key: cord-0975725-og814nwm authors: Shen, X.; Sha, W.; Yang, C.; Pan, Q.; Cohen, T.; Chen, S.; Cai, Q.; Kan, X.; Zong, P.; Zeng, Z.; Tan, S.; Liang, R.; Bai, L.; Xia, J.; Wu, S.; Sun, P.; Wu, G.; Cai, C.; Wang, X.; Ai, K.; Liu, J.; Yuan, Z. title: Continuity of services for patients with tuberculosis in China in the COVID-19 era date: 2020-07-17 journal: nan DOI: 10.1101/2020.07.16.20150292 sha: 3197f796b39659765c646ac3f08c8bcff36f6ebe doc_id: 975725 cord_uid: og814nwm It is crucial to maintain continuity of essential services for people affected by tuberculosis (TB). Efforts to deliver these essential services in many global settings have been complicated by the emergence and global spread of SARS-CoV-2 and the pandemic of COVID-19. Understanding how the COVID-19 pandemic has impacted the availability of TB diagnostic and treatment services is critical for identifying policies that can mitigate disruptions of these essential services. China has a dual burden of TB and COVID-19. We conducted a survey and collected data from 13 provinces in China to evaluate the early impact of COVID-19 on TB services and to document interventions that were adopted to maintain the continuity services for TB patients during the pandemic. We use these data to identify additional opportunities that will improve the ability of TB programs to maintain essential services during this crisis. While health systems and underlying epidemiology differ between countries, we believe that sharing China's experience can inform the design of locally tailored strategies to maintain essential TB services during the COVID-19 pandemic. It is crucial to maintain continuity of essential services for people affected by tuberculosis (TB) . 48 Efforts to deliver these essential services in many global settings have been complicated by the 49 emergence and global spread of SARS-CoV-2 and the pandemic of COVID-19. Understanding how 50 the COVID-19 pandemic has impacted the availability of TB diagnostic and treatment services is 51 critical for identifying policies that can mitigate disruptions of these essential services. China has a 52 dual burden of TB and COVID-19. We conducted a survey and collected data from 13 provinces in 53 China to evaluate the early impact of COVID-19 on TB services and to document interventions that 54 were adopted to maintain the continuity services for TB patients during the pandemic. We use these 55 data to identify additional opportunities which will improve the ability of TB programs to maintain 56 essential services during this crisis. While health systems and underlying epidemiology differ between 57 countries, we believe that sharing China's experience can inform the design of locally tailored 58 strategies to maintain essential TB services during the COVID-19 pandemic. 59 The emergence and spread of the novel coronavirus SARS-CoV-2 has caused a pandemic of COVID-61 19 1 . The COVID-19 pandemic poses unprecedented challenges for health systems. In addition to 62 imposing new demands of these systems to respond to this novel virus, the rapid spread of SARS-63 CoV2 threatens access to and delivery of essential health services that were needed prior to the 64 pandemic 2 . 65 Tuberculosis (TB) is the leading infectious cause of death due to a single pathogen. TB diagnosis 66 depends on individuals with symptoms having access to diagnostic facilities, and TB treatment 67 requires daily adherence to antibiotic treatment, often directly observed by healthcare personnel, for 68 six months or longer. TB diagnosis and care is thus a major public health undertaking, and while 69 investment in TB control is one of the single most cost-effective health interventions, TB programs 70 are often operating with limited budgets. Although the sample size of the survey is limited, it covers all seven regions in mainland China 107 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted July 17, 2020. . (Figure 1 ), and thus the survey results represent the status of tuberculosis diagnosis and treatment 108 services at the provincial level tuberculosis designated hospitals during the COVID-19 outbreak. 109 In this survey, we divided COVID-19 epidemics in China in three periods: the pre-pandemic phase 110 (2019), the outbreak emergency response phase (January through March, 2020); and the outbreak 111 mitigation phase (April, 2020). We conducted a pilot study in one hospital prior the full scale-up of 112 the survey. We collected information about three aspects of TB diagnosis and care during the 113 outbreak: 1) Changes in hospital-based diagnosis of TB patients; 2) Changes in the availability of 114 hospital-based TB services; and 3) Adjustment of hospital-based TB services. 115 Changes in the detection of TB. Compared with the same period of 2019, the number of TB patients 117 diagnosed significantly decreased during the pandemic ( Compared with the same period in the previous year (January-March 2019), there were 34% (6-99%) 133 and 30% (11-100%) reductions in the number of outpatient visits and the number of admissions in the 134 emergency response phase, respectively (Table 1) . 