The impact of the COVID-19 pandemic and associated suppression measures on the burden of tuberculosis in India

Thesis (Master's)--University of Washington, 2021Background: Mycobacterium tuberculosis (TB) is the main infectious cause of death globally. India carries the highest share of the global TB burden. The COVID-19 pandemic has severely impacted access to diagnosis of TB in India, yet there is limited data on by how much TB case reporting has decreased since the pandemic began and which factors most strongly determine the decrease in case notification. Methods: We utilized publicly available data on TB case reporting through the Indian Central TB Division from January 2017 through April of 2021 (prior to the first COVID-19 related lockdown). Using a Poisson model, we estimated seasonal and yearly patterns in TB case notification in India from January 2017 through February 2020 and extended this estimate as the counterfactual expected TB cases notified from March 2020 through April 2021. We characterized the differences in case notification observed and those expected in the absence of the pandemic by State and Territory. We then performed a linear regression to examine the relationship between the logit ratio of reported TB to counterfactual cases and mask use, mobility, daily hospitalizations/100,000 population, and public/total TB case reporting. Findings: We found that 1,320,203 cases of TB may not have been reported during the pandemic period from March 2020 through April 2021 in India, representing a 48.1% difference with expected cases. We found that mobility data and average hospital admissions per month per population were correlated with differences in TB case notification, compared to the counterfactual in the absence of the pandemic (p > 0.001). Interpretation: There was a large difference between reported TB cases in India and those expected in the absence of the pandemic. This information can help inform the Indian TB program as they consider interventions to accelerate case finding and notification once the pandemic related TB service disruptions improve. Mobility data and hospital admissions are surrogate measures that correlate with a greater difference in reported/expected TB cases and may correlate with a disruption in TB diagnostic services. However, further research is needed to clarify this association and identify other key contributors to gaps in TB case notifications in India