key: cord-0985570-hnjuuo6g
authors: Downey, Laura E.; Gadsden, Thomas; Vilas, Victor Del Rio; Peiris, David; Jan, Stephen
title: The impact of COVID-19 on essential health service provision for endemic infectious diseases in the South-East Asia region: A systematic review
date: 2022-05-05
journal: The Lancet Regional Health - Southeast Asia
DOI: 10.1016/j.lansea.2022.04.007
sha: debbd726c117281e1df0fcbe61b8a4b17022d40f
doc_id: 985570
cord_uid: hnjuuo6g

Background There is increasing evidence that the COVID-19 pandemic has impacted adversely on the provision of essential health services. The South East Asia region (SEAR) has experienced extremely high rates of COVID-19 infection, and continues to bear a significant proportion of communicable disease burden worldwide. Methods We conducted a systematic literature review of quantitative evidence to estimate the impact of COVID-19 on the provision of essential prevention, detection, treatment, and management services for five high-burden infectious diseases across the SEAR. Findings A total of 2338 studies were reviewed, and 12 studies were included in our analysis, covering six countries across the SEAR (Bhutan, Sri Lanka, Nepal, Myanmar, Thailand, and India) for three conditions of interest (HIV, TB, dengue fever). We identified significant disruption to TB testing (range=25% to 77.9%) and diagnoses (range=50% to 58%) in India, Nepal, and Indonesia; and similar disruptions were observed for screening, new diagnoses and commencing HIV treatment in India and Thailand. There was also drastically reduced case detection for dengue fever (range=75% to 90% disrupted) in Bhutan and Sri Lanka. No studies were identified for malaria nor hepatitis in any country, and nor for any service in the remaining six SEAR countries. Interpretation We identified evidence of significant disruption to the prevention, diagnoses, treatment, and management of TB, HIV, and dengue fever due to the COVID-19 pandemic across multiple SEAR country settings. This has the potential to set back hard-fought gains in infectious disease control across the region. The lack of evidence for the impact of the pandemic on malaria and hepatitis services, and in the remaining six SEAR countries, is an important evidence gap that should be addressed in order to inform future policy for service protection and pandemic preparedness. Funding This work was supported by the WHO Sri Lanka Country office.

Evidence before this study It has been well-documented since the beginning of the pandemic that COVID-19 has had a devastating impact on the provision of essential health services, and that this is especially so in countries where health systems are under-resourced and overburdened. Estimates of essential service disruption have largely come from the PULSE survey distributed by the WHO to all member states, which reports crude single informant estimates of disruption across 4 broad categories (not disrupted -severely disrupted). Communicable disease services were broadly reported as moderately affected by the pandemic across the South East Asia Region (SEAR) in the PULSE survey. However, no comprehensive analysis of quantitative evidence documenting the displacement of communicable disease services from the SEAR has been undertaken to date. In this study, we reviewed 2338 studies and analysed data from nine peerreviewed studies and three reports documenting quantitative pre-post estimates of communicable disease-related service disruption as a result of the COVID-19 pandemic. We identified substantial disruption to HIV, TB, and Dengue fever services in six SEAR countries. We did not identify any evidence for malaria or HCV service disruption, nor for any condition of interest in the remaining six SEAR countries.

This study represents the first systematic review and evidence synthesis of published evidence to estimate the quantitative impact of the COVID-19 pandemic on essential service provision for high-burden communicable disease in the SEAR.

Implications of all the available evidence Our findings highlight the significant disruption to HIV, TB, and Dengue fever service provision across the SEAR. This indicates a need for more extensive research to understand how communicable disease-related services have been impacted by the pandemic in subsequent waves of infection to estimate the potential long-term health and social impacts of this displacement and to inform future policy for pandemic preparedness.

The World Health Organisation declared the COVID-19 pandemic to be a global health emergency in January 2020 1 . At the time of publication, the officially reported global death toll has surpassed 5 million, though the true figure is likely to be significantly higher.

