File000011 1044626722

BMJ Open
Impact of COVID-19 pandemic on TB prevention and care in

Addis Ababa, Ethiopia: A challenge for national end TB
program
Journal: BMJ Open
Manuscript ID bmjopen-2021-053290
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Article Type: Original research
Date Submitted by the

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10-May-2021
Author:
Complete List of Authors: Arega, B; Yekatit 12 Hospital

Negesso, Abebe; Addis Ababa City Administration Health Bureau
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Taye, Bethelihem; Addis Ababa City Administration Health Bureau

Weldeyohhans, Getachew; Yekatit 12 Hospital
Bewket, Bekure; Yekatit 12 Hospital
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Negussie, Tesfaye; Yekatit 12 Hospital

Teshome, Ayele; Yekatit 12 Hospital
Endazenew, Getabalew; Yekatit 12 Hospital
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Keywords: COVID-19, Tuberculosis < INFECTIOUS DISEASES, EPIDEMIOLOGY

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For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml

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Impact of COVID-19 pandemic on TB prevention and care in Addis Ababa,
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Ethiopia: A challenge for national end TB program
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8 Balew Arega1*, Abebe Negesso2, Bethelihem Taye3, Getachew Weldeyohhans4, Bekure
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10 Bewket5 , Tesfaye Negussie6, Ayele Teshome7, Getabalew Endazenew8
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12 1Yekatit 12 Hospital medical college, balewmlt@gmail.com, Addis Ababa, Ethiopia
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14 2 Addis
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Abeba City Administrative Health Bureau, abenagi47@gmail.com, Addis Ababa Ethiopia
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17 3Addis Abeba City Administrative Health Bureau, betelhem.taye@gmail.com, Addis Ababa
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20 Ethiopia
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22 4Yekatit 12 Hospital Medical College, gechwy2001@yahoo.com Addis Ababa, Ethiopia
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5Yekatit 12 Hospital Medical College, bekurebewkets15@gmail.com, Addis Ababa, Ethiopia
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27 6 Yekatit 12 Hospital Medical College, tesfayefantu03@gmail.com, Addis Ababa, Ethiopia

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30 7 Yekatit 12 Hospital Medical College, ayumesif@yahoo.com, Addis Ababa, Ethiopia

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32 8Yekatit 12 hospital Medical College, eyobgetabalew@gmail.com, Addis Ababa, Ethiopia
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35 *CorspondingAuther:
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Email: -balewmlt@gmail.com
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40 P.O.Box:- 257,Sidst kilo square , Addis Ababa ,Ethiopia
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3 ABSTRACT
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6 Objectives: COVID-19 is likely to have catastrophic effects on routine TB service in Ethiopia.
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9 This study aimed to assess the impact of COVID-19 on TB service indicators in Addis Ababa;
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11 more than two-thirds of the COVID-19 cases and death are reported.
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14 Design: We performed a comparative retrospective study to evaluate the impact of COVID-19
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16 on TB services during the pre-COVID-19 era (April 2019 to March 2020) and the COVID-19 era
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(April 2020 to March 2021) in Addis Ababa, Ethiopia. We extracted data on total TB detection
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21 rate, TB treatment success rate, isoniazid prophylaxis therapy, and drug susceptibility tests from
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23 the Health information system. Using Poisson regression, we estimated incidence rate ratios
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25 comparing rates of the indicators (number per quarter and year) in the COVID-19 and pre-
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28 COVID eras, adjusting for the year.
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31 Results: Compared to the pre-COVID-19 era, the total TB detection, TB treatment success rate,
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33 latent TB infection treatment, and community health workers’ engagement in TB detection

