportunity to Mitigate the Threats 90 Here, we need to remind a long pervading infectious disease and mortality related to it -which is tuberculosis (TB). TB is world's leading infectious killer disease, nearly 10 million people get affected and around 15% succumb to it each year [2]. India accounts for 27 per cent of the global burden with an estimated 2.69 million cases annually. TB deaths have an adverse effect on the Indian economy and the associated cost is measured to be at least $32 billion each year [3].
Due to the pandemic situation there is irregularities and uncertainties in sputum sample collection and transportation. Due to irregularity of hospital services and movement restriction there is less presumptive TB patient foot fall in the hospitals. All these are leading to less TB case detection and notification. We know from previous epidemics that reduced access to care, medicines and diagnostics for people with life-threatening conditions, such as TB, can lead to an increase of deaths from these underlying conditions [4].

Objective of the Study
Considering these backgrounds, the objective of this study was to explore the TB notification status of India during COVID19 pandemic and explore options to mitigate the issue.

Methods
A secondary data analysis was performed on open source TB notification database of Nikshay portal [5]. For state wise comparison data from twenty larger states (states with a population of more than 10 million as per census 2011) were taken into consideration. Data were accessed for the period of 1 st January 2019 -31 st July 2020. Year to date comparison for the period of Jan-July were made. Total TB notification (public + private) and notification from private sector were separately compared. While comparing the notification data in each state, percentage loss in TB notification during January -July 2020 as compared to January -July 2019 was calculated. All the analyses were done using Microsoft ® Excel ® (2016). Month-wise trend of notification (public and private) since last one year (Aug-19-Jul-20) has been shown as line diagrams.
For this article public domain secondary data (aggregated numbers only) without any personal identifying information of any human participant was used.
Relevant literature review done to find out remedies based on the different initiative taken by different states of India. Table 1 summarizes the state wise total and private TB notification during January 19-July 19 compared to January 20-July 20.    Decreased notification is due to COVID? Due to COVID pandemic, performance of many program has been declined and TB program

State
is not an exception. Notification started declining since February 2020 and the first COVID case in India was on 27 th January 2020 [7].
Lowest notification was in the month of April and India declared country-wide lock down on 24 th March [8]. All these temporality strongly suggesting that TB notification decreased due to the direct & indirect effects of COVID-Pandemic.
Mitigation plan can prevent the disaster: Study is showing that the trend of notification began to improve since May 2020 when GOI, WHO, State Governments started taking innovative initiatives like Integrated TB Covid Case Search (ITCS) [9].

Recommendations
Amidst the immense threat there are few opportunities also to improve TB case findings: • Vulnerability mapping: The population who are vulnerable to TB, mostly they are vulnerable to COVID-19 also. During COVID period one of the earliest activities should be the vulnerability mapping exercise. This mapping exercise can be done jointly with COVID response team. Activities like active case findings (ACF) can be focused based on this exercise.
• Active case findings: Nation or Statewide ACF can be planned after cessation of the community spread of COVID-19. Focal ACF (not district-wide) can be planned immediately for the area of high proportion of vulnerable population but not having active COVID transmission.
• Strengthening sample transport system: Lockdown and irregularity of general transport system caused disruption of sputum sample transport from peripheral health center to Designated Microscopy Center (DMC)/Cartridge Based Nucleic Acid

Conclusion
Due to the ongoing COVID-19 pandemic the notifications of TB cases declined noticeably which has a serious implication in terms of silent spread within household and community. Though the pandemic has a potential to have a devastating effect on healthcare program performances, but the outbreak is giving an opportunity to find weakness in our system to strengthen it. Due to striking similarities in mode of transmission and disease manifestation a comprehensive approach can be adopted for COVID control which will further help in case finding and controlling of TB.