MINISTRY OF HEALTH
National Tuberculosis Control
Programme
Annual Report 2009
September 2010
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Swaziland National TB Control Programme Annual Report 2009
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Preface
Tuberculosis (TB) has become a major threat to the health of the Swazi populace. The
country is not only having the highest TB incidence in the world, but also has one of the
highest TB/HIV co-infection rates where 80% of incident TB cases are already HIV
positive. TB kills an estimated 2,780 people in Swaziland annually mostly within the
most productive age group. Preliminary results of a country wide drug susceptibility
testing survey shows that the prevalence of MDR TB among the new cases is 7.7%
among new TB cases and more than 33.9% among previously treated cases. The
combined effect of HIV and AIDS and tuberculosis has virtually overburdened the health
system, overstrained the limited health personnel and consigned communities to a state of
hopelessness. The double edged epidemic situation seems to be escalating with severe
socioeconomic and developmental consequences unless extraordinary measures are
taken.
The National Tuberculosis Control Program (NCTP) has forged national, regional and
even community based responses to curb the sweeping endemic through introduction of
Directly Observed Treatment Short Course (DOTS), expanded case detection, and
adherence to medication. However, these efforts have been frustrated by the effects of
HIV and AIDS, limited service outlets with adequate equipment and human resources,
and the situation of Multi-drug resistant TB (MDR-TB) and Extensively Drug Resistant
TB (XDR-TB).
To this end, the need for extreme measures has become inevitable to arrest the scourge.
There is need to implement emergency action plan that includes massive community
awareness, increase the qualified human resources, increase rate of case detection and
treatment success, expand TB diagnostic health care centres, decentralization of TB and
HIV care to clinics and communities, and shifting the tasks to low level cadres, scale up
collaborative HIV & AIDS and TB programs interventions, and strengthen prevention,
diagnosis and treatment of drug resistant tuberculosis.
Successfully addressing the TB epidemic is feasible with prompt implementation of
extreme, but proven TB control interventions.
This national strategic plan represents the government’s strategic direction to
comprehensively address the tuberculosis problem on a sustainable basis for which a total
of USD 117m is required to effectively implement. A considerable funding gap remains
to ensure the successful implementation of the plan. We acknowledge the current support
of our partners and hope that with their support, government will meet this gap.
This plan renews our resolve as a nation to fight TB and ensure its elimination as a public
Health problem in the country in line with the MDGs and Stop TB Partnership target of
2015. It is our hope that this plan will translate Government’s vision in this regard.
Hon. Benedict Xaba
Hon Minister of Health
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Foreword
Tuberculosis continues to be a major public health problem in Swaziland. Apart from the
overall number of cases increasing in the last three years the incidence rates have been on
an upward trend as well since 1990. It is estimated that the TB incidence has increased
more than six fold over the last 20 years (1990-2009). Notable variations in TB cases
have been seen among regions especially the densely populated ones where tuberculosis
remains very high. Some population sub-groups are more affected by the disease than
others particularly the economically productive ages 15-44 years giving rise to concerns
over the future of the country’s economy. Similarly, more cases of TB have been
observed among females than males in the overall population of the country. With these
trends more concern is raised over infection control measures and prevention of
transmission to children particularly in women who are breast feeding. In light of these
frightening trends of TB the national TB control programme is therefore, maintaining its
high priority for its work on tuberculosis in support of the ministry of health overall
vision of a healthy and productive Swazi nation.
The annual report differs from previous reports in two key ways. It includes, for the first
time, detailed information on programmatic achievements and strategic direction. The
incorporating of this information will enhance in facilitating public understanding about
the work of the program and act as an advocacy document for resource mobilization.
This annual report also differs in providing not only a summary of surveillance data, but
also examples of the control of tuberculosis in a number of varying circumstances across
the four regions and highlighting some of the key service developments and
achievements for the year under review. This report is intended to be an easily accessible
summary of the occurrence of tuberculosis in Swaziland, for the public and professionals
alike, and to highlight the challenges ahead as well as priority interventions.
On the research front the NTCP has engaged in a drug resistance survey covering the
whole country and preliminary findings of the study would throw light on the impact of
drug resistance in achieving desired treatment outcomes. Such findings will also help in
facilitating learning from in-country situation in contrast to regional situations.
Default, still being a challenge, has been studied on a national scale in different
geographical settings and detailed report is being compiled for submission to the
Directorate General of Health Services.
Mr Themba Dlamini
National TB Control Program Manager
Ministry of Health
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Acknowledgements
The successful completion of the National TB Control Programme (NTCP) Annual report
2009 was made possible by joint efforts of a number of dedicated individuals at facility,
regional and national level. Firstly, I want to thank the Monitoring and Evaluation Unit
within at the central level for their dedication in ensuring accuracy of reported data. I also
like to thank the health workers at regional and health facility levels who recording and
timely reporting of TB data has necessitated the contents of this report. To them I say
keep up the good work and dedication to the call for a healthy Swazi nation.
The focal persons from all the TB diagnostic sites are especially thanked and their
immense contribution to the work of the program acknowledged. I also like to extend my
appreciation to the NTCP writing team: Mr Thabo Hlophe, Ms Siphiwe Khumalo, Ms
Lindiwe Mdluli, Ms Philile Mndzebele, Mr Thabo Kunene and Mr Enerst Nhlengethwa.
We are also grateful to the URC team: Dr Samson Haumba, Ms Cindy Dladla, Futhi
Dlamini and Mr Khisimusi Sibandze and WHO TB specialist Dr Kefas Samson for the
Technical assistance and guidance in writing this report. Special thanks also go to Mr
Sandile Ginindza for reviewing and editing the report prior to publishing, your inputs are
invaluable.
I extend my gratitude to the Government of the Kingdom of Swaziland for the dedicated
commitment to TB control and for providing funds to implement the planned activities. I
would like to recognize, in particular, the support from the following local and
international developmental and implementing partners; World Health Organization
(WHO), University Research Co., LLC (URC), Medicens San Frontiers (MSF), The
Global Fund Against AIDS, TB and Malaria (GFATM), National Emergency Response
Council on HIV and AIDS (NERCHA) and many others for which we are grateful.
Mr Themba Dlamini
National TB Control Programme Manager
Ministry of Health
September 2010
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Swaziland National TB Control Programme Annual Report 2009
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Table of contents
Contents
Preface ............................................................................................................................................ 2
Foreword ........................................................................................................................................ 3
Foreword ............................................................................................ Error! Bookmark not defined.
Acknowledgements ....................................................................................................................... 4
List of abbreviations and acronyms ............................................................................................ 7
Executive Summary ...................................................................................................................... 8
1.
Introduction ........................................................................................................................... 9
1.1
COUNTRY CONTEXT ................................................................................................................... 9
1.1.1
Geography and demographic information.............................................................................. 9
1.1.2
Economy and socioeconomic development ............................................................................. 9
THE HEALTH SECTOR .............................................................................................................. 10
1.2.1
Health status of the population ..............................................................................................10
1.2.2
The Health system ..................................................................................................................10
1.2.3
Organization of health services .............................................................................................10
1.2.4
Human Resources for Health .................................................................................................12
1.2.5
1.2.6. Main Health indicators: ..............................................................................................13
1.2.6
1.2.7. The Tuberculosis situation ...........................................................................................13
1.2
2.
