Tuberculosis care cascade in Zambia - identifying the gaps in order to improve outcomes: a population-based analysis

Abstract

ObjectiveTuberculosis (TB) remains a leading cause of morbidity and mortality in Zambia, especially for people living with HIV (PLHIV). We undertook a care cascade analysis to quantify gaps in care and align programme improvement measures with areas of need.DesignRetrospective, population-based analysis.SettingWe derived national-level estimates for each step of the TB care cascade in Zambia. Estimates were informed by WHO incidence estimates, nationally aggregated laboratory and notification registers, and individual-level programme data from four provinces.ParticipantsParticipants included all individuals with active TB disease in Zambia in 2018. We characterised the overall TB cascade and disaggregated by drug susceptibility results and HIV status.ResultsIn 2018, the total burden of TB in Zambia was estimated to be 72 495 (range, 40 495–111 495) cases. Of these, 43 387 (59.8%) accessed TB testing, 40 176 (55.4%) were diagnosed with TB, 36 431 (50.3%) were started on treatment and 32 700 (45.1%) completed treatment. Among all persons with TB lost at any step along the care cascade (n=39 795), 29 108 (73.1%) were lost prior to accessing diagnostic services, 3211 (8.1%) prior to diagnosis, 3745 (9.4%) prior to initiating treatment and 3731 (9.4%) prior to treatment completion. PLHIV were less likely than HIV-negative individuals to successfully complete the care cascade (42.8% vs 50.2%, p<0.001). Among those with rifampicin-resistant TB, there was substantial attrition at each step of the cascade and only 22.8% were estimated to have successfully completed treatment.ConclusionsLosses throughout the care cascade resulted in a large proportion of individuals with TB not completing treatment. Ongoing health systems strengthening and patient-centred engagement strategies are needed at every step of the care cascade; however, scale-up of active case finding strategies is particularly critical to ensure individuals with TB in the population reach initial stages of care. Additionally, a renewed focus on PLHIV and individuals with drug-resistant TB is urgently needed to improve TB-related outcomes in Zambia.

Leveraging HIV Care Infrastructures for Integrated Chronic Disease and Pandemic Management in Sub-Saharan Africa

“…In Sub-Saharan Africa (SSA), declining rates of extreme poverty [1,2] have been accompanied by increasing rates of non-communicable diseases (NCDs) [3][4][5][6][7], persistent burdens of infectious disease [8][9][10][11][12], and emerging pathogens such as the novel coronavirus (COVID-19) [13]. Given the magnitude of the epidemics of human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) and tuberculosis (TB), targeted resources have come from donor nations, the U.S. President's Emergency Plan for AIDS Relief (PEPFAR), the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund), and ministries of health to scale-up testing and treatment [14].…”

Incidental Tuberculosis in sudden, unexpected, and violent deaths in the community Lusaka, Zambia - A descriptive forensic post-mortem examination study

“…In sub-Saharan Africa, poor economic and social factors together with suboptimal performance of national TB programs due to lack of resources required to proactively screen, find and treat all cases of TB, continue to drive the TB epidemic (WHO, Fact sheets 2021). In 2019, the incidence rate of TB was 333 per 100 000 per year in Zambia, with 15 400 TB-related deaths (Lungu, et al, 2021).…”

“…In 2018, the total burden of TB in Zambia was estimated to be 72 495, and of these, 40 176 (55%) were diagnosed with TB. Of the 36 431 (50%) started on treatment, only 32 700 (45%) completed treatment (Lungu et al, 2021).…”

Community and health systems factors contributing to delayed tuberculosis detection in an urban setting: situating software and hardware bottlenecks in local health systems

“…Zambia is ranked 13th globally in terms of TB prevalence, with over 70 percent of identi ed TB cases co-infected with HIV [2]. In 2017, the country saw over 62,000 individuals contract TB, making it one of the most heavily burdened nations worldwide [11].…”