# Preplanned Studies: Predicted Impact of the COVID-19 Responses on Deaths of Tuberculosis — China, 2020

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• ### Summary

The World Health Organization has estimated the impact of reductions in the performance of global tuberculosis (TB) detection and care on TB deaths. However, the actual impact of COVID-19 pandemic on TB deaths in China remains unclear.

What is added by this report?

The stringent public interventions to fight COVID-19 including lockdown led to more than 20% decrease of TB detection in China. It was predicted that the reduction of TB detection might result in 11,700 excess deaths based on assumption of no detection rebound. Based on the prediction the total deaths will be 51,100 in 2020 which might surpass the deaths in 2011.

What are the implications for public health practice?

Rapid restoration of TB diagnosis and care services is critical for minimizing the potential effects on TB-related deaths and bringing TB burden back to control. It is urgent to ramp up case detection including active case finding and to provide an uninterrupted supply of quality-assured treatment and care for TB cases in post-COVID-19 outbreak.

•  [1] Pan A, Liu L, Wang C, Guo H, Hao XJ, Wang Q, et al. Association of public health interventions with the epidemiology of the COVID-19 outbreak in Wuhan, China. JAMA 2020;323(19):1915 − 23. http://dx.doi.org/10.1001/jama.2020.6130CrossRef [2] Tian HY, Liu YH, Li YD, Wu CH, Chen B, Kraemer MUG, et al. An investigation of transmission control measures during the first 50 days of the COVID-19 epidemic in China. Science 2020;368(6490):638 − 42. http://dx.doi.org/10.1126/science.abb6105CrossRef [3] Zhang JJ, Litvinova M, Liang YX, Wang Y, Wang W, Zhao SL, et al. Changes in contact patterns shape the dynamics of the COVID-19 outbreak in China. Science 2020;368(6498):1481 − 6. http://dx.doi.org/10.1126/science.abb8001CrossRef [4] Burdorf A, Porru F, Rugulies R. The COVID-19 (coronavirus) pandemic: consequences for occupational health. Scand J Work Environ Health 2020;46(3):229 − 30. http://dx.doi.org/10.5271/sjweh.3893CrossRef [5] Adepoju P. Tuberculosis and HIV responses threatened by COVID-19. Lancet 2020;7(5):e319 − 20. http://dx.doi.org/10.1016/S2352-3018(20)30109-0CrossRef [6] World Health Organization (WHO). Global tuberculosis report 2019. Geneva (Switzerland): World Health Organization; 2019. https://apps.who.int/iris/handle/10665/329368.[2020-08-10]. [7] World Health Organization. WHO’s global tuberculosis database. https://www.who.int/tb/data/en/. [2020-08-15]. [8] Amimo F, Lambert B, Magit A. What does the COVID-19 pandemic mean for HIV, tuberculosis, and malaria control? Trop Med Health 2020;48:32. http://dx.doi.org/10.1186/s41182-020-00219-6CrossRef [9] Glaziou P. Predicted impact of the COVID-19 pandemic on global tuberculosis deaths in 2020. http://dx.doi.org/10.1101/2020.04.28.20079582. [2020-08-12].
• FIGURE 1.  The reduction in tuberculosis case detection in China overall, in Hubei, and in Wuhan in different phases in 2020.

Phase I: January 23, 2020 to February 11, 2020; Phase II: February 12, 2020 to March 24, 2020; Phase III: March 25, 2020 to April 8, 2020; Phase IV: April 9, 2020 to June 30, 2020.

TABLE 1.  The predicted number of tuberculosis deaths including tuberculosis (TB) deaths in HIV-negative and in HIV-positive cases during different phases in China overall, in Hubei, and in Wuhan in 2020.

