Impact of the COVID-19 pandemic on tuberculosis notification in Brazil

BackgroundThe COVID-19 pandemic notably impacted tuberculosis notification and detection in Brazil. We estimated the number of unnotified tuberculosis cases by group population over the first two years (2020-2021) of the pandemic. MethodsWe extracted tuberculosis case notifications from routine national surveillance records and population from Ministry of Health. We estimated trends for case notification during pre-pandemic period (2015-2019), stratified by sex, age group, and State with a mixed-effects model. We calculated the unnotified cases during 2020-2021 as the difference between expected, and reported values. ResultsWe estimated 11647 (95% uncertain interval [95%UI]: 829,22466) unnotified cases for 2020; and, 6170 (95%UI: -4629,16968) for 2021; amounting 17817 unnotified cases over the two years. Of the estimated expected tuberculosis cases in 2020 and 2021, 11.2% were not notified. Across sex and age, men aged 30-59 years had the highest number of unnotified cases, and men aged 0-14 years had the highest proportion of unnotified cases. Case underreporting was significant for 13 (of the 27 States) in 2020, and for four in 2021. ConclusionsTuberculosis cases notification decreased substantially during the COVID-19 pandemic in Brazil. Our analysis helped identify the most affected populations to plan strategies to mitigate the effects of the pandemic on tuberculosis control. Research in contextO_ST_ABSEvidence before this studyC_ST_ABSA systematic review was conducted to retrieve studies that aimed the impact of the COVID-19 pandemic on tuberculosis detection in PubMed with the following terms: "(TB or tuberculosis) and (incidence or case or notification or burden) and (COVID-19 or pandemic)" from January 2020 to May 2022, returning 189 records. Out of these studies, we analyzed 17 that reported a decrease in tuberculosis notification during the pandemic years, and most of them with data only from the first year of the pandemic. Two studies were carried out with Brazilian data. One of them focused on the number of tuberculosis consultations at the benning of the pandemic, and the other was a government bulletin describing tuberculosis notification. As far as we know, no study has examined the tuberculosis case notification in Brazil during the two years of the pandemic, by group population. Furthermore, none of them had predicted the expected cases considering local trends in both the incidence of tuberculosis and its main determinants. Added value of this studyUsing tuberculosis case reports from routine national surveillance registries, we estimated case notification trends during the pre-pandemic period (2015-2019), stratified by sex, age group, and State and calculated the unnotified cases during 2020-2021. Brazil lost 11647 (95% uncertain interval [95%UI]: 829,22466) tuberculosis cases in 2020; and, 6170 (95%UI: - 4629,16968) in 2021, which represents 11.2% of underreporting in both years. Across sex and age, men aged 30 to 59 years had the highest number of unnotified cases, and men aged 0 to 14 years had the highest proportion of unnotified cases. Case underreporting was significant for 13 (of the 27 States) in 2020, and for four in 2021. Implications of all the available evidenceThe COVID-19 pandemic had a catastrophic effect in tuberculosis notification in Brazil during 2020 and 2021. This resulted in a setback in progress made over decades in tuberculosis control, and highlight the threat posed by tuberculosis transmission. Several lessons learned from response to COVID-19 provide an opportunity to improve the notification of respiratory diseases.