As a new acute respiratory infectious disease, coronavirus disease 2019 (COVID-19) has become one of the world’s most important public health problems. As a high tuberculosis (TB) burden country, China promptly adopted two overarching strategies of containment and suppression in response to the COVID-19 epidemic (1), which have already affected TB control, including notification, follow-up examinations, and treatment outcomes (2-4). However, existing studies presented the impact mainly based on routine surveillance data from the TB service system. The impact on TB patients’ behavior of seeking medical care from the perspective of TB patients remains unknown. To address this issue, China CDC randomly selected 294 counties from 31 provincial-level administrative divisions (PLADs) and conducted a national questionnaire survey in May 2020. The survey result showed that about half of TB patients did not revisit the hospital due to personal reasons, and the reasons for irregular medication and postponing or canceling examination after full treatment course were different. Therefore, health education should be strengthened for better TB patient management in addition to guaranteed uninterrupted service system.
To better understand the potential impact of COVID-19 on TB patients’ medical care seeking behavior, we conducted a national TB patients survey. A total of 294 counties were randomly selected (10% of all counties) by PLADs, and whether the county had reported cases of COVID-19, of which 116 counties reported COVID-19 cases and 178 counties did not report COVID-19 cases. Then, a total of 18 cases were randomly selected for each county including 6 TB cases with treatment for less than 2 months, 6 cases treated for 2 months, and 6 cases that finished the whole treatment course from the period of January 25 to April 8, 2020, which was defined as the COVID-19 period as it marked the starting point of the national emergency response to COVID-19 to the reopening of Wuhan city. If there were fewer than 6 cases for any category in the county, then all the TB cases in that category were surveyed. Finally, a total of 3,224 TB cases were selected and investigated by CDC staff, with 665, 1,224, and 1,335 cases from each group, respectively. In the questionnaire, some questions were for all cases and some questions were for specific TB cases (Table 1).
Questions Treated less than 2 months Treated for 2 months Finished treatment If diagnosis of TB was affected and the main underlying reason Yes Yes No If regular intake of medication was affected and the main underlying reason Yes Yes Yes If sputum examination after 2 months’ treatment was affected and the main underlying reason No Yes No If sputum examination after full treatment course was affected and the main underlying reason No No Yes
Table 1. Main questions surveyed for different groups of tuberculosis (TB) cases conducted by China CDC in China — May, 2020.
Of the 850 TB cases that were diagnosed in the COVID-19 period, the diagnoses of 192 (22.6%) cases were affected. There were 81 (42.2%), 52 (27.1%), and 59 (30.7%) cases who postponed seeking medical care due to traffic restrictions, TB service disruptions, and personal reasons, respectively. No significant differences existed between counties with/without COVID-19 in terms of the diagnosis of TB (P=0.597) and the main underlying reason for postponing seeking care (P=0.231).
Of the 3,224 TB cases that should have taken anti-TB drugs regularly in the COVID-19 period, only 110 (3.4%) cases reported irregular intake of medication and no significant differences existed between counties with/without COVID-19 (P=0.618). Due to side effects and personal reasons, 48 (43.6%) and 62 (56.4%) cases, respectively, did not take medication regularly. There were significant differences between counties with COVID-19 and without COVID-19 in terms of the main underlying reason for irregular medication (P<0.001).
Of the 1,224 TB cases that should have sputum examination after 2 months’ treatment in the intensive period, 322 (26.3%) cases were affected. A total of 110 (34.2%), 51 (15.8%), and 161 (50.0%) cases postponed or canceled the examination due to traffic restrictions, TB service disruptions, and personal reasons, respectively. There were no significant differences between counties with COVID-19 and without COVID-19 in terms of the percentage of sputum examination (P=0.794) and the main underlying reason (P=0.454).
Of the 1,335 TB cases that should have sputum examination after full treatment course in the intensive period, 379 (28.4%) cases were affected, and there was no significant difference between counties with COVID-19 and without COVID-19 (P=0.794). A total of 129 (34.0%), 41 (10.8%), and 209 (55.2%) cases postponed or canceled the examination due to traffic restrictions, TB service disruptions, and personal reasons, respectively. There were significant differences between counties with COVID-19 and without COVID-19 in terms of the main underlying reason (P=0.002) (Table 2).
Type Total Surveyed counties P-value No COVID-19 COVID-19 Diagnosis of TB 0.597 Not affected 658 (77.4) 267 (76.5) 391 (78.0) Affected 192 (22.6) 82 (23.5) 110 (22.0) Reason of diagnosis delay 0.231 Traffic restriction 81 (42.2) 29 (35.4) 52 (47.3) TB service disruption 52 (27.1) 26 (31.7) 26 (23.6) Personal reason 59 (30.7) 27 (32.9) 32 (29.1) Regular intake of medication 0.618 Not affected 3,114 (96.6) 1,177 (96.8) 1,937 (96.5) Affected 110 (3.4) 39 (3.2) 71 (3.5) Reason of irregular medication <0.001 Side effect 48 (43.6) 26 (66.7) 22 (31.0) Personal reason 62 (56.4) 13 (33.3) 49 (69.0) Sputum examination after 2 months’ treatment 0.794 Yes 902 (73.7) 326 (73.3) 576 (73.9) No 322 (26.3) 119 (26.7) 203 (26.1) Reason of postponing or cancelling examination after 2 months’ treatment 0.454 Traffic restriction 110 (34.2) 41 (34.5) 69 (34.0) TB service disruption 51 (15.8) 15 (12.6) 36 (17.7) Personal reason 161 (50.0) 63 (52.9) 98 (48.3) Sputum examination after full treatment course 0.794 Yes 956 (71.6) 363 (72.0) 593 (71.4) No 379 (28.4) 141 (28.0) 238 (28.6) Reason of postponing or cancelling examination after full treatment course 0.002 Traffic restriction 129 (34.0) 33 (23.4) 96 (40.3) TB service disruption 41 (10.8) 15 (10.6) 26 (10.9) Personal reason 209 (55.2) 93 (66.0) 116 (48.8) Note: Data are presented as n (%) unless otherwise stated.
Table 2. The questionnaire results of tuberculosis (TB) cases from randomly selected counties conducted by China CDC in China — May, 2020.