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 Table of Contents  
Year : 2021  |  Volume : 4  |  Issue : 2  |  Page : 65-68

Analysis of tuberculosis-related mortality during the first wave of the COVID pandemic at GHTM, tambaram sanatorium

1 Department of Pulmonary Medicine, Government Stanley Medical College, Chennai, Tamil Nadu, India
2 Stanley Medical College, Chennai, Tamil Nadu, India

Date of Submission06-Oct-2021
Date of Decision12-Oct-2021
Date of Acceptance14-Oct-2021
Date of Web Publication21-Jan-2022

Correspondence Address:
Vinod Kumar Viswanathan
Professor of Pulmonary Medicine, Govt Stanley Medical College, Chennai, Tamil Nadu
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/japt.japt_41_21

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Introduction: Analysis of tuberculosis (TB) mortality serves to understand the impact of health delivery services and steps needed to eliminate the global burden of TB. With the advent of the COVID pandemic in 2020, there were challenges in delivery of TB services, and this study was undertaken to understand the impact of pandemic on TB mortality. Methodology: Retrospective analysis of death records of patients died due to TB in the year 2020 was done. Results: The data of 250 patients who died due to TB in GHTM in 2020 were analyzed. Most were males in the productive age group of 20 to 60 years. Sputum positivity, male gender, drug resistance, and presence of comorbidities such as DM and HIV contributed to most of the mortality. A drop in presumptive TB cases and notification of TB cases compared to the previous years was noted. Discussion: The demographic profile of patients and risk factors for TB mortality in this study was consistent with known risk factors such as male, sputum positive status, drug resistance, and comorbidities. Drop in notification of TB cases due to the pandemic was noted, and necessary steps for tracing and diagnosing these cases will help reduce mortality due to impact of the pandemic. Analysis of mortality data also reflects on the need for early diagnosis and the use of appropriate treatment protocols and need for new drugs to eliminate and reduce TB mortality. Conclusion: This study emphasises on the need for ensuring continued diagnosis and uninterrupted treatment of TB even in pandemic situations to make the goal of TB elimination a reality.

Keywords: COVID, death, mortality, tuberculosis

How to cite this article:
Sridhar R, Viswanathan VK, Singh R, Keyzare R. Analysis of tuberculosis-related mortality during the first wave of the COVID pandemic at GHTM, tambaram sanatorium. J Assoc Pulmonologist Tamilnadu 2021;4:65-8

How to cite this URL:
Sridhar R, Viswanathan VK, Singh R, Keyzare R. Analysis of tuberculosis-related mortality during the first wave of the COVID pandemic at GHTM, tambaram sanatorium. J Assoc Pulmonologist Tamilnadu [serial online] 2021 [cited 2022 May 16];4:65-8. Available from: http://www.japt.com/text.asp?2021/4/2/65/336171

  Introduction Top

The theme of this year's World tuberculosis (TB) day (2021) “The clock is ticking” is a grim reminder that the global and Indian targets for TB elimination are fast approaching, and more public health measures are needed if we are to realistically achieve these goals.

Analysis of TB mortality gives us an idea about the reasons why we still continue to lose patients due to TB and provides insights into the public health system including the late presentation of cases, the quantum of lung reserve lost due to the disease, access to drugs and health care, and response to chemotherapy. The available data in the COVID period have shown us that cases have been missed, lost to follow-up, and about the difficulty in accessing health care in the lockdown phase and these have led to disruptions in the planned TB elimination activities and set the clock back on TB control.[1]

The current study was undertaken to analyze the TB mortality data during the first wave of the COVID pandemic in GHTM, Tambaram sanatorium, a tertiary care institution catering to drug sensitive, drug-resistant TB, and HIV TB coinfection.

  Methodology Top

This study was a retrospective study using case records. The data of patients who had died of TB in the period between January 1 and December 31, 2020, the year corresponding to the first wave of the COVID pandemic were collected. Demographic details, the recorded cause of death, sputum status, sensitivity status, treatment status, COVID status, comorbidities, and time to mortality were statistically analyzed. Standard definitions of TB death, drug sensitive, and drug-resistant TB as per the National TB elimination program were used to define the parameters.

  Results Top

During the period between January 1, 2020 and December 31, 2020, 250 deaths due to TB had occurred in the institution.

