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Welcome to the CIDRZ Published Research Collection. This collection serves as a central repository of peer-reviewed publications authored, co-authored, or supported by the Centre for Infectious Disease Research in Zambia (CIDRZ). It provides open access to scientific knowledge that contributes to public health, clinical research, and evidence-based policy in Zambia and beyond.
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Item Engagement of private health care facilities in TB management in Lusaka district of Zambia: lessons learned and achievements.(2024-Mar-14) Hambwalula R; Kagujje M; Mwaba I; Musonda D; Singini D; Mutti L; Sanjase N; Kaumba PC; Ziko LM; Zimba KM; Kasese-Chanda P; Muyoyeta M; Division of Health, United States Agency for International Development, Lusaka, Zambia.; TB department, Centre of Infectious Disease Research in Zambia, Plot # 34620 Off Alick Nkhata Road, Mass Media, P.O. Box 34681, Lusaka, 10101, Zambia. Mary.Kagujje@cidrz.org.; Lusaka District Health Office, Ministry of Health, Great East Road, Lusaka, Zambia.; TB department, Centre of Infectious Disease Research in Zambia, Plot # 34620 Off Alick Nkhata Road, Mass Media, P.O. Box 34681, Lusaka, 10101, Zambia.; CIDRZ; Centre for Infectious Disease Research in Zambia (CIDRZ)BACKGROUND: Globally, at least 3 million TB patients are missed every year. In Zambia, the TB treatment coverage increased from 66% in 2020 to 92% in 2022. Involvement of all levels of health care service delivery is critical to finding all the missing TB patients. METHODS: A survey was undertaken in 15 private facilities in Lusaka district of Zambia using a structured tool administered by project team and a district health team member. Data collected during the survey was analysed and results were used to determine the type of TB services that were offered as well as barriers and enablers to TB service provision. This was followed by a set of interventions that included; training and mentorship on active case finding and systematic TB screening, increased diagnostic capacity, provision of national recording and reporting tools and provision of TB medication through linkage with the National TB program (NTP). We report findings from the baseline survey and changes in presumptive TB identification and notification following interventions. RESULTS: Major barriers to TB service delivery were the high cost of TB diagnostic testing and treatment in facilities where services were not supported by the National TB program; the mean cost was 33 (SD 33) and 93 (SD 148) for GeneXpert testing and a full course of treatment respectively. Pre-intervention, presumptive TB identification appeared to increase monthly by 4 (P = 0.000, CI=[3.00-5.00]). The monthly trends of presumptive TB identification during the intervention period increased by 5.32 (P = 0.000, [CI 4.31-6.33. Pre-intervention, the notification of TB appeared to decrease every month by -4.0 (P = 0.114, CI=[-9.00-0.10]) followed by an immediate increase in notifications of 13.94 TB patients (P = 0.001, CI [6.51, 21.36] in the first month on intervention. The monthly trends of notification during the intervention period changed by 0.34 (P = 0.000 [CI 0.19-0.48]). Private facility contribution to TB notification increased from 3 to 7%. CONCLUSION: Engagement and inclusion of private health facilities in TB service provision through a systems strengthening approach can increase contribution to TB notification by private health facilities.Item Reaching for 90:90:90 in Correctional Facilities in South Africa and Zambia: Virtual Cross-Section of Coverage of HIV Testing and Antiretroviral Therapy During Universal Test and Treat Implementation.(2024-Aug-15) Hoffmann CJ; Herce ME; Chimoyi L; Smith HJ; Tlali M; Olivier CJ; Topp SM; Muyoyeta M; Reid SE; Hausler H; Charalambous S; Fielding K; Institute for Global Health and Infectious Diseases, School of Medicine, University of North Carolina, Chapel Hill, NC.; College of Public Health Medicine and Veterinary Sciences, James Cook University, Townsville, Australia.; Department of Medicine, Johns Hopkins University, Baltimore, MD.; Nossal Institute for Global Health, University of Melbourne, Melbourne, Australia.; Department of Family Medicine, School of Medicine, University of Pretoria, Pretoria, South Africa; and.; Department of Medicine, Division of Infectious Diseases, School of Medicine, University of Alabama at Birmingham, Birmingham, AL.; TB HIV Care, Cape Town, South Africa.; The Aurum Institute, Johannesburg, South Africa.; School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa.; Centre for Infectious Disease Research in Zambia (CIDRZ), Lusaka, Zambia.; Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, United Kingdom.BACKGROUND: