Cover
POLICY BRIEF
EPIDEMIC PROJECTIONS AND OPPORTUNITIES TO
ACCELERATE CONTROL OF TUBERCULOSIS IN MOZAMBIQUE:
FINDINGS FROM AN OPTIMA
MODELLING ANALYSIS
INTRODUCTION
M Challenges
ozambique is one of the 30 highest TANZANIA
tuberculosis (TB) burden countries in
MALAWI
the world with respect to total incidence
ZIMBABWE
ESWATINI
Case for optimization
S. AFRICA
(estimated at 361 new TB cases per 100,000 population), Estimated TB incidence of
HIV-associated TB (estimated at 34%), and drug 361 cases per 100,000
resistant TB (estimated at 3.7% of new cases and 13% population
of previously treated cases), while less than 40% of
TB diagnoses are bacteriologically confirmed (Global MDR-TB incidence of 30 per
TB Report, 2020). However, the national 2018/19 TB 100,000 population
prevalence survey data and historical data from the
National Tuberculosis Programme (NTP) show a rapid 34% TB patients living
increase in the TB case detection rate (from 36% in with HIV
year 2010 to 53% in 2017, and 80% in 2019). Coupled
Estimated 20% of TB incidence
with a high treatment success rate for drug susceptible
undetected each year
tuberculosis (DS-TB) (over 90%), Mozambique has
become one of seven high TB burden countries to have Only 30% of MDR-TB cases
already reached the 2020 milestone of a 35% reduction receive a correct diagnosis
in TB deaths since 2015.
Active case finding programs in Mozambique have been expanding, and community-based
efforts now account for around 25% of detected cases. This involves both contact tracing of
notified cases and other community-level interventions such as active house-to-house screening
and testing, mobile van outreach in TB hotspots, and screening and testing of community health
workers. However, there are opportunities for further expansion. Active case finding programs
Epidemic Projections and Opportunities to Accelerate Control of Tuberculosis in Mozambique
that focus on key populations, including prisoners, miners, and people living with HIV, have
been implemented on a small scale. In 2017 the average number of contacts traced per notified
TB case was 1.3, and although this increased rapidly to 2 contacts traced and screened per
notified TB case in 2019 and 2020, this value is still much lower than the average household
size of 4.4 in Mozambique. Within budget limitations, to remain on track to achieve the national
target of 90% TB diagnosis by 2025, targeted active case finding programs are critical. This
policy brief summarizes the findings of an allocative efficiency analysis using the Optima TB
model (accessible from http://optimamodel.com/tb), and highlights opportunities to maximize the
impact of TB spending in Mozambique.
KEY FINDINGS
KEY MESSAGE 1: TB incidence and TB-related death rates are projected to continue
declining to 2035, partially thanks to improvement in ART coverage along with TB testing
and treatment, leading to reduced TB infection among people living with HIV.
Incidence of TB among people living with HIV in Mozambique has been declining over recent
years, thanks primarily to improvements in case finding programs and ART coverage and TB
testing and treatment among people living with HIV. Given the importance of HIV diagnosis and
treatment on the incidence of TB in this context, in consultation with local experts, 90% ART
coverage among adults by 2035 (compared with 55% in 2017; UNAIDS) was used as a realistic
target for this analysis. Assuming constant conditions of TB intervention coverage and outcomes,
and that ART coverage in Mozambique will reach 90% by 2035, TB incidence and TB-related
deaths are projected to decline. The incidence of TB is projected to drop from 320 per 100,000
in 2019 to 100 per 100,000 by 2035 (Figure 1). However, due to a rapidly increasing population
size, the absolute number of TB cases is projected to reduce at a lesser rate, especially among
those who are not infected with HIV, from a total of 100,000 in 2019 to 50,000 by 2035 across all
populations (Figure 2).
Figure 1 Historical and projected new TB cases Figure 2 Historical and projected total
per 100,000 population annual new TB cases
Source: Optima TB model output, WHO estimates.
Note: TB = tuberculosis.
KEY MESSAGE 2: Universal HIV treatment remains a top priority for TB control.
Scaling up ART coverage from 55% in 2017 to 90% by 2035 is projected to lead to reductions
in the number of incident TB cases among adults living with HIV in 2035 by around 35%
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Findings From an Optima Modelling Analysis
compared with ART coverage Figure 3 Projected incident TB cases among people living
only reaching 70% by 2035. with HIV
Furthermore, if the 90% ART
coverage target could be
achieved earlier, many more
cumulative TB infections
could be averted (Figure 3) in
addition to the direct impact on
reducing HIV transmission. This
highlights the importance of
rapidly expanding access to HIV
treatment and ensuring ART
adherence by as many people Source: Optima TB model output.
