National trends of case notification rates for all tuberculosis cases and all forms per 100 000 population, January 2019-June 2021
Table 1
Quarterly Expected and Incident TB Cases, proportion of expected TB cases notified, proportion of notified cases by sex, Case Notification rates and Treatment success rates before and during the COVID-19 pandemic in Uganda, January 2019-June 2021
Period | Estimated | Incident | % Notified of expected Incident TB cases | % Male | % Female | CNR/100,000 | % TSR |
Jan-19 | 20154 | 16746 | 83.1 | 62.0 | 37.6 | 169 | 71.9 |
Apr-19 | 20154 | 16127 | 80.0 | 62.0 | 37.6 | 161 | 73.8 |
Jul-19 | 20896 | 18099 | 86.6 | 62.0 | 37.6 | 188 | 74.7 |
Oct-19 | 20896 | 14948 | 71.5 | 62.1 | 37.9 | 152 | 75.8 |
Jan-20 | 20896 | 16400 | 78.5 | 64.1 | 35.9 | 161 | 79.3 |
Apr-20 | 20896 | 12871 | 61.6 | 63.5 | 36.5 | 133 | 81.1 |
Jul-20 | 20585 | 15801 | 76.8 | 62.2 | 37.8 | 159 | 83.2 |
Oct-20 | 20585 | 15819 | 76.8 | 63.0 | 37.0 | 160 | 83.6 |
Jan-21 | 20585 | 18238 | 88.6 | 61.4 | 38.4 | 178 | 85.2 |
Apr-21 | 20585 | 19217 | 93.4 | 60.5 | 39.7 | 190 | 85.3 |
Average | 20623 | 16427 | 79.7 | 62.0 | 38.0 | 165.1 | 79.0 |
Generally, there was a fluctuating trend in the national TB case notification rates between January 2019-June 2021. However, there was a 22% decline in the April-June 2020 quarter, where the CNR decreased from 161/100,000 in January -March 2020 quarter to 133/100,000 in April 2020 quarter (Table 1). A total of 164,427 incident (new and relapse) TB cases were notified during January 2019-June 2021, with an average quarterly notification rate of 165/100,000 population. Half (82,320) of the total incident cases were reported in each of the COVID19 periods. The highest quarterly notification rate was 190/100,000 in the quarter of April-June 2021 in the later quarters of the COVID-19 pandemic, while the lowest was 133/100,000 in quarter of April 2020, in the first quarter of COVID-19 and lockdown declaration (Fig. 1). About two thirds (79.9%) of the expected TB cases were notified pre-COVID-19 while 79.4% was notified during the COVID-19 pandemic. Consistent with the lowest CNR (133/100,000) and first quarter of COVID-19 and lockdown declaration in Uganda, the quarter of April 2020 had the lowest number of incident TB cases notified (12,871), which was only 61.6% of the expected TB 20,896 cases in the same quarter (Fig. 1). TB cases notified between January 2019-June 2021 were majorly males (62%), which was almost twice as high as the females. This was consistent in all quarters pre and during COVID-19 period (Table 1).
Interrupted time series regression analysis of the national trends of TB case notification rates in Uganda, January 2019–June 2021
Table 2
Interrupted Time Series Analysis for Impact of COVID-19 on the National, Kampala and Outside Kampala quarterly TB Case notification rates, January 2019-June 2021
Parameter | Coefficient | 95% CI | p value |
National | | | |
| Intercept β0 | 171.2 | [156.8 -185.6] | < 0.001 |
| Baseline trend β1 | -2.5 | [-7.5 2.5] | 0.270 |
| Level change after intervention β2 | -21.3 | [-41.5 -1.1] ** | 0.042 |
| Trend change after cap β3 | 15.8 | [10.0 21.6] *** | 0.001 |
Kampala | | | |
| Intercept β0 | 504.4 | [485.9 522.9] *** | < 0.001 |
| Baseline trend β1 | -24.90 | [-38.3 -11.5] *** | 0.004 |
| Level change after intervention β2 | -77.70 | [-182.5 27.2] | 0.120 |
| Trend change after cap β3 | 39 | [15.7 62.3] *** | 0.006 |
Elsewhere/outside Kampala | | | |
| Intercept β0 | 168.3 | [153.8 182.8] *** | < 0.001 |
| Baseline trend β1 | -2.31 | [-7.3 2.7] | 0.306 |
| Level change after intervention β2 | -20.48 | [-40.6 -0.3] ** | 0.047 |
| Trend change after cap β3 | 15.46 | [9.6 21.3] *** | 0.001 |
*Significant association at *** p < 0.01, ** p < 0.05, * p < 0.1 |
The CNR at the beginning of the observation period pre-COVID-19 was at 171.2 cases per 100,000. There was a decrease in the CNR of 2.5 cases/100,000 (p = 0.270, CI = [-7.5, 2.5]) per quarter pre-COVID-19, although this decline was not statistically significant. In the immediate quarter (April-June 2020) after the declaration of COVID-19 and lockdown, there was a statistically significant decline of 21.3 cases/100,000 (p < 0.042, CI = [-41.5, -1.1]) in the national CNR. This was followed by a statistically significant sustained quarterly increase of 15.8 cases/100,000 (p < 0.001, CI = [10.0, 21.6]) in national TB CNR in the subsequent quarters during COVID-19 (Table 2).