People in correctional settings are a key population for HIV epidemic control. We sought to demonstrate scale-up of universal test and treat in correctional facilities in South Africa and Zambia through a virtual cross-sectional analysis. METHODS: We used routine data on 2 dates: At the start of universal test and treat implementation (time 1, T1) and 1 year later (time 2, T2). We obtained correctional facility census lists for the selected dates and matched HIV testing and treatment data to generate virtual cross-sections of HIV care continuum indicators. RESULTS: In the South African site, there were 4193 and 3868 people in the facility at times T1 and T2; 43% and 36% were matched with HIV testing or treatment data, respectively. At T1 and T2, respectively, 1803 (43%) and 1386 (36%) had known HIV status, 804 (19%) and 845 (21%) were known to be living with HIV, and 60% and 56% of those with known HIV were receiving antiretroviral therapy (ART). In the Zambian site, there were 1467 and 1366 people in the facility at times T1 and T2; 58% and 92% were matched with HIV testing or treatment data, respectively. At T1 and T2, respectively, 857 (59%) and 1263 (92%) had known HIV status, 277 (19%) and 647 (47%) were known to be living with HIV, and 68% and 68% of those with known HIV were receiving ART. CONCLUSIONS: This virtual cross-sectional analysis identified gaps in HIV testing coverage, and ART initiation that was not clearly demonstrated by prior cohort-based studies.Item Expanding molecular diagnostic coverage for tuberculosis by combining computer-aided chest radiography and sputum specimen pooling: a modeling study from four high-burden countries.(2024) Codlin AJ; Vo LNQ; Garg T; Banu S; Ahmed S; John S; Abdulkarim S; Muyoyeta M; Sanjase N; Wingfield T; Iem V; Squire B; Creswell J; Stop TB Partnership, Geneva, Switzerland.; Liverpool School of Tropical Medicine, Liverpool, United Kingdom.; Karolinska Institutet, Stockholm, Sweden.; Liverpool University Hospitals NHS Foundation Trust, Liverpool, United Kingdom.; Janna Health Foundation, Yola, Nigeria.; icddr,b, Dhaka, Bangladesh.; Centre for Infectious Disease Research in Zambia, Lusaka, Zambia.; Friends for International TB Relief, Hanoi, Viet Nam.; CIDRZ; Centre for Infectious Disease Research in Zambia (CIDRZ)BACKGROUND: In 2022, fewer than half of persons with tuberculosis (TB) had access to molecular diagnostic tests for TB due to their high costs. Studies have found that the use of artificial intelligence (AI) software for chest X-ray (CXR) interpretation and sputum specimen pooling can each reduce the cost of testing. We modeled the combination of both strategies to estimate potential savings in consumables that could be used to expand access to molecular diagnostics. METHODS: We obtained Xpert testing and positivity data segmented into deciles by AI probability scores for TB from the community- and healthcare facility-based active case finding conducted in Bangladesh, Nigeria, Viet Nam, and Zambia. AI scores in the model were based on CAD4TB version 7 (Zambia) and qXR (all other countries). We modeled four ordinal screening and testing approaches involving AI-aided CXR interpretation to indicate individual and pooled testing. Setting a false negative rate of 5%, for each approach we calculated additional and cumulative savings over the baseline of universal Xpert testing, as well as the theoretical expansion in diagnostic coverage. RESULTS: In each country, the optimal screening and testing approach was to use AI to rule out testing in deciles with low AI scores and to guide pooled vs individual testing in persons with moderate and high AI scores, respectively. This approach yielded cumulative savings in Xpert tests over baseline ranging from 50.8% in Zambia to 57.5% in Nigeria and 61.5% in Bangladesh and Viet Nam. Using these savings, diagnostic coverage theoretically could be expanded by 34% to 160% across the different approaches and countries. CONCLUSIONS: Using AI software data generated during CXR interpretation to inform a differentiated pooled testing strategy may optimize TB diagnostic test use, and could extend molecular tests to more people who need them. The optimal AI thresholds and pooled testing strategy varied across countries, which suggests that bespoke screening and testing approaches may be needed for differing populations and settings. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1186/s44263-024-00081-2.Item Comparison of indoor contact time data in Zambia and Western Cape, South Africa suggests targeting of interventions to reduce Mycobacterium tuberculosis transmission should be informed by local data.