key: cord-0939287-6mfnxkaw authors: Bhargava, Anurag; Shewade, Hemant Deepak title: The potential impact of the COVID-19 response related lockdown on TB incidence and mortality in India date: 2020-07-10 journal: Indian J Tuberc DOI: 10.1016/j.ijtb.2020.07.004 sha: a346928e2fd2fb935ad1c72d6da4f9ace6f31df1 doc_id: 939287 cord_uid: 6mfnxkaw India has the highest burden of incident tuberculosis (TB) cases and deaths globally. TB is strongly associated with poverty and this risk is largely mediated by undernutrition in India. COVID-19 response related lockdown has resulted in an economic crisis which may double levels of poverty, has exacerbated food insecurity, and disrupted TB services. These developments may have serious implications for TB progression and transmission in India. The nutritional status of a population is a strong determinant of the TB incidence, and undernutrition in adults alone accounts for 32-44% of TB incidence in India. A systematic review has shown that a 14% increase in TB incidence can occur per one unit decrease in body mass index (BMI), across the BMI range of 18.5-30 kg/m2. We believe that one unit decrease in BMI (corresponding to a 2-3 kg weight loss) may result in the poor in India as a result of the lockdown and its aftermath. This may result in an increase in estimated (uncertainty interval) incident TB by 185 610 (180 230, 190 990) cases. A 59% reduction in TB case detection between end March and May 2020, may result in an estimated (uncertainty interval) additional 87 711 (59 998, 120 630) TB deaths [19.5% increase (14.5, 24.7)] in 2020. Disadvantaged social groups, those living in states with higher levels of poverty, undernutrition, and migrant workers are at particular risk. We suggest enhanced rations including pulses through the public distribution system, direct cash transfers to the poor pending restoration of livelihoods. TB services should be resumed immediately with enhanced efforts at case detection including active case finding. To prevent deaths among TB detected within the national TB programme, systemic identification, referral and management of severe disease at notification should be considered. India has the highest burden of incident tuberculosis (TB) cases and deaths globally. TB is strongly associated with poverty and this risk is largely mediated by undernutrition in 6 India. COVID-19 response related lockdown has resulted in an economic crisis which may 7 double levels of poverty, has exacerbated food insecurity, and disrupted TB services. These 8 developments may have serious implications for TB progression and transmission in India. 9 The nutritional status of a population is a strong determinant of the TB incidence, and 10 undernutrition in adults alone accounts for 32-44% of TB incidence in India. A systematic 11 review has shown that a 14% increase in TB incidence can occur per one unit decrease in 12 body mass index (BMI), across the BMI range of 18.5-30 kg/m2. We believe that one unit 50 Globally, India has the highest numbers of poor people according to the World Bank. 7 Using 51 a monthly per capita expenditure cut-off, the Government of India estimated in 2011-12 that 52 22% live below the poverty line. 8 In India poverty is closely associated with childhood and adult undernutrition. According to the results of the National Family Health Survey-4 (NFHS-4), 23% of adult 55 women and 19% of adult men have undernutrition defined as a body mass index (BMI) less 56 than 18.5 kg/m 2 . 9 The prevalence of undernutrition is higher in rural India, especially in the 57 states of Jharkhand, Bihar, Madhya Pradesh, Odisha and Uttar Pradesh, in women, in those 58 belonging to scheduled tribes and scheduled castes, and in the poor. While 11.8% of women 59 in the highest wealth index were underweight, in the lowest wealth index, 35.8% had a low 60 BMI, with a similar differential in the men. 9 According to the World Health Organization leafy vegetables, fruits is below recommended intakes. A particular concern is protein 69 intake which is predominantly derived from cereals, and cereal proteins are of poorer In a systematic review of six large cohort studies, it was seen that BMI and TB incidence 90 had a consistent and inverse exponential relationship and that low BMI was causally 91 related to TB incidence. 