Trends of TB case notification rates at national level and Kampala, January 2019–June 2021
At the start of the observation period pre-COVID-19, there was an estimated CNR of 171.2 cases per 100,000 at the national level, 168.3 cases/100,000 for other districts outside Kampala, and 504.4 cases/100,000 in Kampala. The CNR appeared to decrease slightly every quarter prior to COVID-19 and lockdown declaration. However, the decrease in trend of CNR was only significant in Kampala. For each quarter, the CNR significantly decreased by 24.90 cases/100,000 per quarter in Kampala (Fig. 2). Although there was a decreasing trend in CNR at the National level of 2.5 cases/100,000(p = 0.270, CI= [-7.5-2.5] and 2.31 cases/100,000 (p = 0.306 CI= [-7.3- 2.7]) per quarter elsewhere outside Kampala, this decrease was not significant. In the first quarter of the COVID-19 and lockdown declaration, there appeared to be a statistically significant decrease in quarterly CNR of 21.30 cases/100,000 (p < 0.05, 95% CI = [-41.5, -1.1]) at national level and 20.48 cases/100,000 (p < 0.05, 95%CI = [-40.7, -0.31]) in other districts outside Kampala. However, despite the 77.70 cases/100,000 (p = 0.120, 95%CI= [-182.5 27.2]) decrease in CNR, the decrease was not statistically significant in Kampala. This was followed by a statistically significant increase in CNR of 39 cases/100,000 (p < 0.01, 95% CI = [15.66, 62.34]) in Kampala, 15.46 cases/100,000 (p < 0.01, 95% CI = [9.66, 21.26]) outside Kampala and 15.80 cases/100,000 (p < 0.01,95% CI = [10.04, 21.56]) at the National level per quarter in the subsequent quarters during COVID-19. (Table 2).
Trends of TB case notification rates by region before and during the COVID-19 pandemic
Generally, there was no noticeable change in TB CNR at national level throughout the study period, pre and during COVID-19. However, the regional trends showed a 27.5% decline in TB CNR in Kampala, and a 10.8 increase in TB CNR in Karamoja during the COVID-19 pandemic.
Interrupted time series regression analysis of the regional trends of TB case notification rates in Uganda, January 2019–June 2021
Table 3
Interrupted time series regression analysis for the impact of COVID-19 on the regional trends of TB Case Notification rates in Uganda, January 2019-June 2021
Parameter | Coefficient | 95% CI | p value |
Acholi Region | | | |
| Intercept β0 | 254.9 | 211.4–298.3 | < 0.0005 |
| Baseline trend β1 | -21.7 | -36.1 -7.3 | 0.010 |
| Level change after intervention β2 | 39.4 | -18.2–96.9 | 0.145 |
| Trend change after cap β3 | 26.0 | 8.2–43.8 | **0.012 |
Ankole | | | |
| Intercept β0 | 119.3 | 112.0–126.6 | < 0.001 |
| Baseline trend β1 | -2.4 | -7.7– 2.9 | 0.314 |
| Level change after intervention β2 | -25.5 | -49.1–1.9 | 0.038 |
| Trend change after cap β3 | 14.3 | 8.2–20.4 | 0.001 |
Bugisu | | | |
| Intercept β0 | 98.6 | 91.9–105.2 | < 0.001 |
| Baseline trend β1 | 2.7 | -1.4–6.8 | 0.156 |
| Level change after intervention β2 | -18.7 | -38.6–1.2 | 0.061 |
| Trend change after cap β3 | 5.1 | 1.6–8.7 | 0.012 |
Bukedi | | | |
| Intercept β0 | 69.7 | 36.4–102.9 | 0.002 |
| Baseline trend β1 | -3.2 | -14.6-8.2 | 0.522 |