The National TB Control Programme ................................................................................ 14
2.1
2.2
HISTORY AND PROGRAMME STRUCTURE ................................................................................... 14
ORGANIZATION OF TB CONTROL SERVICES .............................................................................. 14
2.2.1
Central Unit ...........................................................................................................................14
2.2.2
Regional Level .......................................................................................................................15
2.2.3
Health Facilities ....................................................................................................................15
2.2.4
The National TB Hospital ......................................................................................................15
2.2.5
Community Level ...................................................................................................................16
2.2.6
Intra-ministerial collaboration ..............................................................................................16
2.2.7
Central Medical Stores (CMS) ..............................................................................................16
2.2.8
National Reference Laboratory (NRL) ..................................................................................17
2.2.9
NTP Partners .........................................................................................................................17
2.2.10 NTP funding...........................................................................................................................17
NTP GOALS, OBJECTIVES AND EXPECTED RESULTS .................................................................. 18
2.3.1
Guiding principle (Relevant development frameworks) ........................................................18
2.3.2
Government Policy on Tuberculosis Control ........................................................................18
2.3.3
Programme Goal ...................................................................................................................18
2.3.4
NTP Strategic objectives........................................................................................................19
2.3.5
The Strategic approach..........................................................................................................19
2.3
3.
Epidemiological progress in TB control ........................................................................... 21
3.1
3.2
TB INCIDENCE, PREVALENCE AND MORTALITY ........................................................................... 21
TB CASE NOTIFICATIONS .......................................................................................................... 21
3.2.1
Notifications by type of TB ....................................................................................................22
3.2.2
Regional distribution of notified TB cases .............................................................................23
3.2.3
TB case notification by age and gender .................................................................................26
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3.3
3.2.4
Notification of childhood cases..............................................................................................27
3.2.5
TB/HIV co-infection ...............................................................................................................27
3.2.6
Notification of Drug resistant tuberculosis............................................................................27
TB CASE DETECTION AND TREATMENT SUCCESS....................................................................... 28
3.3.1
TB case detection rate ...........................................................................................................28
3.3.2
TB treatment success rate ......................................................................................................29
3.3.3
Treatment outcome of TB/HIV patients .................................................................................29
3.3.4
Unfavourable treatment outcomes .........................................................................................30
3.3.5
Monitoring Smear conversion ...............................................................................................30
4.
Progress in implementing the Stop TB Strategy ............................................................. 31
4.1
4.8
HIGH QUALITY DOTS EXPANSION AND ENHANCEMENT............................................................... 31
4.1.1
Government commitment: .....................................................................................................32
4.1.2
TB Diagnosis .........................................................................................................................33
4.1.3
TB treatment and patient support ..........................................................................................34
4.1.4
Procurement and Supply Management (PSM) system for anti-TB drugs ..............................34
4.1.5
Monitoring and Evaluation system and impact measurement ...............................................35
4.1.6
Programme Management and supervision ............................................................................36
4.1.7
Human Resource Development, training and technical assistance. ......................................36
TB/HIV COLLABORATIVE ACTIVITIES ......................................................................................... 37
4.2.1
TB Infection Control ..............................................................................................................38
MDR/XDR-TB PREVENTION AND CONTROL .............................................................................. 38
TB CONTROL AMONG HIGH- RISK POPULATIONS......................................................................... 39
4.4.1
TB in Children .......................................................................................................................40
HEALTH SYSTEMS STRENGTHENING (HSS) INITIATIVES............................................................. 40
ENGAGEMENT OF ALL CARE PROVIDERS IN TB CONTROL .......................................................... 40
4.6.1
Public-Private Mix initiatives;...............................................................................................40
EMPOWERMENT OF PEOPLE WITH TB, AND COMMUNITIES .......................................................... 41
4.7.1
Community participation in TB Care ....................................................................................41
PROGRAMME-BASED OPERATIONAL RESEARCH ......................................................................... 42
5.
Regional scenarios ............................................................................................................. 43
5.1
5.2
5.3
5.4
MANZINI REGION ..................................................................................................................... 43
LUBOMBO REGION ................................................................................................................... 43
SHISELWENI REGION................................................................................................................ 44
HHOHHO REGION..................................................................................................................... 44
6.
Challenges and constraints ............................................................................................... 45
7.
Recommendations and priorities for 2010 ....................................................................... 46
8.
Conclusion .......................................................................................................................... 47
4.2
4.3
4.4
4.5
4.6
4.7
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List of abbreviations and acronyms
AIDS
ART
CANGO
CBCS
CBO
CSO
DHS
DOTS
GDP
HAART
HDI
HIV
HMIS
HTC
M&E
MDGs
MTR
NDP
NDS
NERCHA
NGOs
NSP
PEPFAR
PLWHA
PRSAP
SDHS
STIs
TWGs
UN
WFP
WHO
Acquired Immuno-Deficiency Syndrome
Antiretroviral Therapy
Coordinating Assembly of NGOs
Community Based Care Services
Community Based Organization
Civil Society Organization
Demographic & Health Survey
Directly Observed Treatment, Short-course
Gross Domestic Product
Highly Active Antiretroviral Therapy
Human Development Index
Human Immuno-deficiency Virus
Health Management Information Systems
HIV Testing and Counselling
Monitoring and Evaluation
Millenium Development Goals
Medium Term Review
National Development Plan
National Development Strategy
National Emergency Response Council on HIV and AIDS
Non-Governmental Organizations
National Strategic Plan
President’s Emergency Plan for HIV/AIDS Relief
People Living With HIV and AIDS
Poverty Reduction Strategy and Action Plan
Swaziland Demographic and Health Survey
Sexually Transmitted Infections
Technical Working Groups
United Nations
World Food Programme
World Health Organization
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Executive Summary
This annual report on Tuberculosis in Swaziland is the third such report to be compiled
by the National TB Control Programme. The report presents surveillance data for 2009,
which is essential for informing and strengthening tuberculosis prevention and control
and guiding the strategic direction of the NTCP. A total of 11032 tuberculosis cases were
reported in 2009 in Swaziland, a rate of 1103.2 per 100,000 population. This marked a
12.5% increase from the 9656 cases reported in 2008 which on itself is an achievement
on the part of intensified TB case finding.
A trend analysis of the TB situation in the country in the early 1990s indicates that our
TB incidence has increased more than five folds compared to the 1990 levels. This is
evidence in the 2009 WHO report which put Swaziland as the leading country among
the top fifteen countries in the world with the highest TB incidence. The Manzini region
accounted for the largest proportion of cases (30%) but had a slightly lower rate (1020
cases per 100,000) compared to Hhohho region which accounted for 29% of the cases
with a higher rate of 1127 cases per 100 000 populace.
The majority of TB cases in the country occurred in young adults aged 15-44 years, and
in all the age groups women were more affected than men. Multi-drug resistance
increased in 2009 to such levels that about 15 -20 new drug resistant patients are
enrolled on treatment by the country’s main MDR-TB hospital. This is a very serious
challenge for TB control as it can potentially exceed the annual estimated 200 cases by
WHO. Case detection rates have improved over the years and stood at 78% by end of
the year 2009. Similarly improvements are noted in treatment success rates though the
global stop TB target of 85% treatment success is not yet achieved. The proportion of
cases successfully treated stood at 68%, while most common reasons for not completing
treatment were death (10%), loss to follow up (8%) and treatment failure (7%).
The Ministry of Health and international development partners continue to provide
services to support the national TB programme in tuberculosis control. These
contributions include the provision of laboratory services, exemplified by the delivery of
diagnostic services, leadership in the investigation and control of tuberculosis incidents
especially in managing the new strains of TB which are the multi-drug resistant and
extensive drug resistant, and the provision of support and expert mentorship in data
management and monitoring activities of the NTCP. The NTCP strategic plan 2010-2014
recognized a number of key areas important for the successful control of tuberculosis in
Swaziland. Impact Measurement in monitoring and evaluation has been identified to
drive the research agenda of the NTCP to effectively respond to the epidemic and an
Advocacy Communication and Social Mobilization Strategy aimed at increasing
community support and awareness on TB is being developed for implementation in
2010.
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1. Introduction
1.1 Country context
1.1.1 Geography and demographic information
Swaziland is a small landlocked country situated between South Africa and Mozambique
covering an area of 17,364km2. The country has a predominantly (77%) rural population
of 1,018,449 million inhabitants (CSO, 2007).