This pandemic has created enormous strain on health systems globally, and there is increasing evidence from multiple settings that it has impacted adversely on the provision of a wide range of essential health services [2] [3] [4] [5] [6] . Those who are likely to be most affected by this disruption in health services are those in low-income and middle-income countries (LMICs), where health systems have high levels of unmet demand [7] [8] [9] .

Management of the COVID-19 pandemic and the protection of essential health service provision is particularly challenging in the South East Asia region (SEAR), which has experienced extremely high levels of COVID-19 disease burden and associated strain on fragile health systems [10] [11] [12] [13] [14] . SEAR is a geographical bloc comprising 11 socially, politically, economically, and geographically diverse countries (India, Bangladesh, Myanmar, Maldives, Indonesia, Sri Lanka, Timor-Leste, Nepal, Bhutan, People's Democratic Republic of Korea, and Thailand). This diversity has led to heterogeneity in levels of development and maturity of healthcare systems 15 . Significant progress towards Universal Health Coverage (UHC) has been observed across SEAR countries over the last few decades, best evidenced by substantial expansion of primary care services, government-sponsored health insurance and assurance programs, and preventive and curative care services 15, 16 . However, the COVID-19 pandemic, and the measures put in place across the SEAR to control it, has significantly impacted UHC aspirations, setting many countries back against these hard-fought gains [17] [18] [19] .

Despite substantial progress in recent years, which has seen reductions in deaths from HIV and malaria and an increase in tuberculosis (TB) treatment coverage, the SEA region continues to bear a significant proportion of the communicable disease burden worldwide 20 . South Asia has the third largest HIV epidemic globally and the highest TB burden, accounting for more than a quarter of the global burden 20 . The second-highest incidence of malaria, amongst all WHO regions, occurs in the SEAR, and India bears the third-highest proportion of malaria cases globally 20 . Recent estimates report that the global displacement of essential services for infectious disease could cause an increase in deaths due to HIV, tuberculosis, and malaria over 5 years by up to 10%, 20%, and 36%, respectively 6 . Indeed, the WHO now estimates that half a million more people may have died from TB in 2020 alone 21 .

Numerous mathematical models have been produced in an attempt to estimate the potential impact of the pandemic on the provision of infectious disease services. These models combine demographic and epidemiological information with COVID-19 disease burden to estimate the impact of the pandemic on incidence and mortality across a range of infectious diseases under a range of scenarios 6, [22] [23] [24] [25] [26] [27] [28] [29] [30] . These models have relied on different structures, assumptions, and data sources, with varying precision and face validity. One primary source of data used in these models is the WHO National PULSE survey on continuity of essential health services during the COVID-19 pandemic 31, 32 . The WHO has now published three rounds of information capture from these surveys, which comprise questions of health service provision across approximately 25 condition areas, later narrowed to 10 tracer condition and service areas for rounds 2 and 3. Respondents provide crude ranges of estimated service disruption that broadly correspond to three categories: 5-50%, >50%, or completely disrupted. Information within the PULSE survey is usually provided by a single informant for each set of questions pertaining to a given condition or service area (e.g. non-communicable disease, or maternal and child health), raising questions regarding its validity and utility for the purpose of informing government health policy.

An evidence-based approach to understanding the true impact of the COVID-19 pandemic on the provision and potential displacement of infectious disease services across SEAR is essential to support efforts to mitigate its impact, restore and protect infectious disease service provision, and allocate resources accordingly. Here, we review the published quantitative evidence on the impact of COVID-19, compared to pre-pandemic data, on the provision of essential prevention, detection, treatment, and management services for five infectious diseases across the SEAR: HIV, TB, malaria, hepatitis, and dengue fever. These diseases were selected on the basis of their being the highest infectious contributors to morbidity and mortality in adults in the SEAR for which a combination of continuous prevention, diagnosis, treatment, and management activities are essential.

A systematic review was conducted to identify quantitative evidence detailing essential health service provision post the emergence of COVID-19 in early 2020 as compared to service provision estimates from 2019 and earlier in each of the 11 countries within the SEA region. For reporting, we used the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement 33 , and prospectively submitted the systematic review protocol for registration on PROSPERO (CRD42020187629R).