Notes: ART = antiretroviral treatment; TB = tuberculosis.
living with HIV as possible, and
as soon as possible.
KEY MESSAGE 3: The End TB Strategy target of 95% reduction in TB-related deaths by
2035 over 2015 may be within reach with optimized additional investment in targeted TB
programs.
There were 23,000 model estimated TB-related deaths in 2015, meaning meeting the End TB
Strategy target of a 95% reduction in deaths by 2035 will require reducing deaths to 1,150 by
2035. The 2020 milestone of reducing TB-related deaths by 35% from 2015 levels has been
achieved based on reported numbers, and the 2025 milestone of a 75% reduction could be within
reach if investment across TB programs is optimized over this period. If 50% more investment is
optimized across existing TB program modalities, then the 2030 Sustainable Development Goal
(SDG) 3 target of a 90% reduction in TB-related deaths and the 2035 End TB Strategy target of a
95% reduction in TB deaths compared with 2015 are both within reach.
Figure 4 Modelled progress toward 2035 End TB Strategy target for reducing TB-related deaths
by 95% over 2015 levels
Source: Optima TB model output.
Note: SDG = Sustainable Development Goals; TB = tuberculosis.
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Epidemic Projections and Opportunities to Accelerate Control of Tuberculosis in Mozambique
KEY MESSAGE 4: With the most recently reported budget level, even if allocated
optimally, Mozambique is unlikely to achieve the End TB Strategy target of a 90%
reduction in TB incidence relative to 2015.
Modelled TB incidence for 2015 was 350 per 100,000 population, therefore, meeting the End TB
Strategy target would require reducing incidence to 35 per 100,000 by 2035. It is projected that
if the estimated TB spending for 2019 were increased by 50% and optimally allocated, then TB
incidence could be reduced to 110 cases per 100,000 by 2035 (Figure 5).
It is projected that more TB spending will result in more rapid reductions in TB. More budget
can facilitate expanded contact tracing and preventive therapy which can break the transmission
chain and rapidly reduce new latent TB infections and thus new active TB infections in those
exposed. =. Reducing activation of latent TB infections in those who were infected with latent
TB more than five years ago, as well as relapse/incomplete treatment cases is not directly
addressed by current interventions, making it more challenging to achieve an overall 90%
reduction in new active TB infections. It is not projected to be feasible to meet the End TB
Strategy 2035 target to reduce TB incidence by 90% over 2015 levels without broader strategies
to address the social determinants of health, such as income, housing, and nutrition, which
significantly impact progression to active TB.
Figure 5 Modelled progress towards 2035 End TB Strategy target for reducing TB-related deaths
by 95% over 2015 levels
Source: Optima TB model output.
Note: SDG = Sustainable Development Goals; TB = tuberculosis.
KEY MESSAGE 5: The optimized resource allocation scenario suggests a need to
significantly increase investment in active TB case finding programs for key populations.
Assuming the same amount of funding for targeted TB programs as for 2019 of 37.1 million
USD remains available each year to 2035, optimizing the budget allocation prioritizes increasing
annual funding for outpatient screening, including regular TB screening for all people living
with HIV at outpatient clinics (currently at 74% coverage), prioritizing case-finding programs
for key populations, such as prisoners and health workers, and increasing funding for treatment
programs to accommodate increased numbers of notifications. Within the limited most recently
reported budget level, additional funding for targeted outreach programs is made possible
through a reallocation of funds from community outreach case finding programs (Figure 6). If
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Findings From an Optima Modelling Analysis
additional resources become available, maintaining, and then expanding community outreach as
well as targeted active TB case finding should be the highest priority (Figure 7).
It is worth noting that data on coverage and yield for testing programs in Mozambique was
limited. As such, global estimates from the literature were used for several key inputs for this
modelling analysis. More data should be collected on the diagnostic yield of different TB case
finding strategies, as well as their differentiated costs, to better inform local best practices in
Mozambique.
Figure 6 Impact of different amounts of expenditure on TB prevalence
Decrease Increase
Ambulatory MDR treatment (short course)
USD 1.4M (325% increase)
Ambulatory MDR treatment (long course)
USD -0.8M (75% decrease)
Active case nding (prisons)
USD 0.5M (475% increase)
Active case nding (community outreach)
USD -4.8M (75% decrease) Active case nding (contact tracing)
USD 1.6M (135% increase)
HIV outpatient screening
USD 1.5M (50% increase)
Preventive treatment (PLHIV)
USD 0.8M (20% increase)
Source: Optima TB model output.
Note: M = millions; MDR = multi-drug resistant; PLHIV = people living with HIV; TB = tuberculosis; USD =
United States Dollar.
