Undernotification and underreporting of tuberculosis in Zambia: a national data quality assessment.

BACKGROUND: Despite national implementation of several high impact interventions and innovations to bolster tuberculosis (TB) detection and improve quality of TB services in Zambia, notifications have been declining since 2004. A countrywide data quality assessment (DQA) of Zambia's National TB and Leprosy Programme (NTLP) was undertaken to quantify the degree to which undernotification and underreporting of TB notifications may be occurring. METHODS: The NTLP conducted a retrospective DQA of health facilities in high burden districts in all ten Zambian provinces. Multiple routine programmatic data sources were triangulated through a multi-step verification process to enumerate the total number of unique TB patients diagnosed between 1st January and 31st August 2019; both bacteriologically confirmed and clinically diagnosed TB patients were included. Undernotification was defined as the number of TB patients identified through the DQA that were not documented in facility treatment registers, while underreporting was defined as the number of notified TB cases not reported to the NTLP. RESULTS: Overall, 265 health facilities across 55 districts were assessed from which 28,402 TB patients were identified; 94.5% of TB patients were ≥ 15 years old, 65.1% were male, 52.0% were HIV-positive, and 89.6% were a new/relapse case. Among all TB cases, 32.8% (95%CI: 32.2-33.3) were unnotified. Undernotification was associated with age ≥ 15 years old (adjusted prevalence odds ratio [aPOR] = 2.4 [95%CI: 2.0-2.9]), HIV-positive status (aPOR = 1.6 [95%CI: 1.5-1.8]), being a new/relapse TB case (aPOR = 17.5 [95%CI: 13.4-22.8]), being a clinically diagnosed TB case (aPOR = 4.2 [95%CI:3.8-4.6]), and being diagnosed at a hospital (range, aPOR = 1.5 [95%CI: 1.3-1.6] to 2.6 [95%CI: 2.3-2.9]). There was substantial heterogeneity in the proportion of unnotified TB cases by province (range, 18.2% to 43.6%). In a sub-analysis among 22,199 TB patients with further data available, 55.9% (95%CI: 55.2-56.6) were notified and reported to the NTLP, 32.8% (95%CI: 32.2-33.4) were unnotified, and 11.3% (95%CI: 10.9-11.7) went unreported to the NTLP. CONCLUSIONS: The findings from Zambia's first countrywide TB programme DQA demonstrate substantial undernotification and underreporting of TB cases across all provinces. This underscores the urgent need to implement a robust and integrated data management system to facilitate timely registration and reporting of all TB patients who are diagnosed and treated.

Designing an operational research TB training program in Zambia.

BACKGROUND: The USAID-funded Eradicate TB Project (ETB) partnered with the National Tuberculosis and Leprosy Control Program (NTLP) to establish an operational research (OR) training program in order to generate local evidence to enhance TB care in Zambia. METHOD: Between 2017 and 2021, healthcare workers (HCWs) from district teams underwent two 10-day intensive training sessions. The program evolved to include a competitive application process and an additional primer workshop on developing feasible research questions. RESULTS: Of the 36 enrollees in the OR training program, 26 (72.2%) completed it, leading to nine OR studies that informed interventions for TB care improvement. Notable achievements include reduced TB mortality, increased pediatric notifications, and enhanced sputum courier systems, with all studies disseminated at national and international conferences, four submitted to peer-reviewed journals, of which three were published. Two studies were replicated by the NTLP at provincial and national levels. CONCLUSIONS: Integrating OR training into TB initiatives is feasible and beneficial. The program's phased execution and adaptive strategies provide valuable insights for similar settings, although challenges in sustainability of mentorship and funding persist. This success underscores the importance of continuous OR capacity strengthening among HCWs in Zambia.