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35 decreased respectively by 8%, 7%, 51%, and 84% during the COVID -19 periods. The
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rifampicin resistance increased by 50 % during the same period. Comparative analysis showed a
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40 significant decline in these TB service indicators (P <0.001)
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43 Conclusion: The COVID-19 epidemic has negatively impacted the TB services indicators in
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45 Addis Ababa. This indicates the need to strengthen TB service, using alternative digital health
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technology to screen TB and integrating TB and COVID-19 services to minimize the challenges
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50 that COVID-19 presents to TB prevention and care.
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53 Keywords: Impact, TB, COVID-19, Addis Ababa, Ethiopia
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3 Strength and limitations of this study
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 It is the first study investigating the impact of COVID-19 pandemics on basic TB indicators in
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8 the epicenter of the pandemic in Ethiopia
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10  Data collection occurs one year before and one year during the COVID-19 era.
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12  The TB service indicators measurements and definitions have been presented based on the
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15 national TB guideline
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 We have not collected patient-level data so can’t assess what happens to individual patients.
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3 BACKGROUND
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6 Tuberculosis (TB) has long been the leading cause of public health due to infectious diseases and
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8 globally kills more than 1.5 million with an estimated 10 million new cases in 2019.1 The current
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10 pandemic of SARS-CoV-2 (called COVID-19) is predicted to result in an additional 6 million
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13 TB cases and 1.4 million TB-related deaths between 2020 and 2025.2 During this pandemic,
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15 people with TB symptoms face difficulties in accessing health care facilities due to lockdowns or
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17 movement restrictions, fear of catching COVID-19 infection in hospital settings, and the
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diversion of TB services3. Besides, the attention of the public, government, media, and health
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22 professions is focused on COVID-19, and other endemic diseases such as TB have received less
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24 attention.4 These factors prolong diagnostic delays; increase the rate of undetected TB cases in
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the community, poor treatment outcomes, and risks of developing drug-resistant (DR) TB, and of
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29 which would lead to more transmission and TB cases in the upcoming years.4 These problems
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31 are expected to worsen in low-income countries including Ethiopia because the diagnostic
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33 capacity of TB cases is sub-optimal and there are many undiagnosed TB that likely to have
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36 worse outcomes in these areas.6
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39 Ethiopia is among the 30 high-burden TB countries and the disease is an ongoing topmost killer
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41 in the country.7 Currently, the government of Ethiopia has implemented the global End TB
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43 program to end the TB epidemic by 2035. This has been implemented through active TB
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screening, early diagnosis, appropriate treatment, and universal drug sensitivity tests (DST) (at
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48 least for rifampicin.8 However, the current crisis of COVID-19 in Ethiopia challenged its
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50 implementation and a serious setback in the progress toward the End TB strategy milestones and
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targets.9 In Ethiopia, the first case of COVID-19 was reported on March 13, 2020, and, the virus
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55 infected 227,255 people among 2,437,495 samples tested (positivity 9.32%), with 3,146 deaths
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3 (11th April 2021), and the number continues to rise at an alarming rate. Nearly three-quarters of
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6 these cases are concentrated in and around Addis Ababa.10 On the other hand, the essential
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8 measures to control and prevent COVID-19 in the country such as mandatory quarantine periods
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10 for all travelers, restrictions on public gatherings, school closures, mandatory facemasks in
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public places, and fewer passengers using public transport either loosen or lifted.11 12 In the city,
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15 previously conducted research showed a significant decrease in the numbers of patients
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17 presenting with signs and symptoms for TB during COVID-19 periods.13 However, this study
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not investigated the impact of COVID-19 on the TB service indicators. Therefore, we sought to
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22 assess the effect of the COVID-19 pandemic on selected TB service indicators at Addis Ababa
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24 (COVID-19 epicenter) using secondary (Health information system) data collected from all
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26 health facilities in the city. These are important for understanding the potential impact of
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29 COVID-19 on TB and use it to design prevention strategies.
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32 METHODS
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35 Study design
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37 We performed a comparative retrospective study to evaluate the impact of COVID-19 on TB
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39 services before and during the pandemic using Health information system reports.
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Study setting
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This study was conducted in Addis Ababa, the capital city of Ethiopia. According to the 2007
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47 national census, the city is categorized into eleven administrative sub-cities with a total of 3, 770,
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49 554 inhabitants.14 It has seven public hospitals and 100 public health centers stratified into three
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51 categories, in order of hierarchy from health centers to general hospitals, and specialized
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54 hospitals. This network of public health facilities delivers services throughout the city on a pay-
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56 per-service basis, except for children under five years of age, pregnant women, HIV, and
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3 tuberculosis who are covered by the free health care policy. Allowing the different national
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6 special TB programs such as the Millennium Development Goals (goal 6) and the currently
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8 launched end TB, all health facilities in each health care level provide TB care. They reported
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10 TB cases to the city administrative health bureau using the nationally set and structured reporting
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form every quarter (every three months).
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Data source and variables
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18 We used data from the Health Management Information System (HMIS) in the Addis Ababa
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20 health bureau, between April 2019 and March 2021. It draws its data from routine service and
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administrative records and the indicators are based on the priorities of the Plan for Accelerated
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25 and Sustained Development to End Poverty, the needs and priorities of local authorities, and the
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27 requirements of international agreements, such as the Millennium Development Goals. We