Swaziland enjoys a tropical to a near-temperate climate along the western highlands,
which rises to an altitude of over 1,800 metres above the sea level, while the lowveld
areas are generally hot. The country lies in a summer rainfall region. The majority of the
population consists of ethnic Swazis.
The political system in Swaziland is an evolving balance between modern institutions and a
dominant monarchy with extensive powers entrusted in the King. The new Constitution that
became effective in January 2006 provides for separation of powers between the executive,
legislative and judicial arms of government and stipulates various individual rights.
1.1.2 Economy and socioeconomic development
With a GNI per capita income of USD 2,280, Swaziland is classified by the World Bank as a
low-middle income country and therefore placed in the IBRD lending category. However, the
real GDP growth rate has fallen in recent years to 2.8% in 2007. However, despite this
relative high per capita income, income distribution is markedly uneven (GINI index
51% according to PRSAP 2006). Life expectancy currently stands at 32 years, being 56
years in 1986, and 69% of the population living below the upper poverty line of USD 7.2
/capita/month. About 66% of the population live below the poverty line (Swaziland Human
Development Report, 2000) with high rural-urban disparities in access to basic services. For
example, whilst 91% of the urban population has access to safe water, it is only 37% for the
rural population. The per capita expenditure on health for the urban population is 3 times that
for the rural population.
Furthermore, 69% of children between 0-18 years are exposed to chronic hunger, child
labour and other forms of abuse. For girls the situation is further aggravated by teenage
pregnancies, early marriage and prostitution. This depressing picture is made worse due
to the severe impact of the HIV/AIDS epidemic with 24% HIV prevalence among the
general population and 38% of adult women (15-49) infected.
The country’s economy is mostly dependent on agriculture and the associated agro-allied
industrial activities, which includes sugar processing, wood pulp production, food canning etc.
Other agricultural products include corn, citrus fruits, livestock, and pineapple among others.
Manufacturing also contributes a growing share to Swaziland’s GDP.
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1.2 The Health sector
1.2.1 Health status of the population
Communicable diseases contribute the largest share of the burden of disease in Swaziland
with HIV/AIDS and TB rates the highest in the world. Some 58.000 people are in need of
ART treatment, but currently 52% (some 30.000) receive treatment in 32 health facilities
(out of the total 223 facilities).
1.2.2 The Health system
The Swaziland health system consists of three main levels namely primary, secondary and
tertiary with Primary Health Care (PHC) as the underlying principle. The primary level of care
consists of clinics, out-reach services and community-based delivery of care and support, while
the secondary level comprises of health centres that provide out-patient and in-patient services
and serve as referral points for the primary level. The tertiary level of care consists of regional
hospitals, specialized hospitals and the national referral hospital.
The Ministry of Health operates has a National Health Sector Strategic Plan 2008 to 2013,
which is currently being implement.
1.2.3 Organization of health services
The health care delivery system consists of both formal and informal sectors. The formal sector
consists of both public and private service providers including NGOs, mission, industry health
services and private practitioners, while the informal sector consists mainly of traditional and
other complementary or alternative health care providers.
At the apex of the organization of the health system is the Ministry of Health with its
departments and units. The internal organization is currently under revision by the Prime
Minister’s Office. A new structure has been proposed and being finalized for
Operationalization. The ‘operational branch’ of MOH is situated in the 4 Regional
Offices, headed by a Health Administrator and supported by the Regional Health
Management Team (RHMT).
The service delivery system itself is loosely organized into a three-tier system including
(i) three national (referral) and five regional hospitals (total some 1800 beds); (ii) Primary
Health Care services, being composed of Health Centres (HCs) 1, Rural Clinics2 and a
network of outreach sites and (iii) Community Based Care, where Rural Health
Motivators (RHM), Traditional Births Attendants (TBAs), Home Based Care (HBC)
volunteers and traditional practitioners provide care, support and treatment.
According to the Service Availability Mapping study (SAM, November 2008), the
majority of the Swazi population (85%) is within a range of 8 km for a health facility.
However, there are a variety reasons to suggest that coverage may be lower than
generally assumed, with particular differences noticed if a range of 5 km is used
1
Health Centres in general have between 20-60 beds and should have a Public Health Unit
(PHU). It is unclear whether they should have a functional operating theatre. There are five HCs
in the country (see map).
2 Clinic Type A does not have a without maternity unit, while Clinic Type B has a maternity unit.
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(recommended by the WHO). Low coverage may also be attributable to the type of health
facility and transport availability; there are only 5 health centres in the whole country and
most clinics provide only out patient care, with few maternity units or labs. The
functionality of these facilities can also limit access, for example through lack of drugs or
staff. In addition, with on average only some 45% of health facilities under the public
sector (and 23% operated by the private-for-profit sector), equity and accessibility of the
(rural) population remain important issues on the policy agenda. The two tables below
provide some relevant background.
Table . Distribution of hospitals, Health Centres and Clinics by region
REGIONS
POPULATION GENERAL HEALTH CLINICS TOTAL HF/
HOSPITAL CENTRES Type
NO OF 100.000
A/B
HF
HHOHHO
282.734
2
2
62
64
22.6
LUBOMBO
207.731
1
2
43
45
21.7
MANZINI
319.530
2
0
80
80
25.0
SHISELWENI
208.454
1
1
33
34
16.3
TOTAL
1.018.449
6
5
218
223
21.9
HF = Health Facility, being HCs + Clinics
Note: Public Health Units (7) exist in most HCs and in all Hospitals
Table . Ownership of health facilities by region
REGIONS
Public
Industry Facilities NGO Private
Private TOTALS
Sector
(Doctor) (Nurse)
(Clinic +
HC)
HHOHHO
24+2
4
11
4
19
0
64
LUBOMBO
8
7
0
4
3
45
21+2
MANZINI
28+0
15
12
4
18
3
80
SHISELWENI
1
3
4
3
0
34
22+1
TOTAL
95+5
28
33
12
44
6
223
Percentages %
45%
12%
15%
5%
20%
3%
100%
HF = Health Facility, being HCs + Clinics
Note: Public Health Units (7) exist in most HCs and in all Hospitals
From a functional perspective, 172 HF provide ANC (77%); 137 provide PMTCT (61%);
70 HF provide ART (31%) and 170 provide AIDS testing and counselling (70%). SAM
identified 204 doctors (40% Swazi; 20/100,000) and 1778 Nurses (90/100,000).
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The health service indicators are summarized in table below:
Indicator
Hhohho
Lubombo
Population
# Health facilities
40
35
Health facilities per 100,000 12
14
pop
Facilities with in-patient 9
9
beds
# in-patient beds
363
302
In-patient beds per 100,000 115
121
pop
Doctors per 100,000 pop
17
6
Nurses per 100,000 pop
70
52
Midwives per 100,000 pop
72
47
Estimated population growth
rate
Source: MOH Service Availability Mapping 2006
Manzini
Shiselweni Total
52
14
27
11
154
13
14
4
36
813
226
257
106
1755
148
10
57
80
5
41
46
10
56
64
Functionally, the public health system is decentralized from the central ministry to the four
Regional Health Offices (RHOs) in Hhohho, Lubombo, Manzini and Shiselweni. The central
level performs executive and administrative functions as well as providing strategic direction
and guidance on delivery of essential health care package at all service delivery levels.
The Regional Health Offices are headed by Regional Health Administrators (RHAs) and
supported by Regional Health Management Teams (RHMTs) whose main mandate is to
provide technical leadership in execution of MOH policies. The RHMT is also responsible for
planning, monitoring and supervision of all health related activities within their respective
regions.
At the community level, a network of community health workers exists, which consists of
Rural Health Motivators to promote community participation in health activities at that level.
