Armed conflict intensity and inequalities in tuberculosis outcomes in Colombia municipalities, 2008-2019

Colombia's prolonged armed conflict has significantly impacted public health. This study constructs a municipal-level armed conflict intensity index for Colombia (2008-2019) and assess inequalities in tuberculosis (TB) case notifications, mortality and fatality rates across levels of conflict intensity.

This retrospective ecological study included 1122 Colombian municipalities from 2008 to 2019. Data on conflict were obtained from the National Observatory of Historical Memory, and TB mortality and morbidity data were sourced from the National Public Health Surveillance System. A Conflict Intensity Index (CII), summarising intensity of armed conflict at the municipal level by ranking municipalities, was estimated using principal component analysis (PCA) to analyse two time periods (2008-2013 and 2014-2019). Age-adjusted and sex-adjusted TB rates were calculated, and disparities were assessed using the Relative Index of Inequality (RII) and Slope Index of Inequality.

Areas with higher conflict intensity showed a greater TB burden in both mortality and case notifications. Although TB notification rates decreased by 16% nationally over the study period, this reduction was not evenly distributed, and inequalities persisted, with TB notifications and mortality concentrated in high-conflict areas. Children under 1 year faced the highest inequities, with an RII of 1.39, indicating a 39% higher likelihood of TB in these areas. Women also exhibited sustained disparities, and high-conflict municipalities continued to have elevated mortality rates despite a national reduction of 9%.

The impact of armed conflict on TB was not uniform across all settings. Persistent inequalities affecting young children and women in high-conflict municipalities highlight the need for territorially differentiated TB control strategies. Integrating conflict-sensitive approaches into TB surveillance, prevention and care is essential to reduce inequities and translate epidemiological evidence into effective public health action.