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29 divided the data into two periods: the COVID-19 era (from April 2020 to March 2021 and
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32 above) and the Pre-COVID-19 era (April 2019 to March 2020). We collected the data based on
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34 the national HIMs indicators for TB services reported every quarter. Specifically, we extracted
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36 data that included a year of study(months), total tuberculosis detection rate (including relapse),
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retreatment rate, the TB treatment success rate (both clinically and bacteriologically diagnosed),
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41 under fifteen years age contact screening, the isoniazid prophylaxis therapy (IPT) for eligible
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43 among under fifteen years aged children, TB DST, and level of rifampicin resistance. The
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definition and calculation of each parameter present in Box 1.
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3 Box 1. Operational definition of outcome variables15
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5 Indicators Definitions
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7 TB case detection rate: The proportion of all forms of TB (new and relapse) cases detected
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9 The treatment success rate The proportion of new TB cases registered during a specific cohort
10 among drug susceptibility period that completed treatment
11 TB case detection through The proportion of TB cases detection contributed by the community
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community TB care out of all TB cases identified during the reporting period
14 Contact screening coverage Percentage of screened under fifteen years children among those
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16 LTBI treatment coverage for The proportion of children aged <15 years who have a history of
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17 under 15 years children contact with pulmonary TB cases started on LTBI treatment
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The proportion of presumptive Percentage of Pulmonary TB (new and retreatment) cases and
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21 DST reporting period

22 Number of rifampicin resistance The Number of DR-TB cases detected during the reporting period
23 MTB cases detected
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24 LTBI=Latent TB Infection, DR= Drug resistance, DST= Drug Susceptibility Test

