Impacts of COVID-19-related service disruptions on TB incidence and deaths in Indonesia, Kyrgyzstan, Malawi, Mozambique, and Peru: Implications for national TB responses

Abstract

Initial global-level estimates reported in June 2020 by the World Health Organization suggested that levels of disruption to TB service delivery could be as high as 25%-50% and result in an additional 6·3 million cases of tuberculosis (TB) and an additional 1·4 million TB-related deaths attributable to COVID-19 between 2020 and 2025. Quarterly epidemiological estimates and programmatic TB data capturing disruption levels to each TB service were collected by National TB Programmes in Indonesia, Kyrgyzstan, Malawi, Mozambique, and Peru. Data from 2019, for a pre-COVID-19 baseline, and throughout 2020, together with the NTP’s COVID-19 response plans, were used within Optima TB models to project TB incidence and deaths over five years because of COVID-19-related disruptions, and the extent to which those impacts may be mitigated through proposed catch-up strategies in each country. Countries reported disruptions of up to 64% to demand-driven TB diagnosis. However, TB service availability disruptions were shorter and less severe, with TB treatment experiencing levels of disruption of up to 21%. We predicted that under the worse-case scenario cumulative new latent TB infections, new active TB infections, and TB-related deaths could increase by up to 23%, 11%, and 20%, respectively, by 2024. However, three of the five countries were on track to mitigate these increases to 3% or less by maintaining TB services in 2021 and 2022 and by implementing proposed catch-up strategies. Indonesia was already experiencing the worse-case scenario, which could lead to 270,000 additional active TB infections and 36,000 additional TB-related deaths by the end of 2024. The COVID-19 pandemic is projected to negatively affect progress towards 2035 End TB targets, especially in countries already off-track. Findings highlight both successful TB service delivery adaptions in 2020 and the need to proactively maintain TB service availability despite potential future waves of more transmissible COVID-19 variants.

The changes in health service utilisation in Malawi during the COVID-19 pandemic

“…These findings complement other studies in Malawi that have found changes in single programmes like HIV, TB and neonatal care, or examined changes in a subset of health facilities [ 4 – 6 , 16 – 19 ]. The overall picture that emerges does not match the worst-case scenarios considered at the outset of the pandemic, in which the most key services were reduced to very low levels [ 33 – 35 ].…”

“…Retrospective evaluations have since found that disruptions to healthcare services did occur, especially in low-income and middle-income countries (LMICs) in Africa, South-East Asia and Eastern Mediterranean Regions [ 1 – 3 , 7 – 15 ], including Malawi [ 4 – 6 , 16 – 19 ], which is a low-income country in sub-Saharan Africa with a fragile healthcare system [ 20 ]. These studies have described disruptions to services relating to HIV, TB, routine immunisation, maternal and child health care, and outpatient visits (e.g.…”

Care pathways of individuals with tuberculosis before and during the COVID-19 pandemic in Bandung, Indonesia

“…Interestingly, after controlling for previously identified associated factors, the COVID-19 pandemic did not have a statistically significant effect on patient, doctor delay, or treatment delay. We observed that this may be related to the overall lower power of the data collected during the pandemic compared to pre-pandemic, as COVID-19 disruptions to the Indonesian health system were reported by several studies [ 51 , 52 ]. We also could not establish the associations between the delays and previously identified factors, such as age, educational level, and insurance status [ 50 , 53 , 54 ].…”

COVID-19 pandemic and other factors associated with unfavorable tuberculosis treatment outcomes—Almaty, Kazakhstan, 2018–2021

“…A recent study in Italy showed that, despite efforts to maintain TB services, there was a sudden increase in service disruption during the COVID-19 outbreak (9). These service interruptions will likely have long-term consequences on TB burden, and a modeling study predicts a 4% increase in TB deaths worldwide and 5.7% excess deaths in India over the period from 2020 to 2025 due to the COVID-19 lockdown (10)(11)(12). Studies using national data to assess the impact of the COVID-19 pandemic on TB services have not previously been conducted in any Central Asian country.…”