The Impact of COVID-19 on Tuberculosis Program Performance in the Kingdom of Lesotho.

BACKGROUND: As tuberculosis (TB) is an airborne disease requiring multi-month therapy, systems of TB detection and care were profoundly impacted by the COVID-19 pandemic. The worsening economic situation, including income, food, and housing insecurity, impacted the social conditions in which TB-already a leading killer in resource-limited settings-thrives. This study assesses the impact of COVID-19 on TB detection and treatment in Lesotho. METHODS: We used routine program data from 78 health facilities in Lesotho. We created time series models from July 2018 to March 2021 to quantify COVID-19-related disruptions to TB program indicators: outpatient visits; presumptive, diagnosed, treated, and HIV co-infected cases; and treatment outcomes including successful (cured and completed) and unsuccessful (death and treatment outcome unknown). RESULTS: We observed a significant decline in cumulative outpatient visits (-37.4%, 95% prediction interval [PI]: -40.1%, -28.7%) and new TB cases diagnosed (-38.7%, 95%PI: -47.2%, -28.4%) during the pandemic, as well as TB-HIV co-infections (-67.0%, 95%PI: -72.6%, -60.0%). However, we observed no difference in treatment success (-2.1%, 95%PI: -17.0%, 15.8%). CONCLUSIONS: TB case detection in Lesotho fell during the COVID-19 pandemic, likely related to the uptake of overall health services. However, treatment success rates did not change, indicating a strong health system and the success of local strategies to maintain treatment programs.

The impact of COVID-19 and national pandemic responses on health service utilisation in seven low- and middle-income countries.

BACKGROUND: The COVID-19 pandemic has disrupted health services worldwide, which may have led to increased mortality and secondary disease outbreaks. Disruptions vary by patient population, geographic area, and service. While many reasons have been put forward to explain disruptions, few studies have empirically investigated their causes. OBJECTIVE: We quantify disruptions to outpatient services, facility-based deliveries, and family planning in seven low- and middle-income countries during the COVID-19 pandemic and quantify relationships between disruptions and the intensity of national pandemic responses. METHODS: We leveraged routine data from 104 Partners In Health-supported facilities from January 2016 to December 2021. We first quantified COVID-19-related disruptions in each country by month using negative binomial time series models. We then modelled the relationship between disruptions and the intensity of national pandemic responses, as measured by the stringency index from the Oxford COVID-19 Government Response Tracker. RESULTS: For all the studied countries, we observed at least one month with a significant decline in outpatient visits during the COVID-19 pandemic. We also observed significant cumulative drops in outpatient visits across all months in Lesotho, Liberia, Malawi, Rwanda, and Sierra Leone. A significant cumulative decrease in facility-based deliveries was observed in Haiti, Lesotho, Mexico, and Sierra Leone. No country had significant cumulative drops in family planning visits. For a 10-unit increase in the average monthly stringency index, the proportion deviation in monthly facility outpatient visits compared to expected fell by 3.9% (95% CI: -5.1%, -1.6%). No relationship between stringency of pandemic responses and utilisation was observed for facility-based deliveries or family planning. CONCLUSIONS: Context-specific strategies show the ability of health systems to sustain essential health services during the pandemic. The link between pandemic responses and healthcare utilisation can inform purposeful strategies to ensure communities have access to care and provide lessons for promoting the utilisation of health services elsewhere.

Impact of COVID-19 on access to cancer care in Rwanda: a retrospective time-series study using electronic medical records data.

INTRODUCTION: The COVID-19 pandemic has caused disruptions in access to routine healthcare services worldwide, with a particularly high impact on chronic care patients and low and middle-income countries. In this study, we used routinely collected electronic medical records data to assess the impact of the COVID-19 pandemic on access to cancer care at the Butaro Cancer Center of Excellence (BCCOE) in rural Rwanda. METHODS: We conducted a retrospective time-series study among all Rwandan patients who received cancer care at the BCCOE between 1 January 2016 and 31 July 2021. The primary outcomes of interest included a comparison of the number of patients who were predicted based on time-series models of pre-COVID-19 trends versus the actual number of patients who presented during the COVID-19 period (between March 2020 and July 2021) across four key indicators: the number of new patients, number of scheduled appointments, number of clinical visits attended and the proportion of scheduled appointments completed on time. RESULTS: In total, 8970 patients (7140 patients enrolled before COVID-19 and 1830 patients enrolled during COVID-19) were included in this study. During the COVID-19 period, enrolment of new patients dropped by 21.7% (95% prediction interval (PI): -31.3%, -11.7%) compared with the pre-COVID-19 period. Similarly, the number of clinical visits was 25.0% (95% PI: -31.1%, -19.1%) lower than expected and the proportion of scheduled visits completed on time was 27.9% (95% PI: -39.8%, -14.1%) lower than expected. However, the number of scheduled visits did not deviate significantly from expected. CONCLUSION: Although scheduling procedures for visits continued as expected, our findings reveal that the COVID-19 pandemic interrupted patients' ability to access cancer care and attend scheduled appointments at the BCCOE. This interruption in care suggests delayed diagnosis and loss to follow-up, potentially resulting in a higher rate of negative health outcomes among cancer patients in Rwanda.

