The social determinants of tuberculosis and their association with TB/HIV co-infection in Lusaka, Zambia

Introduction: Tuberculosis (TB) is a major public health problem globally.Progress made in TB control through the implementation of the DOTS strategy, has been retarded by factors such as poverty, the HIV pandemic and the advent of multidrug resistant tuberculosis. There is currently an increasing shift in TB control strategies to emphasize the importance of social determinants of TB if notable impact has to be attained. However, limited data exist that describe these determinants in high burden settings such as Zambia. This study was conducted to explore the social determinants of TB and their association with TB/HIV co-infection, in order to inform TB control strategies that would lead to appropriate action for impact.Method: A cross-section study of TB patients presenting to four peri-urban health facilities in Lusaka through administration of a standard structured questionnaire. STATA 12 Version 1 was used for analysis.Results: There were 1,259 TB patients enrolled. The median age was 35 (IQR; 29 – 41). The main determinants that were associated with TB/HIV co-infection were: being in the age-group 24-49 (p = 0.0001); being female (p = 0.0001); re-treatment (p = 0.0001); having extrapulmonary TB (p = 0.02); being married or widowed (p = 0.05 and p = 0.01, respectively)Conclusions: Describing the social determinants of TB and their association with TB/HIV co-infection highlighted a number of opportunities to strengthen control beyond the Stop TB Strategy

Tuberculosis among older adults in Zambia: Burden and characteristics among a neglected group

BACKGROUND: The 2010 Global Burden of Disease estimates show that 57% of all TB deaths globally occurred among adults older than 50 years of age. Few studies document the TB burden among older adults in Southern Africa. We focused on adults older than 55 years to assess the relative TB burden and associated demographic factors. METHODS: A cross sectional nationally representative TB prevalence survey conducted of Zambian residents aged 15 years and above from 66 clusters across all the 10 provinces of Zambia. Evaluation included testing for TB as well as an in-depth questionnaire. We compared survey data for those aged 55 and older to those aged 15-54 years. Survey results were also compared with 2013 routinely collected programmatic notification data to generate future hypotheses regarding active and passive case finding. RESULTS: Among older adults with TB, 30/ 54 (55.6%) were male, 3/27 (11.1%) were HIV infected and 35/54 (64.8%) lived in rural areas. TB prevalence was higher in those aged ≥55 (0.7%) than in the 15-54 age group (0.5%). Males had higher rates of TB across both age groups with 0.7% (15-54) and 1.0% (≥55) compared with females 0.4% (15-54) and 0.6% (≥55). In rural areas, the prevalence of TB was significantly higher among older than younger adults (0.7% vs 0.3%), while the HIV infection rate was among TB patients was lower (11.1% vs 30.8%). The prevalence survey detected TB in 54/7484 (0.7%) of older adults compared to 3619/723,000 (0.5% ) reported in 2013 programmatic data. CONCLUSION: High TB rates among older adults in TB endemic areas justify consideration of active TB case finding and prevention strategies

Characterization and Local Perceptions of Poverty Among Rural Households in Northern Zambia

Background: Poverty has been linked with poor  health outcomes in world health reports and cited by many scholars and leading health economists and public health specialist as a cause for poor health seeking behaviours especially for the rural poor. Poverty and ill-health are so closely intertwined that it is possible to use the words interchangeably, and still mean the same thing. Poverty has been defined as “a state of relative equilibrium of body form and function which results from its successful dynamic adjustments to forces tending to disturb it. It is not a passive interplay between body and forces impinging upon it but an active response of body forces working towards readjustment”. Poverty on the other hand has been defined as a “lack of access to income, employment, and normal internal entitlements for the citizens to such things as freely determined consumption of goods and services, shelter and other basic needs of life”. The poverty and ill-health situation has grown grimmer for Africa and some Asian countries. The last decade has seen an emergence of new and a resurgence of old infections with a virulence and velocity hard to compare. East Asia and Sub-Saharan Africa have been at the receiving end of most the consequences of poverty and the ill health that result exacerbated by the HIV and AIDS pandemic. It has been suggested that attacking poverty is the answer to better health. Many agree with this notion of improving health. The million dollar question has however remained how to proceed with the war against poverty. Experts and scholars have done commendable work studying, defining and designing solutions for poverty. That much has been achieved in these lines, again there is no denying. Success in reducing poverty has however remained elusive, especially in sub-Saharan Africa. World Health Organisation (WHO) in its World Health Report for 2005, admits failure in improvement of most health indicators in sub-Saharan Africa and more so for Zambia.Methods: The participatory action research (PAR) was conducted in Chikoti village in Luwingu area among 212 households, Kungu village in Kasama with 236 households, Mpepo village in Mpika with 220 households and Ilondola village with 360 households. The study investigated the relationship between poverty and ill-health and how the rural poor respond to this discourse.Results: The communities demonstrated a clear understanding of their own environment and were able to define factors which make them vulnerable to poverty and inversely to poor health. The study communities were able to distinctly define their own poverty levels and identify the categories of community members into the poverty status that is: managing poor, moderately poor and the extremely poor according to their local conditions and in their own local language.Conclusion: It is clear from the study findings that the rural communities do perceive poverty to affect all of the community members equally regardless of age or education levels. The study participants also demonstrated that they understood the vulnerability of women and children to poverty and its effects. It was also observed that poverty stricken communities often give preference to food than health, introducing ill-health due to negligence

