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

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.