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.

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.

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.

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.

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'.