Impact of the COVID-19 epidemic on HIV, tuberculosis and childhood vaccination programmes, and policy and health system factors fostering programme resilience (COHERE)

Funder: OUCRU (Wellcome Funding)
Principal Investigators: Iqbal Elyazar and Raph Hamers
Study location: Jakarta
Collaborators: National HIV Control Program, National Tuberculosis Control Program, Childhood Immunisation Programme, Arbovrus programme, Ministry of Health

The number of deaths from COVID-19 continues to rise globally, but data quantifying the impact of the pandemic on other major infectious disease burdens in low- and middle-income countries (LMIC) are scarce. Interruption of supply chains, diversion of resources and overwhelmed health systems could have severe collateral effects on existing public health programmes. COVID-19 control measures, such as lockdowns and patient hesitancy might limit access to and uptake of health care services, affecting diagnostic testing, disease management, vaccine uptake, among others. Models have estimated that in high-burden settings, deaths due to HIV (mostly due to antiretroviral therapy [ART] interruptions) and tuberculosis (mostly due to reductions in timely diagnosis and treatment) could increase by up to 10% and 20%, respectively, over 5 years, compared with if there was no COVID-19 pandemic. Further, reduced uptake of routine childhood vaccinations, due to temporary programme suspensions or hesitancy, could lead to excess vaccine-preventable deaths. Moreover, it is crucial to define health system factors at the district level associated with lesser or greater resilience to the COVID-19 burden, and to identify those target groups who were more or less affected.
Indonesia is a diverse, middle-income nation, with the world’s fourth largest population (270 million) spread out across the vast archipelago, has unique challenges to reaching universal health coverage through a decentralized health system. Concurrent with growing non-communicable disease burdens, high infectious disease burdens persist, particularly of respiratory infections, diarrheal diseases and tuberculosis. Globally, it is ranked the 3rd high-burden TB country (~1 million new cases per year; incidence 391/100,000 pop), and it has one of the fastest growing HIV epidemics (~46,000 new cases per year; ~640,000 people living with HIV). Pre-COVID, only 58% of children aged 12-23 months were fully immunized -below the 93% government target8.
Indonesia has the second highest number of COVID-19 cases (>4 million) and deaths (>145,000) in Asia, and an estimated 61% excess mortality in Jakarta. Moreover, concerns have been raised around impacts of the COVID-19 epidemic and lockdowns on government’s health services, but to date no rigorous analyses have been conducted to quantify national and district-level impacts on the care cascades for HIV, TB and childhood vaccination uptake.

Primary Objectives:
To measure the impact of the COVID-19 pandemic and lockdowns within the respective national programmes in Indonesia, at the national, provincial and district levels and and identify policy and health system factors of resilience and population disparities for key risk groups:
TB care cascades (testing, diagnosis, linkage to care and treatment)
HIV care cascades (testing, diagnosis, linkage to care and treatment)
Childhood vaccination uptake

Importance:
To date, there are few published data from LMIC that quantify the effects of COVID-19 on health services and patient-related outcomes of the major infectious diseases HIV, tuberculosis and vaccine-preventable diseases, which may set back individual health and broader public health goals in the long-term. There are even fewer studies seeking to learn lessons from pre-pandemic district level health policy and health system preparedness that foster resilience to major shocks such as Covid-19; lessons that would enhance robust health systems in a post-pandemic world. As Indonesia is managing the COVID-19 epidemic, the health system should be strenghtened to make efforts to catch-up with any gaps in HIV and TB testing and treatment as well as vaccination uptake with the highest priority. The study findings can help identify public health priorities and inform innovative strategies. Research into service disruptions, and the factors that impeded those services during the COVID-19 lockdown, can inform public health responses to future outbreaks.