Impact of the COVID‐19 pandemic on TB services at ART programmes in low‐ and middle‐income countries: a multi‐cohort survey

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Abstract

Introduction

COVID‐19 stretched healthcare systems to their limits, particularly in settings with a pre‐existing high burden of infectious diseases, including HIV and tuberculosis (TB). We studied the impact of COVID‐19 on TB services at antiretroviral therapy (ART) clinics in low‐ and middle‐income countries.

Methods

We surveyed ART clinics providing TB services in the International Epidemiology Databases to Evaluate AIDS (IeDEA) consortium in Africa and the Asia‐Pacific until July 2021 (TB diagnoses until the end of 2021). We collected site‐level data using standardized questionnaires.

Results

Of 46 participating ART clinics, 32 (70%) were in Africa and 14 (30%) in the Asia‐Pacific; 52% provided tertiary care. Most clinics (85%) reported disrupted routine HIV care services during the pandemic, both in Africa (84%) and the Asia‐Pacific (86%). The most frequently reported impacts were on staff (52%) and resource shortages (37%; protective clothing, face masks and disinfectants). Restrictions in TB health services were observed in 12 clinics (26%), mainly reduced access to TB diagnosis and postponed follow‐up visits (6/12, 50% each), and restrictions in TB laboratory services (22%). Restrictions of TB services were addressed by dispensing TB drugs for longer periods than usual (7/12, 58%), providing telehealth services (3/12, 25%) and with changes in directly observed therapy (DOT) (e.g. virtual DOT, 3/12). The number of TB diagnoses at participating clinics decreased by 21% in 2020 compared to 2019; the decline was more pronounced in tertiary than primary/secondary clinics (24% vs. 12%) and in sites from the Asia‐Pacific compared to Africa (46% vs. 14%). In 2021, TB diagnoses continued to decline in Africa (–8%) but not in the Asia‐Pacific (+62%) compared to 2020. During the pandemic, new infection control measures were introduced or intensified at the clinics, including wearing face masks, hand sanitation and patient triage.

Conclusions

The COVID‐19 pandemic led to staff shortages, reduced access to TB care and delays in follow‐up visits for people with TB across IeDEA sites in Africa and the Asia‐Pacific. Increased efforts are needed to restore and secure ongoing access to essential TB services in these contexts.

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Most cited references 20

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Research electronic data capture (REDCap)--a metadata-driven methodology and workflow process for providing translational research informatics support.

Paul A. Harris, Robert Taylor, Robert Thielke … (2009)

Research electronic data capture (REDCap) is a novel workflow methodology and software solution designed for rapid development and deployment of electronic data capture tools to support clinical and translational research. We present: (1) a brief description of the REDCap metadata-driven software toolset; (2) detail concerning the capture and use of study-related metadata from scientific research teams; (3) measures of impact for REDCap; (4) details concerning a consortium network of domestic and international institutions collaborating on the project; and (5) strengths and limitations of the REDCap system. REDCap is currently supporting 286 translational research projects in a growing collaborative network including 27 active partner institutions.

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The REDCap consortium: Building an international community of software platform partners

Paul Harris, Robert Taylor, Brenda Minor … (2019)

The Research Electronic Data Capture (REDCap) data management platform was developed in 2004 to address an institutional need at Vanderbilt University, then shared with a limited number of adopting sites beginning in 2006. Given bi-directional benefit in early sharing experiments, we created a broader consortium sharing and support model for any academic, non-profit, or government partner wishing to adopt the software. Our sharing framework and consortium-based support model have evolved over time along with the size of the consortium (currently more than 3200 REDCap partners across 128 countries). While the "REDCap Consortium" model represents only one example of how to build and disseminate a software platform, lessons learned from our approach may assist other research institutions seeking to build and disseminate innovative technologies.

