Date of Award

January 2024

Document Type


Degree Name

Master of Public Health (MPH)


School of Public Health

First Advisor

Ted Cohen

Second Advisor

Nimalan Arinaminpathy


Background: The COVID-19 pandemic posed unprecedented challenges to global health systems, significantly impacting the delivery of essential health services, including tuberculosis (TB) care. It is important to analyze the factors associated with the reductions in TB notifications during the pandemic, with a focus on high TB burden countries, to inform strategies for making TB programs more resilient to health system shocks.

Methods: Amongst 98 selected high-burden countries, a GLM analysis was employed to examine the association between ‘missed’ TB case notifications from 2020 to 2021, and various country-level factors including: COVID-19 mortality estimates, lockdown stringency index, GDP per capita, health expenditure, population density, TB case detection rate (CDR), TB incidence rate, and WHO region.

Results: Disruptions to TB services were driven more by the stringency of restrictions than by the severity of the pandemic itself. GDP per capita emerged as the sole factor exerting a protective influence against service disruptions. Unexpectedly, higher levels of health expenditure correlated with greater disruptions in TB services. Additionally, countries within the Southeast Asia region experienced more severe service disruptions than in the Africa Region.

Conclusions: Although several factors are likely to have played a role, our analysis highlights the stringency of restrictions as a driving factor in TB service disruptions. In future such health shocks, those countries experiencing the most stringent restrictions, rather than those with the greatest pandemic burden, would benefit most from emergency mitigating measures to ensure continuity of TB services.


This thesis is restricted to Yale network users only. It will be made publicly available on 05/07/2026