CONTEXTE: Le projet Eradicate TB (ETB) financé par l'USAID s'est associé au programme National de contrôle de la Tuberculose et de la Lèpre (NTLP) pour mettre en place un programme de formation à la recherche opérationnelle (OR), afin de générer des preuves locales pour améliorer les soins de la TB en Zambie. MÉTHODE: Entre 2017 et 2021, des travailleurs de la santé (HCWs) provenant d'équipes de district ont suivi deux sessions de formation intensive de 10 jours. Le programme a évolué pour inclure un processus de candidature concurrentiel et un atelier d'initiation supplémentaire sur l'élaboration de questions de recherche réalisables. RÉSULTATS: Vingt-six (72,2%) des HCW inscrits au programme ont terminé leur formation, ce qui a donné lieu à neuf études de OR qui ont servi de base à des interventions visant à améliorer les soins antituberculeux. Parmi les réalisations notables, citons la réduction de la mortalité due à la TB, l'augmentation des notifications pédiatriques et l'amélioration des systèmes de messagerie des expectorations. Toutes les études ont été diffusées lors de conférences nationales et internationales, quatre ont été soumises à des revues à comité de lecture et trois ont été publiées. Deux études ont été reproduites par le NTLP aux niveaux provincial et national. CONCLUSIONS: L'intégration de la formation OR dans les initiatives de lutte contre la TB est faisable et bénéfique. L'exécution progressive du programme et les stratégies adaptatives fournissent des indications précieuses pour des contextes similaires, bien que les défis liés à la durabilité du mentorat et du financement persistent. Ce succès souligne l'importance d'un renforcement continu des capacités OR parmi les HCW en Zambie.

Disability, comorbidities and risk determinants at end of TB treatment in Kenya, Uganda, Zambia and Zimbabwe.

BACKGROUND: We examined the feasibility of assessing and referring adults successfully completing TB treatment for comorbidities, risk determinants and disability in health facilities in Kenya, Uganda, Zambia and Zimbabwe. METHODS: This was a cross-sectional study within national TB programmes. RESULTS: Health workers assessed 1,063 patients (78% of eligible) in a median of 22 min [IQR 16-35] and found it useful and feasible to accomplish in addition to other responsibilities. For comorbidities, 476 (44%) had HIV co-infection, 172 (16%) had high blood pressure (newly detected in 124), 43 (4%) had mental health disorders (newly detected in 33) and 36 (3%) had diabetes mellitus. The most common risk determinants were 'probable alcohol dependence' (15%) and malnutrition (14%). Disability, defined as walking <400 m in 6 min, was found in 151/882 (17%). Overall, 763 (72%) patients had at least one comorbidity, risk determinant and/or disability. At least two-thirds of eligible patients were referred for care, although 80% of those with disability needed referral outside their original health facility. CONCLUSIONS: Seven in 10 patients completing TB treatment had at least one comorbidity, risk determinant and/or disability. This emphasises the need for offering early patient-centred care, including pulmonary rehabilitation, to improve quality of life, reduce TB recurrence and increase long-term survival.

CONTEXTE: Nous avons examiné la faisabilité d'évaluer et de référer les adultes ayant terminé avec succès le traitement de la TB pour les comorbidités, les déterminants de risque et l'invalidité dans les établissements de santé au Kenya, en Ouganda, en Zambie et au Zimbabwe. MÉTHODES: Il s'agissait d'une étude transversale menée dans le cadre des programmes nationaux de lutte contre la TB. RÉSULTATS: Les agents de santé ont évalué 1 063 patients (78% des personnes éligibles) en médiane de 22 min (IQR 16­35) et ont jugé utile et réalisable d'accomplir cette tâche en plus de leurs autres responsabilités. Pour les comorbidités, 476 (44%) étaient co-infectés par le VIH, 172 (16%) souffraient d'hypertension artérielle (dont 124 nouvellement diagnostiqués), 43 (4%) présentaient des troubles de santé mentale (dont 33 nouvellement diagnostiqués) et 36 (3%) étaient diabétiques. Les déterminants de risque les plus courants étaient une « dépendance probable à l'alcool ¼ (15%) et la malnutrition (14%). L'invalidité, définie comme une marche <400 m en 6 min, a été observée chez 151/882 (17%) des patients. Dans l'ensemble, 763 (72%) des patients présentaient au moins une comorbidité, un déterminant de risque et/ou une invalidité. Au moins deux tiers des patients éligibles ont été référés pour des soins, bien que 80% de ceux souffrant d'invalidité aient besoin d'être référés en dehors de leur établissement de santé d'origine. CONCLUSIONS: Sept patients sur 10 ayant terminé le traitement de la TB présentaient au moins une comorbidité, un déterminant de risque et/ou une invalidité. Cela souligne la nécessité d'offrir des soins précoces centrés sur le patient, y compris une réadaptation pulmonaire, pour améliorer la qualité de vie, réduire la récurrence de la TB et augmenter la survie à long terme.