(2016-Feb-09) McCreesh N; Looker C; Dodd PJ; Plumb ID; Shanaube K; Muyoyeta M; Godfrey-Faussett P; Corbett EL; Ayles H; White RG; TB Modelling Group, Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK. clare_looker@hotmail.com.; Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK. faussettp@unaids.org.; ZAMBART Project, School of Medicine, University of Zambia, Lusaka, Zambia. Monde.Muyoyeta@cidrz.org.; TB Modelling Group, Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK. idplumb@gmail.com.; ZAMBART Project, School of Medicine, University of Zambia, Lusaka, Zambia. helen@zambart.org.zm.; Health Economics and Decision Science, School of Health and Related Research, University of Sheffield, Sheffield, UK. p.j.dodd@sheffield.ac.uk.; TB Modelling Group, Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK. p.j.dodd@sheffield.ac.uk.; Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK. lizcorbett04@gmail.com.; HIV and TB Theme, Malawi Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi. lizcorbett04@gmail.com.; TB Modelling Group, Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK. richard.white@lshtm.ac.uk.; TB Modelling Group, Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK. nicky.mccreesh@lshtm.ac.uk.; TB Department, Centre for Infectious Disease Research in Zambia, Lusaka, Zambia. Monde.Muyoyeta@cidrz.org.; ZAMBART Project, School of Medicine, University of Zambia, Lusaka, Zambia. kshanaube@zambart.org.zm.; Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK. helen@zambart.org.zm.; CIDRZ; Centre for Infectious Disease Research in Zambia (CIDRZ)BACKGROUND: In high incidence settings, the majority of Mycobacterium tuberculosis (M.tb) transmission occurs outside the household. Little is known about where people's indoor contacts occur outside the household, and how this differs between different settings. We estimate the number of contact hours that occur between adults and adult/youths and children in different building types in urban areas in Western Cape, South Africa, and Zambia. METHODS: Data were collected from 3206 adults using a cross-sectional survey, on buildings visited in a 24-h period, including building function, visit duration, and number of adults/youths and children (5-12 years) present. The mean numbers of contact hours per day by building function were calculated. RESULTS: Adults in Western Cape were more likely to visit workplaces, and less likely to visit shops and churches than adults in Zambia. Adults in Western Cape spent longer per visit in other homes and workplaces than adults in Zambia. More adults/youths were present at visits to shops and churches in Western Cape than in Zambia, and fewer at homes and hairdressers. More children were present at visits to shops in Western Cape than in Zambia, and fewer at schools and hairdressers. Overall numbers of adult/youth indoor contact hours were the same at both sites (35.4 and 37.6 h in Western Cape and Zambia respectively, p = 0.4). Child contact hours were higher in Zambia (16.0 vs 13.7 h, p = 0.03). Adult/youth and child contact hours were highest in workplaces in Western Cape and churches in Zambia. Compared to Zambia, adult contact hours in Western Cape were higher in workplaces (15.2 vs 8.0 h, p = 0.004), and lower in churches (3.7 vs 8.6 h, p = 0.002). Child contact hours were higher in other peoples' homes (2.8 vs 1.6 h, p = 0.03) and workplaces (4.9 vs 2.1 h, p = 0.003), and lower in churches (2.5 vs 6.2, p = 0.004) and schools (0.4 vs 1.5, p = 0.01). CONCLUSIONS: Patterns of indoor contact between adults and adults/youths and children differ between different sites in high M.tb incidence areas. Targeting public buildings with interventions to reduce M.tb transmission (e.g. increasing ventilation or UV irradiation) should be informed by local data.Item Coordinating the prevention, treatment, and care continuum for HIV-associated tuberculosis in prisons: a health systems strengthening approach.(2018-Nov) Herce ME; Muyoyeta M; Topp SM; Henostroza G; Reid SE; Division of Infectious Diseases, Department of Medicine, University of Alabama at Birmingham, School of Medicine, Birmingham, Alabama, USA.; Centre for Infectious Disease Research in Zambia (CIDRZ), Lusaka, Zambia.; College of Public Health, Medical and Veterinary Sciences, James Cook University, Queensland, Australia.; Division of Infectious Diseases, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA.PURPOSE OF REVIEW: To advance a re-conceptualized prevention, treatment, and care continuum (PTCC) for HIV-associated tuberculosis (TB) in prisons, and to make recommendations for strengthening prison health systems and reducing HIV-associated TB morbidity and mortality throughout the cycle of pretrial detention, incarceration, and release. RECENT FINDINGS: Despite evidence of increased HIV-associated TB burden in prisons compared to the general population, prisoners face entrenched barriers to accessing