135 In the mitigation phase, the fraction of TB medical resources deployed for COVID-19 gradually 136 decreased. Five hospitals still shifted the TB beds for COVID-19 but with a deceased median 137 proportion of 43·6% (5·0-53·3%) compared to emergency response phase. Twelve TB hospitals 138 continue to dispatch professional TB staff for COVID-19, but the proportion of TB staff repurposed 139 for decreased from 28% to 10% (Table 1 ). The number of hospitals that set stricter indications for 140 hospitalization or set a restriction for maximum outpatient visits both decreased to three (23·1%). 141 Compared with the same period of April 2019, the decline has narrowed for the number of outpatient 142 visits, the number of patients' admission and discharge for each TB hospitals ( CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted July 17, 2020. and nine hospitals allowed only a single visitor, the remaining one did not set any restriction. 205 In this survey, we have gained insight into the impact of the COVID-19 outbreak on the continuity of 207 hospital-based TB services. Most TB services, including diagnosis inpatient and outpatient care, 208 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted July 17, 2020. . with surveillance and monitoring systems, as well as diagnostic tools such as GeneXpert and chest 243 radiography. In countries with local transmission of COVID-19, the case-finding strategies are being 244 modified to an active approach. Although active TB case finding has not been scale-up in many high 245 TB burden countries, there is a potential for the collaboration between activities of case finding for 246 both TB and COVID-19, such as close contact screening and tracing, testing of patients with severe 247 pneumonia that does not respond to antibiotics, which can help to quickly detect patients with both 248 diseases. 249 250 Our survey reveals a significant disruption of TB diagnosis and care at major hospitals throughout 252 China as a result of COVID-19. These disruptions were most dramatic at the peak of the epidemic, 253 and numbers of TB diagnoses and TB inpatient facilities have gradually returned toward normal 254 levels as COVID-19 incidence receded in April 2020. We also report innovative efforts adopted by 255 hospitals to maintain the continuity of care TB patients during the pandemic. As many countries with 256 high TB burden are still attempting to control COVID-19, our experiences in China offer important 257 lessons for other health systems grappling with maintain TB services in the midst of this crisis. We 258 believe that patient-centered approaches to TB diagnosis and care, which were already being 259 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted July 17, 2020. . https://doi.org/10.1101/2020.07.16.20150292 doi: medRxiv preprint promoted before the emergence of COVID-19, should have new urgency and motivation. We urgently 260 call for additional investment directed toward improving the availability of diagnostics and 261 therapeutics such that equitable access to care can be maintained during times of crisis. 262 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted July 17, 2020. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted July 17, 2020. -19 patients by 277 April 30, 2020 in the 13 provinces. The size of circle represents the number of tuberculosis (orange) 278 and COVID-19 cases (blue). The Hubei province was the only one with more accumulated COVID-279 19 cases than the annual notified tuberculosis cases. 280 Tables 281 Table 1 . Impact of COVID-19 on TB services in 13 TB hospitals in China, 2020 282 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted July 17, 2020. World Health Organization. WHO Director-General's opening remarks at the media briefing on 286 COVID-19 Fair Allocation of Scarce Medical Resources in the Time of 289 Covid-19 Predicted impact of the COVID-19 pandemic on global tuberculosis deaths in 2020 Clinical course and risk factors for mortality of adult inpatients with 293 COVID-19 in Wuhan, China: a retrospective cohort study Global tuberculosis report Active case finding with case management: the key to tackling the 297 COVID-19 pandemic Epidemiological and clinical characteristics of 99 cases of 2019 300 novel coronavirus pneumonia in Wuhan, China: a descriptive study Early dynamics of transmission and control of 303 COVID-19: a mathematical modelling study An investigation of transmission control measures during the first 50 305 days of the COVID-19 epidemic in China Spatiotemporal Analysis of Tuberculosis Incidence and Its Associated 310 Factors in Mainland China Using electronic medication monitoring to guide differential 312 management of tuberculosis patients at the community level in China Effectiveness of Electronic Reminders to Improve Medication 314 Adherence in Tuberculosis Patients: A Cluster-Randomised Trial