Figure 7 Optimizing Mozambique’s TB program funding allocations with increased available
resources
With further
available resources
With an additional
50% TB spending
With an additional
2019 estimated 20% TB spending
spending (Figure 3)
Modeled programs
Expansion of both Expand preventive begin to reach the
outpatient testing therapy for child maximum possible
and preventive contacts of active TB coverage given
therapy for PLHIV cases constraints
Expansion of higher Maintain community Expand active case Explore new
yield active case outreach active case nding through all modalities or
nding modalities nding at 2019 levels, modalities and improvements to the
(contact tracing, in addition to higher available treatment delivery of existing
prisons, health yield active case for drug resistant TB modalities
workers) nding cases
Reallocate spending
away from lower yield
community outreach
active case nding
Source: Optima TB model output.
Note: PLHIV = people living with HIV; TB = tuberculosis.
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Epidemic Projections and Opportunities to Accelerate Control of Tuberculosis in Mozambique
KEY MESSAGE 6: Improved MDR-TB treatment regimens which shorten the treatment
duration and are more acceptable to patients show promise for better MDR-TB outcomes,
as the MDR-TB care cascade shows the largest diagnosis gap.
Diagnosis rates for DS-TB are estimated to be over 80%, but accurate diagnosis of MDR-TB
remains low. Diagnosis rates for MDR-TB are estimated to have improved from 15% in 2015, but
it is estimated that less than one third of new DR-TB cases in 2021 will be diagnosed and will
initiate treatment through an appropriate treatment regimen.
Mozambique already treats all TB patients in an ambulatory setting, which results in reductions
in costs, the impact on patients’ lives, and the risk of hospital-based TB transmission. In
an optimized intervention mix, MDR-TB treatment would receive more funding due to the
increased number of cases diagnosed as a result of increased coverage of active case finding
programs. In-line with WHO guidance, most MDR-TB patients in Mozambique are now treated
with regimens containing bedaquiline, and a shorter course regimen (9–11 months instead of
18–20 months) is being prioritized Figure 8 Modeled MDR-TB care cascade
where suitable for patients. Drug
3.500
costs are higher in the short course
MDR-TB treatment regiment, 3,000 48% TB-related deaths
Incident MDR-TB cases (2021)
however total costs accrued are Undiagnosed recovery
2,500 or loss to follow-up
lower due to reduced costs of
care relative to the longer-course 2,000 Next Stage
regimen. While it is expected 1,500 23%
that the short course regimen
will be non-inferior to the long 1,000 15%
29% 16%
course regimen in treatment 500 19% 69% 69%
outcomes, future policy decisions
0
on the use of MDR-TB regimen Estimated new Noti ed and Treatment
in Mozambique should be closely active cases of initiated Success
Pulmonary TB treatment
monitored, taking into account the
Source: Optima TB model output.
outcomes from ongoing trials.
Note: MDR = multi-drug resistant; TB = tuberculosis.
KEY MESSAGE 7: While COVID-19 has substantially reduced outpatient attendance
and screening, expansion of the Mozambique Local Tuberculosis Response program can
mitigate the impact of COVID-19 on the TB epidemic in Mozambique.
No major disruptions to the availability of TB services were reported in 2020 because of
COVID-19; however, there was a nearly 30% reduction in TB outpatient attendance and a 12%
reduction in TB notifications in Q2 2020 when the reduction in mobility was most substantial.
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Findings From an Optima Modelling Analysis
The impact was distributed unevenly across the country, with more than a 50% reduction in
quarterly TB notifications relative to Q2 2019 in Maputo City, while other provinces such as
Zambezia, which were part of the expanded Mozambique Local Tuberculosis Response program,
had up to a 25% increase in TB notifications relative to Q2 2019. In Q3 2020 during the first
wave of COVID-19 in Mozambique, the national reduction in TB notifications relative to Q3
2019 was 5%, but without the expansion of the Mozambique Local Tuberculosis Response
program this reduction could have been 16% nationally. By Q4 2020, the number of TB
notifications increased by 6% relative to Q4 2019.
Relative to the projected baseline scenario in the absence of COVID-19, it is estimated that active
TB incidence could increase by 1% (0%–3%) or 4,000 (2,000–12,000) additional TB cases, and
TB-related deaths could increase by 7% (2%–17%) or 2,500 (1,000–7,000) additional deaths, over
the five years from 2020 to 2024.