Health committees are also in place to assist in the general management of health care facilities.
It is estimated that 85% of the population in the country currently lives within an 8km radius of
a health facility, while nationally about 20% of the population have limited or no access to a
health facility with the rural poor worst affected. In spite of the apparent reasonable physical
access to health services in comparison to other countries, quality of health care remains a
challenge owing to the high disease burden, chronic shortage of human resources for health,
deteriorating infrastructure, inadequate budgetary allocation and weak support supervision
systems.
1.2.4 Human Resources for Health
The health sector faces a severe Human Resource (HR) shortage across all cadres and at all
levels of the health system. The doctor to patient ratio is 1.8 per 10,000 while the nurse to
patient ratio is 28 per 10,000.
In terms of health sector human resource development, the country has three local training
institutions for health professionals namely the Faculty of Health Sciences of the University of
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Swaziland, the Nazarene College of Nursing and the Good Shepherd Nursing School. While
the University of Swaziland Faculty of Health Sciences trains 70% of professional nursing
cadres in community, medical and surgical nursing, while the Nazarene college accounts for
the remaining 30% of professional registered nurses training. The Good Shepherd nursing
school has an output of about of about 40 nurses annually. Training facilities do not exist for
the rehabilitation therapists, radiographers, laboratory technicians and biomedical engineering
technicians. The Faculty of Health Sciences is planning to establish the training of Clinical
Officers, Pharmacy technicians as well as Dental therapists. Currently cadres such as Medical
Doctors, are sent for training outside the country, who invariably fail to return to work in the
country.
1.2.5. Health Expenditure
Approximately 3.8% of the country’s GDP is spent on health care (including private) of which 60% comes
from the exchequer. Public expenditure on health accounts for 2% of the GDP, and the expenditure as a
proportion of total government spending is currently 11.5%, which is just slightly short of the Abuja target of
at least 15%. Furthermore, more than 70% of the MOH budget is spent on curative services and only 30% on
the preventive arm.
1.2.5
1.2.6. Main Health indicators:
The country faces a major HIV/AIDS challenge which has impeded improvement in health outcomes despite
increased investment in health. The country has an HIV sero-prevalence of 26%, which is the highest in the
world as well as high TB incidence of 1,198 cases per 100,000 population (WHO 2009).
The main health indicators are summarized in table below:
Indicator
Life expectancy
Rate of new HIV infection per year?
Infant Mortality Rate
Under 5 Mortality Rate
Maternal Mortality Ratio (MMR)
% of households with access to safe water
% of households with access to proper sanitation
TB incidence
Current value
2008
32.7 years
3%
85/100 live births
120/1000 live births
589/100,000 live births
59%
52%
1,198/100,000 pop
Target
2013
42 years
<2.3%
65/100 live births
78/1000 live births
295/100,000 live births
80%
80%
724/100,000 pop
1.2.6 1.2.7. The Tuberculosis situation
With an estimated TB incidence of 1,198 per every 100,000 of its population, Swaziland
leads 15 countries of world with the highest estimated TB incidence (WHO Global
Tuberculosis Report 2008). Compared to a 1990 level of 267, TB incidence has increased
five-fold since then, while the incidence among the infectious sputum smear positive
cases tripled within the same period. Similarly, TB mortality has increased from 76 per
100,000 in 1990 to 278 in 2006. In terms of prevalence of disease, the rate of 1,084 TB
cases per 100,000 in the country translates to about 10,840 prevalent TB cases at any
point in time. Similarly, the mortality figure translates to about 2,780 deaths annually due
to TB alone; and an estimated 17,000 TB-related deaths by 2015 if drastic actions are not
taken.
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2. The National TB Control Programme
2.1 History and programme structure
The National TB Control programme was established 40 years ago during which time it
evolved from a clinical service oriented set up to a public health program charged with the
responsibility of planning, implementation, monitoring and evaluation of TB control services in
line with the global and regional strategies.
The National Tuberculosis Programme is structured at three levels namely the National,
regional and facility levels; and operates under the Director of Health Services of the
Ministry of Health, which is in turn under the responsibility of the Principal Secretary
and the Honourable Minister (see annex). Technically, the National TB Programme
Manager is assisted by 4 regional coordinators, a DOTS focal point, TB/HIV focal point,
an M&E Officer and a Pharmacist. Currently, there is no focal point person for
MDR/XDR-TB. The national TB Hospital is staffed by 2 Medical Officers, 2 Matrons, 50
nurses, an Administrator and support staff.
The regional coordinators supervise the activities of DOTS officers at the facility level,
who in turn support the adherence officers and treatment supporters. The regional
coordinators are part of the Regional Health Management Teams (RHMT) of the
respective regions. The Regional TB Coordinators directly supervises the DOTS Officers who
are responsible for TB case registration and treatment in health facilities. At community level
the community DOT supporter reports to the DOTS officers.
At community level, various stakeholders including CHWs, CSOs, NGOs, CBOs, TB
Treatment Supporters and Traditional Healers etc in their varying capacities deliver TB care in
close collaboration with the regional team.
The programme is supported by technical and financial partners including the World Health
Organization (WHO), University Research Corporation (URC), Italian Cooperation, Médecins
sans Frontières (MSF).
2.2 Organization of TB Control services
2.2.1 Central Unit
The main roles of the National TB Programme at central level include the following:
i. Make policies and plans, and secure budgets for the NTP
ii. Coordinate the NTP, including all governmental and non-governmental
organizations working in TB control
iii. Plan for anti-TB drugs and supplies for patient management;
iv. Prepare training programmes for health workers involved in the NTP
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v. Monitor, procure and distribute supplies for the NTP (drugs, equipment,
documentation, health education materials)
vi. Prepare and develop reporting standards
vii. Coordinate national TB surveillance activities
viii. Supervise NTP activities at the Regional level
ix. Conduct research for promotion of the NTP
x. Plan for TB laboratory equipment and reagents;
In order to effectively perform these roles, the central level is supported technically by
WHO and other technical partners.
2.2.2 Regional Level
The regional TB control activities are essentially part of the regional health plan, which is
coordinated through the Regional Health Management Teams (RHMT) with the regional
TB Coordinators as focal points. However, the Central Unit of the National TB
Programme provides technical support and capacity building to that level. Capacity
building being a major prerequisite for successful implementation of TB control at all
levels, staff will be trained in all aspects of TB diagnosis and treatment, recording and
reporting, and importantly, procurement and distribution of drugs, reagents and other
materials. Regions will be responsible for all training at that level, with facilitation by the
Central Unit. The Regional coordinators are therefore responsible for planning and
budgeting for training of different cadres. The central level as well as regional medical
officers may facilitate such trainings. The RHMT will be responsible for supervising
clinics and health centres and the implementation of TB control activities through the
regional TB coordinators.
2.2.3 Health Facilities
Currently, there are 20 health facilities consisting of regional government hospitals,
health centres, mission hospitals, industry health services as well as private practitioners
providing TB diagnostic services in the country, while about 140 clinics provide only
continuation phase treatment. Each of the diagnostic sites has a focal point referred to as
the TB nurses who sees the majority of TB suspects and clients, requests for direct
sputum microscopy, diagnose smear positive cases, and refer others as appropriate for
confirmation of diagnosis by a medical doctor. A DOTS adherence officer, stationed in
each diagnostic site and equipped with a motorbike is responsible for following up
patients, and where community-based TB care has been introduced, in supervising
community DOT supporters.
2.2.4 The National TB Hospital
The national tuberculosis hospital is responsible for specialized management of
tuberculosis that includes drug resistant tuberculosis. It is equipped with highly skilled
professionals and will be responsible for implementing the clinical components of the
drug resistant tuberculosis guidelines. The admission criteria to the TB hospital are as
follows:
All confirmed MDR cases will be admitted for a minimum of 4 weeks but maybe
prolonged for up to even more than 6 months if clinically indicated. The referring health
facility should inform the outpatient department of the TB hospital before transporting
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the patients for admission. Transport for clients referred to the TB hospital shall be
arranged by the national TB referral hospital.
