Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
. 2021 Aug 10;11(8):e044867.
doi: 10.1136/bmjopen-2020-044867.

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

Patrick Lungu #  1   2 , Andrew D Kerkhoff #  3 , Clara C Kasapo  4 , Judith Mzyece  4 , Sulani Nyimbili  4 , Rhehab Chimzizi  4 , Andrew Silumesii  5 , Mary Kagujje  6 , Ramnath Subbaraman  7 , Monde Muyoyeta  6 , Kennedy Malama  8
Affiliations

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

Patrick Lungu et al. BMJ Open. .

Abstract

Objective: Tuberculosis (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.

Design: Retrospective, population-based analysis.

Setting: We 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.

Participants: Participants 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.

Results: In 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.

Conclusions: Losses 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.

Keywords: HIV & AIDS; epidemiology; public health; tuberculosis.

PubMed Disclaimer

Conflict of interest statement

Competing interests: None declared.

Figures

Figure 1
Figure 1
The tuberculosis (TB) care cascade in Zambia in 2018 among (A) all tuberculosis cases; (B) drug-susceptible cases; (C) rifampicin-resistant cases; (D) drug-susceptible cases among HIV-positive individuals; and (E) drug-susceptible cases among HIV-negative individuals.
Figure 2
Figure 2
Diagnoses and notifications of (A) all forms of drug-susceptible pulmonary TB in Zambia between 2015 and 2018 and (B) drug-resistant TB in Zambia between 2015 and 2018. DS, drug susceptible MDR-TB, multidrug-resistant tuberculosis; PTB, pulmonary tuberculosis; RR-TB, rifampicin-resistant tuberculosis; TB, tuberculosis.
Figure 3
Figure 3
Overview of drug-susceptible tuberculosis (TB) treatment outcomes in Zambia between 2015 and 2018, disaggregated according to tuberculosis type. Shapes represent the proportion of patients completing tuberculosis treatment.PTB, pulmonary tuberculosis
See this image and copyright information in PMC

References

    1. World Health Organization . The End TB strategy. Geneva: World Health Organization, 2015.
    1. World Health Organization . Global tuberculosis report 2020. Geneva: World Health Organization, 2020.
    1. Centers for Disease Control . CDC in Zambia. Center for disease control and prevention. Atlanta, 2017.
    1. Medland NA, McMahon JH, Chow EPF, et al. . The HIV care cascade: a systematic review of data sources, methodology and comparability. J Int AIDS Soc 2015;18:20634. 10.7448/IAS.18.1.20634 - DOI - PMC - PubMed
    1. Reid MJA, Goosby E. Lessons learned from the HIV care cascade can help end TB. Int J Tuberc Lung Dis 2017;21:245–6. 10.5588/ijtld.17.0027 - DOI - PubMed

Publication types