Transcript country xeperience and response to mdr and xdr tuberculosis

COUNTRY XEPERIENCE AND
RESPONSE TO MDR AND XDR
TUBERCULOSIS
PRESENTED AT THE WHO TB/HIV PLANNING MEETING,
ADDIS ABBABA, 11-12, NOVEMBER 2008
BY
MS GUGU SHONGWE
SWAZILAND NATIONAL TUBERCULOSIS CONTROL
PROGRAMME
PRESENTATION OUTLINE
 TB SITUATION IN SWAZILAND
 COUNTRY RESPONSE TO M(X) DR TB
 CHALLENGES
Country situation
 Swaziland has a population of about 1.1 million with
an area of 17 373 Km².
 The country is divided into 4 regions which are
Hhohho, Lubombo, Shiselweni and Manzini.
 According to the WHO Global TB Report of 2008, the
incidence rate of TB in Swaziland is the highest in the
world OF 1155 PER 100,000 population.
 The TB programme faces problems of poor diagnosis
of cases, poor case holding and high defaulter rates.
 The treatment success for new pulmonary smear
positive was 42% while that for all cases (new and
retreatment) was 34%.
 In 2007, 9636 of TB cases were notified.
 79.6% of TB patients are co-infected with HIV
Country efforts to control TB:
focus(1)
 improving the quantity and quality of staff involved in
TB control;
 increasing TB case detection and treatment success
rates with expanded DOTS coverage at national and
lower levels;
 scaling up access to counseling and testing for HIV
among TB patients
 scaling up interventions to manage TB and HIV
together, including increased access to anti-retroviral
therapy for TB patients who are co-infected with HIV;
 Increase investment in laboratory infrastructures to
enable better detection and management of resistant
cases.
Swaziland Experience and
Response: The Emergency Plan
MDR/XDR-TB Task force was formed after XDR-TB was
diagnosed in 2006
The Task force developed an Emergency MDR/XDR
response plan in 2006 and the Objectives of the
emergency response plan for drug resistant TB were:





To Conduct a rapid survey of drug-resistant TB to establish
whether Swaziland has cases of Extreme Multi drug
Resistant TB;
To build capacity of a critical mass of clinicians, Nurses and
TB programme staff to effectively respond to M(X)DR-TB;
To Strengthen and expand current national TB laboratory
capacity to deal with diagnosis for drug resistant TB;
To develop comprehensive DR-TB guidelines that
incorporate collaborative TB/HIV activities
To Declare tuberculosis a national disaster.
Swaziland Experience and
Response: Priority activities
1. Establishment of a case management plan
for patients suspected of M(X) DR, once
identified.
 identification of a facility where these patients
would be admitted/Isolated: a TB hospital has
been built for this purpose
 ensure the availability of N 95 masks to protect
health workers from the infection: N95 masks
were procured and health care workers trained
on their use;
 Fast-track drug susceptibility testing for 1st and
2nd-line anti-TB drugs for such suspects; DST
capacity at the NRL was developed for first line
DST and collaboration established with SA MRC
for second line DST
Swaziland Experience and Response: Develop
MDR-TB guidelines
2. Develop technical guidelines and train health workers
on suspicion, management, follow up and discharge of
Mdr/Xdr TB: Draft Drug Resistant TB guidelines are
under finalization; 60 nurses and 45 doctors have
been trained on MDR-TB in 2008
3. Implement case finding strategies for MDR-TB and
expand the availability and use of culture and DST
for:
 Contacts of known MDR(X)TB patients, including health
care workers;
 All patients being retreated for TB;
 All patients with sputum results remaining smearpositive at 2-3 months;
 All patients failing to improve clinically;
Swaziland Experience and Response: Training on
XDR/MDR-TB
4. Identify and build a data base on all MDR-TB that are
currently under treatment in Swaziland, who are potential
of developing XDR and could be promoting ongoing
transmission; Printing of MDR-TB registers, treatment and
patient cards has been done. Currently 98 MDR-TB
patients are on treatment.
5. Conduct a rapid survey of drug-resistant TB: rapid survey on
XDR-TB was conducted July-Aug 2007 using standardized
protocols developed by WHO, CDC, SAMRC and URC to
assess the presence of M(X) DR-TB in among high risk
patients and contacts. 4 XDR-TB patients were identified.
2 died before initiation of therapy and the other 2 are still
on treatment and doing well
6. Conduct BCC and IEC activities to enhance M(X)DR TB
identification and management: Flyers and other IEC
materials have been developed
Swaziland Experience and
Response
7. Ensure strict control and proper use of firstand second-line anti-TB drugs by following
WHO Guidelines in an effort to prevent
emergence of further drug resistance: drug
management focal person was appointed in
the NTP in June 2007.
 Health care workers were trained on
management of TB pharmaceuticals and
supplies in May 2007
8. Apply to the Green Light Committee for
access to quality second-line drugs
:Application submitted in September 2008
Swaziland Experience and
Response: strengthen lab capacity
9. Strengthen and expand current national TB laboratory capacity:
 Strengthening all aspects of TB laboratory processes,-.
specimen collection and transport, smear microscopy,
culture, drug susceptibility testing (DST), and information
management;
 Establish linkages with a supra national laboratory to
harness capacity for rapid detection resistance to first
second-line anti-TB drugs, and proficiency testing for first
line drugs DST; MRC sends quarterly DST panels
 Implement quality control and quality assurance of the TB
laboratory network according to international guidelines;
NICD has been contracted to support QA
 Fast-track hiring and training of laboratory personnel to
increase capacity for microscopy, cultures and DST and
technical oversight: 2 lab technicians, 6 microscopists
employed
Swaziland Experience and
Response: Infection Control
9. Implement appropriate infection control precautions in
health care facilities, with special emphasis on those
facilities providing care for people living with
HIV/AIDS:
 Develop and implement appropriate institution-level
infection control plans consisting of: Administrative
control measures
 Environmental control measures;
respiratory personal protection equipment:
N95
Draft infection control guidelines have been
developed. A senior nurse attended a 3 day
International training on Infection control in
Botswana in November 2007 and was
expected to conduct the in-country training
Swaziland Experience and Response: MDR-TB
and collaborative TB/HIV activities
10. Implement TB/HIV collaborative activities:
 Provide HIV testing for all TB patients
including MDR-TB patients: Ongoing
 Provide ART to eligible TB HIV positive
patients including MDR-TB patients:
ongoing
 Provide cotrimoxazole for all HIV positive
patients including MDR-TB patients:
ongoing
Challenges










Inadequate follow up and support mechanisms for patients on
MDR-TB treatment
Inadequate contact tracing mechanisms for contacts of MDRTB patients
No protocols for doing cultures for the MDR TB and XDRTB
suspects
Lack of capacity (human resource capacity)
Human resource: Numbers and skills and knowledge on XDRTB
No monitoring and reporting tool to the programme
(surveillance system)
Pill burden creates high default rates and increase occurrence
of side effects
Referral system between the two programmes is weak
(collaborative TB/HIV at facility level still a challenge)
Health workers not utilizing N95 masks
TB has not been declared national disaster