The main indications for hospitalization include the following:
 Initiation of treatment
 Adherence problems
 Clinically deteriorated patients
 Severe adverse effects
 Patients that are confined to bed;
 Vulnerable patients e.g. disadvantaged-orphan, mentally , socially or
physically handicapped
All confirmed XDR-TB patients will be admitted and managed in isolation until
sputum culture conversion.
2.2.5 Community Level
The NTP currently works with community-based organisations (CBOs) wherever
possible to assist in the early identification of persons with signs and symptoms of
tuberculosis. The NTP also intends to engage traditional and non-traditional partners to
assist with the provision of community-based TB care. The home-based care networks
for HIV/AIDS have provided a unique opportunity to expand the control of tuberculosis
in the community through the Rural Health Motivators. Currently about 70% of the TB
patients on treatment are being supervised by community treatment supporters.
2.2.6 Intra-ministerial collaboration
The NTP and the National AIDS Programme (SNAP) are housed in separate locations at
national level, hindering close collaboration in planning and implementation of
collaborative programme activities. Both programmes should share their comparative
advantages to their mutual benefit. E.g., the NTP’s experience in directly observed
treatment, recording and reporting can be valuable to the SNAP in implementation and
effective monitoring of the ART programme. The latter in turn can assist the NTP with its
wealth of experience in advocacy, communication, education and multi-sectoral
collaboration.
Since currently about 80% of TB patients are also co-infected with HIV, the NTP can
significantly contribute to increasing access of ART by ensuring screening of all TB
suspects and patients in all TB sites. Similarly, mainstreaming of TB activities in
HIV/AIDS planning and management is essential, as is providing HIV/AIDS prevention,
care and support activities to people with TB disease. To this end, the NTP should closely
collaborate with NGOs, CBOs, FBOs and other organisations that provide home-based
care services, which will in turn contribute to expanding community-based TB care. The
national TB programme also has a functional collaboration with the National Malaria
Control Programme (NMCP)
2.2.7 Central Medical Stores (CMS)
To ensure an uninterrupted supply of quality-assured first and second line anti-TB drugs,
the national TB programme has established collaboration with the Global TB drugs
facility (GDF) as well as the WHO Green Light Committee mechanism (GLC). The
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Global Drug Facility (first-line TB drugs) and Green Light Committee (Second-line TB
drugs) are part of the Stop-TB Partnership.
In order to ensure an effective supply chain management system, the programme
collaborates actively with the Central Medical stores (CMS) and has a dedicated
pharmacist.
2.2.8 National Reference Laboratory (NRL)
Effective laboratory services are critical to a successful TB control programme. The
national TB laboratory network consists of 16 sites under the leadership of the National
TB Reference Laboratory (NRL), which operates under the overall national laboratory
complex in the capital Mbabane. The NRL has established collaboration with the Medical
Research Council (MRC) and the National Institute for Communicable Diseases (NICD)
laboratories in the Republic of South Africa (RSA) which serves as the Supra-National
Reference Laboratory (SNRL). The NRL has capacity for routine microscopy;
mycobacterium culture and Drug Susceptibility Testing (DST) for first line anti-TB drugs
(FLD), while the other 15 laboratories provide direct sputum smear microscopy services.
The NRL is also responsible for maintaining national quality control as well as capacity
development for all laboratory staff.
The national TB programme has established a strong collaboration with the NRL to
facilitate quality TB diagnostic services.
2.2.9 NTCP Partners
The national TB Programme collaborates with technical and financial partners within and
outside the country. The technical partners include the World Health Organization, the
University Research Corporation (URC), Italian Cooperation, Médicens sans Frontières
(MSF) and the Royal Netherlands Tuberculosis Foundation (KNCV). The NTP has
numerous implementation partners who recently transformed into an umbrella body
referred to as the Swaziland Stop TB Partnership. The members of the Swaziland Stop
TB partnership include Good Shepherd Hospital, The Nazarene, Catholic Health
Services, Cabrini Ministries, FLAS and many others who are implementers in TB
control.
2.2.10 NTP funding
The national TB Programme is funded mostly by the Swaziland Government with
additional funds from the Global Fund (GFATM). The programme has an established
budget line that covers human resources, first and second line anti-TB drugs and
administrative costs. PEPFAR through the University Research Corporation (URC)
provides funding for TB/HIV care and treatment quality improvement programme.
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2.3 NTP Goals, objectives and expected results
2.3.1 Guiding principle (Relevant development frameworks)
The goals and objectives of the national TB programme as envisaged in the Strategic plan
are consistent with national aspirations as enshrined in the countries Poverty Reduction
Strategy Paper (PRSP), the World Health Organization’s Stop TB initiative and the
Millennium Development Goals (MDGs) of the United Nations (UN).
2.3.1.1
UN Millennium Development Goals (MDGs)
Among the UN Millennium Development Goals are two broad targets for global TB
control: by 2015, to have halted and begun to reverse the incidence of TB, and between
1990 and 2015, to halve TB prevalence and deaths rates, which targets can only be
attained if the targets for global TB control of 85% case detection and 70% treatment
success of new smear-positive positive TB patients are reached and maintained. This
requires increased political commitment and financial resources, as called for by the
Amsterdam Declaration to Stop TB of March 2000 and the World Health Assembly
(WHA) resolution of May 2000. MDG Target 6.C: Have halted by 2015 and begun to
reverse the incidence of malaria and other major diseases
 Indicator 6.8: Incidence, prevalence and death rates associated with tuberculosis
 Indicator 6.9: Proportion of tuberculosis cases detected and cured under DOTS
(the internationally recommended strategy for TB control)
2.3.1.2




Stop TB Partnership targets
By 2005: At least 70% of people with sputum smear-positive TB will be
diagnosed (i.e. under the DOTS strategy), and
at least 85% cured. These are targets set by the World Health Assembly of WHO.
By 2015: The global burden of TB (per capita prevalence and death rates) will be
reduced by 50% relative to 1990 levels.
By 2050: The global incidence of active TB will be less than 1 case per million
population per year.
2.3.2 Government Policy on Tuberculosis Control
It is the policy of the Government of Swaziland to provide free TB services which
includes investigations of suspected TB cases and TB contacts in health facilities, and
provision of anti-tuberculosis drugs to all confirmed cases.
2.3.3 Programme Goal
To reduce TB-related morbidity and mortality to such an extent that the disease no longer
a public health problem to the Swaziland nation.
2.3.3.1
NTP Mission Statement.
The mission of the NTCP is to provide effective national leadership in the country’s
response to the tuberculosis problem that will result in halting the epidemic, reducing
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mortality; and significantly mitigating the socioeconomic impact of the disease on the
population thereby ensuring a healthy and productive Swazi nation.
2.3.3.2
NTCP Philosophy
NTP philosophy is to ‘access for all’ which aims to ensure equitable access to the highest
possible quality of TB, TB/HIV and MDR-TB services to all without any form of
discrimination on the basis gender, status, ethnicity or creed. It incorporates partnership
with patients, communities and all providers to deliver patient-centred, cost-effective and
sustainable services to all those in need.
2.3.3.3
NTCP Value Statement
Swaziland being a member state of the World Health Organization endorses the values
and principles of Health for all as a way of improving the health of individuals, families
and communities. NTP will thrive to ensure equitable access to quality, integrated
patient-centred TB and TB/HIV services to all populations, to be delivered with integrity,
accountability and uttermost respect for the rights of individuals, patients, families and
communities.