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Estimating excess mortality due to the COVID-19 pandemic: a systematic analysis of COVID-19-related mortality, 2020–21

(2022)

Background Mortality statistics are fundamental to public health decision making. Mortality varies by time and location, and its measurement is affected by well known biases that have been exacerbated during the COVID-19 pandemic. This paper aims to estimate excess mortality from the COVID-19 pandemic in 191 countries and territories, and 252 subnational units for selected countries, from Jan 1, 2020, to Dec 31, 2021. Methods All-cause mortality reports were collected for 74 countries and territories and 266 subnational locations (including 31 locations in low-income and middle-income countries) that had reported either weekly or monthly deaths from all causes during the pandemic in 2020 and 2021, and for up to 11 year previously. In addition, we obtained excess mortality data for 12 states in India. Excess mortality over time was calculated as observed mortality, after excluding data from periods affected by late registration and anomalies such as heat waves, minus expected mortality. Six models were used to estimate expected mortality; final estimates of expected mortality were based on an ensemble of these models. Ensemble weights were based on root mean squared errors derived from an out-of-sample predictive validity test. As mortality records are incomplete worldwide, we built a statistical model that predicted the excess mortality rate for locations and periods where all-cause mortality data were not available. We used least absolute shrinkage and selection operator (LASSO) regression as a variable selection mechanism and selected 15 covariates, including both covariates pertaining to the COVID-19 pandemic, such as seroprevalence, and to background population health metrics, such as the Healthcare Access and Quality Index, with direction of effects on excess mortality concordant with a meta-analysis by the US Centers for Disease Control and Prevention. With the selected best model, we ran a prediction process using 100 draws for each covariate and 100 draws of estimated coefficients and residuals, estimated from the regressions run at the draw level using draw-level input data on both excess mortality and covariates. Mean values and 95% uncertainty intervals were then generated at national, regional, and global levels. Out-of-sample predictive validity testing was done on the basis of our final model specification. Findings Although reported COVID-19 deaths between Jan 1, 2020, and Dec 31, 2021, totalled 5·94 million worldwide, we estimate that 18·2 million (95% uncertainty interval 17·1–19·6) people died worldwide because of the COVID-19 pandemic (as measured by excess mortality) over that period. The global all-age rate of excess mortality due to the COVID-19 pandemic was 120·3 deaths (113·1–129·3) per 100 000 of the population, and excess mortality rate exceeded 300 deaths per 100 000 of the population in 21 countries. The number of excess deaths due to COVID-19 was largest in the regions of south Asia, north Africa and the Middle East, and eastern Europe. At the country level, the highest numbers of cumulative excess deaths due to COVID-19 were estimated in India (4·07 million [3·71–4·36]), the USA (1·13 million [1·08–1·18]), Russia (1·07 million [1·06–1·08]), Mexico (798 000 [741 000–867 000]), Brazil (792 000 [730 000–847 000]), Indonesia (736 000 [594 000–955 000]), and Pakistan (664 000 [498 000–847 000]). Among these countries, the excess mortality rate was highest in Russia (374·6 deaths [369·7–378·4] per 100 000) and Mexico (325·1 [301·6–353·3] per 100 000), and was similar in Brazil (186·9 [172·2–199·8] per 100 000) and the USA (179·3 [170·7–187·5] per 100 000). Interpretation The full impact of the pandemic has been much greater than what is indicated by reported deaths due to COVID-19 alone. Strengthening death registration systems around the world, long understood to be crucial to global public health strategy, is necessary for improved monitoring of this pandemic and future pandemics. In addition, further research is warranted to help distinguish the proportion of excess mortality that was directly caused by SARS-CoV-2 infection and the changes in causes of death as an indirect consequence of the pandemic. Funding Bill & Melinda Gates Foundation, J Stanton, T Gillespie, and J and E Nordstrom

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Author and article information

Contributors

Lukas Fenner:

ORCID: https://orcid.org/0000-0003-3309-4835

Lukas.Fenner@ispm.unibe.ch

Journal

Journal ID (nlm-ta): J Int AIDS Soc

Journal ID (iso-abbrev): J Int AIDS Soc

Journal ID (doi): 10.1002/(ISSN)1758-2652

Journal ID (publisher-id): JIA2

Title: Journal of the International AIDS Society

Publisher: John Wiley and Sons Inc. (Hoboken )

ISSN (Electronic): 1758-2652

Publication date (Electronic): 26 October 2022

Publication date Collection: October 2022

Volume: 25

Issue: 10 ( doiID: 10.1002/jia2.v25.10 )

Electronic Location Identifier: e26018

Affiliations

[ ¹ ] Institute of Social and Preventive Medicine University of Bern Bern Switzerland