The detailed search strategy included all reasonable permutations of the three primary areas of interest: country/region (each of the aforementioned SEA countries); AND COVID-19;

AND infectious disease (Tuberculosis, HIV, Hepatitis, Dengue fever, and malaria). Between 

In this systematic review, articles were considered for inclusion if the title and/or abstract indicated the report of results of original research that used a pre-post design to report comparative cross-sectional data on the provision of screening or prevention programs, the number of new diagnoses, those seeking treatment, or engagement with the health service for ongoing condition management from 2019 and prior as compared to the start of the COVID-19 pandemic in 2020 in a SEA setting. Studies in non-SEAR countries or studies that reported only qualitative results were excluded, as were commentaries, opinions, and clinical guidelines. Electronic citations, including available abstracts of all articles retrieved from the search, were screened by two authors (LD and TG) to select articles for full-text review.

Duplicates were removed from the initial search. Thereafter, full-texts of potentially relevant studies were reviewed to determine eligibility for inclusion. A full list of inclusion and exclusion criteria for the studies is provided in table 1. All articles identified in the searches were imported into the Covidence systematic review software (version 2, Veritas Health Innovation, Melbourne, VIC, Australia), and title and abstract screening, full text review, data extraction, and quality assessment were all performed in Covidence. 

We 

Data were extracted in Covidence using a standard template that was modified to include key parameters of interest. Key information extracted for each paper included the following: country; setting; condition of interest; service of interest; population details; data sources; % change in service delivery metrics from pre-COVID to peri-COVID. The following COVID-19 related information was also extracted from papers where possible: whether data collection coincided with a 'peak' of infection and/or lockdown; whether any service protection/mitigation measures were in place during the period of data collection; the reported efficacy of the mitigation measures; and reported consequences of forgone or displaced health services as a consequence of COVID-19. Essential health services were divided into the following categories of interest, in line with patient pathways of care: health promotion/prevention; screening; diagnosis; pharmacological treatment; inpatient treatment; outpatient care; and ongoing management.

Given the heterogeneity in setting, population, condition, and service area, meta-analyses were not undertaken. A narrative synthesis was conducted following the 'synthesis without meta-analysis (SWIM)'in systematic review reporting guidelines 34 to explore, describe, and

interpret key findings related to the impact of COVID-19 on the provision of essential health services for TB, HIV, hepatitis, malaria, and dengue fever during 2020 and 2021 in the SEA region.

Office. The funder of the study had no role in study design, data collection, data analysis, data interpretation, or writing of the report. The WHO-SL office and the WHO South East

Asia Regional Office (WHO-SEARO) have reviewed and approved this manuscript for publication.

TG is supported by a university post graduate award from the University of New South

Wales. VDRV receives a salary from the World Health Organisation South East Asia Regional Office. DP and SJ are both supported by individual investigator grants from the Australian National Health and Medical Research Council.

Ethical approval was not required for this review as all information collected was available in the public domain. 

Tuberculosis (TB) Table 3 provides a summary of each of the four included peer-reviewed studies that report information on the displacement of TB-related services due to the COVID-19 pandemic.

Three studies report from India and one from Nepal. Myanmar. It should be noted that this study was rated of very low quality (Supplementary file 2), primarily due to the lack of reporting of raw data.

Two studies were identified that reported on disruption of Dengue fever-related services as a result of the COVID-19 pandemic in Bhutan and Sri Lanka, respectively. This information is summarised in Table 5 . 

Three non-per reviewed information sources were identified from 2 multilateral organisations The Global Fund reports that 0.4m less tests for TB were conducted in India in 2020 compared to 2019, translating to a 20% reduction 45 . In India treatment numbers for TB in 2020 also dropped by 20% compared to 2019. The Global Fund also reports that 12 million fewer HIV tests were taken in India in 2020 compared to 2019

Finally, the WHO Global TB report 21 outlines that the countries that contributed most to the global drop in TB case notifications between 2019 and 2020 were India with a 41% reduction in case notifications, and Indonesia with a 14% reduction in case notifications.