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28 Data variables, sources of data, and data collection
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30 The data were collected and analyzed in stata (vs. 16) for analyses. A descriptive analysis was
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32 performed to calculate the proportions of each indicator. We compared each of the selected
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35 indicators on a quarterly and yearly basis between periods (COVID-19 era and pre-COVID-19
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37 era). Poisson regression was done to estimate rate ratios comparing registrations per study period
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39 in the COVID-19 era to the pre-COVID-19 era, adjusted for year and quarter. A 95% confidence
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interval (CI) and levels of significance set at 5% (P <0.05).
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44 Patient and Public involvement
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46 No patient involved
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48 RESULTS
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50 1. Total TB notification
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53 For this study, we reviewed 24 months of health information system (12 months each during
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55 pre-COVID-19 and COVID-19 era) data. During these periods, we found a total of 19,250
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3 registered new TB cases. Of these, 10720(54.9%) and 9072 (44.1%) were reported during the
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6 pre-COVID-19 and COVID-19 eras, respectively.
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9 1.1. Trends of total TB detection rate
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12 The number of new TB patients reported per quarter during the pre-COVID-19 and the COVID-
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14 19 era are shown in Figure 1. The detection rate of all forms of TB was decreased with the range
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16 of 1% to 15% during the quarters at COVID-19 era. Compared to pre-COVID-19 era, there was
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a 6% (incidence rate ratio=0.94 p<0.001) total TB reduction during the COVID-19 era (table 1).
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2. TB Treatment success
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24 During the study period, an overall TB treatment success was reported in 79.02% (15213/19,250)
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0.96), P=.0.001) during the COVID-19 compared to the Pre-COVID-19 periods.
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3. Types of TB diagnosis
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34 Based on the type of evidence for diagnosis, 3824(40.9%) and 3372(34%) was bacteriologically
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6363(59.1%) TB cases during the pre-COVID-19 period and 5700(66%) during the COVID-19
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41 era were clinically diagnosed. The trend of rate of detection of bacteriologically confirmed TB
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43 varied from 4% to 18 % per quarter during the COVID-19 era compared to the pre-COVID-19
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45 era (figure 2). The overall rate of detection of bacteriological confirmed TB between the study
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48 periods is not significantly different (p-value =0.6)(not shown in the table)
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3 4. TB case detection through community TB care
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6 Only 1.9 %( 366/19250) of the total TB cases were detected through community health workers.
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9 Compared to the pre-COVID-19 era, the community-based TB detection decrease by 84%
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11 (P<0.001) during the COVI-19 era.
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14 5. TB contact screening and ITP provision
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A total of 2588 under fifteen year children had TB contact and screened for TB during the study
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19 periods. Of these, 1209 (46.7%) was in the pre-COVID-19 era and 1169(53.3%) in the COVID-
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19 era ( P=0.49). The rate of ITP provision per quarter among screened TB contact of under
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24 fifteen-year children decreased from 1%-57% ( figure 3) in the COVID-19 era compared to the
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28 the difference was significant (AOR, 0.49, p-value =0.02)(table 1).
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31 6. Drug susceptibility testing and Rifampicin-resistant
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34 A drug susceptibility test was done for 55.14% (2317/4202) of the presumptive MDR TB
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37 patients and the DST test performance does not differ between the pre-COVID-19 and COVID-
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39 19 eras (P-value=0.29). Of the total 230 rifampicin-resistant MTB detected during the study
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41 period, more than half, 129/10839 (11.2%) detected during COVID-era and the remaining
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101/1234 (7.1%) during the pre-COVID-19 era (Figure 4). During the COVID-19 era, rifampicin
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46 resistance increase by 50 %( AOR, 1.5) compared to Pre-COVID-19 (table 1).
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3 Table 1: TB service indicators difference between pre-COVID-19 and COVID-19 eras in Addis
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6 Ababa from April 2019 and March 2021.
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9 TB service indicators Period AOR(95% CI) P-Value
10 COVID-19 era Pre-COVID-19 era
11 TB case detection rate 8.3%(9072 /108,720 ) 9.1%(10,187/112,000#)
© 0.92(0.89 ,0.94) 0.001*
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13 TB treatment success rate 77.2%(6900 /8943) 81.7%(8313 /10176) 0.93( 0.90, 0.96) 0.001*
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15 TB case detection by 0.7% (68/9343) 2.84%(298/10,187) 0.26 (0.19, 0.33) 0.001*
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17 Contact screening coverage 94.1%(1297/1379) 96.7%(1169/1209) 0.97(0.89,1.05) 0.49
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under 15 year’s children
20 LTBI treatment coverage for 55.5%(515/1297) 62.3%(933 /1169) 0.49 (0.45, 0.55) 0.001*
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22 DST performed for at least 54%(1083/2010) 56.3%(1234/2192) 0.96(0.88,1.04) 0.29
23 rifampicin
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Rifampicin/MDR resistance 11.2% (129/1083) 7.1%(101/1234) 1.5 (1.12,1.91) 0.004*
26 TB cases detected
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3 DISCUSSION
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6 The COVID-19 pandemic threatens to reverse recent progress in reducing the global burden of
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9 TB disease and there is an urgent need to identify novel strategies to ensure the continuum of TB
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11 care at the time of the COVID-19 pandemic. In this study, we found a significant reduction in
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13 total TB detection, TB treatment success, TB case detection by the community, latent TB ITP
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provision among less than 15 years children, and an increased rate of rifampicin-resistant MTB
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18 during COVID-19.
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20 Evaluating the total TB detection in our study during the COVID-19 era (April 2020 –march
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2021) showed a significant reduction in TB detection (6%). In other studies in African countries,
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TB notification rates have decreased 43% in Uganda 16, 34% in Nigeria 17, and 33% in South
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27 Africa18 during the pandemics. This might be due to re-organization hospitals and health centers
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29 for COVID-19 care and isolation, patients' fear of getting infected with COVID-19 in the health
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32 facilities, and the reallocation of healthcare workers for COVID-19 care and another measure.
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34 However, the lower rate of TB detection reduction in our study compared to the previously cited
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36 researches might be due to the difference in COVID-19 control measures taken by our country.
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Ethiopia was taken a short period banning large meetings, closing schools/colleges, limiting the
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43 isolation.19 Besides, in other studies cited, some collected a short time data up to 5-months
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maximum17 18, and others aimed to investigate the effect of the specific public measure such as
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48 lockdown on TB notification.16 In support of our findings, a model study assumes that TB
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50 incidence in 2020 continues its slow decline from previous years and its trends are not
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52 significantly affected in the short term by the Covid-19 pandemic.20 The decrease in the
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55 notification rate of TB observed does not mean a decrease of incidence but may represent an
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3 under-diagnosis. The marked decrease in TB case detection due to missed diagnoses has resulted
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6 in an accumulation of undetected TB, contributing to ongoing TB transmission and higher rates
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8 of latent TB infection. Therefore, the use of virtual care and digital health technologies,
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the screening of both COVID-19 and TB might be the solution to halt the impact of the
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15 pandemic on TB services.
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17 Ethiopia has implemented directly observed therapy (DOT) for TB for more than a decade and
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has a recorded effect on tuberculosis treatment success In this program, the patients are
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22 expected to visit the DOT centers every day especially during the first 4 months of treatment in a
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24 6-month course of TB therapy. However, during these pandemics, either related to the economic
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26 impact, movement restriction, or the stigma to the disease, such health facility dependent
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29 services are expected to be affected.22 In the current study, the TB treatment success rate
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31 decrease from 81.7% in the pre-COVID-19 to 77.6 % during the COVID-19 pandemic. This is
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33 consistent with the study in Korea with a treatment success rate declined from 89.4% to
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84.5 %.23 A decrease in TB treatment success increases the risk of poor treatment outcomes and
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the development of drug-resistant and worse the ongoing problem of drug-resistant TB in the
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Ethiopia TB programs (NTPs) have often concentrated on promoting access to effective TB care
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45 through government health facilities, however, since 2003 the NTPs increasingly implementing