2.3.4 NTCP Strategic objectives
The National TB Programme shall within the framework of the global Stop TB Strategy
aim at achieving the following strategic results by 2014
1. Treatment success (cure + completion) rate increased from 58% to 85% for
patients with smear-positive tuberculosis by 2014;
2. Case detection of patients with smear-positive tuberculosis increased from 55% to
70% by 2014;
3. Adequate and competent human resources for TB control in place at all levels;
4. All PLHA and PLTB have access to care and support services for TB and
HIV/AIDS in all health care facilities and in the community by 2012;
5. Adequate capacity for operational research and epidemiological surveillance
created for programme management by 2012;
6. Improve the level of knowledge on tuberculosis disease and services for improved
health-seeking behaviour and treatment adherence by 2014.
2.3.5 The Strategic approach
The current NTCP Strategic approach is based on the effective implementation of the
Stop TB Strategy as a means of achieving the Millennium Development Goals (MDG s)
for TB control.
The national Strategic Plan covers the period 2010-2014 consisting of the following
strategic components:
1. Pursuance of high quality DOTS
a. Government commitment
b. Detection by quality-assured bacteriology
c. Standardized case management
d. Un-interrupted supply of quality-assured drugs
e. M&E that enables outcome measurement
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2.
3.
4.
5.
6.
Address TB/HIV and MDR-TB
Contribute to Health system strengthening
Engage all care providers
Engage patients and communities
Enable and encourage research
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3. Epidemiological progress in TB control
3.1 TB Incidence, prevalence and mortality
WHO currently estimates that Swaziland has a TB incidence of 1,198 per 100,000 of its
population, and leads 15 countries of world with the highest estimated incidence globally.
Compared to the 1990 estimate of 267 all forms of TB cases per 100,000 population, the
current figure represents five-fold increase (Fig 1). Within the same period, the incidence
of infectious sputum smear positive pulmonary TB cases has more than tripled. Currently
tuberculosis accounts for about 10% of in-patient morbidity in the country.
Figure 1:
Rate per 100,000 population
Trend of estimated TB incidence 1990 to 2009
1400
1200
1000
800
600
Estimated incidence
400
200
0
Year
The current estimated TB prevalence is put at 812 TB cases per 100,000 compared to the
1990 level of 629 per 100,000 population. Similarly, TB-related mortality has increased
from 76 per 100,000 in 1990 to the current level of 317 per 100,000 population. This
mortality figure translates to about 2,780 deaths annually due to TB alone. Current MOH
statistics show that 20% of in-patient deaths are attributable to tuberculosis.
Attainment of the MDG goal 6 target 8 by 2015 for TB in Swaziland translates to: 1)
reduction of current incidence level to below 135/100,000; 2) reduction of the current
prevalence to below 315 per 100,000 population; and 3) reduction of the mortality to
below 158 per 100,000 population. Given the current levels, achievement of the MDG
targets may not be realized. However, intensified efforts are required to substantially
reduce the impact of TB in the country over the next coming years.
3.2 TB case notifications
In 2009, a total of 10,038 new and relapse and 994 other previously treated TB cases
giving a total figure of 11,032 cases. This gives a notification rate of 912/100,000
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population. Of the 10,038 new and relapse cases, 3,978 (39.6%) are new sputum smear
positive, 2,193 (21.8%) pulmonary smear negative, 1,964 (19.6%) pulmonary TB cases
without diagnostic smear result, and 1,903 (19%) extra-pulmonary cases. The
notification rate for sputum smear positive TB cases is 318/100,000 population.
Compared to 9,565 notified in 2008, the figures of 2009 represent a 5% increase in all
notifications.
Figure 2:
900
800
700
600
500
400
300
200
100
0
CNR
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
Rate per 100,000 population
Trend of TB case notifications 1990 to 2009
Year
3.2.1
Notifications by type of TB
Figure 3:
Figure 4:
National TB notifications by type
- 2008
National TB notifications by
type - 2009
PTB pos
18%
6%
PTB-Neg
PTB-snd
32%
1%
2%
Relapses
5%
Failure
19%
16%
PTB pos
17%
7%
32%
PTB-snd
1%
1%
4%
After Default
EPTB
18%
PTB-Neg
Relapses
20%
Failure
After Default
The breakdown of notifications by type of TB (in fig above) shows slight increase in the
numbers across all types in 2009 compared to the situation in 2008. While the proportion
of new smear positive PTB cases has remained same at 32% in 2008 and 2009, the
proportion of PTB negative cases has increased from 16% in 2008 to 20% in 2009, which
may be explained by the high HIV co-infection rates. Of particular concern is the high
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Swaziland National TB Control Programme Annual Report 2009
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proportion (19%) of pulmonary TB cases diagnosed without sputum smear result (19% in
2008, and 18% in 2009, which may point to inadequate access to or use of sputum smear
microscopy in the diagnostic process. The proportion of retreatment cases among all
notified in 2009 was 13%, which represents a decline over the figure of 15% in 2008.
However, it underscores the need to continuously assess for development of MDR-TB.
The proportion of retreatment cases in 13% showed a decline from 15% in 2008.
Figure 5:
%
Proportion of retreatment cases among all TB notified cases
2007-2009
16%
14%
12%
10%
8%
6%
4%
2%
0%
2007
2008
2009
2007
2008
2009
Year
3.2.2 Regional distribution of notified TB cases
The four regions of the country seem to be equally affected by TB as annual notification
figures show almost even distribution of cases among the regions. In terms of numbers,
30% of all cases are notified from Manzini, 29% from Mbabane, 24% from Shiselweni
and 17% from Lubombo region. However, in terms of notification rates, the picture is
different.
TB case notification rates by region 2008
Region
Hhohho
Lubombo
Manzini
Shiselweni
Total
Population
282,734
207,731
319,530
208,454
1,018,449
Sm+
697
532
1,184
695
3,108
All cases
2,483
1,975
2,949
2,249
9,656
CNR Sm+
210
214
329
288
263
CNR All
748
793
819
932
817
All cases
3,186
1,887
3,259
CNR Sm+
254
221
352
CNR All
960
757
905
TB case notification rates by region 2009
Region
Hhohho
Lubombo
Manzini
Population
282,734
207,731
319,530
Sm+
844
550
1,268
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Shiselweni
Total
208,454
1,018,449
826
3,488
2,700
11,032
342
295
1,119
933
Figure 6:
Distriburion of TB cases among regions
24%
29%
Hhohho
Manzini
Lubombo
Shiselweni
17%
30%
From the Case notification rates, which can be considered a proxy measure of TB
incidence, the Shiselweni region, with CNR for all cases 1,119/100,000 population and
342/100,000 for pulmonary smear positive cases, has the highest burden of the disease in
the country. This is closely followed by Manzini region which has 905/100,000
population for all TB cases and 352/100,000 for pulmonary smear positive cases. This
indicates that, in terms of the case notification rate for smear positive TB cases, Manzini
has the highest burden in the country, while Shiselweni has the highest notification rate
for all cases. Lubombo region has lower rates compared to the other regions in the
country with 757/100,000 population for all TB cases, and 221/100,000 for pulmonary
smear positive cases. Nonetheless, this is still very high compared to the 300 cases per
100,000 population benchmark for high incidence set by WHO AFRO.
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Swaziland National TB Control Programme Annual Report 2009
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Figure 7:
Figure 8:
TB Case notification rate per 100,000
population:
All cases by Region 2009
TB Case notification rate per 100,000
population:
PTB positive cases by Region 2009
Key: TB Case notification rate per 100,000 population
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3.2.3
TB case notification by age and gender
Figure 9:
2008: Distribution of new smear
positive TB cases
by age and sex
800
Cases
600
400
Male
200
Female
0-4
5-14 15-24 25-34 35-44 45-54 55-64
65+
Age group
Figure 10:
2009: Distribution of new smear
positive TB cases
by age and sex
800
Cases
600
400
Male
200
Female
0-4
5-14 15-24 25-34 35-44 45-54 55-64
65+
Age group
The age group 15-45 yrs account for 81% and 82% of all newly diagnosed sputum smear
positive tuberculosis cases in the years 2008 and 2009 respectively. This indicates that
the impact of the disease is on the most productive segment of the Swazi population who
are also worst hit by the prevailing HIV epidemic. Furthermore, females are
disproportionately affected within this age group especially before the age of 35 years.
