Inequalities in the impact of COVID-19-associated disruptions on tuberculosis diagnosis by age and sex in 45 high TB burden countries

Background: Tuberculosis remains a major public health priority and is the second leading cause of mortality from infectious disease worldwide. TB case detection rates are unacceptably low for men, the elderly and children. Disruptions in TB services due to the COVID-19 pandemic may have exacerbated these and other inequalities.

Methods: We modelled trends in age- and sex- disaggregated case notifications for all forms of new and relapse TB reported to the World Health Organization for 45 high TB, TB/HIV and MDR-TB burden countries from 2013 to 2019. We compared trend predicted notifications to observed notifications in 2020 to estimate the number of people with TB likely to have missed or delayed diagnosis. We estimated the risk ratio (RR) of missed or delayed TB diagnosis for children (aged < 15 years) or the elderly (aged ≥ 65 years) compared to adults (aged 15–64 years) and women compared to men (both aged ≥ 15 years) using a random-effects meta-analysis.

Results: An estimated 195,449 children (95% confidence interval, CI: 189,673–201,562, 37.8% of an expected 517,168), 1,126,133 adults (CI: 1,107,146–1,145,704, 21.8% of an expected 5,170,592) and 235,402 elderly (CI: 228,108–243,202, 28.5% of an expected 826,563) had a missed or delayed TB diagnosis in 2020. This included 511,546 women (CI: 499,623–523,869, 22.7%, of an expected 2,250,097) and 863,916 men (CI: 847,591–880,515, 23.0% of an expected 3,763,363). There was no evidence globally that the risk of having TB diagnosis missed or delayed was different for children and adults (RR: 1.09, CI: 0.41–2.91), the elderly and adults (RR: 1.40, CI: 0.62–3.16) or men and women (RR: 0.59, CI: 0.25–1.42). However, there was evidence of disparities in risk by age and/or sex in some WHO regions and in most countries.

Conclusions: There is no evidence at an aggregate global level of any difference by age or sex in the risk of disruption to TB diagnosis as a result of the COVID-19 pandemic. However, in many countries, disruptions in TB services have been greater for some groups than others. It is important to recognise these context-specific inequalities when prioritising key populations for catch-up campaigns.