Tuberculosis healthcare service disruptions during the COVID-19 pandemic in Brazil, India and South Africa: A model-based analysis of country-level data

Tuberculosis (TB) is the leading infectious disease cause of death worldwide. In recent years, stringent measures to contain the spread of SARS-CoV-2 have led to considerable disruptions of healthcare services for TB in many countries. The extent to which these measures have affected TB testing, treatment initiation and outcomes has not been comprehensively assessed. We aimed to estimate TB healthcare service disruptions occurring during the COVID-19 pandemic in Brazil, India, and South Africa. We obtained country-level TB programme and laboratory data and used autoregressive integrated moving average (ARIMA) time-series models to estimate healthcare service disruptions with respect to TB testing, treatment initiation, and treatment outcomes. We quantified disruptions as the percentage difference between TB indicator data observed during the COVID-19 pandemic compared with values for a hypothetical no-COVID scenario, predicted through forecasting of trends during a three-year pre-pandemic period. Annual estimates for 2020-2022 were derived from aggregated monthly data. We estimated that in 2020, the number of bacteriological tests conducted for TB diagnosis was 24.3% (95% uncertainty interval: 8.4%;36.6%) lower in Brazil, 27.8% (19.8;3 4.8%) lower in India, and 32.0% (28.9%;34.9%) lower in South Africa compared with values predicted for the no-COVID scenario. TB treatment initiations were 17.4% (13.9%;20.6%) lower than predicted in Brazil, 43.3% (39.8%;46.4%) in India, and 27.0% (15.2%;36.3%) in South Africa. Reductions in 2021 were less severe compared with 2020. The percentage deaths during TB treatment were 13.7% (8.1%; 19.7%) higher than predicted in Brazil, 1.7% (-8.9%;14.0%) in India and 21.8% (7.4%;39.2%) in South Africa. Our analysis suggests considerable disruptions of TB healthcare services occurred during the early phase of the COVID-19 pandemic in Brazil, India, and South Africa, with at least partial recovery in the following years. Sustained efforts to mitigate the detrimental impact of COVID-19 on TB healthcare services are needed.