Among the 250 patients, 201 (80.4%) were males and 49 (19.6%) were females [Table 1].
Table 1: Gender distribution among the tuberculosis demised (n=250)

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Most of the TB mortality was among males compared to females [Table 2].
Table 2: Age distribution among the tuberculosis demised (n=250)

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Most of the death was among pulmonary TB reflecting that respiratory failure and destruction of pulmonary reserve were the main cause of death among TB. Disseminated TB cases included those with extrapulmonary manifestations including abdominal, pleural effusion, spinal, and meningeal TB [Table 3].
Table 3: Pulmonary involvement among the deaths (n=250)

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Most of the patients were positive at the time of death reflecting the fact that sputum positivity has higher bacillary load and persistent active disease leading to higher mortality [Table 4].
Table 4: Sputum status at time of death

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During the study period, eight cases of PTB on treatment were found to be infected with COVID-19, which imply COVID per se did not add to the TB mortality. Four patients were diagnosed sputum positive in the postCOVID period [Table 5].
Table 5: Tuberculosis-COVID coinfection

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Prior history of ATT intake was present in 32% of the study group reflecting the fact that relapse and default still cause a large number of death due to TB. Further 28% of the deaths occurred in patients lost to follow-up, which highlights the fact that case holding has to be ensured up to the completion of treatment [Table 6].
Table 6: Prior history of antituberculosis treatment intake

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In the study period, almost 10% of patients lost had drug-resistant TB. Despite 89% of the patients had drug-sensitive TB, we could not save them either due to late diagnosis/advanced disease or other comorbidities [Table 7].
Table 7: Drug sensitivity status among the tuberculosis demised

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Among the comorbidities associated with TB mortality, diabetes and HIV-positive status stand out as the major associations [Table 8].
Table 8: Comorbidities among the tuberculosis demised

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Roughly 80% of the patients had died within 7 days of hospitalization reflecting the late referrals and extensive disease which was not diagnosed on time causing significant loss of lung reserve [Table 9] and [Table 10].
Table 9: Cause of death

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Table 10: Duration from admission to time of death

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The increase in mortality during the COVID pandemic compared to previous years is probably due to the delayed diagnosis, cases lost to follow-up, and extensive disease at presentation due to difficulty in access to health-care services. The table also points out that the notification of TB cases has come down due to the pandemic and many cases have been missed and steps for diagnosis and retrieval of such cases should be done [Table 11].
Table 11: Comparison of tuberculosis mortality between Tamil Nadu State and GHTM for 3 consecutive years (2)

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  Discussion Top

India has set the ambitious target of eliminating TB as a public health problem by 2025 and steps are being taken in this regard. The onset of the Global COVID pandemic in 2020 became a spoke in the wheel of the TB elimination activities and the lockdown imposed in April, May 2020 became a hurdle to TB elimination activities. Initially, there was a drop in notification of cases and various challenges in the NTEP including drug delivery and access to health care due to lockdown, migration, and fear among the public and health-care professionals. By the initiation of various mitigation activities including active case finding and catch-up campaigns at the end of December 2020, we were able to bridge the gap in diagnosis and initiation of TB treatment.[2]

Provisional data compiled by the World Health Organization (WHO) from 84 countries indicate that an estimated 1.4 million fewer people received care for TB in 2020 than in 2019 – a reduction of 21% from 2019. The WHO estimates that these COVID-19-related disruptions in access to TB care could cause an additional half a million TB deaths. TB remains one of the world's top infectious killers.[3],[4]

Analysis of mortality data of a disease is a reflection of true effectiveness of a control program and about the health infrastructure and delivery services. This study was undertaken to understand the mortality data of TB patients attending GHTM, Tambaram sanatorium, a tertiary care institution and referral center catering to the management of all forms of TB including drug-resistant and drug-sensitive TB and HIV TB coinfection. The year 2020 was a challenging year for all national programs including NTEP due to the global pandemic situation and affected life and livelihood in various ways. Therefore, we analyzed the mortality of TB patients during the first wave of the pandemic to understand the health delivery system impact due to the pandemic.

Males showed a higher mortality compared to females, and most of the mortality (>80%) is still among the productive age group of 20 to 60 years. This is a reflection of the socioeconomic burden of TB where the earning member in most households is in this age group and loss of the breadwinner adversely affects the lives and livelihoods of all family members.