Consistent with planned further expansion of mobile TB services in 2021 via the Mozambique
Local Tuberculosis Response, this modelling suggests that a further 10% increase in total
TB diagnosis (e.g., a 30% increase in active case finding) combined with a 10% increase in
preventive therapy over 12-months would return Mozambique to the pre-COVID-19 trajectory
for the TB epidemic and ‘catch-up’ on lost progress toward the End TB 2035 targets.
Figure 5 Modeled impact of COVID-19-related TB service disruption on TB-related deaths
Source: Optima TB model output
Note: Q= quarter; TB = tuberculosis
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Epidemic Projections and Opportunities to Accelerate Control of Tuberculosis in Mozambique
RECOMMENDATIONS
1. Prioritize and expand active case finding programs
About 74% of people newly enrolled in HIV care were screened for TB in 2017.
Screening all people living with HIV for TB at each outpatient visit will likely
improve TB case detection rates. Healthcare workers, prisoners, and cross-border
miners should be screened annually, as these groups are at higher risk of TB infection
and are relatively accessible.
With limited resources, it is most important to prioritize active TB case finding
including contact tracing in populations with higher TB case yields. With additional
resources, community case finding interventions that already contribute around 25%
of notified cases in Mozambique should also be expanded as they will likely play a
key role in further improving the TB case detection rate in Mozambique
2. Continue expanding ART coverage and reaching 95-95-95 by 2035
Increasing ART coverage has a significant impact on TB incidence amongst PLHIV
and continued expansion of ART care will significantly reduce TB infection. In
addition, further expansion of coverage in TB preventive therapy for people newly
diagnosed with HIV, as well as routine TB screening will significantly reduce
the number of new active TB infections, with the added benefits of making faster
progress towards HIV targets.
3. Explore strategies to address social determinants of health
Existing TB interventions for active case finding and rapid diagnosis will have a
huge impact on the number of new TB cases projected in future years, but these
interventions alone will not directly address the burden of latent TB in Mozambique,
leading to a projection that the End TB Strategy 2035 target of a 90% reduction in TB
incidence over 2015 levels is out of reach under existing TB interventions.
More rapid progress toward this target will require coordination with other health
programs to improve societal enablers such as income, housing, and nutrition in
populations at high risk of TB, to substantially reduce the progression to active TB in
those populations.
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Findings From an Optima Modelling Analysis
ADDITIONAL RECOMMENDATIONS
1. Continue ambulatory-focused care for both DS-TB and DR-TB patients
Avoiding unnecessary hospitalization for care reduces costs without affecting
TB outcomes, provided directly observed treatment (DOT) is in place. This has
added benefits such as reduced burden on hospitals, reduced hospital-acquired TB
transmission, and a reduced financial and economic impact on patients.
2. Increase bacteriological confirmation of TB cases, including drug susceptibility
testing
As 60% of cases are clinically diagnosed, any increase in funding should include
investment in increasing the proportion of TB cases that are bacteriologically
confirmed, by increasing testing done through GeneXpert or other rapid diagnostic
testing. Increasing bacteriological confirmation rates will help to assess true progress
in increasing the TB diagnosis rate and ensuring TB treatment resources are directed
effectively.
3. Maximize the collection and use of routine TB data to inform programming and
policies
Key data sources include tracking TB-specific expenditures, reporting of how TB
cases are identified (by intervention modality including specific key population and
community outreach modalities), and keeping better records of implementation
activities (which are often fragmented). Monitoring and evaluation systems should
be streamlined, and cost and coverage data should be collected for all TB programs
(NTP led and non-NTP led). More comprehensive data collection on active case
finding modalities especially could better inform programmatic decisions.
4. More funding is needed for TB programs in Mozambique
The national 2018/19 TB Prevalence Survey substantially revised estimates of
TB incidence from 551 per 100,000 population to 361 per 100,000 population and
estimates of TB-related mortality from 72 per 100,000 population to 19 per 100,000
population. This Optima TB analysis supports the conclusion that Mozambique has
had significant achievements in its effort to control the TB epidemic. However, the
country’s TB incidence remains amongst the highest in the world. A 50% increase in
available resources to allocate to effective, impactful TB interventions is projected
to bring the End TB target of a 95% reduction in TB related deaths by 2035 within
reach.
National TB Program, Mozambique
Pereira Zindoga, Jorge Jone, Raimundo Machava, Ivan Manhica
World Bank
Lung Vu, Nejma Cheikh, Nicole Fraser-Hurt, Humberto Cossa, Zara Shubber,
Marelize Görgens, David Wilson, Theo Hawkins (content design)
Burnet Institute
Rowan Martin-Hughes, Romesh Abeysuriya, Sherrie Kelly, David Kedziora,
Anna Roberts, David P Wilson
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Epidemic Projections and Opportunities to Accelerate Control of Tuberculosis in Mozambique
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