This systematic review summarises the available quantitative data from across South East Asia on the effects of the COVID-19 pandemic on essential health service provision for non-COVID-19 infectious diseases. We found highly disrupted testing and diagnoses for TB in India 38, 39, 43 , Nepal 42 , and Indonesia; and for screening, new diagnoses and those put on treatment for HIV in India 41 and Thailand 37 . We also found drastically reduced case detection of dengue fever in Bhutan 35 and Sri Lanka 36 . We found no quantitative pre-post evidence for the impact of COVID-19 on services for malaria, nor hepatitis, nor for any infectious disease- This is the first review, to the best of the authors' knowledge, to systematically identify all evidence pertaining to the quantitative comparison of pre-pandemic and post pandemic onset of essential health service provision for infectious diseases in the SEAR.

We used a narrative synthesis without meta-analyses methodology to ensure that all relevant data were captured and to allow for comparison across country settings. We limiting our ability to speculate as to the primary drivers of this success, and to generate lessons across the region. All studies that reported reduced testing for infectious disease also reported a concomitant reduction in new cases diagnosed [35] [36] [37] [38] [39] 41, 43 , which is a highly correlated and unsurprising finding and should be considered as such when reviewing the results. All studies reported on a post-pandemic period of less than 12 months, rendering it impossible to assess longitudinal trends in service disruption and potential recovery across services, conditions, and countries. Finally, we could not exclude the risk of underreporting in peer-reviewed and international media, and therefore missing country-level data of relevance in this review, due public inaccessibility of National government reports. We believe that country-level data for pre-pandemic and post pandemic onset is available for all services of interest, across all conditions and countries of interest, however much of these data are not publicly available, nor disaggregated by country, service, or year, when published as part of a global report.

Modelling studies published at the beginning of the pandemic suggested that COVID-19 would have a devastating impact on the recent gains made by countries towards improvement in prevention, detection, and management of infectious diseases 6, 22, 24, [26] [27] [28] 30 .

Data from the first round of the WHO PULSE survey 31 indicated that infectious diseaserelated essential health services were on average moderately affected by the pandemic across the SEA region. The empirical studies included in this review largely concur with PULSE survey findings of significant decrease in the provision of screening, detection, and treatment provision for TB, HIV, and dengue fever. For TB and HIV in particular, this reduction in case detection was observed to be substantially higher than the expected 10% reduction in cases as a result of the social distancing and lockdown measures put into place across the region to mitigate the impact of COVID-19 22 . This is also higher than the widely cited 25% and 50% reduction in various aspects of service provision 6 modelled by numerous groups, indicating that the associated health and mortality effects of displaced essential infectious-disease health services are potentially higher than estimates produced early in the pandemic.

The reductions in screening, testing, diagnoses, and treatment provision for TB and HIV across the SEA region are likely to be the result of a complex interplay between both supply and demand-side factors. On the supply-side, authors of multiple studies included in this review highlight that laboratories for testing blood and sputum samples were diverted to testing of suspected COVID-19 samples; hospitals, clinics, and community outreach services that usually provided infectious-disease-related services were similarly either diverted to provide COVID-19-related services or temporarily closed [41] [42] [43] . Doctors, nurses, community and allied health workers were also either infected themselves by COVID-19, or redeployed to support pandemic-related service, thus limiting or temporarily ceasing usual business. On the demand-side too, changes in population behaviour were raised as important drivers of reduced service provision and uptake. Social distancing and stay at home orders are hypothesized to have had a small positive impact on reducing transmission of TB and HIV, though some have also speculated that by forcing groups of people off the streets and into enclosed spaces for long periods of time, transmission may have also increased 39, 43 . Fear of contracting COVID-19, or of using health services and inadvertently displacing the care of someone perceived to need it more, were also cited as reasons why some may not seek care or engage with the health service during the pandemic. Finally, we cannot discount the possibility that the reduction in individuals seeking treatment might in fact be capturing, at least in part, the direct impact of COVID-19 on mortality among this cohort of immunocompromised individuals.

