TO THE EDITOR,
 
The spread of Severe Acute Respiratory Syndrome - Coronavirus 2 (SARS-CoV-2) continues to progress, causing damage in several countries of the world due to its rapid transmissibility and significant mortality rates,(1,2) despite government measures to contain its transmission, such as movement control, the closing of schools, bans on travel and public gatherings, the mandatory use of masks, and hand hygiene.(1,2,3,4,5,6) The coronavirus disease (COVID-19) has clinical manifestations that are similar to those found in other infections also transmitted through the airways, such as pulmonary tuberculosis (TB).(1,2,3,4,5,6) Although TB is a global health problem, it is a curable disease, with affordable treatment and prevention. Nonetheless, it remains one of the leading causes of death from a single infectious agent worldwide, a situation threatened by COVID-19.(1,2,3,4,5,6,7)
 
The elimination of COVID-19 has been made a priority in relation to other diseases that can be treated through public healthcare.(7,8) During the COVID-19 pandemic, a major impact on the provision of TB health services was observed in several countries, through measures of relocation of professionals and budgets, and the interruption of services.(3,4,5,6,7,8). However, we do not know the true extent of this damage; an increase in the number of undiagnosed TB cases is expected worldwide, which may reveal poor treatment results.(3,4,5,6,7,8) The simultaneous presentation of TB and COVID-19 is a matter of concern since the patient may be at a greater risk of poor outcomes and death than patients with COVID-19 alone.(7,8)
 
In Brazil, TB is a public health problem and one of compulsory notification, and the current situation presents a high burden regarding TB and TB-HIV co-infection.(9,10) The objective of the present study was to compare data from the Unified Health System (SUS) on the number of pulmonary TB cases reported in the 5 Brazilian geographic regions (North, Northeast, Southeast, South, and Midwest) from 2017 to 2019 with the same periods of 2020, the latter representing the period of the pandemic, to verify the real impact of the pandemic on the number of TB cases in Brazil.
 
The analyzed data were extracted from the Brazilian public database - Ministry of Health (MH) - Primary Care Health Information System (SISAB) https://sisab.saude.gov.br/ - of the SUS, which contains the average number of consultations of pulmonary TB in the Brazilian territory. These data came from consultations in public primary healthcare services carried out by doctors and nurses, whose patients’ disease was suggestively classified as pulmonary TB (confirmed and laboratory-unconfirmed cases). Data from the MH - SUS for the past 12 months are subject to changes and updates.
 
The differences in the average number of pulmonary TB consultations reported by the Brazilian public health system in all geographical regions, in 2017, 2018, and 2019, compared to the same period in 2020, are shown in Figure 1. In this descriptive analysis of data by region, there was a significant increase in the percentage of pulmonary TB consultations in all Brazilian regions during the COVID-19 pandemic. Such increase ranged from 27,492 (156.0%) consultations, on average, in the Southeast region to 1,523 (25.0%) consultations, on average, in the South region. Considering all the Brazilian regions, the total average of consultations went from 48,688 in the period from 2017 to 2019 to 108,269 in 2020, representing a 122.4% increase in average TB consultations during the pandemic period.

 
Given the relevance of TB, it became necessary to include the data extracted from the Brazilian public database - MH - Notifiable Diseases Information System - SINAN (http://portalsinan.saude.gov.br/tuberculosis) in this study, in which the annual average of confirmed cases of pulmonary TB notified in Brazilian territory was obtained. Figure 1 shows the difference in the annual average of confirmed cases of pulmonary TB reported by the Brazilian public health system in all geographical regions in 2017, 2018, and 2019 compared to the same period of 2020, which represented the period of the pandemic.
 
