High childhood TB rates and local hotspots in the Western Cape

Tuberculosis in children remains a critical public health problem in high-burden places, and a new analysis led by Lauren Brown focuses on the Western Cape province of South Africa. The research team used routine health records to study where and how often children and adolescents were diagnosed with TB, how those trends changed over time, and where the health system is failing to follow through. They looked at every TB episode recorded in the Western Cape Provincial Health Data Centre (PHDC) between 2017 and 2023, sorting cases into five-year age groups and comparing paediatric patterns with adult episodes. The investigators also examined key clinical and programmatic factors available in the records — HIV status, drug resistance status, whether microbiological testing was done, how disease was classified, where diagnoses occurred, and outcomes of TB treatment. To estimate gaps in reporting, the team compared episodes found in the PHDC to national notification records. Incidence rates were calculated using mid-year population estimates so the findings reflect diagnosed disease relative to the population at risk.

The study combined a broad routine-data approach with age-specific comparisons and district-level mapping to highlight important findings. In 2023 the rates of diagnosed TB in the Western Cape per 100,000 population were reported as 722.4 for ages 0–4, 189.1 for ages 5–9, 171.2 for ages 10–14, and 523.4 for ages 15–19. Young children aged 0–4 made up 47.9% of all paediatric TB episodes. Patterns varied markedly by place: in the Cape Winelands district in 2023, TB incidence among 0–4-year-olds was about double the rate seen in adults in that district and two to four times higher than the 0–4 rates in other districts. The PHDC data also revealed problems in the care cascade: 17.3% of PHDC-recorded TB episodes were not reported to the national system, and only 70.3% of diagnosed children and adolescents completed TB treatment in 2023. These results come from the PHDC records spanning 2017–2023 and the analyses that assessed HIV and drug resistance status, microbiological testing, disease classification, place of diagnosis, and treatment outcomes.

These findings have clear implications for policy and practice. The heavy concentration of disease in the youngest children and the sharp differences between districts suggest that local social and health-system drivers are shaping where paediatric TB is most severe; simple province-wide averages hide those hotspots. The substantial share of cases that are recorded in the provincial system but not reported nationally, together with treatment completion rates that are well below full success, point to gaps across the paediatric TB care cascade — from detection and reporting to retention and cure. Strengthening integrated data systems beyond traditional TB treatment registers could reduce missed notifications, help health managers target interventions where they are most needed, and ultimately improve prevention and outcomes for children and adolescents. The work highlights that better local surveillance and tailored responses are essential to turn high childhood TB rates around in the Western Cape.