What happened to patients with RMP-resistant/MDR-TB in Zambia reported as lost to follow-up from 2011 to 2014?

SETTING: University Teaching Hospital, Lusaka, and Ndola Central Hospital, Ndola, Zambia, which implemented active tracing of multidrug-resistant tuberculosis (MDR-TB) patients reported as lost to follow-up (LTFU). OBJECTIVE: To determine 1) the number of patients treated for MDR-TB between 2011 and 2014; 2) the number, proportion, month when LTFU and characteristics of patients registered as LTFU; and 3) final outcomes observed following active patient tracing. DESIGN: Retrospective cohort study. RESULTS: Of 184 patients treated for confirmed MDR-TB, 76 (41%) were reported as LTFU. From 2011 to 2014, the proportions reported each year as LTFU were respectively 21%, 47%, 51% and 39%. Of patients who were LTFU, 43 (57%) had stopped attending the clinic during the intensive phase. These patients were predominantly male, aged 15-44 years, had pulmonary disease and had failed previous treatment. Of 57 (75%) patients with known human immunodeficiency virus (HIV) status, 42 (74%) were HIV-positive, 57% of whom were on antiretroviral treatment. After active patient tracing, 29 (38%) patients could not be found and the observed outcome remained LTFU. Of the remaining 47 patients, 29 (62%) were alive and had completed or were still on treatment, 14 (30%) were alive but had stopped treatment and 4 (8%) had died. CONCLUSION: Zambia has been underreporting its favourable outcomes for MDR-TB treatment and should continue with active tracing of LTFU patients.

The role of technical assistance in expanding access to Xpert(®) MTB/RIF: experience in sub-Saharan Africa.

To improve tuberculosis (TB) diagnosis, many national TB programmes have committed to deploying Xpert(®) MTB/RIF. Implementation of this relatively new technology has suffered from a lack of comprehensive technical assistance, however, including the formulation of policies and plans to address operational issues. While providing technical assistance, we observed numerous operational challenges in the implementation and scale-up of Xpert in five sub-Saharan African countries: low coverage, poor laboratory infrastructure, limited access, poor linkages to treatment, inadequate data on outcomes, problems with specimen transport, diagnostic algorithms that are not aligned with updated World Health Organization recommendations on target patient groups and financing challenges. We recommend better country preparedness and training, laboratory information and quality systems, supply management and referral mechanisms.

De nombreux programmes nationaux tuberculose (TB) se sont engagés à déployer le Xpert® MTB/RIF afin d'améliorer le diagnostic de la TB. La mise en oeuvre de cette technique relativement nouvelle a cependant souffert d'un manque d'assistance technique d'ensemble, notamment la formulation de politiques et de plans destinés à prendre en compte les problèmes opérationnels. Lorsque nous avons fourni cette assistance technique, nous avons observé de nombreux défis opérationnels dans la mise en oeuvre et l'expansion du Xpert dans cinq pays d'Afrique sub-saharienne : une faible couverture, une infrastructure de laboratoire limitée, un accès limité, des liens médiocres avec la prise en charge thérapeutique, des données insuffisantes sur les résultats, des problèmes de transport des échantillons, des algorithmes de diagnostic qui ne sont pas en accord avec les dernières recommandations de l'Organisation Mondiale de la Santé relatives aux groupes cibles de patients et des défis financiers. Nous recommandons une meilleure préparation et formation des pays, une information des laboratoires et des systèmes de contrôle de qualité, une gestion des stocks et des mécanismes de référence.

