Interrupted time-series analysis of active case-finding for tuberculosis during the COVID-19 pandemic, Zambia.

Objective: To evaluate the impact of the coronavirus disease 2019 (COVID-19) pandemic and the subsequent implementation of tuberculosis response measures on tuberculosis notifications in Zambia. Methods: We used an interrupted time-series design to compare monthly tuberculosis notifications in Zambia before the pandemic (January 2019 to February 2020), after implementation of national pandemic mitigation measures (April 2020 to June 2020) and after response measures to improve tuberculosis detection (August 2020 to September 2021). The tuberculosis response included enhanced data surveillance, facility-based active case-finding and activities to generate demand for services. We used nationally aggregated, facility-level tuberculosis notification data for the analysis. Findings: Pre-pandemic tuberculosis case notifications rose steadily from 2890 in January 2019 to 3337 in February 2020. After the start of the pandemic and mitigation measures, there was a -22% (95% confidence interval, CI: -24 to -19) immediate decline in notifications in April 2020. Larger immediate declines in notifications were seen among human immunodeficiency virus (HIV)-positive compared with HIV-negative individuals (-36%; 95% CI: -38 to -35; versus -12%; 95% CI: -17 to -6). Following roll-out of tuberculosis response measures in July 2020, notifications immediately increased by 45% (95% CI: 38 to 51) nationally and across all subgroups and provinces. The trend in notifications remained stable through September 2021, with similar numbers to the predicted number had the pandemic not occurred. Conclusion: Implementation of a coordinated public health response including active tuberculosis case-finding was associated with reversal of the adverse impact of the pandemic and mitigation measures. The gains were sustained throughout subsequent waves of the pandemic.

Mortality among persons with tuberculosis in Zambian hospitals: A retrospective cohort study.

Tuberculosis (TB) mortality in Zambia remains high at 86 per 100,000 populations, translating to approximately 15,000 TB-related deaths annually. We conducted a nationwide retrospective cohort study to understand predictors, time to death, and probable causes of mortality among persons on TB treatment in Zambia. We reviewed medical records for persons with TB registered in 54 purposively selected hospitals in Zambia between January and December 2019. We fitted a Cox proportional hazards model to identify predictors of mortality. Of the 13,220 records abstracted, 10,987 were analyzed after excluding records of persons who transferred in from other hospitals, those with inconsistent dates and those whose treatment outcome was not evaluated. The majority of persons with TB were men, (61.5%, n = 6,761) with a median age of 36 years (IQR: 27-46 years). Overall, 1,063 (9.7%) died before completing TB treatment (incidence rate = 16.9 deaths per 1,000 person-months). Median age at death was 40 years (IQR: 31-52). The majority of deaths (75.7%, n = 799) occurred in the first two months of TB treatment, with a median time to death of 21 days (IQR: 6-57). Independent risk factors for TB mortality included age >54 years, being treated in Eastern, Southern, Western, Muchinga and Central provinces, receiving treatment from a third-level or mission hospital, methods of diagnosis other than Xpert MTB/RIF, extrapulmonary TB (EPTB), and positive HIV status. Probable causes of death were septic shock (18.8%), TB Immune Reconstitution Inflammatory Syndrome (TB IRIS) (17.8%), end-organ damage (13.4%), pulmonary TB (11.4%), anemia (9.6%) and TB meningitis (7.8%). These results show high mortality among people undergoing TB treatment in Zambia. Interventions targeted at persons most at risk such as the elderly, those with EPTB, and those living with HIV, can help reduce TB-related mortalities in Zambia.

Losses along the tuberculosis sputum sample referral cascade for Mpongwe District, Zambia.