| Level change after intervention β2 | -3.9 | -37.5–29.7 | 0.79 |
| Trend change after cap β3 | 14.5 | 1.7–27.2 | 0.032 |
Bunyoro | | | |
| Intercept β0 | 169.4 | 151.2–187.5 | < 0.001 |
| Baseline trend β1 | -1.9 | -8.2– 4.4 | 0.489 |
| Level change after intervention β2 | -48.1 | -99.2–3.0 | 0.061 |
| Trend change after cap β3 | 17.4 | 2.2–32.6 | 0.031 |
Busoga | | | |
| Intercept β0 | 105.5 | 95.4–115.6 | < 0.001 |
| Baseline trend β1 | -0.3 | -4.3– -3.7 | 0.859 |
| Level change after intervention β2 | -14.9 | -32.3–2.5 | 0.081 |
| Trend change after cap β3 | 11.9 | 4.4–19.5 | 0.008 |
Kampala | | | |
| Intercept β0 | 504.4 | 485.9–522.9*** | < 0.001 |
| Baseline trend β1 | -24.90 | -38.3 -11.5 *** | 0.004 |
| Level change after intervention β2 | -77.70 | -182.5–27.2 | 0.120 |
| Trend change after cap β3 | 39 | 15.7–62.3 *** | 0.006 |
Karamoja | | | |
| Intercept β0 | 318.3 | 261.5–375.1 | < 0.001 |
| Baseline trend β1 | 11.6 | -8.7–31.9 | 0.211 |
| Level change after intervention β2 | -11.9 | -123.3–99.5 | 0.803 |
| Trend change after cap β3 | -4.2 | -49.4–41.0 | 0.828 |
Kigezi | | | |
| Intercept β0 | 157.6 | 140.5–174.7 | < 0.001 |
| Baseline trend β1 | -11.6 | -18.2– -5.0 | 0.005 |
| Level change after intervention β2 | -19.2 | -43.3–4.9 | 0.099 |
| Trend change after cap β3 | 21.8 | 13.3–30.2 | 0.001 |
Lango | | | |
| Intercept β0 | 242.4 | 188.6–296.2 | < 0.001 |
| Baseline trend β1 | -6.2 | -25.1–12.6 | 0.450 |
| Level change after intervention β2 | -14.9 | -82.1–52.2 | 0.606 |
| Trend change after cap β3 | 18.7 | -5.0–42.4 | 0.101 |
North Central | | | |
| Intercept β0 | 160.1 | 151.2–168.9 | < 0.001 |
| Baseline trend β1 | 1.8 | -1.7–5.4 | 0.245 |
| Level change after intervention β2 | -59.3 | -84.9–33.7 | 0.001 |
| Trend change after cap β3 | 20.2 | 9.6–30.8 | 0.003 |
South Central | | | |
| Intercept β0 | 233.3 | 210.2–256.4 | < 0.001 |
| Baseline trend β1 | -6.5 | -15.3–2.3 | 0.122 |
| Level change after intervention β2 | -23.1 | -53.9–7.7 | 0.116 |
| Trend change after cap β3 | 28.7 | 18.6–38.9 | < 0.001 |
Teso | | | |
| Intercept β0 | 92.4 | 70.6–114.2 | < 0.001 |
| Baseline trend β1 | -1.3 | -9.3–6.7 | 0.707 |
| Level change after intervention β2 | -23.2 | -57.9–11.6 | 0.155 |
| Trend change after cap β3 | 9.6 | -2.9-22.1 | 0.109 |
Toro | | | |
| Intercept β0 | 155.0 | 138.5–171.5 | < 0.001 |
| Baseline trend β1 | -5.4 | -14.4–3.7 | 0.199 |
| Level change after intervention β2 | -15.0 | -47.3–17.2 | 0.298 |
West Nile | | | |
| Intercept β0 | 166.0 | 108.1–223.8 | < 0.001 |
| Baseline trend β1 | 6.7 | -13.7–26.9 | 0.459 |
| Level change after intervention β2 | -22.5 | -82.7–37.8 | 0.397 |
| Trend change after cap β3 | 2.9 | -23.9–29.8 | 0.798 |
*Significant association at p < 0.05 **Marginally significant association at p ≥ 0.05 < 0.1 |
There was a general decline in TB CNR in quarters pre and immediately after the COVID-19 outbreak declaration across all regions in Uganda, while there was a general increase in the subsequent quarters during the COVID-19 pandemic in majority of the regions. However, CNR were generally consistent in Karamoja, Lango, Teso, and West Nile regions throughout the study period both pre and during COVID-19 (Table 3).