anti-TB therapy, antiretroviral therapy, and evidence-based HIV and TB prevention. New approaches, suitable for the complexities of healthcare delivery in prisons, have emerged that may address these barriers, and include: novel TB diagnostics, universal test and treat for HIV, medication-assisted treatment for opioid dependence, comprehensive transitional case management, and peer navigation, among others. SUMMARY: Realizing ambitious international HIV and TB targets in prisons will only be possible by first addressing the root causes of the TB/HIV syndemic, which are deeply intertwined with human rights violations and weaknesses in prison health systems, and, second, fundamentally re-organizing HIV and TB services around a coordinated PTCC. Taking these steps can help ensure universal access to comprehensive, good-quality, free and voluntary TB/HIV prevention, treatment, and care, and advance efforts to strengthen health resourcing, staffing, information management, and primary care access within prisons.Item Integrating HIV care and treatment into tuberculosis clinics in Lusaka, Zambia: results from a before-after quasi-experimental study.(2018-Oct-26) Herce ME; Morse J; Luhanga D; Harris J; Smith HJ; Besa S; Samungole G; Kancheya N; Muyoyeta M; Reid SE; Lusaka District Health Office, Ministry of Health, Government of the Republic of Zambia, Lusaka, Zambia.; Division of Infectious Diseases, Department of Medicine, University of Alabama at Birmingham School of Medicine, Birmingham, AL, USA.; Division of Infectious Diseases, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA. michael.herce@cidrz.org.; Centre for Infectious Disease Research in Zambia (CIDRZ), Lusaka, Zambia.; Centre for Infectious Disease Research in Zambia (CIDRZ), Lusaka, Zambia. michael.herce@cidrz.org.BACKGROUND: Patients with HIV-associated tuberculosis (TB) often have their TB and HIV managed in separate vertical programs that offer care for each disease with little coordination. Such "siloed" approaches are associated with diagnostic and treatment delays, which contribute to unnecessary morbidity and mortality. To improve TB/HIV care coordination and early ART initiation, we integrated HIV care and treatment into two busy TB clinics in Zambia. We report here the effects of our intervention on outcomes of linkage to HIV care, early ART uptake, and TB treatment success for patients with HIV-associated TB in Lusaka, Zambia. METHODS: We provided integrated HIV treatment and care using a "one-stop shop" model intervention. All new or relapse HIV-positive TB patients were offered immediate HIV program enrolment and ART within 8 weeks of anti-TB therapy (ATT) initiation. We used a quasi-experimental design, review of routine program data, and survival analysis and logistic regression methods to estimate study outcomes before (June 1, 2010-January 31, 2011) and after (August 1, 2011-March 31, 2012) our intervention among 473 patients with HIV-associated TB categorized into pre- (n = 248) and post-intervention (n = 225) cohorts. RESULTS: Patients in the pre- and post-intervention cohorts were mostly male (60.1% and 52.9%, respectively) and young (median age: 33 years). In time-to-event analyses, a significantly higher proportion of patients in the post-intervention cohort linked to HIV care by 4 weeks post-ATT initiation (53.9% vs. 43.4%, p = 0.03), with median time to care linkage being 59 and 25 days in the pre- and post-intervention cohorts, respectively. In Cox proportional hazard modelling, patients receiving the integration intervention started ART by 8 weeks post-ATT at 1.33 times the rate (HR = 1.33, 95% CI: 1.00-1.77) as patients pre-intervention. In logistic regression modelling, patients receiving the intervention were 2.02 times (95% CI: 1.11-3.67) as likely to have a successful TB treatment outcome as patients not receiving the intervention. CONCLUSIONS: Integrating HIV treatment and care services into routine TB clinics using a one-stop shop model increased linkage to HIV care, rates of early ART initiation, and TB treatment success among patients with HIV-associated TB in Lusaka, Zambia.Item Implementation of isoniazid preventive therapy in people living with HIV in Zambia: challenges and lessons.