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47 and promoting access to effective TB care through the community health worker (CHWs) using
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49 health extension workers (HEWs), and community Volunteers. 24 They are tasked to identify
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52 presumptive TB and referring them to health centers for diagnosis; providing treatment support;
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54 tracing people lost to follow-up, and carrying out contact investigation.25 In this case, a
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3 previously conducted study using CHWs in south Ethiopia increase the TB case detection rate,
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6 and practical changes were observed by applying a community-based TB intervention.22 In our
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8 study, however, less than 4% of the total TB patients were detected through the CHWs and the
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10 detection rate is significantly low during the COVID-19 era.
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Contact screening of people living with HIV and children under five years (currently 15 years) of
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15 age who are contacts of patients with TB is part of the TB elimination strategy and end TB
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17 program in Ethiopia. In this regard, WHO/CDC and a recent meta-analysis reported that IPT is
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effective for about 93% of under-five children and 59% among children aged 15 years or
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22 younger .26 27 In this study, less than two-thirds of children aged 15 years or younger who had
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26 lower during the COVID-19 era (55.2%) compared to the pr-COVID-19 era (62.3%). This is
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29 consistent with other studies conducted before the COVID-19 era in Ethiopia (64%) and South
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31 Africa (68%) .28 29 A significantly lower ITP provision during COVID-19 in this study might be
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33 related to stigma and fear of COVID-19 infection at health care facilities, discouraging people
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from visiting TB services. This is because the current national contact tracing largely relies on
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passive child contact screening by asking parents to bring their children to the health facility.
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40 However, the lower level of the ITP provision in this study in the presence of a high level of
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contact screening (95%) showed missed opportunities for IPT in at-risk children. These gaps
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45 could indicate that health care providers should also be equipped with the knowledge, skills, and
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47 tools to counsel parents or caregivers about the important preventive treatment even for
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49 otherwise healthy children.
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52 The results of this study showed no significant differences in the rate of drug susceptibility tests
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54 before and during the COVID-19 pandemic and nearly half of the bacteriologically confirmed
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1
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3 TB were tested for at least for rifampicin. Similarly, globally in 2019, 61% of people with
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6 bacteriologically confirmed TB were tested for rifampicin resistance, up from 51% in 2017.30
7
8 Interestingly, the rate of rifampicin resistance increase by 50% during the COVID-19 era
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10 compared with the pre-COVID-19 era in our study. Therefore, we could hypothesize that
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12
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increasing numbers of rifampicin-resistant MTB cases and decrease in treatment success rate
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15 attribute to the ongoing increase in the MDR and a higher level of DR-TB in the study setting.
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17 This is likely to lead to community transmission of drug resistance at a critical time when
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sustained tuberculosis control efforts in Ethiopia have resulted in significant improvement in
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22 tuberculosis burden in the last two decades.
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24 We note that the present analysis does not address the potential for direct interactions between
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26 TB and COVID-19. We used aggregated data quarterly collected; we can determine the
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27
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29 individual socio-demographic characteristics and the public health preventive measures on the
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31 TB service indicators and trends. The study focused only on the trend in the TB cascade and did
32
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33 not explore other confounders to the declining trend through qualitative means.
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35
36
In Conclusion, findings from this study revealed the negative impact of COVID-19 on basic TB
37
service indicators including detection, treatment success, community engagement, ITP provision
on
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40 and exaggerated the rifampicin /MDT TB resistance in the last year. To address these challenges,
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the TB program needs to adapt urgently to the new normal and strengthen the patient-centered
43
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45 approach to TB care, embrace digital health technology, increase awareness creation, strengthen
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47 community-based active TB case finding and integrate the COVID-19 and TB screening service.
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49 It is possible to address the community and screen for TB through the COVID-19 service such as
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52 during vaccination, especially in high-risk populations. Strengthen the existing programs and
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1
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3 adopting new ones enable our country to preserve the gains made over the last decade in the fight
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6 against TB, control programs, and attain the End TB programs set.
7
8
9 Abbreviations
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11 TB: Tuberculosis
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13 DST: Drug susceptibility tests
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15
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HMIS: Health management information system
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18 IPT: isoniazid prophylaxis therapy
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20 MTB: Mycobacterium tuberculosis
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WHO: World Health Organization
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25 Declarations
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27 Ethical approval and consent to participate: We obtained ethical approval from the Y12HMC
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29 Ethical Committee. The institutional review the board waived the need for written informed
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32 consent from participants since the study required no direct contact with human subjects (no
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34 interview or sample collection) and only used pooled program/ Health information system/
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36 Consent for publication:Not applicable
37
on
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Availability of data and materials: All the data and materials are readily available and freely
40
41 available to any researcher wishing to use them.
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43 Competing interests: The authors declare that they have no competing interests
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45
Funding: the authors declare that they did not receive funding for this research from any source.
46
47
48 Authors’ contributions: BA and AN contributed to the design of the study; collected, entered,
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50 analyzed, and interpreted the data; and prepared the paper. BT and GW contributed to the
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52 conception and design of the study, collected and drafted the paper. BB TN and AT contributed
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55 to the interpretation and data analysis reviewing of the results. GE contributed to the
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15
1
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3 interpretation of the results, and in drafting and critically reviewing the paper. All authors read
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6 and approved the final paper.
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8 Author Details: 1,4-8Yekatit12 Hospital Medical College, P.O.Box. 257, Addis Ababa, Ethiopia,
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10 2,3Addis Abeba City Administrative Health Bureau, P.O.Box, 708, Addis Ababa, Ethiopia
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13 Acknowledgments: We would like to thank the Addis Abeba City Administrative Health
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15 Bureau HMIS unit workers for their cooperation during data extraction.
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6 Reference
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8 1. WHO. Global tuberculosis report. 2020
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10 2. Stop TB Partnership. The potential impact of the covid-19 response on tuberculosis in high-
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15 3. World Health Organization (WHO) Information Note: Tuberculosis and COVID-19. Date:
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34 8. Abraham Haileamlak. Ethiopia is on Track to Achieving the WHO End Tuberculosis
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32 20. Lucia Cillonia,1, Han Fua,1, Juan F VesgaaThe potential impact of the COVID-19 pandemic
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35 21. Federal Ministry of Health Ethiopia.Tuberculosis, Leprosy and TB/HIV Prevention and
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47 2003–2018: successes and challenges toward universal coverage for primary healthcare
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49 services. Global Health 15, 24 (2019). https://doi.org/10.1186/s12992-019-0470-1.
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51 25. Khatri, U. & Davis, N. Quality of Tuberculosis Services Assessment in Ethiopia: Report.
52 Chapel Hill, NC, USA: MEASURE Evaluation, University of North Carolina. 2020
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3 26. Yimer S, Holm-Hansen C, Yimaldu T, Bjune G. Evaluating an active case-finding strategy to
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10 management. The International Journal of Tuberculosis and Lung Disease 2007; 11(1):12–
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12 15.
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14 28. Ayieko J, Abuogi L, Simchowitz B, Bukusi EA, Smith AH, Reingold A. Efficacy of
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isoniazid prophylactic therapy in prevention of tuberculosis in children. a meta-analysis.
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17 BMC Infectious Diseases 2014; 14:91.
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19 29. Tadesse Y, Gebre N, Daba S et al Uptake of Isoniazid Preventive Therapy among Under
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21 Five Children: TB Contact Investigation as an Entry Point. PLoS ONE 2016;11(5),

