Epidemiological insights into paediatric tuberculosis trends in the Western Cape, South Africa

Abstract

Background and objectives: Paediatric tuberculosis (TB) remains a major public health concern in high-burden settings like the Western Cape (WC), South Africa. We analysed geographic differences in TB burden among children and adolescents, described temporal trends, and quantified gaps in the TB care cascade.

Methods: We analysed TB episodes recorded in the WC Provincial Health Data Centre (PHDC) from 2017-2023, stratified by 5-year age groups, and compared them to adult episodes. We assessed HIV status, drug resistance status, microbiological testing, disease classification, place of diagnosis, and TB treatment outcomes. Reporting gaps were estimated by comparing PHDC-recorded episodes to national notifications. Incidence rates were calculated using mid-year population estimates.

Results: In 2023, TB incidence rates of diagnosis in the WC were 722.4, 189.1, 171.2, and 523.4 per 100,000 population ages 0-4, 5-9, 10-14, and 15-19 years. Children aged 0-4 years accounted for 47.9% of paediatric TB episodes. In the Cape Winelands district in 2023, TB incidence among 0-4-year-olds was double that of adults in the district and 2-4 times higher than 0-4-year-olds in other districts. Among PHDC-recorded episodes, 17.3% were not reported at national level. Treatment success was low, with only 70.3% of diagnosed children and adolescents completing treatment in 2023.

Conclusions: Our findings highlight geographic variation in paediatric TB burden in the WC, emphasizing the need to address local drivers to inform targeted interventions. Gaps in the paediatric TB care cascade remain major concerns. Strengthening integrated data systems beyond TB treatment registers, could improve surveillance, health system planning, and patient outcomes.

Figure 1:

TB incidence rates in the WC between 2017 and 2023 for different age groups spanning children, adolescents and adults. Time points represent incidence based on cumulative totals at the end of each year. *Incidence refers to the incidence of TB diagnosis as opposed to true TB incidence.

Figure 2:

District-level indicators in the WC in 2023. (A) Proportion of TB episodes in 0–14-year-olds relative to total TB episodes, including adults. (B) Ratio of TB episodes in 0–4-year-olds versus 5–14-year-olds. CK = Central Karoo, CPT = City of Cape Town, CW = Cape Winelands, GR = Garden Route, Ov = Overberg, WC = West Coast.

Figure 3:

Age-stratified TB care cascades for children and adolescents in 2023 in the Western Cape. The true burden of TB in these age groups has not been adequately estimated in South Africa, represented by the “unknown” first pillar in the cascade. The green bars represent numbers of episodes at each step of the care cascade, including diagnosis, treatment initiation and registration, and successful treatment (including those still on treatment at the time of data extraction). Percentage differences between each pillar are illustrated in grey blocks. Includes children treated for both drug-resistant and drug-susceptible TB.

Figure 4:

District-level losses along the TB care cascade among children and adolescents in 2023. (A) the reporting gap between the PHDC versus the TB treatment register, and (B) combined ILTFU and treatment LTFU. CK = Central Karoo, CPT = City of Cape Town, CW = Cape Winelands, GR = Garden Route, Ov = Overberg, WC = West Coast.