(2019-Oct-22) Kagujje M; Mubiana ML; Mwamba E; Muyoyeta M; Centre for Infectious Disease Research in Zambia, Plot # 34620, Off Alick Nkhata Road between ERB and FAZ, Mass Media, P. O Box 34681, 10101, Lusaka, Zambia.; Centre for Infectious Disease Research in Zambia, Plot # 34620, Off Alick Nkhata Road between ERB and FAZ, Mass Media, P. O Box 34681, 10101, Lusaka, Zambia. mkagujje@gmail.com.; CIDRZ; Centre for Infectious Disease Research in Zambia (CIDRZ)BACKGROUND: Uptake of Isoniazid Preventive Therapy (IPT) among People Living with HIV in Zambia has continued to be low despite various evidence for its added benefit in reducing TB incidence and mortality when taken with antiretroviral therapy. In 2017, only 18% of People Living with HIV newly enrolled in care were initiated on IPT in Zambia. MAIN TEXT: Various challenges including policy and management level factors, supply chain factors, health worker perceptions about IPT, monitoring and evaluation factors and limited demand creation activities have constrained the scale up of IPT in Zambia. Lessons that have been learnt while addressing the above challenges are shared and they can be applied by government ministries, project managers, public health specialists to strengthen IPT activities in their settings. CONCLUSION: Zambia has both a high burden of TB and HIV and without preventing new cases of TB from reactivation of latent TB infection, it will be difficult to control TB. All stakeholders involved in prevention of TB among PLHIV need to commit to addressing the challenges limiting scale up of IPT.Item Early user perspectives on using computer-aided detection software for interpreting chest X-ray images to enhance access and quality of care for persons with tuberculosis.(2023-Dec-21) Creswell J; Vo LNQ; Qin ZZ; Muyoyeta M; Tovar M; Wong EB; Ahmed S; Vijayan S; John S; Maniar R; Rahman T; MacPherson P; Banu S; Codlin AJ; Department of Global Health, WHO Collaboration Centre On Tuberculosis and Social Medicine, Karolinska Institutet, Stockholm, Sweden.; Stop TB Partnership, Geneva, Switzerland.; Friends for International TB Relief (FIT), Hanoi, Vietnam.; Division of Infectious Diseases, Heersink School of Medicine, University of Alabama Birmingham, Birmingham, AL, USA.; Africa Health Research Institute, KwaZulu-Natal, South Africa.; PATH India, Mumbai, India.; Socios En Salud Sucursal Peru, Lima, Peru.; Interactive Research and Development (IRD) Pakistan, Karachi, Pakistan.; London School of Hygiene & Tropical Medicine, London, UK.; Janna Health Foundation, Yola, Nigeria.; International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh.; Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi.; Stop TB Partnership, Geneva, Switzerland. jacobc@stoptb.org.; Centre for Infectious Disease Research in Zambia, Lusaka, Zambia.; School of Health & Wellbeing, University of Glasgow, Glasgow, UK.; CIDRZ; Centre for Infectious Disease Research in Zambia (CIDRZ)Despite 30 years as a public health emergency, tuberculosis (TB) remains one of the world's deadliest diseases. Most deaths are among persons with TB who are not reached with diagnosis and treatment. Thus, timely screening and accurate detection of TB, particularly using sensitive tools such as chest radiography, is crucial for reducing the global burden of this disease. However, lack of qualified human resources represents a common limiting factor in many high TB-burden countries. Artificial intelligence (AI) has emerged as a powerful complement in many facets of life, including for the interpretation of chest X-ray images. However, while AI may serve as a viable alternative to human radiographers and radiologists, there is a high likelihood that those suffering from TB will not reap the benefits of this technological advance without appropriate, clinically effective use and cost-conscious deployment. The World Health Organization recommended the use of AI for TB screening in 2021, and early adopters of the technology have been using the technology in many ways. In this manuscript, we present a compilation of early user experiences from nine high TB-burden countries focused on practical considerations and best practices related to deployment, threshold and use case selection, and scale-up. While we offer technical and operational guidance on the use of AI for interpreting chest X-ray images for TB detection, our aim remains to maximize the benefit that programs, implementers, and ultimately TB-affected individuals can derive from this innovative technology.Item Active TB case finding in a high burden setting; comparison of community and facility-based strategies in Lusaka, Zambia.