key: cord-1015889-wcaivcvw authors: Rojas‐Bolivar, Daniel; Intimayta‐Escalante, Claudio; Cardenas‐Jara, Ariana; Jandarov, Roman; Huaman, Moises A. title: COVID‐19 case fatality rate and tuberculosis in a metropolitan setting date: 2021-02-23 journal: J Med Virol DOI: 10.1002/jmv.26868 sha: 25fc2affbeba33a9bab42dabfd83b20fffc9bd56 doc_id: 1015889 cord_uid: wcaivcvw In this study, we aimed to assess the relationship between tuberculosis case rate and COVID‐19 case fatality rate (CFR) among districts within a tuberculosis‐endemic metropolitan area. We analyzed data from 43 districts in Lima, Peru. We used districts as the units of observation. Linear regressions were used to investigate the relationship between COVID‐19 CFRs and tuberculosis case rates. The mean COVID‐19 CFR in each district for reporting Weeks 5–32 was used as the dependent variable. Independent variable was the mean rate of confirmed pulmonary tuberculosis cases for 2017–2019 period. Analyses were adjusted by population density, socioeconomic status, crowded housing, health facility density, and case rates of hypertension, diabetes mellitus, and HIV infection. The mean COVID‐19 CFR in Lima was 4.0% ± 1.1%. The mean tuberculosis rate was 16.0 cases per 10,000 inhabitants. In multivariate analysis, tuberculosis case rate was associated with COVID‐19 CFR (β = 1.26; 95% confidence interval: 0.24–2.28; p = .02), after adjusting for potential confounders. We found that Lima districts with a higher burden of tuberculosis exhibited higher COVID‐19 CFRs, independent of socioeconomic, and morbidity variables. The novel COVID-19 pandemic is intersecting with other epidemics including tuberculosis. The response to the COVID-19 pandemic has affected tuberculosis prevention and control programs worldwide. 1, 2 COVID-19 may occur in patients with active tuberculosis or tuberculosis sequela. 3 There is growing evidence of the effect of tuberculosis on COVID-19 susceptibility and prognosis, 4,5 although a meta-analysis of Chinese studies did not show a significant association between tuberculosis and COVID-19 severity. 6 Clearly, it is urgent to improve our understanding of the intersection between COVID-19 and tuberculosis, especially in countries with a high burden of both diseases. A setting in the world conducive to studying the confluence of these two scourges is Peru. Tuberculosis is endemic in Peru, accounting for the highest rates of multidrug resistant tuberculosis in Latin America. 7 Moreover, Peru has been one of the countries most affected by the COVID-19 pandemic. By August 2020, Peru ranked second among countries with the highest mortality rate of COVID-19 reported worldwide, with approximately 600,000 confirmed COVID-19 cases and 28,000 COVID-19 related deaths. 8 To provide some insight on the interplay between COVID-19 and tuberculosis, we studied the relationship between COVID-19 case fatality rates (CFRs) and of tuberculosis case rates in Metropolitan Lima, Peru. We conducted an ecological study where the units of observation were individual districts of Metropolitan Lima, which contained a total of 43 districts and approximately 9 million inhabitants living within a 2670.4 km 2 geographic area. For our analyses, the dependent variable was COVID-19 CFR per 100 COVID-19 cases. The main covariable was the rate of pulmonary tuberculosis cases con- In bivariate analysis, tuberculosis case rate was associated with COVID-19 CFR (β = 1.76; 95% confidence interval [CI]: 1.13-2.39; p < .001; Figure 1 ). Population density, crowded housing, and case rates of diabetes mellitus, hypertension, HIV infection were also associated with COVID-19 CFR (Table 1) . In multivariate analysis, tuberculosis case rate remained associated with COVID-19 CFR (β = 1.26; 95% CI: 0.24-2.28; p = .02; Table 1 ), as well as population density (β = 5.2 × 10 −5 ; 95% CI: 0.5 × 10 −5 -9.9 × 10 −5 ; p = .03; Table 1 ). No mediation effects nor significant interaction were detected (Tables S1 and S2a-g) We found a positive correlation between district tuberculosis case rate and COVID-19 CFR in a metropolitan area with high COVID-19 and tuberculosis burden, independent of district socioeconomic status, population density, crowded housing and morbidity variables, including case rates of diabetes mellitus, hypertension, and HIV infection. Our findings support the possibility of an important synergy between tuberculosis and COVID-19. The mechanism remains speculative. Tuberculosis may be a marker of individual comorbid or socioeconomic conditions known to increase the risk of progression to severe COVID-19. 14 In addition, it is possible that tuberculosis could affect clinical outcomes of COVID-19 patients through direct pathogenic effects, 15 as both infections share common disease pathways. 16 Although a meta-analysis of Chinese studies did not find an association between tuberculosis and COVID-19 severity, 6 it is important to note that these results may have been af- In conclusion, our findings indicate that districts with a higher burden of tuberculosis may also be the most affected by COVID-19 CFRs in metropolitan settings, independently of socioeconomic characteristics, and morbidity rates from other diseases. Tuberculosis hotspots might need to be prioritized in COVID-19 control strategies. Research is needed to better understand the interplay between COVID-19 and tuberculosis at individual and aggregate levels. 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Perú: resultados definitivos de los censos nacionales 2017 Perú: estimaciones y proyecciones de población por departamento, provincia y distrito COVID-19, tuberculosis and poverty: preventing a perfect storm COVID-19-Tuberculosis interactions: when dark forces collide IFN signaling and neutrophil degranulation transcriptional signatures are induced during SARS-CoV-2 infection Implications of COVID-19 in high burden countries for HIV/TB: a systematic review of evidence Tuberculosis, COVID-19 and migrants: Preliminary analysis of deaths occurring in 69 patients from two cohorts The authors declare that there are no conflict of interests. The peer review history for this article is available at https://publons. com/publon/10.1002/jmv.26868 The data that support the findings of this study are available from the corresponding author upon reasonable request. Daniel Rojas-Bolivar http://orcid.org/0000-0003-0585-4155Claudio Intimayta-Escalante https://orcid.org/0000-0003- Ariana Cardenas-Jara https://orcid.org/0000-0002-4408-5769Roman Jandarov https://orcid.org/0000-0003-2145-045XMoises A. Huaman https://orcid.org/0000-0002-6839-5809