key: cord-1018812-n72eawgx authors: Rodrigues, Inês; Aguiar, Ana; Migliori, Giovanni Battista; Duarte, Raquel title: Impact of the COVID-19 pandemic on tuberculosis services date: 2022-02-07 journal: Pulmonology DOI: 10.1016/j.pulmoe.2022.01.015 sha: 7006fdae827f1bdb47ca414a0b2b412027c8e09b doc_id: 1018812 cord_uid: n72eawgx BACKGROUND: In Portugal, Outpatient Tuberculosis Centres (OTBC) are responsible for the diagnosis, treatment, screening and prevention of tuberculosis (TB), and only severe or resistant cases are hospitalized. AIM: To understand how infection control norms and standards were applied and how these centres responded during the pandemic. METHOD: We sent an electronic questionnaire to all coordinators of OTBC. The questionnaire included questions on infection control during the COVID-19 pandemic and evaluation of the functioning of the OTBC in two periods: during the 1st National State of Emergency and after 1 year. RESULTS: Thirty-two responses were obtained (52.5%). The infection control norms were globally applied; diagnosis, treatment, and prevention were kept, and contact screening was only affected during the 1st State of Emergency. However, half of the respondents (53.1%) believed that there were diagnostic delays during the 1st State of Emergency, rising to 68.8% after 1 year. Only 31.3% performed Directly Observed Therapy (DOT) in all patients during the 1st State of Emergency, and 59.4% after 1 year. Half the inquiries expected an increase in TB incidence in the near future. CONCLUSION: The pandemic affected OTBC functioning, although the services were kept open; diagnostic delay and DOT appliance were the most affected. Since the beginning of 2020, the coronavirus disease 2019 (COVID- 19) pandemic has caused a significant disruption in all areas of healthcare worldwide. [1] [2] [3] The functioning and response of many health services, including tuberculosis (TB) services, were profoundly affected by the policies adopted to respond to the pandemic, such as country lockdowns, reallocation of health professionals, materials, and diagnostic tools, and reduction of outpatient care. [4] [5] [6] [7] [8] Hence, it is not surprising that several studies carried in high-burden countries for TB report a significant decrease in TB detection and notifications in the first months of the pandemic. [9] [10] [11] Following this, a modelling analysis from Glaziou 12 and the -Stop TB Partnership‖ 13 predicted, for a 3-month lockdown period, an annual increase in TB deaths between 200,000 -400,000, raising the total deaths to ~1.6 -1.8 million, numbers comparable to the ones seen between 2012 and 2015. 12, 13 Low-burden countries for TB also report significant changes in TB detection and patient care. A study carried out in Spain compared data from March-June in 2019 and 2020 and described an increase in latent and active TB in children of patient households (5.3% vs 7.7% in 2019 and 2020, respectively, p < 0.001); additionally, patients with the active disease diagnosed during the pandemic showed more severe manifestations. 14 In a worldwide study by the Global Tuberculosis Network, a significant decline in detection of TB (and multidrug-resistant TB) cases and TB infection was observed, with an increase in telehealth consultations. 2 Although much was written on the impact of COVID-19 on TB services and workplace safety resulting from infection control practices, not much is known on this, 15, 16 and country-specific analyses are not available. In Portugal, before the pandemic, there was a downward trend in the incidence and notification rate of TB over the last 10 years. 17 Between 2015 and 2019, there was a 24.6% decrease in the notification rate, placing it at 17.2 cases per 100 thousand inhabitants in 2019, with an estimated incidence rate of 19.0 cases per 100 thousand inhabitants. 18 The National Tuberculosis Program is responsible for the monitoring and surveillance of TB; implementing control and elimination strategies, action plans, and protocols for the management of the disease. 19 The diagnosis, screening, treatment, and follow-up of individual patients are performed at Outpatient TB Centres (OTBC), overseen by the National Tuberculosis Program. Aguiar et al. 20 We conducted a cross-sectional study using an electronic online questionnaire created in Google Forms. A pilot survey was performed in two OTBC to assess the questionnaire's relevance and understandability, and the final version was sent via e-mail to all OTBC's coordinators. The National Tuberculosis Program provided the list with the coordinator's electronic addresses. Responses were collected during March and April 2021. Participation was entirely voluntary, and the anonymity of the participants was ensured. Ethical approval was obtained from the Ethics Committee of the Institute of Public Health of the University of Porto on September 19, 2020 (reference CE20170). According to the Ethical Principles for Medical Research involving human subjects expressed in the Declaration of Helsinki and the current national legislation, all participants are asked to give their informed consent. Furthermore, because this was an online survey, participants had to choose -I accept to participate‖ to continue with the questionnaire. An online questionnaire was prepared. The questionnaire consisted of 32 questions, divided into three sections. The first part contained 4 demographic questions: age, sex, profession, and workplace. To guarantee the anonymity of the responders and further explore possible asymmetries between regions, workplaces were grouped into Regional Health Administrations: North, Centre, Questions were mostly closed (e.g., yes/no), but contained an -other" option where inquires could justify their answers, when appropriate. The last question was completely open, and responders were free to share their final comments. The results of the survey were compared with the findings of a recent Global Tuberculosis Network study. 