22 30. WHO. Global tuberculosis report.2019
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25 Figure legends
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27 Figure 1. Numbers of TB patients who were notified in the pre and during the COVID-19 era in
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the health facilities in Addis Ababa between April 2019 and March 2021.
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Figure 2. Bacteriological confirmed TB cases in pre and during the COVID-19 era in health
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35 facilitates in Addis Ababa between April 2019 and March 2021.
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40 before and during COVID-19 pandemics in Addis Ababa between April 2019 and March 2021
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43 Figure 4. Drug susceptibility performed at least for rifampicin and level of rifampicin resistance
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in the health facilitates before and during COVID-19 pandemics in Addis Ababa between April
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48 219 and March 2021.
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31 Figure 1. Numbers of TB patients who were notified in the pre and during the COVID-19 era in the health
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81x60mm (300 x 300 DPI)
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Reporting checklist for a cross-sectional study.
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6 Based on the STROBE cross-sectional guidelines.
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9 Instructions to authors
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12 Complete this checklist by entering the page numbers from your manuscript where readers will find each of the items listed below.
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14 Your article may not currently address all the items on the checklist. Please modify your text to include the missing information. If you are certain that an
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16 item does not apply, please write "n/a" and provide a short explanation.
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19 Upload your completed checklist as an extra file when you submit it to a journal.
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24 von Elm E, Altman DG, Egger M, Pocock SJ, Gotzsche PC, Vandenbroucke JP. The Strengthening the Reporting of Observational Studies in
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26 Epidemiology (STROBE) Statement: guidelines for reporting observational studies.
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28 Reporting Item Page
29 Number
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32 Title #1a Indicate the study’s design with a commonly used term in the title or the abstract 1
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Background / #2 Explain the scientific background and rationale for the investigation being reported 4-5
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39 rationale
40 Objectives #3 State specific objectives, including any prespecified hypotheses 5
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45 Setting #5 Describe the setting, locations, and relevant dates, including periods of recruitment, exposure, follow-up, 5
46 and data collection
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Eligibility criteria #6a Give the eligibility criteria, and the sources and methods of selection of participants. 6
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49 #7 Clearly define all outcomes, exposures, predictors, potential confounders, and effect modifiers. Give 7
50 diagnostic criteria, if applicable
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52 Data sources / #8 For each variable of interest give sources of data and details of methods of assessment (measurement). 7
53 measurement Describe comparability of assessment methods if there is more than one group. Give information separately
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for for exposed and unexposed groups if applicable.
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56 Bias #9 Describe any efforts to address potential sources of bias n/a
57 Study size #10 Explain how the study size was arrived at
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59 Quantitative #11 Explain how quantitative variables were handled in the analyses. If applicable, describe which groupings 7
variables were chosen, and why