 Perturbation Predicted excess deaths among HIV-positive cases (N) Predicted excess deaths among HIV-negative cases (N) Predicted total excess deaths (N) Excess deaths/annually deaths in 2018 (%) Wuhan City Phase I 0.962 0 34 34 11.8 Phase II 0.915 1 77 78 26.6 Phase III 0.987 0 12 12 4.1 Phase IV 0.932 1 61 62 21.3 Subtotal 2 184 186 63.8 Hubei Province Phase I 0.963 2 201 203 11.5 Phase II 0.963 4 427 430 24.4 Phase III 0.986 1 79 79 4.5 Phase IV 0.922 0 47 47 2.7 Subtotal 6 753 760 43.1 Nationwide Phase I 0.977 24 2,827 2,851 7.2 Phase II 0.959 43 5,022 5,065 12.9 Phase III 0.993 7 835 842 2.1 Phase IV 0.976 25 2,917 2,942 7.5 Total 98 11,601 11,700 29.7 Note: The study estimated excess TB deaths in 3 geographic areas (Wuhan City, Hubei Province and China overall) and 4 phases (Phase I: January 23, 2020 to February 11, 2020; Phase II: February 12, 2020 to March 24, 2020; Phase III: March 25, 2020 to April 8, 2020; Phase IV: April 9, 2020 to June 30, 2020).

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###### 通讯作者: 陈斌, bchen63@163.com
• 1.

沈阳化工大学材料科学与工程学院 沈阳 110142

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## Predicted Impact of the COVID-19 Responses on Deaths of Tuberculosis — China, 2020

View author affiliation

### Summary

The World Health Organization has estimated the impact of reductions in the performance of global tuberculosis (TB) detection and care on TB deaths. However, the actual impact of COVID-19 pandemic on TB deaths in China remains unclear.

What is added by this report?

The stringent public interventions to fight COVID-19 including lockdown led to more than 20% decrease of TB detection in China. It was predicted that the reduction of TB detection might result in 11,700 excess deaths based on assumption of no detection rebound. Based on the prediction the total deaths will be 51,100 in 2020 which might surpass the deaths in 2011.

What are the implications for public health practice?

Rapid restoration of TB diagnosis and care services is critical for minimizing the potential effects on TB-related deaths and bringing TB burden back to control. It is urgent to ramp up case detection including active case finding and to provide an uninterrupted supply of quality-assured treatment and care for TB cases in post-COVID-19 outbreak.

• 1. Chinese Center for Disease Control and Prevention, Beijing, China
###### & Joint first authors.
• In order to reduce transmission of coronavirus disease 2019 (COVID-19), China implemented a series of public health interventions including cancelling public transportation; prohibiting public gatherings; closing schools, libraries, and other public spaces; recommending a 14-day home quarantine for individuals from highly-affected areas; and deploying a large amount of resources and dispatched health workers to fight the epidemic (1-3). All these interventions have successfully brought COVID-19 under control. But at the same time, these interventions have adversely affected other public health issues that deserve the public’s concern and should be addressed including tuberculosis (TB) control (45).

TB is a bacterial disease predominantly affecting the lungs. During 2018, an estimated 10 million new TB cases occurred globally, while 0.86 million cases were registered in China, which ranks second in the world (6). Although, TB-related mortality declined from 8.7/100,000 person-years (PY) in 2000 to 2.6/100,000 PY in 2018, TB still caused an estimated 39,400 deaths (including TB/HIV deaths) in 2018 in China (7).

Some studies have discussed the possible impact of COVID-19 on the performance of TB control regarding diagnosis, treatment, and management (8). The World Health Organization (WHO) has estimated the impact of reductions in the performance of global TB detection and care on TB deaths (9). However, the actual impact of COVID-19 pandemic on TB deaths in China remains unclear.

The TB detection data was extracted from Tuberculosis Information Management System (TBIMS) on July 15, 2020. Considering the epidemic of COVID-19, the study estimated excess TB deaths in 3 geographic areas (Wuhan City, Hubei Province and China overall) and 4 phases (Phase I: January 23, 2020 to February 11, 2020; Phase II: February 12, 2020 to March 24, 2020; Phase III: March 25, 2020 to April 8, 2020; Phase IV: April 9, 2020 to June 30, 2020). These phases were divided based on 4 events: 1) January 23, 2020, lockdown of Wuhan City; 2) February 11, 2020, China CDC issued a notice to guide management of TB patients during the COVID-19 epidemic; 3) March 24, 2020 (World TB day), China promoted a campaign of “Jointly fighting COVID-19 and TB, and breathing healthy together” and the National Health Commission issued a “Notice on Further Strengthening TB Control and Prevention” and 4) April 8, 2020, China lifted the 76-day lockdown on Wuhan which meant the whole country started gradually returning to normal life.

