Trends of Zambia’s tuberculosis burden over the past two decades Nathan Kapata 1,2,3 , Pascalina Chanda-Kapata 1,2 , Justin O’Grady 3,4 , Samana Schwank 3,4 , Mathew Bates 3,4 , Victor Mukonka 1 , Alimuddin Zumla 3,4 and Peter Mwaba 1,3 1 Ministry of Health, Lusaka, Zambia 2 National TB and Leprosy Control Program, Ministry of Health, Lusaka, Zambia 3 University of Zambia and University College London Medical School Research and Training Programme, University Teaching Hospital, Lusaka, Zambia 4 Department of Infection, Division of Infection and Immunity, University College London Medical School, London, UK Summary objectives To study trends in Zambia’s TB notification rates between 1990 and 2010 and to ascertain progress made towards TB control. methods Retrospective review of TB notification returns and TB programme reports for the period from 1990 to 2010. results Two distinct TB trend periods were identified: a period of rising trends up to a peak between 1990 and 2004 and a period of moderately declining trends between 2004 and 2010. Treatment out- comes improved over the two decades. Data on trends in paediatric TB, TB in prisoners and TB in pregnant women remain scanty and unreliable owing to poor diagnostic capability. There were no data available on trends on drug-resistant TB because of the lack of laboratory services to perform drug sensitivity testing. conclusions The period of increasing TB between 1990 and 2000 coincided with an increase in HIV / AIDS. The period of slightly decreasing TB between 2004 and 2010 can be attributed to improved TB care, sustained DOTS implementation and improvement in TB diagnostic services. Newer diag- nostics technologies for the rapid diagnosis of active TB cases and for drug-resistant testing, recently endorsed by the WHO, need to be implemented into the national TB programmes to detect more cases and to provide epidemiological and surveillance data from which to obtain an evidence base for guided investments for TB control. Alignment of TB and HIV services is required to achieve improved management outcomes. keywords TB, Zambia, epidemiology, directly observed treatment short course, national TB Programme, control Introduction WHO declared tuberculosis (TB) a global emergency in 1993 and recommended directly observed treatment short course (DOTS) in 1995 as a cost-effective strategy for TB control worldwide (WHO 1995). However, TB remains a major public health problem (WHO 2010a). The global burden of TB in 2009 was estimated to be approximately 9.4 million incident cases (equivalent to 137 cases per 100 000 population) and 1.7 million people died of TB. Women accounted for 35% of all cases (WHO 2010a). Approximately 80% of the TB cases notified worldwide were from the 22 high-burden countries (HBCs), and WHO concentrates mainly on these HBCs to show progress and programme performance. In Zambia, a country with a population of 13 million people, TB continues to be among the big public health problems (Mulenga et al. 2010b), more than 40 years after launching the TB / Leprosy National Control Programme (NTP) (Bosman 2000). The burden of the disease is exacerbated by the high prevalence of HIV / AIDS, estimated to be approximately 13.5% (UNAIDS 2010); by widespread poverty (CSO 2011b); and by inadequate control strategies in congregate settings such as prisons that act as reservoirs for the disease (Todrys 2010; O’Grady et al. 2011a,b). However, Zambia is not currently listed as one of the 22 HBCs, presumably owing to its relatively small population, and does not receive the same support as the HBCs for TB control. Tropical Medicine and International Health doi:10.1111/j.1365-3156.2011.02849.x volume 00 no 00 ª 2011 Blackwell Publishing Ltd 1