Global Excess Tuberculosis Mortality DuringCOVID-19: A Country-Level Modeling Study of Policy and Development Correlates

Global Excess Tuberculosis Mortality DuringCOVID-19: A Country-Level Modeling Study of Policy and Development Correlates | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Global Excess Tuberculosis Mortality DuringCOVID-19: A Country-Level Modeling Study of Policy and Development Correlates Hamed Karami, Svenn-Erik Mamelund, Alexandra Smirnova, Gerardo Chowell This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6806070/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 31 Oct, 2025 Read the published version in BMC Public Health → Version 1 posted 14 You are reading this latest preprint version Abstract Background: The COVID-19 pandemic disrupted global tuberculosis (TB) con-trol efforts, leading to a surge in TB-related excess mortality, particularly inlow- and middle-income countries. Pandemic mitigation measures—such as lock-downs, reallocation of healthcare resources, and reduced access to diagnosis andtreatment—contributed to delayed TB care and disease progression. Quantifyingthis collateral damage is crucial to bolstering health system resilience. Methods: We estimated country-level excess TB mortality between 2020 and2023 using annual TB mortality data reported by the World Health Organization(WHO). Our approach leverages the SubEpiPredict toolbox of the ensemble sub-epidemic modeling framework, calibrated to pre-pandemic trends (2010–2019) toforecast expected TB deaths in the absence of COVID-19 disruptions. We selectedthe best-fitting model based on AICc and compared projected and reporteddeaths to quantify excess mortality, incorporating both normal and Poissonerror structures. We further examined associations between excess TB mortalityand country-level indicators, including the COVID-19 Stringency Index, GlobalHealth Security (GHS) Index, and Socio-demographic Index (SDI). Results: Our global estimate of 750,000 excess TB deaths aligns closely withWHO’s estimate of 700,000, while offering granular country-level insights withuncertainty bounds. We found substantial geographic heterogeneity, with thehighest TB excess mortality rates observed in southern Africa, South Asia, andparts of South America. Countries with high GHS or SDI scores did not nec-essarily exhibit lower excess TB mortality, suggesting that pandemic-specificdisruptions and competing priorities may have overridden structural advantages.Weak-to-moderate correlations were observed between excess mortality and pan-demic stringency, peaking in 2021 and waning by 2022, possibly reflecting healthsystem adaptation. Conclusion: This study presents a systematic, model-based analysis of globalexcess TB mortality during the COVID-19 pandemic, emphasizing disparities inpandemic response impacts across countries. The findings highlight the need forintegrated and resilient public health systems capable of maintaining essentialservices amid global crises. Our methodology can support real-time monitor-ing of collateral effects of pandemics on endemic diseases and guide strategicinvestments in TB surveillance and care continuity. Excess deaths Tuberculosis COVID-19 Stringency index Full Text Additional Declarations No competing interests reported. Supplementary Files supplementary.pdf Cite Share Download PDF Status: Published Journal Publication published 31 Oct, 2025 Read the published version in BMC Public Health → Version 1 posted Editorial decision: Revision requested 16 Jul, 2025 Reviews received at journal 14 Jul, 2025 Reviews received at journal 10 Jul, 2025 Reviews received at journal 08 Jul, 2025 Reviewers agreed at journal 29 Jun, 2025 Reviewers agreed at journal 25 Jun, 2025 Reviewers agreed at journal 25 Jun, 2025 Reviewers agreed at journal 25 Jun, 2025 Reviewers agreed at journal 24 Jun, 2025 Reviewers invited by journal 19 Jun, 2025 Editor invited by journal 09 Jun, 2025 Editor assigned by journal 06 Jun, 2025 Submission checks completed at journal 06 Jun, 2025 First submitted to journal 02 Jun, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Excess deaths, Tuberculosis, COVID-19, Stringency index","lastPublishedDoi":"10.21203/rs.3.rs-6806070/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6806070/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e The COVID-19 pandemic disrupted global tuberculosis (TB) con-trol efforts, leading to a surge in TB-related excess mortality, particularly inlow- and middle-income countries. Pandemic mitigation measures—such as lock-downs, reallocation of healthcare resources, and reduced access to diagnosis andtreatment—contributed to delayed TB care and disease progression. Quantifyingthis collateral damage is crucial to bolstering health system resilience.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e We estimated country-level excess TB mortality between 2020 and2023 using annual TB mortality data reported by the World Health Organization(WHO). Our approach leverages the SubEpiPredict toolbox of the ensemble sub-epidemic modeling framework, calibrated to pre-pandemic trends (2010–2019) toforecast expected TB deaths in the absence of COVID-19 disruptions. We selectedthe best-fitting model based on AICc and compared projected and reporteddeaths to quantify excess mortality, incorporating both normal and Poissonerror structures. We further examined associations between excess TB mortalityand country-level indicators, including the COVID-19 Stringency Index, GlobalHealth Security (GHS) Index, and Socio-demographic Index (SDI).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e Our global estimate of 750,000 excess TB deaths aligns closely withWHO’s estimate of 700,000, while offering granular country-level insights withuncertainty bounds. We found substantial geographic heterogeneity, with thehighest TB excess mortality rates observed in southern Africa, South Asia, andparts of South America. Countries with high GHS or SDI scores did not nec-essarily exhibit lower excess TB mortality, suggesting that pandemic-specificdisruptions and competing priorities may have overridden structural advantages.Weak-to-moderate correlations were observed between excess mortality and pan-demic stringency, peaking in 2021 and waning by 2022, possibly reflecting healthsystem adaptation.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e This study presents a systematic, model-based analysis of globalexcess TB mortality during the COVID-19 pandemic, emphasizing disparities inpandemic response impacts across countries. The findings highlight the need forintegrated and resilient public health systems capable of maintaining essentialservices amid global crises. Our methodology can support real-time monitor-ing of collateral effects of pandemics on endemic diseases and guide strategicinvestments in TB surveillance and care continuity.\u003c/p\u003e","manuscriptTitle":"Global Excess Tuberculosis Mortality DuringCOVID-19: A Country-Level Modeling Study of Policy and Development Correlates","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-12 01:47:41","doi":"10.21203/rs.3.rs-6806070/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-07-16T18:24:55+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-14T19:22:44+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-11T01:13:20+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-08T09:42:28+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"54744008387914159092829785280696077686","date":"2025-06-29T09:14:24+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"318059747010255032394240978945759253128","date":"2025-06-25T16:54:08+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"145978302385248638621441128019233042302","date":"2025-06-25T10:14:39+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"143045410104982361603188487637115623815","date":"2025-06-25T05:09:16+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"164855984730020342926151707628525146156","date":"2025-06-24T14:04:18+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-06-19T14:08:49+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-06-09T18:28:01+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-06-07T03:37:32+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-06-07T03:35:40+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Public Health","date":"2025-06-03T02:09:57+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"90215181-d336-4316-ab09-cda8efd4d1b2","owner":[],"postedDate":"June 12th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-11-03T15:59:26+00:00","versionOfRecord":{"articleIdentity":"rs-6806070","link":"https://doi.org/10.1186/s12889-025-24858-8","journal":{"identity":"bmc-public-health","isVorOnly":false,"title":"BMC Public Health"},"publishedOn":"2025-10-31 15:56:56","publishedOnDateReadable":"October 31st, 2025"},"versionCreatedAt":"2025-06-12 01:47:41","video":"","vorDoi":"10.1186/s12889-025-24858-8","vorDoiUrl":"https://doi.org/10.1186/s12889-025-24858-8","workflowStages":[]},"version":"v1","identity":"rs-6806070","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6806070","identity":"rs-6806070","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}