(2020) Kagujje M; Chilukutu L; Somwe P; Mutale J; Chiyenu K; Lumpa M; Mwanza W; Muyoyeta M; Strategic Information Department, Centre for Infectious Disease Research in Zambia, Lusaka, Zambia.; Tuberculosis Department, Centre for Infectious Disease Research in Zambia, Lusaka, Zambia.; CIDRZ; Centre for Infectious Disease Research in Zambia (CIDRZ)INTRODUCTION: We conducted an implementation science study to increase TB case detection through a combination of interventions at health facility and community levels. We determined the impact of the study in terms of additional cases detected and notification rate and compared the yield of bacteriologically confirmed TB of facility based and community based case finding. METHODOLOGY: Over a period of 18 months, similar case finding activities were conducted at George health facility in Lusaka Zambia and its catchment community, an informal peri-urban settlement. Activities included awareness and demand creation activities, TB screening with digital chest x-ray or symptom screening, sputum evaluation using geneXpert MTB/RIF, TB diagnosis and linkage to treatment. RESULTS: A total of 18,194 individuals were screened of which 9,846 (54.1%) were screened at the facility and 8,348 (45.9%) were screened in the community. The total number of TB cases diagnosed during the intervention period were 1,026, compared to 759 in the pre-intervention period; an additional 267 TB cases were diagnosed. Of the 563 bacteriologically confirmed TB cases diagnosed under the study, 515/563 (91.5%) and 48/563 (8.5%) were identified at the facility and in the community respectively (P<0.0001). The TB notification rate increased from 246 per 100,000 population pre-intervention to 395 per 100,000 population in the last year of the intervention. CONCLUSIONS: Facility active case finding was more effective in detecting TB cases than community active case finding. Strengthening health systems to appropriately identify and evaluate patients for TB needs to be optimised in high burden settings. At a minimum, provider initiated TB symptom screening with completion of the TB screening and diagnostic cascade should be provided at the health facility in high burden settings. Community screening needs to be systematic and targeted at high risk groups and communities with access barriers.Item Tuberculosis care cascade in Zambia - identifying the gaps in order to improve outcomes: a population-based analysis.(2021-Aug-10) Lungu P; Kerkhoff AD; Kasapo CC; Mzyece J; Nyimbili S; Chimzizi R; Silumesii A; Kagujje M; Subbaraman R; Muyoyeta M; Malama K; Department of Public Health and Research, Ministry of Health, Lusaka, Zambia.; National Tuberculosis and Leprosy Control Programme, Lusaka, Zambia patrickpj456@yahoo.co.uk.; Tuberculosis Department, Center for Infectious Disease Research in Zambia, Lusaka, Zambia.; Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, Massachusetts, USA.; National Tuberculosis and Leprosy Control Programme, Lusaka, Zambia.; Department of Internal Medicine, University Teaching Hospital, Lusaka, Zambia.; Ministry of Health, Lusaka, Zambia.; Division of HIV, Infectious Diseases and Global Medicine, Zuckerberg San Francisco General Hospital and Trauma Center, University of California San Francisco, San Francisco, California, USA.; CIDRZ; Centre for Infectious Disease Research in Zambia (CIDRZ)OBJECTIVE: Tuberculosis (TB) remains a leading cause of morbidity and mortality in Zambia, especially for people living with HIV (PLHIV). We undertook a care cascade analysis to quantify gaps in care and align programme improvement measures with areas of need. DESIGN: Retrospective, population-based analysis. SETTING: We derived national-level estimates for each step of the TB care cascade in Zambia. Estimates were informed by WHO incidence estimates, nationally aggregated laboratory and notification registers, and individual-level programme data from four provinces. PARTICIPANTS: Participants included all individuals with active TB disease in Zambia in 2018. We characterised the overall TB cascade and disaggregated by drug susceptibility results and HIV status. RESULTS: In 2018, the total burden of TB in Zambia was estimated to be 72 495 (range, 40 495-111 495) cases. Of these, 43 387 (59.8%) accessed TB testing, 40 176 (55.4%) were diagnosed with TB, 36 431 (50.3%) were started on treatment and 32 700 (45.1%) completed treatment. Among all persons with TB lost at any step along the care cascade (n=39 795), 29 108 (73.1%) were lost prior to accessing diagnostic services, 3211 (8.1%) prior to diagnosis, 3745 (9.4%) prior to initiating treatment and 3731 (9.4%) prior to treatment completion. PLHIV were less likely than HIV-negative individuals to successfully complete the care cascade (42.8% vs 50.2%, p<0.001). Among those with rifampicin-resistant TB, there was substantial attrition at each step of the cascade and only 22.8% were estimated to have successfully completed treatment. CONCLUSIONS: Losses throughout the care cascade resulted in a large proportion of individuals with TB not completing treatment. Ongoing health systems strengthening and patient-centred engagement strategies are needed at every step of the care cascade; however, scale-up of active case finding strategies is particularly critical to ensure individuals with TB in the population reach initial stages of care. Additionally, a renewed focus on PLHIV and individuals with drug-resistant TB is urgently needed to improve TB-related outcomes in Zambia.