[ ² ] The Ryan White Center for Pediatric Infectious Disease and Global Health Department of Pediatrics Indiana University School of Medicine Indianapolis Indiana USA

[ ³ ] Department of Medicine Moi University School of Medicine Eldoret Kenya

[ ⁴ ] Department of Medicine Moi Teaching and Referral Hospital Eldoret Kenya

[ ⁵ ] University of Bordeaux, Inserm U1219 IRD EMR271 Bordeaux France

[ ⁶ ] Division of General Internal Medicine Department of Medicine Albert Einstein College of Medicine Bronx New York USA

[ ⁷ ] Centre National de Référence en matière de VIH/SIDA Burundi (CNR) Bujumbura Burundi

[ ⁸ ] Chiangrai Prachanukroh Hospital Chiang Rai Thailand

[ ⁹ ] Faculty of Medicine Universitas Indonesia Dr. Cipto Mangunkusumo General Hospital Jakarta Indonesia

[ ¹⁰ ] Rahima Moosa Mother and Child Hospital Department of Paediatrics and Child Health Faculty of Health Sciences University of the Witwatersrand Johannesburg South Africa

[ ¹¹ ] Emory Rollins School of Public Health Emory University Atlanta Georgia USA

[ ¹² ] Centre for Infectious Disease Epidemiology and Research Faculty of Health Sciences University of Cape Town Cape Town South Africa

[ ¹³ ] Population Health Sciences Bristol Medical School University of Bristol Bristol UK

Author notes

[*] [* ] Corresponding author: Lukas Fenner, Institute of Social and Preventive Medicine, University of Bern, 3012 Bern, Switzerland. Tel: +41 31 631 35 21. ( Lukas.Fenner@ 123456ispm.unibe.ch )

[#]

These authors have contributed equally to this work.

Author information

Kathrin Zürcher https://orcid.org/0000-0002-7915-3194

Leslie A. Enane https://orcid.org/0000-0001-8390-5881

Olivier Marcy https://orcid.org/0000-0003-3350-112X

Thierry Tiendrebeogo https://orcid.org/0000-0002-9393-9732

Christelle Twizere https://orcid.org/0000-0003-1102-5564

Suwimon Khusuwan https://orcid.org/0000-0001-6975-057X

Evy Yunihastuti https://orcid.org/0000-0001-6650-0559

Matthias Egger https://orcid.org/0000-0001-7462-5132

Marie Ballif https://orcid.org/0000-0003-3133-3011

Lukas Fenner https://orcid.org/0000-0003-3309-4835

Article

Publisher ID: JIA226018

DOI: 10.1002/jia2.26018

PMC ID: 9597377

PubMed ID: 36285602

SO-VID: 631d6b85-fb64-4de9-b455-1fdcaf1f14c2

License:

This is an open access article under the terms of the http://creativecommons.org/licenses/by/4.0/ License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited.

History

Date received : 13 June 2022

Date accepted : 21 September 2022

Page count

Figures: 4, Tables: 2, Pages: 9, Words: 5716

Custom metadata

source-schema-version-number 2.0

cover-date October 2022

details-of-publishers-convertor Converter:WILEY_ML3GV2_TO_JATSPMC version:6.2.0 mode:remove_FC converted:26.10.2022

ScienceOpen disciplines: Infectious disease & Microbiology

Keywords: tuberculosis,covid‐19,hiv clinic,antiretroviral therapy,low‐ and middle‐income countries,differentiated service delivery

Data availability:

ScienceOpen disciplines: Infectious disease & Microbiology

Keywords: tuberculosis, covid‐19, hiv clinic, antiretroviral therapy, low‐ and middle‐income countries, differentiated service delivery

Impact of the COVID‐19 pandemic on TB services at ART programmes in low‐ and middle‐income countries: a multi‐cohort survey

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Introduction

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Conclusions

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Novel Coronavirus Disease COVID-19

Most cited references 20

Research electronic data capture (REDCap)--a metadata-driven methodology and workflow process for providing translational research informatics support.

The REDCap consortium: Building an international community of software platform partners

Estimating excess mortality due to the COVID-19 pandemic: a systematic analysis of COVID-19-related mortality, 2020–21

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