The lack of evidence for malaria-related service provision in any country within SEAR in 2020 compared to 2019, then increased by almost 270% by the end of 2021. As countries across the SEA region begin to recover from COVID-19 and resume normal service delivery, a similar spike in dengue fever may be on the horizon. Vector control measures should be resumed and/or scaled up as a matter of urgency to prevent catastrophic consequences.

Level of service displacement is directly impacted by measures put in place to mitigate service disruption due to COVID-19. A number of the studies that we identified in this review describe measures taken to rapidly restructure essential health services and deliver care remotely using diverse models, including telephone or video-based appointments 37, 40 . Although telemedicine has been reported to provide a COVID-19-secure path to continuity of essential health services, including for infectious disease services, the screening and diagnostic services that form the backbone of communicable disease care do require in-person samples to be provided in most circumstances. These kinds of remote consultations also require reliable access to internet and/or telephone services that are not always available to the most vulnerable to these forms of disease 48 . Health-care providers across SEAR planning for service delivery reconfiguration in the ongoing pandemic must consider how to establish inclusive and robust infectious disease care pathways that explicitly reach out to vulnerable individuals and communities, such as that described by the authors in Myanmar 40 . Preventative health services for infectious disease must not cease or decrease during times of health system strain, or this creates further strain on the health service and greater morbidity and mortality later down the line 49, 50 . Public health messaging must also emphasise the importance of care seeking behaviour for suspected infectious disease and provide numerous and varied avenues of support for those at risk so that no one is left behind. National governments and the international bodies that support them should also consider how to effectively prioritise resources and allocate financial support or incentives to those most vulnerable to infectious disease, considering that each individual case averted in turn averts many more. Protecting infectious disease services is in the interest of everyone, not only those most vulnerable to them.

There remains a significant and highly important opportunity to address the primary evidence gap in health service provision for infectious diseases across the SEA region. This evidence gap is likely to be exacerbated in many SEA countries due to under-reporting of data. While each country is mandated to report case numbers for specified infectious diseases annually under their duty as a member state of the WHO, there is well-established evidence that LMICs that depend on under-resourced and often antiquated information architecture are ill-equipped to accurately report case numbers or services provided [51] [52] [53] .

This is likely to be exacerbated in times of great system stress, such as during the COVID-19 pandemic. Indeed, one study included in this review reported that a number of sites had stopped reporting TB case numbers during the pandemic 44 . Therefore, the true impact of essential health service displacement for infectious diseases is likely to be far greater than what is reported at the national level to Government and to bodies such as the WHO and the Global Fund. It is noteworthy that all studies included in this review were published after the first 'peak' of COVID-19 infection across Asia, when the second 'peak' was reported to be more severe in terms of number of infections and hospitalisations in comparison. There is an urgent need to conduct timely, comprehensive local research on the provision of prevention, screening, diagnostic, management, and ongoing care services for those at risk, suspected of, or living with infectious diseases across the SEA region to inform evidence-based decisions regarding efforts for service provision and protection towards future health system resilience and pandemic preparedness. 

This work was supported by the WHO Sri Lanka Country office. TG is supported by a University Postgraduate Award from the University of New South Wales. SJ and DP are supported by NHMRC Principal Research Fellowships.

All data generated or analysed during this study are included in this published article (and its supplementary information files). The study protocol is publicly available at PROSPERO (CRD42020187629).

