Impact of the COVID-19 pandemic on tuberculosis control in Indonesia: a nationwide analysis of programme data and health system vulnerabilities

BackgroundThere are limited measures of the impact of the COVID-19 pandemic on tuberculosis (TB) control in high-burden countries like Indonesia. MethodsWe analysed district-level data of reported TB cases, treatment and deaths, COVID-19 incidence and mortality, health care capacity, economic status, education level, and public health development index from all 514 districts in Indonesia. We compared data before (2016-2019) and during (2020-2021) the pandemic. FindingsCompared to the preceding year (2019), in the first pandemic year (2020) the TB case notification declined by 31% (from median 172 [IQR 129-244] in 2019 to 119 [IQR 87-170] in 2020 per 100,000 population; 565,669 vs 393,323 cases, respectively); mortality increased by 8% (from median 4{middle dot}2 [IQR 2{middle dot}0-7{middle dot}4] to 5{middle dot}0 (IQR 3{middle dot}1-7{middle dot}5) per 100,000 population; 13,059 vs 14,148 deaths, respectively); and the overall proportion of cases who started treatment declined by 7% (from 98% to 91%). The second pandemic year (2021) saw a partial recovery of case notifications (median 142 [IQR 99-204]; 473,006) and deaths (4{middle dot}1 [IQR 2{middle dot}5-6{middle dot}8]; 12,016), but a persistently reduced treatment coverage (84%). Reductions in TB notifications between districts were associated with higher COVID-19 incidence and fewer per capita GeneXpert machines for TB diagnosis. Likewise, reduced TB treatment coverage was associated with fewer per capita doctors, and increased reported TB deaths was associated with fewer per capita primary health centres, lower per capita domestic expenditure and higher education. InterpretationThe COVID-19 pandemic significantly, yet unevenly, impacted the national TB control programme across Indonesia, with the greatest impacts in districts with the least resilient health systems. FundingWellcome Africa Asia Programme Vietnam