20 In the most recent cohort study which examined the effect of 92 BMI and TB incidence, low BMI (<18.5 kg/m 2 ) was associated with an adjusted hazard incident and prevalent TB. In a cohort study a protein intake less than 50% was strongly 111 associated with TB incidence. 21 Low levels of serum albumin and serum transferrin (both 112 markers of protein nutritional status) were strongly associated with an increased risk of 113 TB. 21 In a case-control study in Zambia, the effect of household socioeconomic position 114 on TB prevalence was largely mediated by protein intake (adjusted odds ratio 3.1). In this 115 high HIV prevalence setting, the population attributable fraction for TB was higher for 116 protein deficiency in diet (42%) when compared to HIV (36%). 24 In India (2011-12), as 117 the poorest 30% of the population also consume less protein, 16,25 therefore, low protein 118 consumption may be a risk factor for development of TB. The potential impact of weight loss in the poor households on TB incidence can be 150 estimated using the results of a systematic review of cohort studies linking BMI to TB 151 incidence. 20 The average slope gave a reduction of TB incidence of 13.8% [95% CI: 13.4, 14.2] for an increase of BMI by one kg/m 2 for BMIs in the range of 18.5-30 kg/ as well as the 153 converse increase in TB incidence by 13.8% for one unit decrease of BMI. 20 Therefore, a 154 reduction in BMI at population level due to reduction in consumption among the poorest 155 sections of the society is also conversely expected to be associated with a 13.8% increase in 156 TB incidence in the poorest sections. The under-detection was more than 70% in Andaman & Nicobar, Uttar Pradesh and 224 Bihar; and less than 30% in Odisha, Goa, Arunachal Pradesh, Mizoram and Sikkim. There 225 was no effect of lockdown on TB under-detection in Lakshadweep (0%) and Ladakh (21% 226 over-detection). (see Table 1and 229 Globally, it has been predicted that an average 25% decrease in TB case detection over a 230 period of three months of lockdown will lead to an additional 190 000 (13% increase) deaths 231 in 2020. This is assuming an absence of a rebound in case detection above values prior to the 232 lockdown. 40 We applied the same model to India using 2018 estimates. 1 Considering the 233 observed 59% reduction in detection over an eight week period, there will be an estimated Due to the COVID-19 related lockdown, the potential increase in incidence and mortality due 253 to TB has the potential to wipe out the gains made in the last few years. To address the issue of excess mortality due to lockdown related under-detection, and BMI is based on six studies, all from high-income countries 20 We have also not provided 307 a combined increase in TB incidence and mortality due to lockdown induced impoverishment 308 and under-detection. Despite this, the numbers estimated and presented are significant 309 enough for the programme to act. We have assumed similar under-detection among TB 310 patients living with and without HIV. The present situation is dynamic and evolving there are many other factors that can 312 modify the final impact. Among these, the response of the public health system, the social 313 protection provided by different state governments to the poor and the responsiveness of the 314 economy to the stimulus offered will shape the future of the TB epidemic. The author(s) received no specific funding for this work. World Health Organization (WHO) Revised National Tuberculosis Control Programme (RNTCP) National Strategic Plan for TB Elimination 2017-25 The Global Burden of Latent Tuberculosis Infection: A Re-345 estimation Using Mathematical Modelling 348 5. Bhargava A. Undernutrition, nutritionally acquired immunodeficiency, and 349 tuberculosis control Tuberculosis control in India: Refocus on 351 nutrition Half of the world's poor live in just 5 countries Accessed May 8, 2020. 