2 Thirty-two OTBC coordinators accepted to answer the questionnaire, from a total of 61 (52.5% response rate). The Regional Health Administrations most represented were Alentejo and Algarve, with a 66.7% response rate each. Two locations were kept undisclosed (one didn't answer, and the other was not revealed to protect the anonymity of the responder). OTBC coordinator's characteristics and response rate by region are summarised in Table 1 . Answers concerning hygiene and safety measures during the pandemic are summarised in Table 2 . Surgical masks and alcohol sanitizing solution were provided to healthcare professionals in all OTBC, but FFP2 masks were not supplied in 2 centres. Also, in 2 centres, patients were not routinely provided with surgical masks or sanitizing solution. Disinfection of common areas was carried out, at least once a day, in all OTBC except one. In 83.9% of all OTBC, there was a contingency plan for managing cases with suspected or confirmed SARS-CoV-2 (Severe Acute Respiratory Syndrome Coronavirus-2). The majority (81.3%) considered that their OTBC complied with the safety standards established by the Directorate-General of Health. Comparing the functioning of the OTBC during the 1 st State of Emergency and after 1 year (Table 3) , responders stated that those consultations (face-to-face and/or by telephone) were maintained in both periods (except during the 1st State of Emergency). Almost 60% reported limitations in the number of consultations carried out daily, although only 6.3% referred to delays in scheduling new appointments. More than two-thirds of the respondents considered that, in both periods, there were fewer outpatient visits to the OTBC; three coordinators suggested that this was due to a decrease in referral by other health units. In addition, half of the respondents believed that there were delays in diagnosing active disease in the Half of the responders believed the pandemic will lead to an increased incidence of TB in Portugal in the near future. On the final question, the following problems were raised: the occupation of the OTBC installations by other services; patients missing their appointments more often since the beginning of the pandemic; fear of the effect of immunosuppression used to treat COVID-19 patients in TB epidemic and severity of the disease; patients fears about to recourse to health units; lack of cameras to make video calls; and delays in patient's referral from primary care units. Overall, there were no apparent asymmetries between Portuguese Regional Health Administrations. However, there were some irregularities in particular areas: one region changed OTBC practice during the 1 st State of Emergency, and two had difficulties related to the disposable masks. Regarding the latter, the inquires did not clarify if this happened at the beginning or throughout the pandemic, but several newspapers reported a lack of provision of masks at TB diagnostic delays were described in both periods. The reduction of diagnostic and treatment delay is a priority to the National Tuberculosis Program, 17 so changes need to be made to reverse this outcome. It is important to note, however, that other countries faced the same problem 10, 14, 33, 36 The Global Tuberculosis Network study reports a significant decline in newly diagnosed TB disease in outpatient clinics (613±57 per month in 2019 versus 475±90 per month in 2020; p=0.0005) and in drug-resistant TB disease (393±31 per month in 2019 versus 127±32 per month in 2020; p<0.001), despite the significant increase of telehealth activities in 2020. 2 Narita et al. 37 described the stories of three patients in the United States of America with TB diagnosis delays: one had risk factors for TB and had to wait a month to get chest radiography; the second was tested 13 times for SARS-CoV-2 before her TB diagnosis; and the third had a chest radiograph that revealed right-upper-lobe opacities without cavities, so TB was not considered until 2 months later when her symptoms and chest radiography got worse. 37 of all surveyed participants with active TB), and stigmatization. 39 In our survey, the lack of material and human resources was the main reason for the lack of DOT use. Hiring more staff for centres struggling to use DOT is a possible solution but may not be feasible during the pandemic. Another option is the acquisition of cameras for more widespread use of Video Observed Therapy, which seems to be as effective as DOT. 40 Our study has some limitations that needed to be highlighted. First, the response rate was not homogeneous across all Regional Health Administrations, which limits our comparisons between different regions. Still, we consider a 52.5% response rate to be fairly representative of the national panorama. Secondly, variables concerning the 1st State of Emergency were collected retrospectively. Apart from this, some strengths should be highlighted. This is, as far as we know, the first national study being conducted on this theme; we achieved a significant participation rate in the regions with the highest incidence of TB and highest number of OTBC. The accuracy of findings allows us to discuss the example of Portugal in comparison with recent multi-country studies published by the Global Tuberculosis Network. Overall, most OTBC's were able to follow the set of norms published by the Directorate-General of Health and maintain diagnostic, treatment, screening and prevention of TB during the pandemic, which contributed to protecting Portugal from the worse consequences of the subsequent waves of the COVD-19 pandemic. Nevertheless, attention should be given to enhance COVID-19 prevention (by encouraging anti-COVID-19 vaccination) and, specifically for TB, to reduce diagnostic delay and barriers to DOT implementation. No specific funding was received for this work. However, Ana Aguiar holds a PhD Grant (2020.09390.BD), co-funded by the FCT and the FSE Program. IR and RD formulated the initial research questions and study methodology. IR and RD contributed to refining the research and study methodology. 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Programa Nacional para a infeção VIH/SIDA e Tuberculose European Society of Clinical Microbiology and Infectious Diseases Study Group for Mycobacterial Infections (ESGMYC) Increase in Tuberculosis Diagnostic Delay during First Wave of the COVID-19 Pandemic: Data from an Italian Infectious Disease Referral Hospital Delayed Tuberculosis Diagnoses During the Coronavirus Disease 2019 (COVID-19) Pandemic in 2020 -King County Different disease, same challenges: Social determinants of tuberculosis and COVID-19 Facility-based directly observed therapy (DOT) for tuberculosis during COVID-19: A community perspective Video-observed therapy and medication adherence for tuberculosis patients: Randomized controlled trial in Moldova We would like to thank all of the coordinators of TB centres who have answered the questionnaire. This research initiative would not be possible without their participation.We would also like to thank Ana Isabel Ribeiro for drawing the map of Portugal's Region Health Administrations.The work is part of the scientific activities of Global Tuberculosis Network and of the WHO Collaborating Centre for TB and Lung Diseases in Tradate, Italy (ITA-80).