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2 Statistical methods #12a Describe all statistical methods, including those used to control for confounding 7
3 Statistical methods #12b Describe any methods used to examine subgroups and interactions n/a
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5 Statistical methods #12c Explain how missing data were addressed n/a
6 Statistical methods #12d If applicable, describe analytical methods taking account of sampling strategy n/a
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Statistical methods #12e Describe any sensitivity analyses n/a
9 Results
10 Participants #13a Report numbers of individuals at each stage of study—eg numbers potentially eligible, examined for n/a
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12 eligibility, confirmed eligible, included in the study, completing follow-up, and analysed. Give information
13 separately for for exposed and unexposed groups if applicable.
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Participants #13b Give reasons for non-participation at each stage n/a
16 Participants #13c Consider use of a flow diagram
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Descriptive data #14a Give characteristics of study participants (eg demographic, clinical, social) and information on exposures 8-10
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19 and potential confounders. Give information separately for exposed and unexposed groups if applicable.
20 Descriptive data #14b Indicate number of participants with missing data for each variable of interest n/a
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26 confidence interval). Make clear which confounders were adjusted for and why they were included
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33 Discussion
34 Key results #18 Summarise key results with reference to study objectives 11
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36 Limitations #19 Discuss limitations of the study, taking into account sources of potential bias or imprecision. Discuss both 14
37 direction and magnitude of any potential bias.
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43 Other Information
44 Funding #22 Give the source of funding and the role of the funders for the present study and, if applicable, for the original 15
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46 study on which the present article is based
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48 None The STROBE checklist is distributed under the terms of the Creative Commons Attribution License CC-BY. This checklist can be completed online
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50 using https://www.goodreports.org/, a tool made by the EQUATOR Network in collaboration with Penelope.ai
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BMJ Open