Multidrug-resistant TB in Zambia: review of national data from 2000 to 2011

Multidrug-resistant tuberculosis (MDR-TB) is posing a great threat to global TB control. The burden in Zambia is not well defined because routine surveillance data are scarce. We reviewed national MDR-TB data for the last decade to inform future public health policy with respect to MDR-TB in Zambia

Minimizing the impact of the triple burden of COVID-19, tuberculosis and HIV on health services in sub-Saharan Africa

In this perspective, we discuss the impact of COVID-19 on tuberculosis (TB)/HIV health services and approaches to mitigating the growing burden of these three colliding epidemics in sub-Saharan Africa (SSA). SSA countries bear significantly high proportions of TB and HIV cases reported worldwide, compared to countries in the West. Whilst COVID-19 epidemiology appears to vary across Africa, most countries in this region have reported relatively lower-case counts compared to the West. Nevertheless, the COVID-19 pandemic has added an additional burden to already overstretched health systems in SSA, which, among other things, have been focused on the longstanding dual epidemics of TB and HIV. As with these dual epidemics, inadequate resources and poor case identification and reporting may be contributing to underestimations of the COVID-19 case burden in SSA. Modelling studies predict that the pandemic-related disruptions in TB and HIV services will result in significant increases in associated morbidity and mortality over the next five years. Furthermore, limited empirical evidence suggests that SARS-CoV-2 coinfections with TB and HIV are associated with increased mortality risk in SSA. However, predictive models require a better evidence-base to accurately define the impact of COVID-19, not only on communicable diseases such as TB and HIV, but on non-communicable disease comorbidities. Further research is needed to assess morbidity and mortality data among both adults and children across the African continent, paying attention to geographic disparities, as well as the clinical and socio-economic determinants of COVID-19 in the setting of TB and/or HIV

Tuberculosis, HIV/AIDS and Malaria Health Services in sub-Saharan Africa – A Situation Analysis of the Disruptions and Impact of the COVID-19 Pandemic

Background: The unprecedented and ongoing COVID-19 pandemic has exposed weaknesses in African countries’ health systems. The impact of shifted focus on COVID-19 for the past 2 years on routine health services, especially those for the epidemics of Tuberculosis, HIV/AIDS and Malaria, have been dramatic in both quantity and quality. Methods: In this article, we reflect on the COVID-19 related disruptions on the Tuberculosis, HIV/AIDS and Malaria routine health services across Africa. Results: The COVID-19 pandemic resulted in disruptions of routine health services and diversion of already limited available resources in sub-Saharan Africa. As a result, disease programs like TB, malaria and HIV have recorded gaps in prevention and treatment with the prospects of reversing gains made towards meeting global targets. The extent of the disruption is yet to be fully quantified at country level as most data available is from modelling estimates before and during the pandemic. Conclusions: Accurate country-level data is required to convince donors and governments to invest more into revamping these health services and help prepare for managing future pandemics without disruption of routine services. Increasing government expenditure on health is a critical part of Africa's economic policy. Strengthening health systems at various levels to overcome the negative impacts of COVID-19, and preparing for future epidemics will require strong visionary political leadership. Innovations in service delivery and technological adaptations are required as countries aim to limit disruptions to routine services

Incidental Tuberculosis in sudden, unexpected, and violent deaths in the community Lusaka, Zambia - A descriptive forensic post-mortem examination study

Objectives: Tuberculosis remains a global emergency. In Zambia only 55% of tuberculosis cases are diagnosed. We performed a study to determine incidental cases of tuberculosis seen at forensic autopsy of individuals who died suddenly and unexpectedly in the community in Lusaka, Zambia. Methods: Whole-body autopsies were performed according to Standard Operating Procedures. Representative samples obtained from relevant organs were subjected to pathological examination. Information on circumstances surrounding the death was obtained. Data on patient demographics, gross and microscopic pathological findings, and cause(s) of death were analysed. Results: Incidental tuberculosis was found in 52 cases (45 male, 7 female, age range 14-66) out of 4286 whole-body autopsies. 41/52 (80%) were aged 21-50 years. One was a 14-year old boy who died during a football match. 39/52 (75%) deaths were attributable specifically to tuberculosis only. Other deaths were due to acute alcohol intoxication(4), violence(7), ruptured ectopic pregnancy(1), bacterial meningitis (1). All the cases were from poor socio-economic backgrounds and lived in high-density areas of Lusaka. Conclusions: Incidental cases of active tuberculosis undiagnosed antemortem seen at forensic autopsy reflects major gaps in the national TB control programs. More investments into proactive screening, testing, treatment activities, and accurate data collection are required