Changes in Tuberculosis Incidence and Mortality Following the End TB Strategy and the COVID-19 Pandemic in Brazil: An...

Tuberculosis remains a major global public health challenge, particularly in high-burden countries such as Brazil. The End TB Strategy and the COVID-19 pandemic represent key events associated with changes in tuberculosis incidence and mortality, although their temporal patterns and combined effects remain insufficiently explored.

An ecological study using interrupted time series analysis was conducted with annual tuberculosis incidence and mortality rates in Brazil from 2001 to 2024. Prais-Winsten regression with logarithmic transformation was applied to estimate level and trend changes, considering 2015 and 2020 as interruption points within the same analytical model. Model fit was assessed using the Durbin-Watson test and adjusted R².

In the combined two-intervention model, TB incidence showed no significant immediate change following the End TB Strategy but increased by 3.8% per year (95% CI: 2.1; 5.6; p < 0.001) between 2015 and 2020. Following the onset of the COVID-19 pandemic, incidence decreased immediately by 15.2% (95% CI: -20.6; -9.6; p < 0.001), followed by an annual increase of 3.1% (95% CI: 0.6; 5.6; p = 0.07). Mortality showed no significant immediate changes associated with either interruption but increased by 5.6% per year after 2020 (95% CI: 3.0; 8.2; p < 0.001).

Changes in TB incidence and mortality were temporally associated with the selected interruption points, including an increase in incidence between 2015 and 2020 and a marked decline following the onset of the COVID-19 pandemic. However, causal attribution is limited by the ecological design, absence of a control group and the small number of observations between intervention points and after 2020.