COVID-19 pandemic during the war in Tigray, Northern Ethiopia: a sequential mixed-methods approach

Introduction: The overlapping global crises of war, pandemic, and inflation have hit the poorest countries the hardest. Political and security risks have risen in nearly all nations, with those lacking resources suffering from significant preparedness gaps. Similar to other developing regions, Ethiopia’s Tigray has experienced many of these effects. This study analyzes the only available data to assess COVID-19 incidence and mortality trends and identify the key influencing factors. Methods: A quantitative analysis was performed using the available incidence and mortality data from the Tigray region prior to the war and from Mekelle town for the 11 weeks during the war. This analysis was complemented by qualitative insights obtained conducted through interviews. Vaccination data covering the years 2021–2023 were also available for the Tigray region. Multiple datasets were selected for comparison purposes based on their relevance to the research objectives. Key informant interviews were conducted with members of the regional response team. Narrative analysis and a deductive approach were applied for systematic coding and thematic analysis of the interviews using Atlas.ti. The study was conducted from 1 January 2023 to 10 December 2024. Results: The region established an Emergency Operation Center with seven pillars to coordinate the overall response efforts. The COVID-19 positivity rate before the war varied between 0.97 and 20%. During the war, when services were briefly resumed for 10 weeks in Mekelle city, 3,802 cases were detected from 13,213 tests conducted, resulting in a positivity rate of 28.8%. During the same period, 85 deaths were reported. Only 45.9% of the eligible population was fully vaccinated, while nearly 29% had received only the first dose of a two-dose vaccine. Despite challenges, key opportunities included government commitment, strong communication between local experts and international institutions, and local resource mobilization. However, the crisis exposed the fragility of the health system, leading to a significant loss of life. Conclusion: While the region initially managed to delay the onset of COVID-19 and maintain lower positivity and fatality rates, the war in Tigray led to severe disruption and the eventual collapse of the health system. As a result, the disease was largely neglected and deprioritized, even after the signing of the cessation of hostilities agreement.