Con el propósito de mejorar el diagnóstico de la tuberculosis, muchos programas nacionales han decidido generalizar la práctica de la prueba Xpert® MTB/RIF. Sin embargo, la introducción de esta técnica relativamente nueva se ha dificultado debido a una falta de asistencia técnica integral, que comprenda la formulación de normas y de planes que aborden los aspectos operativos. Durante la experiencia de prestación de asistencia técnica, se observaron múltiples dificultades operativas en la ejecución y en la ampliación de escala de la técnica Xpert en cinco países de África subsahariana, a saber: la baja cobertura, la insuficiencia de las infraestructuras de laboratorio, el acceso limitado, la escasa vinculación con el tratamiento, la deficiencia de los datos sobre los desenlaces, los problemas relacionados con el transporte de las muestras, los algoritmos diagnósticos que no corresponden a las recomendaciones actualizadas de la Organización Mundial de la Salud en materia de grupos destinatarios de pacientes y las dificultades de financiamiento. Se recomienda procurar una mejor preparación y una mayor capacitación en el país, perfeccionar los sistemas de información y control de calidad de los laboratorios y poner en práctica procedimientos de gestión de los suministros y mecanismos de remisión.

Scaling up antiretroviral therapy in Africa: learning from tuberculosis control programmes--the case of Malawi.

The rapid and massive scale-up of antiretroviral drug therapy (ART) so needed in sub-Saharan Africa will not be possible using a 'medicalised' model. A more simple approach is required. DOTS has been used now for many years to provide successful anti-tuberculosis treatment to millions of patients in poor countries of the world, and many of the established concepts can be used for the delivery of ART. Malawi, a small and impoverished country in sub-Saharan Africa, is embarking on a national scale-up of ART. In this review we describe how we have adopted several of the principles of DOTS for delivering ART in Malawi: case finding and registration, treatment, monitoring, drug procurement, staffing and the issue of free drugs. We also discuss ART for HIV-infected TB patients. We hope that by using the DOTS approach we will be able to deliver ART to large numbers of HIV-infected patients under controlled conditions, and minimise the risk of developing drug resistance.

Scaling up HIV/AIDS and joint HIV-TB services in Malawi.

Two country-wide surveys were undertaken to assess progress in scaling up human immunodeficiency virus/ acquired immune-deficiency syndrome (HIV/AIDS) and HIV-tuberculosis (TB) services in the public health sector in Malawi between 2002 and 2003. In 2003, 118 sites were performing counselling and HIV testing compared with 70 in 2002. There were 215 269 HIV tests carried out in 2003 compared with 149 540 in 2002, the largest increases being in pregnant women (from 5059 to 26791), patients with TB (from 2130 to 3983) and patients/clients attending health facilities (from 35 407 to 79 584). In 2003, 3703 patients with AIDS were started on antiretroviral therapy compared with 1220 patients in 2002.

Characteristics and outcome of tuberculosis patients whose sputum smears are positive at or after 5 months of treatment.

A country-wide survey was carried out to assess the management of new smear-positive pulmonary TB (PTB) patients whose sputum smears were recorded as positive 5 months or later during treatment. During 2000 and 2001, there were 250 patients, of whom 161 (64%) had positive smears at 5 months and 89 at 7 months. Several inconsistencies and inadequacies in management were identified which need to be remedied: 7% of patients were assessed on one sputum specimen instead of two, and 17% on the basis of one positive smear result; 47% of patients with 5-month positive smears and 52% with 7-month positive smears had sputum smears examined too early or too late; 14% of patients with 5-month positive smears continued treatment, and over 60% of these were recorded as 'cured'.

Preventing recurrent tuberculosis in high HIV-prevalent areas in sub-Saharan Africa: what are the options for tuberculosis control programmes?

Several studies conducted in sub-Saharan Africa have pointed to an increased risk of recurrent TB in patients who are HIV-seropositive. Routine case notification data from the Malawi Tuberculosis Programme, which has improved its registration practices in the last two years, shows that recurrent TB (smear-positive and smear-negative TB) constitutes 9% of total notifications. The objectives of reducing rates of recurrent TB are 1) to complement other interventions to decrease TB incidence rates and transmission of disease, 2) to reduce TB-specific morbidity and mortality and 3) to restore confidence amongst health care staff and patients about the effectiveness of the current TB control strategy. Four possible options for reducing recurrent TB are discussed, and for each option this includes the evidence for effectiveness, current practice and operational considerations. The options are 1) using rifampicin and isoniazid (RH) in the continuation phase of treatment, 2) extending the duration of the continuation phase, 3) providing post-treatment isoniazid prophylaxis to HIV-positive patients who have completed treatment and 4) treating HIV-positive TB patients with highly active antiretroviral therapy (HAART). The last three options all require that TB patients know their HIV serostatus. The authors suggest that this issue of recurrent TB should be considered as one of the important areas for debate and action when considering the dual TB/HIV epidemic.

