Undiagnosed Pulmonary Tuberculosis (TB) and Coronavirus Disease 2019 (COVID-19) in Adults Dying at Home in a High-TB-Burden Setting, Before and During Pandemic COVID-19: An Autopsy Study

Nadia Sabet; Tanvier Omar; Minja Milovanovic; Tebogo Magajane; Modiehi Mosala; Tumelo Moloantoa; Nalukenge Kato-Kalule; Lenise Varela Semedo; Floris Swanepoel; Carole Wallis; Pattamukkil Abraham; Limakatso Lebina; Ebrahim Variava; Neil Martinson

doi:10.1093/cid/ciad212

Undiagnosed Pulmonary Tuberculosis (TB) and Coronavirus Disease 2019 (COVID-19) in Adults Dying at Home in a High-TB-Burden Setting, Before and During Pandemic COVID-19: An Autopsy Study

Clin Infect Dis. 2023 Aug 14;77(3):453-459. doi: 10.1093/cid/ciad212.

Authors

Nadia Sabet^{1

2}, Tanvier Omar³, Minja Milovanovic¹, Tebogo Magajane¹, Modiehi Mosala¹, Tumelo Moloantoa¹, Nalukenge Kato-Kalule^{1

4}, Lenise Varela Semedo², Floris Swanepoel¹, Carole Wallis⁵, Pattamukkil Abraham¹, Limakatso Lebina^{1

6}, Ebrahim Variava^{1

2}, Neil Martinson^{1

7}

Affiliations

¹ Perinatal HIV Research Unit, University of the Witwatersrand, Johannesburg, South Africa.
² Department of Internal Medicine, Klerksdorp-Tshepong Hospital Complex, Klerksdorp, South Africa.
³ Department of Anatomical Pathology, National Health Laboratory Service and University of the Witwatersrand, Johannesburg, South Africa.
⁴ Imperial College Healthcare, National Health Service Trust, London, United Kingdom.
⁵ Bio Analytical Research Corporation, Johannesburg, South Africa.
⁶ Africa Health Research Institute, Durban, South Africa.
⁷ Center for Tuberculosis Research, Johns Hopkins University, Baltimore, Maryland, USA.

PMID: 37041678
DOI: 10.1093/cid/ciad212

Abstract

Background: Missing or undiagnosed patients with tuberculosis (TB) or coronavirus disease 2019 (COVID-19) are of concern. Identifying both infections in patients with no diagnosis prior to death contributes to understanding the burden of disease. To confirm reports of global reduction in TB incidence, a 2012 autopsy study of adults dying at home of natural causes in a high-TB-burden setting was repeated, including severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) assessments after the first COVID-19 surge in South Africa.

Methods: Adult decedents who died at home with insufficient information to determine cause of death, no recent hospitalization, and no current antemortem TB or COVID-19 diagnosis were identified between March 2019 and October 2020 with a 4-month halt during lockdown. A standardized verbal autopsy followed by minimally invasive needle autopsy (MIA) was performed. Biopsies were taken for histopathology from liver, bilateral brain and lung; bronchoalveolar lavage fluid was collected for Xpert (MTB/RIF) and mycobacterial culture, and blood for human immunodeficiency virus (HIV) polymerase chain reaction (PCR) testing. After the start of the COVID-19 pandemic, a nasopharyngeal swab and lung tissue were subjected to SARS-CoV-2 PCR testing.

Results: Sixty-six MIAs were completed in 25 men and 41 women (median age, 60 years); 68.2% had antemortem respiratory symptoms and 30.3% were people with HIV. Overall, TB was diagnosed in 11 of 66 (16.7%) decedents, and 14 of 41 (34.1%) in the COVID-19 pandemic were SARS-CoV-2 positive.

Conclusions: Undiagnosed TB in adults dying at home has decreased but remains unacceptably high. Forty percent of decedents had undiagnosed COVID-19, suggesting that estimates of excess deaths may underestimate the impact of SARS-CoV-2 on mortality.

Keywords: COVID-19; excess deaths; postmortem; prevalence; tuberculosis.

Publication types

Research Support, Non-U.S. Gov't

MeSH terms

Adult
Autopsy
COVID-19 Testing
COVID-19* / complications
COVID-19* / diagnosis
COVID-19* / epidemiology
Communicable Disease Control
Female
HIV Infections* / complications
Humans
Male
Middle Aged
Mycobacterium tuberculosis*
Pandemics
SARS-CoV-2
Tuberculosis* / epidemiology
Tuberculosis, Pulmonary* / diagnosis
Tuberculosis, Pulmonary* / epidemiology