Being a seasonal disease, there was a reduction in reported confirmed cases of pulmonary TB in all Brazilian regions, except for the North, during the pandemic period. The Southeast (-8.2%), South (-8.9%), and Northeast (-10.9%) regions presented a percentage decrease above the national average (-7.9%). During the pandemic period, the average number of reported TB cases decreased by 6,501 cases compared to the period from 2017 to 2019. These data reveal the impact of the pandemic on the number of pulmonary TB cases in Brazil. Therefore, there is a concern that the COVID-19 pandemic will hamper TB elimination goals in all Brazilian regions.(9,10)
 
In 2020, 88,678 cases were confirmed for TB in Brazil, and 4,500 people died due to the disease in 2019.(10) According to the performed analyses, Brazil has experienced different levels of interruption of the health system, which has resulted in a reduction in the total number of notifications of pulmonary TB in the country (Figure 1) due to the measures adopted to contain the spread of SARS-CoV-2.(10) In the pandemic period, essential services for TB were restricted due to decreased resources and inputs, prioritizing the mitigation of COVID-19.(3,5,6) Data presented by the MH revealed an increment in the number of treatment dropouts and an increase in the number of deaths by TB.(10)
 
Overall, these findings are similar to those reported in other countries.(3,4,7,8) It is believed that the measures adopted for the care of COVID-19 influence the goals established by the WHO to reduce the global burden of TB.(3)
 
The increase in the number of consultations and the reduction of confirmed TB cases reported in the pandemic period evidenced herein are extremely worrying. Brazil, with its high burden due to TB, needs to guarantee the continuity of services in the control of Mycobacterium tuberculosis during the COVID-19 pandemic to achieve its TB elimination goals.
 
REFERENCES
 
1.            Silva DR, Mello FCQ, D’Ambrosio L, Centis R, Dalcolmo MP, Migliori GB. Tuberculosis and COVID-19, the new cursed duet: what differs between Brazil and Europe? J Bras Pneumol. 2021 Apr 30;47(2):e20210044. https://doi.org/10.36416/1806-3756/e20210044.
2.            Hale T, Angrist N, Goldszmidt R, Kira B, Petherick A, Phillips T et al. A global panel database of pandemic policies (Oxford COVID-19 Government Response Tracker). Nat Hum Behav. 2021 Apr;5(4):529-538. https://doi.org/10.1038/s41562-021-01079-8. Epub 2021 Mar 8. PMID: 33686204.
3.            McQuaid CF, Vassall A, Cohen T, Fiekert K, White RG. The impact of COVID-19 on TB: a review of the data. Int J Tuberc Lung Dis. 2021 Jun 1;25(6):436-446. https://doi.org/10.5588/ijtld.21.0148.
4.            Ortiz-Martínez Y, Rodríguez-Morales AJ, Henao-Martínez AF. Decreased notification of TB cases during the COVID-19 pandemic. Int J Tuberc Lung Dis. 2022 Feb 1;26(2):177-178. https://doi.org/10.5588/ijtld.21.0651.
5.            Fukunaga R, Glaziou P, Harris JB, Date A, Floyd K, Kasaeva T. Epidemiology of Tuberculosis and Progress Toward Meeting Global Targets - Worldwide, 2019. MMWR Morb Mortal Wkly Rep. 2021 Mar 26;70(12):427-430. https://doi.org/10.15585/mmwr.mm7012a4.
6.            Tadolini M, Codecasa LR, García-García J-M, Blanc F-X, Borisov S, Alffenaar J-W et al. Active tuberculosis, sequelae and COVID-19 co-infection: first cohort of 49 cases. Eur Respir J 2020;56(1):2001398. https://doi.org/10.1183/13993003.01398-2020.
7.            Fei H, Yinyin X, Hui C, Ni W, Xin D, Wei C et al. The impact of the COVID-19 epidemic on tuberculosis control in China. Lancet Reg Health West Pac. 2020 Oct;3:100032. https://doi.org/10.1016/j.lanwpc.2020.100032. Epub 2020 Sep 24.
8.            Arentz M, Ma J, Zheng P, Vos T, Murray CJL, Kyu HH. The impact of the COVID-19 pandemic and associated suppression measures on the burden of tuberculosis in India. BMC Infect Dis. 2022 Jan 27;22(1):92. https://doi.org/10.1186/s12879-022-07078-y.
9.            PAHO. Pan American Health Organization. Diagnosis of new tuberculosis cases in the Americas reduced by 15-20% in 2020 due to the pandemic [Accessed on 10/10/2021]. Available from: https://bit.ly/3pB22YM.
10.          Brazil. Ministry of Health. Department of Chronic Diseases and Sexually Transmitted Infections. General Coordination of Surveillance of Chronic Conditions Respiratory Transmission Diseases. Tuberculosis Epidemiological Bulletin. Mar. 2021. Available from: www.aids.gov.br › pt-br › pub (10/05/2021).