From age of 35 years onwards, there seems to be a reversal of the male : female ratio
with men tending to be more affected.
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3.2.4 Notification of childhood cases
In 2009, the total number of cases reported for childhood tuberculosis (0-14 years) was
1115 which is 10% of all notified TB cases similar to the previous year’s TB notification
of childhood TB (number?). Of the children who are new smear + 68% were female and
32% were males, indicating an increase of 9% from the previous year.
Figure 11:
Childhood TB from 2006 to 2009
0-4 years
5-14 years
580
554
438
411
460
535
451
67
Year 2006
Year 2007
Year 2008
Year 2009
3.2.5 TB/HIV co-infection
The country’s current HIV prevalence rate of 26% (MOH 2009) is also the highest in the
world, and currently 80% of incident TB cases are also co-infected with HIV.
Recognizing that HIV positive individuals have a 50% life-time risk of contracting TB,
the situation will influence further development of new TB infections.
3.2.6
Notification of Drug resistant tuberculosis
WHO estimates about 200 cases occurring annually, 10% of which may be the
extensively drug resistant (XDR-TB) strain. So far the country has detected 317 MDRTB patients registered on treatment with 5 confirmed XDR-TB cases since the rapid
assessment conducted in 2007. Despite limited laboratory capacity, the country still
detects on average 15 to 20 new MDR-TB cases per month, a situation that if left
unchecked will escalate to disastrous levels in view of the high death rates associated
with the disease, the risk of developing the Extensively Drug Resistant strains, as well as
the potential to transmit resistant strains directly to any individual in the communities. A
substantial number of Poly Drug Resistant (PDR) Cases have also been recorded within
the same period with potentials to becoming MDR or XDR-TB cases.
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Figure 12:
Drug resistant TB cases registered 2006 to 2009
200
Cases
150
100
MDR
50
PDR
0
2006
2007
2008
2009
Year
3.3 TB Case detection and treatment success
3.3.1 TB case detection rate
The National TB Control Program recorded progress in improving TB case detection and
treatment outcomes for infectious sputum smear positive tuberculosis cases. While the
TB case detection rate improved from 35% in 2002 to 61% in 2008, the treatment success
rate improved from 42% in 2003 to 58% in 2007 cohorts. However, a lot still needs to
done in view of the universal access as recommended by the World Health Assembly in
2009 (WHA 62.19).
Figure 13:
Trend in sputum smear positive TB
Case detection performance
100
80
%
60
CDR
40
20
0
2001
2002
2003
2004
2005
2006
2007
2008
Year
Fig. 8: Swaziland’s performance in successful treatment of infectious TB cases
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3.3.2 TB treatment success rate
The management of TB in Swaziland continues to improve by the year, shown by
treatment success which combines the cured cases and those who complete treatment but
do not have smear at the end of treatment. Treatment success in the last 3 years lie lowly
at 42% for a cohort registered in 2006 rising to 58% for a cohort notified in 2007, and
continued to rise to 68% for the cohort notified in 2008.
Figure 14:
Trend in TB treatment success performance
100
90
80
70
%
60
50
40
TSR
30
20
10
0
2001
2002
2003
2004
2005
2006
2007
Year
There is significant increase in the cure rates among new smear positive cases from 36%
for the cohort registered in 2007 to 50% for the cohort registered in 2008. With
completion rate it decreased from 22% for the cohort registered in 2007 to 18% for the
cohort registered in 2008, this could be attributed to the strong emphasis on the sputum
testing resulting to a number of evaluated clients, decentralization of TB services,
integration of TB/HIV activities, implementation of the DOTS and training of health care
workers. Smear not done at the end of the treatment period remains a major challenge to
address in the programme.
3.3.3
Treatment outcome of TB/HIV patients
Treatment outcome among TB/HIV co infected clients had a treatment success of 62%
compared to 12% death rate, 7% defaulter rate and 7% failure rate and transfer out at 6%
and the not evaluated 6% among the TB/HIV co infected. With the above observation TB
remains major cause of mortality among HIV positive patients.
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HIV+ TB patients tend to have more commonly ssm- and EPTB, therefore need to also
report on those TB types, not only ssm+.
3.3.4
Unfavourable treatment outcomes
Table 1: Unfavourable treatment outcomes among new smear + case registered in 2008
per region
Region
Manzini N=1227
Lubombo N=589
Hhohho N=709
Shiselweni N=691
National N=3213
Death rate Defaulter rate
Transfer out rate
Failure rate
9%
10%
2%
9%
10%
9%
7%
5%
7%
9%
1%
8%
14%
4%
1%
8%
10%
8%
3%
7%
The trend in death rate in cases registered in 2007 increased from 7% to 10% for case
registered in 2008 nationally which could be attributed to improve reporting. There has
also been a substantial decrease in defaulter rates from 11% to 8% due to improved
defaulter tracing mechanism. However it is worth noting that failure rate increased by 1%
(6% to 7%) which could imply drug resistance as a result there is need for improvement
in the general management of patients.
Health workers in an effort to reduce high transfer out rate experienced in the previous
year (10%) took the initiative to share treatment outcomes during quarterly review
meetings, which has contributed to the number of patients evaluated at the end of
treatment.
3.3.5 Monitoring Smear conversion
TB management requires that a patient diagnosed as smear positive should convert either
at 2/3 months
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Figure 15:
Conversion Rates for Smear positive cases
7%
% Died before Conversion
5%
19%
% Smear not done
17%
18%
% Not Converted
10%
52%
Total % Converted
66%
13%
% Converted at 3mnths
15%
0%
10%
20%
Rx SS+ Cases
30%
40%
50%
60%
70%
New SS+ Cases
Figure 15 above illustrates the differences in smear conversion rates for smear positive
retreatment cases and new smear positive cases. The conversion rate at 2/3 months for
new smear positive cases remains 66%, Smear not done at either 2/3 months was 17% ,
which due to either less emphasis on sputum collection or patients not being able to
produce sputum, hence affecting treatment outcome. Not converted at 2/3 months was
10%, which may imply drug resistance. Not converted at 2/3 months was slightly higher
for retreatment cases (18%) compared to new cases which are likely to become MDR-TB
in the long run. For sure cases health workers are encouraged to do culture and DST.
4. Progress in implementing the Stop TB Strategy
4.1 High quality DOTS expansion and enhancement
The main objective of the NTCP is to ensure universal access to high-quality TB
diagnosis and treatment throughout the country. Swaziland has achieved 100% DOTS
coverage since 2008 with the 4 regions and all constituencies implementing the strategy.
During the year under review, the programme initiated the following interventions with
the view to improving DOTS coverage as well as quality of TB services:
 Development of a comprehensive National DOTS Expansion Strategic Plan for
2010-2014 in line with the Health Sector Strategic Plan (HSSP);
 Mobilization of sustained political commitment for TB control;
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


development of Regional DOTS expansion plans for universal access to quality
DOTS in line with the National Strategy;
strengthening and expanding laboratory services at national and health facility
levels;
ensuring sustainable anti-TB drug supply system through the GDF mechanism;
and
Strengthening the M&E system to generate reliable data for outcome and impact
measurement.
4.1.1 Government commitment:
The Government of Swaziland recognises TB as a major public health problem and has
demonstrated high level of commitment in the fight against the disease at national and
regional levels. The national TB Programme is funded mostly by the Swaziland
Government with additional funds from the Global Fund (GFATM). The programme has
an established annual work plan with a budget line that covers human resources, first and
second line anti-TB drugs and administrative costs.