355 8. Ministry of Statistics and Programme Implementation; Government of India. India in 356 Figures Indian Institute of Population Sciences. National Family and Health Survey (NFHS-4) Physical Status: The Use and Interpretation of 360 Report of a WHO Expert Committee National Sample Survey Office; Ministry of Statistics and Programme 363 Implementation; Government of India Distribution System and Other Sources of Household Consumption National Nutrition Monitoring Bureau. India Rural Third Repeat Survey of Diet and 367 Nutritional Status 2011-12 An Analysis of Protein Consumption in India Through Plant and Animal 369 of Excellence in Public Health Nutrition. Overview of Food and 371 Nutrition in India The Indian National Food Security Act, 2013: 374 A Commentary The Public Distribution System and Food Security in India Self-reported tuberculosis in India: evidence 379 from NFHS-4 Active case finding among 381 marginalised and vulnerable populations reduces catastrophic costs due to tuberculosis 382 diagnosis Tuberculosis and Poverty: Why Are the Poor at Greater Risk in 385 India? A consistent log-linear relationship 387 between tuberculosis incidence and body mass index Nutritional Risk Factors for Tuberculosis 390 Among Adults in the United States, 1971-1992 Undernutrition and the 393 incidence of tuberculosis in India: National and subnational estimates of the 394 population-attributable fraction related to undernutrition Tuberculosis control and elimination 397 2010-50: cure, care, and social development The association between household 400 socioeconomic position and prevalent tuberculosis in zambia: A case-control study Ministry of Statistics and Programme Implementation & World Food Programme Indira Gandhi 405 Institute of Development Research, Mumbai Working Papers 2020-013 Unemployment rate soars to 27.11% amid COVID-19 408 pandemic: CMIE. The Indian Express ILO Monitor: COVID-19 and the World of 410 Work COVID 19 may double poverty in India. Financial Express Stranded Workers Action Network. 21 Days and Counting: COVID-19 Lockdown Migrant Workers, and the Inadequacy of Welfare Measures in India Distress_Report-by-Stranded-Workers-Action-Network.pdf Press Information Bureau; Government of India Lakh Crore relief package under Pradhan Mantri Garib Kalyan Yojana for the poor to 420 help them fight the battle against Corona Virus National Institute of Nutrition. Dietary Guidelines for Indians National Sample Survey Office; Ministry of Statistics and Programme 426 Implementation; Government of India. Nutritional Intake in India Prevalence of undernutrition, its determinants, and seasonal variation among 430 tribal preschool children of Odisha state, India. Asia-Pacific J public Heal The impact of the economic crisis and the US embargo on 433 health in Cuba Towards elimination of tuberculosis 435 in a low income country: the experience of Cuba Increased incidence of tuberculosis in Zimbabwe, in 438 association with food insecurity, and economic collapse: An ecological analysis. PLoS 439 One Predicted impact of the COVID-19 pandemic on global tuberculosis deaths 448 in 2020 Stop TB Partnership in collaboration with Imperial College;Avenir Health Hopkins University and USAID. The Potential Impact of the COVID-19 Response on 452 Tuberculosis in High-Burden Countries: A Modelling Analysis Clinical profiles of early and tuberculosis-related 455 mortality in South Korea between 2015 and 2017: a cross-sectional study Early death by tuberculosis as the underlying cause in a state of Southern 459 Brazil: Profile, comorbidities and associated vulnerabilities Government of India. Ministry of Finance: Finance Minister 462 announces Government Reforms and Enablers across Seven Sectors under Aatma 463 Tuberculosis deaths are predictable and preventable: 466 Comprehensive assessment and clinical care is the key 29101 10616 36 64 Maharashtra 32717 14447 44 56 Manipur 305 137 45 55 Meghalaya 800 474 59 41 Mizoram 425 318 75 25 Nagaland 649 360 55 45 Odisha 8701 6197 71 29 Puducherry 745 254 34 66 Punjab 9852 5144 52 48 Rajasthan 26418 11462 43 57 Sikkim 284 219 77 23 Tamil Nadu 17025 5466 32 68 Telangana 12985 6221 48 52 Tripura 451 227 50 50 Uttar Pradesh 77887 20692 27 73 Uttarakhand 4200 2373 57 44 West Bengal 17098 8261 48 52 Total 380025 154285 41 59** *notification data extracted on 11 June 2020 from the NIKSHAY website 47 ; **when compared with previous year (25 March to 19 May 2019), the national under-detection was 62%• COVID-19 response related national lockdown in India may double levels of poverty, has exacerbated food insecurity, and disrupted TB services.• Worsening of undernutrition among the poor may result in an additional estimated 185 610 incident TB cases • TB under-detection during lockdown could result in an additional estimated 87 711 TB deaths in 2020 • We recommend enhanced rations including pulses and direct cash transfers for the poor.• We recommend ramped up active case finding and early detection of severe disease.