Syndromic surveillance with monthly aggregate health systems information data for COVID-19 pandemic response in Neno, Malawi: a monitoring study

Background In the context of diminutive COVID-19 screening and testing, syndromic surveillance can be used to identify areas with higher-than-expected SARS-CoV-2 symptoms for targeted public health interventions. We used syndromic surveillance to monitor potential SARS-CoV-2 outbreaks in 14 health facilities in the Neno district of rural Malawi. Methods We monitored three indicators identified as potential symptoms of SARS-CoV-2 infection: the proportion of outpatient visits for fast-breathing cases in children under 5 years (FBC<5);the proportion of suspected malaria cases confirmed as non-malaria in children under 5 years (NMC<5);and the same indicator in individuals aged 5 years and older (NMC≥5). We extracted data aggregated by month and at the health facility-level from the District Health Information System. With data from January, 2016, to February, 2020, as a baseline, we used a linear model with a negative binomial distribution to estimate expected proportions for the indicators in absence of the COVID-19 pandemic with 95% prediction intervals (PI) for March, 2020, to July, 2021. We compared the observed proportions to the expected rates, focusing on the first two waves of infections (June to July, 2020, and January to March, 2021). Findings The proportion of FBC<5 was consistently higher than expected, with a peak in May, 2020, when 2·5% of outpatient visits were fast breathing cases in children younger than 5 years of age (compared with the expected rate of 0·8% [95% PI 0·4–1·5]). NMC<5 was as expected throughout the study period. The NMC≥5 indicator remained as expected, except for increases in suspected cases tested negative for malaria, to 31·3% (from the expected 18·6% [95% PI 12·3–28·7]) in November, 2020, and to 32·5% (from the expected 21·7% [95% PI 14·2–32·2]) in July, 2021. Interpretation An increase in FBC<5 and NMC≥5 before observed COVID-19 waves might indicate SARS-CoV-2 infections that were missed before robust testing. This tendency was not seen in NMC<5, which can represent differences in symptomatology leading to decreased health-seeking behaviours for this age group. Syndromic surveillance can allow for real-time responses at facilities, including increased and focused testing and screening to identify potential SARS-CoV-2 infections. Funding Supported by Canadian Institutes of Health Research.

Childhood immunization during the COVID-19 pandemic: experiences in Haiti, Lesotho, Liberia and Malawi.

OBJECTIVE: To examine changes in vaccination of children younger than 1 year during the coronavirus disease 2019 (COVID-19) pandemic (March 2020-August 2021) in Haiti, Lesotho, Liberia and Malawi. METHODS: We used data from health management information systems on vaccination of children aged 12 months or younger in districts supported by Partners In Health. We used data from January 2016 to February 2020 and a linear model with negative binomial distribution to estimate the expected immunization counts for March 2020-August 2021 with 95% prediction intervals, assuming no pandemic. We compared these expected levels with observed values and estimated the immunization deficits or excesses during the pandemic months. FINDINGS: Baseline vaccination counts varied substantially by country, with Lesotho having the lowest count and Haiti the highest. We observed declines in vaccination administration early in the COVID-19 pandemic in Haiti, Lesotho and Liberia. Continued declines largely corresponded to high rates of COVID-19 infection and discrete stock-outs. By August 2021, vaccination levels had returned to close to or above expected levels in Haiti, Liberia and Lesotho; in Malawi levels remained below expected. CONCLUSION: Patterns of childhood immunization coverage varied by country over the course of the pandemic, with significantly lower than expected vaccination levels seen in one country during subsequent COVID-19 waves. Governments and health-care stakeholders should monitor vaccine coverage closely and consider interventions, such as community outreach, to avoid or combat the disruptions in childhood vaccination.