Majority of the regions in Uganda experienced a decline in the TB case notification rates before the emergence of the COVID-19 pandemic and related lockdowns. However, these declines were not statistically significant in majority of the regions except for Acholi, Kampala, and Kigezi regions. The TB CNR at the start of the observation period was 255 cases/100,000 (CI = [211.4–298.3]) in Acholi, 504 cases/100,000(CI = [485.9 522.9]) in Kampala, and 158 cases/100,000 in Kigezi (CI= [140.5–174.7]). There was a statistically significant decrease in CNR every quarter pre-COVID-19, decreasing quarterly by 21.7 cases/100,000 (p = 0.010, CI = [-36.1-7.3]) in Acholi, 24.9 cases/100,000(p = 0.004, CI = [-38.3-11.5]) in Kampala and 11.6 cases/100,000 (p = 0.005, CI = [-18.2- -5.0]) in Kigezi region (Table 3).
In the immediate quarters after the COVID-19 pandemic there was a statistically significant quarterly decline of 26 cases/100,000 (p = 0.038, CI = [-49.1–1.9]) in Ankole and 59 cases/100,000 (p = 0.001, CI = [-84.9-33.7]) in North Central region. The remaining 12 regions experienced declines in the CNR every quarter during the early quarters of COVID-19 but these were not statistically significant. Contrary to the 14 regions that experienced declines in quarterly CNR, Acholi experienced an increase in CNR by 39 cases/100,000 (p = 0.145, CI = [-18.2-96.9]), although this increase was not statistically significant (Table 3).
Unlike the immediate quarters following outbreak of COVID-19 in Uganda where majority of the regions experienced a decline in CNR, there was a sustained general increase in CNR across the different regions in Uganda in the subsequent months after the COVID-19 and lockdown declaration, except Karamoja which had a 4.2 cases/100,000 (p = 0.828, CI = [-49.4–41.0]) non-statistically significant decline in the CNR per quarter. In the majority of the regions (11/15), the increase in CNR was statistically significant while there was no significant change in Lango, Teso, and West Nile. The CNR significantly increased per quarter by 26 cases/100,000 (p = 0.012, CI = [8.2–43.8]) in Acholi, 14 cases/100,000(p = 0.001, CI = [8.2–20.4]) in Ankole, 5 cases/100,000 (p = 0.012, CI = [1.6–8.7]) in Bugisu, 15cases/100,000(p = 0.032, CI = [1.7–27.2]) in Bukedi, 17cases/100,000 (p = 0.031, CI = [2.2–32.6]) in Bunyoro, 12 cases/100,000 (p = 0.008, CI = [4.4–19.5]) in Busoga, 39 cases/100,000(p = 0.006, CI = [15.7–62.3]) in Kampala, 22 cases/100,000 (p = 0.001, CI = [13.3–30.2]) in Kigezi, 20cases/100,000 (p = 0.003, CI = [9.6–30.8]) in North Central, 29 cases/100,000(p < 0.001, CI = [18.6–38.9]) in South Central, and 27cases/100,000 (p = 0.004, CI = [12.3–42.3]) in Toro (Table 3).
Trends of the treatment success rate in Uganda, January 2019-June 2021
Generally, there was a steady increase in the TSR between January 2019-June 2021, which may imply that COVID-19 had no impact on the treatment outcomes (Fig. 3). The average TSR was 79% between January 2019-June 2021 (Table 1). Contrary to the CNR where we saw a decline, there was a 1.8% increase in TSR from 79.3% in the quarter of January 2020 to 81.1% in the quarter of April 2020 when the movement restriction was instituted in Uganda.
Interrupted time series analysis of effect of COVID-19 on treatment success rate
Table 4
Interrupted Time Series Analysis for Impact of COVID-19 on TB treatment success rate in Uganda, January 2019-June 2021
TSR | Coeff | SE | t | p>|t| | [95% CI] |
Time | 1.68*** | 0.204 | 8.22 | 0.000 | [1.18 - 2.18] |
Intervention | 1.46 | 1.079 | 1.35 | 0.225 | [-1.18 - 4.10] |
Time since intervention | -0.64** | 0.192 | -3.33 | 0.016 | [-1.11 -0.17] |
Intercept | 71.74*** | 0.340 | 210.98 | 0.000 | [70.91 − 72.57] |
There was a general increase in the national TSR between January 2019 to June 2021. The TSR at the start of the observation period was 71.74% (p = CI= [70.91–72.57]). There was a statistically significant 1.68 percentage (p < 0.0001, CI= [1.18–2.18]) increase in TSR per quarter before the COVID-19 outbreak in Uganda. In the quarter of April -June 2020 when the movement restrictions were put in place, there was a non-statistically significant 1.46 (p = 0.225, CI= [-1.18-4.10]) percentage increase in TSR per quarter. This was followed by a statistically significant sustained decline in the TSR where we found a 0.64 percentage quarterly decrease (p = 0.016, CI= [-1.11-0.17]). (Table 4)