Excess TB mortality ΔM resulting from the perturbation to TB detection was calculated using the following formula (9):

 $$\Delta M=\sum\limits_{h}\left[(1-d)\left(f_{u}^{\;h}-f_{t}^{\;h}\right) T^{\;h}\right]$$ (1)

The perturbation d of TB detection was expressed in terms of a reduction in the number of treated cases as compared to the expected number in the absence of the COVID-19 pandemic. Subscript u denotes untreated TB and subscript t denotes treated TB. Distributions of f are taken from the death surveillance points of China. It is assumed that the value of d is the same among HIV-positive and HIV-negative individuals. The h represent HIV status.

The number of detected active TB cases in China, Hubei, and Wuhan were found to decrease by 20%, 29%, and 44%, respectively, during January 23 to June 30, 2020 when compared with the same period in 2019. The highest reduction appeared in phase I nationwide and in phase II in Hubei and Wuhan. Wuhan had an especially large reduction at 74% (Figure 1).

Figure 1.  The reduction in tuberculosis case detection in China overall, in Hubei, and in Wuhan in different phases in 2020. Phase I: January 23, 2020 to February 11, 2020; Phase II: February 12, 2020 to March 24, 2020; Phase III: March 25, 2020 to April 8, 2020; Phase IV: April 9, 2020 to June 30, 2020.

The estimated additional TB deaths would be 186 cases, 760 cases and 11,700 cases which brought the total TB deaths to 478 cases, 2,520 cases and 51,100 cases in Wuhan, Hubei, and China, respectively. The estimated nationwide number of deaths surpassed the level of TB deaths in 2011 (50,900) and caused a serious setback in the progress towards the End TB strategy milestones and targets. More than half of the excess deaths were due to the reduction in case in Phase II. The estimated excess deaths during the COVID-19 pandemic accounted for 63.8%, 43.1%, and 29.7% of annual deaths in Wuhan, Hubei, and China, respectively (Table1).

 Perturbation Predicted excess deaths among HIV-positive cases (N) Predicted excess deaths among HIV-negative cases (N) Predicted total excess deaths (N) Excess deaths/annually deaths in 2018 (%) Wuhan City Phase I 0.962 0 34 34 11.8 Phase II 0.915 1 77 78 26.6 Phase III 0.987 0 12 12 4.1 Phase IV 0.932 1 61 62 21.3 Subtotal 2 184 186 63.8 Hubei Province Phase I 0.963 2 201 203 11.5 Phase II 0.963 4 427 430 24.4 Phase III 0.986 1 79 79 4.5 Phase IV 0.922 0 47 47 2.7 Subtotal 6 753 760 43.1 Nationwide Phase I 0.977 24 2,827 2,851 7.2 Phase II 0.959 43 5,022 5,065 12.9 Phase III 0.993 7 835 842 2.1 Phase IV 0.976 25 2,917 2,942 7.5 Total 98 11,601 11,700 29.7 Note: The study estimated excess TB deaths in 3 geographic areas (Wuhan City, Hubei Province and China overall) and 4 phases (Phase I: January 23, 2020 to February 11, 2020; Phase II: February 12, 2020 to March 24, 2020; Phase III: March 25, 2020 to April 8, 2020; Phase IV: April 9, 2020 to June 30, 2020).

Table 1.  The predicted number of tuberculosis deaths including tuberculosis (TB) deaths in HIV-negative and in HIV-positive cases during different phases in China overall, in Hubei, and in Wuhan in 2020.

Reference (9)

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