BACKGROUND: In resource limited-settings, timely tuberculosis (TB) diagnosis depends upon referral of sputum samples from non-diagnostic to diagnostic facilities for examination. The TB programme data for 2018 suggested losses in Mpongwe District's sputum referral cascade. AIM: This study aimed to identify the referral cascade stage where loss of sputum specimen occurred. SETTING: Primary health care facilities in Mpongwe District, Copperbelt Province, Zambia. METHODS: Data were retrospectively collected from one central laboratory and six referring health facilities between January and June 2019, using a paper-based tracking sheet. Descriptive statistics were generated in SPSS version 22. RESULTS: Of the 328 presumptive pulmonary TB patients found in presumptive TB registers at referring facilities, 311 (94.8%) submitted sputum samples and were referred to the diagnostic facilities. Of these, 290 (93.2%) were received at the laboratory, and 275 (94.8%) were examined. The remaining 15 (5.2%) were rejected for reasons such as 'insufficient sample'. Results for all examined samples were sent back and received at referring facilities. Referral cascade completion rate was 88.4%. Median turnaround time was six days (IQR = 1.8). CONCLUSION: Losses in the sputum referral cascade for Mpongwe District mainly occurred between dispatch of sputum samples and receipt at diagnostic facility. Mpongwe District Health Office needs to establish a system to monitor and evaluate the movement of sputum samples along the referral cascade to minimize losses and ensure timely TB diagnosis.Contribution: This study has highlighted, at primary health care level for resource limited settings, the stage in the sputum sample referral cascade where losses mainly occur.

Mortality among persons receiving tuberculosis treatment in Itezhi-Tezhi District of Zambia: A retrospective cohort study.

Itezhi-Tezhi District in southern Zambia has been reporting tuberculosis (TB) mortality rates that are fourfold higher than the national average of six percent. We conducted a retrospective cohort study to establish the demographic and clinical characteristics associated with mortality among persons under treatment for TB in Itezhi-Tezhi District, as well as the likely causes and time to death. We reviewed medical records for persons with TB registered in 19 public health facilities in Itezhi-Tezhi District between January 2015 and December 2018. Of the 506 persons with TB registered in the study period, 426 were included in the analysis. Of these, 71 (16.7%) died before completing treatment. The overall mortality rate was 31.8 per 1,000 person-months of observation. Most of the deaths (53 [74.7%]) occurred in the first month of treatment (median: 16 days; interquartile range: 5-52 days). In a multivariate Cox regression model, type of TB was found to be an independent predictor of mortality while on TB treatment. The risk of dying was more than twice higher for persons with clinically diagnosed PTB compared to those with bacteriologically confirmed PTB (adjusted hazard ratio = 2.2, 95% CI: 1.4-3.6). In a sub-analysis of persons with clinically diagnosed PTB, persons with TB who were on a community-based DOT plan were more than twice more likely to die compared to those on facility-based DOT plan (adjusted hazard ratio = 2.21, 95% CI: 1.1-4.8). Common likely causes of death were pulmonary TB disease (66.0%), anemia (12.8%), cardiac failure (4.3%), pneumocystis jiroveci pneumonia (4.3%), and gastroenteritis (4.2%). These findings show that most deaths occurred during the first month of treatment. Clinical evaluation at initiation of anti-TB treatment and during follow-up care, especially in persons with clinically diagnosed PTB, should include screening and treatment of other conditions.

Losses in the Sputum Specimen Referral Cascade in Mpulungu District, Zambia: A Cross-Sectional Study.

Sputum specimen referral cascades in resource-limited settings are characterized by losses of specimens, resulting in delays in tuberculosis (TB) diagnosis. Mpulungu District Health Office in Zambia conducted a quantitative based cross-sectional study using both primary and secondary data to identify points at which loss of specimens occurred in the sputum referral cascade. Primary data were collected through observations and interviews with 22 TB service providers. Secondary data were collected through examination of patient files and presumptive TB and laboratory registers to retrospectively track sputum specimens referred by ten health centers from April to September 2018. Proportions of specimens/laboratory results at every stage of the referral cascade were calculated using Epi Info v7. Only 49 (23%) out of 209 sputum specimens completed the referral cascade. The remaining 160 (76%) were lost at various stages of the referral cascade. The largest loss (51%) occurred between the release of laboratory results by the diagnostic facility and their receipt at referring facilities. Barriers included an inadequate number of staff oriented in sputum specimen referral, negative staff attitudes, and lack of specimen packaging material and specimen transportation. The district health office should strengthen the sputum specimen referral system by providing transport and specimen packaging material and by training staff in sputum collection transportation and tracking.