Impact of COVID-19 pandemic on TB prevention and care in

Journal: BMJ Open

Article Type: Original research

Date Submitted by the

Complete List of Authors: Arega, B; Yekatit 12 Hospital

Taye, Bethelihem; Addis Ababa City Administration Health Bureau

Negussie, Tesfaye; Yekatit 12 Hospital

Keywords: COVID-19, Tuberculosis < INFECTIOUS DISEASES, EPIDEMIOLOGY

For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml

For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml

27 6 Yekatit 12 Hospital Medical College, tesfayefantu03@gmail.com, Addis Ababa, Ethiopia

30 7 Yekatit 12 Hospital Medical College, ayumesif@yahoo.com, Addis Ababa, Ethiopia

33 latent TB infection treatment, and community health workers’ engagement in TB detection

27 requirements of international agreements, such as the Millennium Development Goals. We

21 DST reporting period

24 LTBI=Latent TB Infection, DR= Drug resistance, DST= Drug Susceptibility Test

21 under 15 years children

24 5. D. Buonsensoa,, F. Iodicec, J. Sorba Biala d, D. GolettieCOVID-19 effects on tuberculosis

21 Int J Tuberc Lung Dis 2020.

33 on the tuberculosis epidemic a modeling analysis. EClinicalMedicine 28 (2020) 100603

21 Five Children: TB Contact Investigation as an Entry Point. PLoS ONE 2016;11(5),

30 Title and abstract

variables were chosen, and why

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