WHO Declares COVID-19 a Pandemic

Minimizing COVID-19 disruption: ensuring the supply of essential health products for health emergencies and routine health services

Impact of COVID-19 pandemic on healthcare workers

COVID-19 restrictive control measures and maternal, sexual and reproductive health issues: risk of a double tragedy for women in sub-Saharan Africa

Impact of the COVID-19 pandemic on breast cancer referrals and diagnoses in 2020 and 2021: a population-based study in England

Potential impact of the COVID-19 pandemic on HIV, tuberculosis, and malaria in low-income and middle-income countries: a modelling study

Emergency and essential surgical healthcare services during COVID-19 in low-and middle-income countries: A perspective

Socioeconomic impacts of COVID-19 in low-income countries

Lancet Commission on COVID-19 Vaccines and Therapeutics Task Force Members. Urgent needs of low-income and middle-income countries for COVID-19 vaccines and therapeutics

COVID-19 in Asia: Transmission factors, re-opening policies, and vaccination simulation

Responses toCOVID -19 in Southeast Asia: Diverse Paths and Ongoing Challenges

Southeast Asia is an emerging hotspot for COVID-19

COVID-19 pandemic in Southeast Asia: intervention and mitigation efforts

Mitigating the impact of the COVID-19 pandemic on progress towards ending tuberculosis in the WHO South-East Asia Region

Health and health-care systems in southeast Asia: diversity and transitions

Progress toward universal health coverage in ASEAN

COVID-19: Universal health coverage now more than ever

Toward universal health coverage in the post-COVID-19 era

COVID-19 and progress towards achieving universal health coverage in Africa: A case of Nigeria

Infectious Diseases in the South-East Asia Region

Global Tuberculosis Programme

The potential impact of COVID-19-related disruption on tuberculosis burden

The potential impact of the COVID-19 pandemic on child growth and development: a systematic review

Estimates of the Potential Impact of the COVID-19 Pandemic on Sexual and Reproductive Health In Low-and Middle-Income Countries

Assessing the potential impact of COVID-19 on life expectancy

The potential impact of the COVID-19 pandemic on the tuberculosis epidemic a modelling analysis

The potential impact of COVID-19 pandemic on the immunization performance in Indonesia

The Potential Impact and Availability of Sexual Health Services During the COVID-19 Pandemic

COVID-19 and the potential long-term impact on antimicrobial resistance

Impact of the COVID-19 Pandemic on Tuberculosis Control: An Overview

Pulse survey on continuity of essential health services during the COVID-19 pandemic: interim report

World Health Organization. Second round of the national pulse survey on continuity of essential health services during the COVID-19 pandemic: interim report

Synthesis without meta-analysis (SWiM) in systematic reviews: reporting guideline

COVID-19 Response and Lessons Learned on Dengue Control in Bhutan

Dengue and leptospirosis infection during the coronavirus 2019 outbreak in Sri Lanka

Evaluation of the integration of telehealth into the same-day antiretroviral therapy initiation service in Bangkok, Thailand in response to COVID-19: a mixed-method analysis of real-world data

The aftermath of COVID-19 pandemic on the diagnosis of TB at a tertiary care hospital in India

Pediatric TB detection in the era of COVID-19

How Myanmar Is Working to Maintain Essential Services for People Living With HIV and Key Populations During the Covid-19 Pandemic

HIV testing & diagnosis in 2020 at the apex tertiary referral hospital of India: impact of COVID-19 pandemic

Impact of COVID-19 on TB detection in the private sector in Nepal. The international journal …

TB positive cases go up in ongoing COVID-19 pandemic despite lower testing of TB: An observational study from a hospital from Northern India

Government of Nepal Ministry of Health and Population Department of Health Services National Tuberculosis Control Center

The Global Fund. The Global Fund results report

Covid-19 and dengue: Double punches for dengueendemic countries in Asia

Dengue amidst COVID-19 in India: the mystery of plummeting cases

Challenges in delivering telemedicine to vulnerable populations: experiences of an addiction medical service during COVID-19

Greater use of preventive services in U.S. health care could save lives at little or no cost

Towards an improved investment approach for an effective response to HIV/AIDS

Factors Influencing Timeliness of Health Management Information System (HMIS) Data in Private not for Profit Health Facilities

Health management information system (HMIS) data quality and associated factors in Massaguet district

Factors influencing quality of health management information system (HMIS) data: The case of Kinondoni district in Dar es Salaam region, Tanzania