This study also shows that sputum positivity and pulmonary TB are associated with a higher mortality which reflects the disease burden and loss of pulmonary reserve and respiratory failure being the major cause of death in TB. Early diagnosis of TB with the advent of newer molecular diagnostic techniques will pave the way to decrease the mortality of this disease.

This study also shows that there is significant mortality of about 32% in patients with previously treated TB including relapse and treatment after default highlighting the need for early diagnosis and ensuring complete course of treatment and proper follow-up of patients when first diagnosed to prevent such recurrences and increased mortality in future. Further difficulty in accessing the public health-care facilities due to restrictions during the COVID pandemic has led to the increased percentage of patients lost to follow-up and subsequent progression of the disease-causing extensive disease and increased mortality.

Twelve cases of TB-COVID coinfection were recorded in the study group. Eight of them were diagnosed TB patients on treatment incidentally detected as COVID coinfection and four were diagnosed as TB in the post-COVID period. This stresses on the need for bidirectional screening of cases for the COVIDTB coinfection.

Comorbidities such as diabetes and HIV still account for most mortality due to TB and the need for proper control of these comorbidities is emphasized. Most deaths are due to respiratory failure highlighting the destruction of lung parenchyma and thereby the pulmonary reserve and the need for early diagnosis and proper treatment of such cases. Almost 80% of deaths happening within the 1st week of admission indicates the late referrals and delay in diagnosis of such cases and public health measures need to hasten the diagnosis and initiate treatment early.

Deaths due to drug-resistant TB are also highlighted in this study and show about the focus of national programs on eliminating the spread of drug-resistant TB. Scaling up of molecular diagnosis and newer treatment algorithms help bring down the morbidity and mortality of drug-resistant TB in near future. Furthermore, preliminary data evolving from the BEAT and STREAM 2 studies are showing promising evidence that all oral shorter MDR regimens will be effective in treating MDR-TB patients.

Analysis of TB mortality had been undertaken by the institution in 2016 and the results of this study show similarity in TB mortality risk factors such as male predominance, productive age group, drug-resistant status, comorbidities such as DM and HIV, and respiratory failure being cause of death.[5] The decrease in the number of notified TB cases along with the increase in mortality in 2020, as compared to the previous 2 years signify the impact of COVID pandemic on the TB services which included difficulty in access to health-care delivery services due to various factors such as lockdown, migration, fear of visiting hospitals, and these have led to late presentation and delay in diagnosis which might have contributed to increased mortality in TB.

The program took care of enrolled TB patients' treatment by the way of delivering anti-TB drugs at their doorstep. However, patients who were having early symptoms of TB did not approach health facilities for early diagnosis. This could be the reason for drop in TB notification as well as higher mortality among notified TB cases.

The economic crisis due to COVID lockdown which has placed an increased stress over the below poverty population, worsening malnutrition, and instigating a mentality of neglect of health due to the livelihood challenges also needs to be appropriately addressed. Further, it also warrants the prompt need for increased TB case detection through active case finding to prevent extensive disease and late presentation, thus aiding in reducing the mortality from TB.[6]

  Conclusion Top

This study emphasizes the importance of taking necessary measures for the uninterrupted diagnosis and treatment services for TB even amidst occurrences such as the COVID pandemic to prevent the delay in diagnosis and treatment which pave the way to more extensive disease and increase in mortality. It is also equally important to ensure case holding and uninterrupted treatment to prevent lost to follow-up.

This study further highlights the various aspects of mortality due to TB and the steps that are needed for early diagnosis of both drug sensitive and drug-resistant TB to make the dream of TB elimination a reality in near future.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

India TB report. Central Tb division. Ministry of Health and Family Welfare, Govt of India 2021.  Back to cited text no. 1
Data from State TB Cell.  Back to cited text no. 2
WHO Technical Document Impact of the COVID 19 Pandemic on TB Detection and Mortality in 2020.  Back to cited text no. 3
Glaziou P. Predicted impact of the COVID-19 pandemic on global tuberculosis deaths in 2020. medRxiv 2020.  Back to cited text no. 4
Vinod Kumar V, Sridhar R, Kumar S. Analysis of tuberculosis related mortality at GHTM, Tambaram sanatorium. Stanley Med J 2017;4:2-4.  Back to cited text no. 5
Bhargava A, Shewade HD. The potential impact of the COVID-19 response related lockdown on TB incidence and mortality in India. Indian J Tuberc 2020;67:S139-46.  Back to cited text no. 6


  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10], [Table 11]


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