When restricted delivery of health-care services in the thick of the COVID-19 pandemic had seriously affected tuberculosis diagnosis and care across nations, Kerala, through an integrated TB-COVID screening programme, had managed to catch up with much of the “missed” TB cases in the State.
However, nearly two years after the pandemic began, delayed diagnosis of TB cases is being reported by clinicians from some districts and this could adversely impact TB-related mortality in the State, it is feared.
TB case notification had gone down in Kerala by 50% during April-July 2020 because COVID-19 had affected patients’ access to hospitals and also because the health system itself had been oriented totally towards COVID care.
But the State had managed to catch up with 90% of its missed cases through field-based active case finding, screening for TB among those with COVID-19 symptoms, implementing integrated testing for TB and COVID-19 and through better systemic services.
“Despite all that was done to ensure that TB care services were not fully disrupted, COVID-19 seems to have adversely affected early TB detection in the State, which was one of our biggest strengths and advantages. Cases of delayed diagnosis of TB have been trickling in from clinicians in many parts of the State, with patients reporting with pulmonary cavitation (cavities in the lungs where the TB bacilli harbour and destroy lung tissues in cave formations) and severe lesions in the lungs,” said P.S. Rakesh, WHO consultant, National TB Elimination Programme.
Increased transmission
“We need to generate more evidence, but patients showing pulmonary cavitation or disseminated TB at the time of diagnosis have been previously unheard of in Kerala. Delayed diagnosis means increased transmission too, as the patient would be transmitting the disease unknowingly, especially within households,” he said.
Delayed diagnosis also points to adverse treatment outcomes and increased TB mortality. Public health experts say that despite the robust TB surveillance mechanism in the State, it is possible that there could have been undocumented TB deaths in the State in 2020, when the patient died before a diagnosis of TB was made. This is very much possible, especially if the patients had co-infection of COVID-19 and TB.
The mortality rate of TB-COVID-19 co-infection in the State is reported to be 15.2%, with 27 out of the 177 cases diagnosed with active TB-COVID-19 co-infection dying.
“It is possible to overlook TB in post-COVID patients because the symptomatology of both are the same, leading to a delay in diagnosis. During the second wave, we did have some young patients who were found to have pulmonary cavitation. But not so much now, after the integrated TB-COVID screening began,” said Arjun P., a senior pulmonologist, KIMS hospital.
Despite the lack of documentation, cases of delayed diagnosis of TB are being reported in the State, a senior clinician in a Government medical college said.
“Treatment failure rates as well as patients lost to follow-up are low in Kerala . But our TB death rate has remained more or less a constant at 5-7%. Early diagnosis is very crucial for reducing the TB mortality rate and hence we are quite concerned about the reports on delayed diagnosis,” he said.