Care of HIV complications in patients receiving anti-tuberculosis treatment in hospitals in Malawi.

A cross-sectional study was carried out in all 43 hospitals in Malawi that register and treat tuberculosis (TB) patients to determine whether there is care and treatment for human immunodeficiency virus (HIV) complications in TB patients. Of 1,416 adults with TB, 861 (61%) had HIV complications, 627 (44%) patients had received no ward round, and of 1,142 patients who had been on anti-tuberculosis treatment for more than 7 days, 294 (26%) had not had a clinical review. Of patients with HIV complications, only 139 (16%) were receiving treatment. There is a lack of regular care and treatment for HIV complications in TB patients in Malawi.

Counselling, HIV testing and adjunctive cotrimoxazole for TB patients in Malawi: from research to routine implementation.

SETTING: Fifteen hospitals in Malawi that offer voluntary counselling and testing (VCT) for the human immunodeficiency virus (HIV) for tuberculosis (TB) patients and cotrimoxazole (CTX) for patients found to be HIV-positive. OBJECTIVES: 1) To describe the process of developing a national TB-HIV plan, conducting a country-wide situational assessment, and producing national guidelines on VCT and CTX for TB patients, and 2) to assess the implementation of VCT and CTX for TB patients registered between July and September 2003. DESIGN: A descriptive study. RESULTS: The 3-year HIV-TB plan was finalised in 2002. Between January and March 2003, an assessment was carried out of HIV/AIDS and joint HIV-TB services in Malawi and a decision made to support 15 hospitals in implementing VCT and CTX for TB patients. Between April and June 2003, national guidelines on VCT and CTX were developed through a consultative process, and treatment units were prepared for implementation. Between July and September 2003, 2397 TB patients were registered, and 1404 (59%) accepted VCT; 956 (68%) were HIV-positive, of whom 927 (97%) started CTX. Deficiencies in the registration process and in patient understanding about VCT and CTX were identified. CONCLUSION: The results show that it is feasible to routinely implement VCT and CTX for TB patients.

Voluntary counselling, HIV testing and adjunctive cotrimoxazole are associated with improved TB treatment outcomes under routine conditions in Thyolo District, Malawi.

SETTING: Two rural districts in Malawi: Thyolo, where voluntary counselling and human immunodeficiency virus (HIV) testing (VCT) is offered to all tuberculosis (TB) patients and adjunctive cotrimoxazole to HIV positives, and Mulanje, where no such interventions are offered. OBJECTIVES: For all TB patients registered in 2001: 1) to determine the uptake of VCT and cotrimoxazole in Thyolo, and 2) to compare treatment outcomes between Thyolo and Mulanje. DESIGN: A cohort study using routinely collected programme data. RESULTS: There were 1239 TB patients in Mulanje and 1103 in Thyolo. In Thylo, 1064 (97%) patients consented to VCT, 1006 were HIV tested (91%) and 761 (69%) were started on cotrimoxazole a median of 4 days from registration; 77% of patients tested in Thyolo were HIV-positive. For all TB patients, in Thyolo and Mulanje, treatment success was respectively 75% and 61% (P < 0.001); death was 21% and 25% (P = 0.026); and other outcomes were 4% and 14% (P < 0.001). The adjusted relative risks of treatment success (1.23), death (0.84) and other outcomes (0.26) in Thyolo were significantly different from those in Mulanje (P < 0.001). CONCLUSION: VCT and adjunctive cotrimoxazole is well accepted by TB patients in Thyolo and, with other HIV care and support services, is associated with good treatment outcome indicators for the National Tuberculosis Programme. This intervention is being expanded to other districts in Malawi, and other African countries should consider a similar approach to the dual HIV-TB epidemic.