During the period under review, government support was evident in the following main
areas:
I.
Provision of running cost of the TB programme,
II.
Opening of the New TB Hospital including Medical, Nursing and support staff;
III.
Provision of running cost for TB Hospital;
IV.
Established Direct Procurement with the Global TB Drug Facility (GDF); and
Procured 1 year working stock plus a year buffer stock through the mechanism.
The National TB Programme has implemented advocacy interventions during the period
under review aiming at further increasing government commitment to support sustainable
TB control as follows:
i.
Organized a 3-day sensitization workshop for parliamentarians in May 2009,
which was attended by members from both chambers of the parliament.
ii. Organized commemoration of the World TB Day on 23rd of March 2009
nationally and across all the 4 regions. During the period community awareness
campaigns were conducted with information desks maintained at key strategic
locations to enhance public access to TB information, as well as screening for
both TB and HIV;
iii. Organized sensitization workshop for journalists on TB as part of the activities of
the 2009 World TB Day celebrations.
iv.
The NTCP engaged relevant government authorities including the Health
Directorate at the MOH, the Emergency Preparedness and Response (EPR) unit,
and the National Disaster Management Authorities (NDMA) and development
partners in consultations towards declaration of TB as an emergency.
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4.1.2
TB Diagnosis
Strengthening the TB diagnostic services at all levels is critical to expanding geographical access
to quality diagnosis, rapid detection of TB cases, and therefore constitutes one of the highest
priorities of the National TB programme.
The Laboratory network consists of the National Reference Laboratory (NRL) and 18
peripheral laboratories. Sputum smear microscopy is performed at 19 TB diagnostic sites
with no established quality assurance system. At the National Reference laboratory,
capacity for performance of Culture & Drug Susceptibility Testing (DST) exists although
exclusively using the liquid culture system i.e. the Mycobacterium Growth Indicator
Tube (MGIT). Quality assurance for the National Reference laboratory on culture and
DST is provided in the form of panel testing by MRC South Africa; and for sputum
smear microscopy by NICD South Africa. Maintenance of laboratory equipment is
provided by the MOH. The National Reference laboratory in collaboration with NTCP
and SNAP has initiated the development of a specimen transportation system that links
peripheral clinics to laboratories to increase access to laboratory services including
sputum smear microscopy to rural areas.
In 2009, support for EQA, training, SOPs, LED microscopy, concentration methods and
mentoring will be provided through NICD South Africa, funded by CDC. External
quality assessment (EQA) of peripheral laboratories is currently done through panel
testing, but a system of blinded rechecking has not yet been fully established. SOPs have
been developed; and supervision of peripheral laboratories is being conducted by the
NRL routinely.
One of the remarkable developments regarding the laboratory strengthening is the s uccessful
negotiations with WHO, FIND, PEPFAR and other partners for Swaziland to benefit
from the Expand TB, which is a component of the WHO Global Laboratory Initiative
(GLI). The National TB Programme, working in collaboration with the Laboratory
Services Department recorded the following achievements during the period under
review:
 Decentralization of sputum microscopy services by increasing the number of TB
diagnostic sites from 15 to 28 by the end of 2009. The turnaround time for
bacteriological results has been reduced in most centres from an average of 7 days
to about 3 days;
 Introduction of the Light-Emitting Diode (LED) microscopy in high volume sites
to improve access and efficiency of microscopy services;
 Continuous provision of quality-assured culture and including DST services for
first line drugs by the National Reference laboratory, while DST for second line
drugs were done externally through collaboration with MRC South Africa. This
has resulted in increased access to the services as reflected by an increase in the
number of culture and DST services offered from ??? in 2008 to ?? in 2009.
 Improved implementation of EQA activities through inclusion of more peripheral
labs;
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



Development of specimen transportation system to improve logistics for sputum
microscopy for the rural areas;
Recruitment of 6 additional phlebotomist for TB microscopy services for the
peripheral laboratories making a total of 12 through the Global Fund R8 TB grant;
Training of the TB microscopists on Sputum smear microscopy;
Increased supervision of peripheral laboratories by the NRL.
Refurbishment of TB laboratory in Nhlangano Health Centre
The proportion of PTB suspects having diagnostic sputum smear result has remained
unchanged at 18% in 2008 and 19% 2009. This remains a challenge to be addressed.
4.1.3 TB treatment and patient support
Treatment of tuberculosis cases based on the recommended WHO treatment regimens for
category I, II and III i.e. 2RHZE / 4RH, 2SRHZE/1RHZE/5RHE and 2RHZ / 4RH
respectively. The Baylor Pediatric Unit is collaborating with the NTP in the treatment of
TB in children including HIV-associated TB in line with national guidelines.
Most of the registered TB patients (about 80%) have identified community-based
treatment supporters at initiation of treatment, while about 20% receive directly observed
treatment (DOT) at facilities. However, a system of supervision of the community
treatment supporters currently does not exist.
Currently, 104 out of 223 health facilities in the country offer continuation phase of TB
treatment services beside the 28 TB diagnostic sites with the intensive phase treatment
limited to the diagnostic sites according to national guidelines. Treatment results of the
2008 cohorts of TB patients revealed that treatment success rate was 68% with default
rate accounting for 8%, and transfer out (including not evaluated) accounting for 3%.
The main achievements with respect to the management of drug susceptible TB include:
 11032 TB cases were treated in the year;
 Decentralization of TB services through enabling 13 clinics to initiate TB
treatment;
 Development of adherence support framework for engagement of CBOs in
collaboration with WHO, URC, MSF and Good Shepherd Hospital;
 Defaulter management has been strengthened as the rates declined from 11% in
2008 to 10% in 2009;
 ??? health care workers trained in TB management;
4.1.4
Procurement and Supply Management (PSM) system for anti-TB
drugs
The Central Medical Stores (CMS) has been responsible for procurement of anti-TB
drugs for the country through local bidding process. The programme faced some
challenges with shortages of anti-TB drugs at various times in the past due to
procurement, and distribution problems. In 2008, the Ministry of Health established a
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direct procurement agreement with the Global TB Drug Facility (GDF). In 2009, the
Ministry of Health procured 2 years supply of first line anti-TB drugs through the GDF
mechanism.
The country has successfully secured the first-term grant for pediatric anti-TB drugs to
last for three (3) years after which the Government is expected to take over. Second-line
drugs are also procured through local tenders. However, the country has successfully
secured a fast-track approval of the WHO Green Light Committee (GLC) in April 2009
to access quality-assured second line anti-TB drugs to treat an initial cohort of 50 MDRTB patients to be funded by the Global.
The NTCP has established collaboration with the Central Medical Stores to strengthen
and maintain sustainable anti-TB drugs procurement and supply management system that
guarantees un-interrupted supply through improvement of storage and distribution
facilities; training as well as the inventory management system. This includes
maintaining collaboration with the Global TB Drug Facility (GDF).
The main achievements were as follows:
 Designation of a full-time Pharmacist at the National TB Programme
 A Direct Procurement agreement between GDF and the MOH established and
an MoU signed;
 In August 2009, training of 80 nurses on drug management according to
national guidelines;
 Development of SOPs for anti-TB drug Management;
 Supervisory visits to peripheral health facility on drug management
conducted;
4.1.5 Monitoring and Evaluation system and impact measurement
The NTCP’s recording and reporting system has been revised in line with the most recent
WHO and IUATLD recommendations. Registers and forms have been updated to capture
all necessary information required in the new WHO online internet-based global TB
reporting. In order to improve data quality and accuracy at the facility level, the
Electronic TB Register (ETR.NET), which is a nominal electronic registration system,
has been implemented in all TB diagnostic sites. The NTCP has a full-time M&E Officer
who conducts Data verification visits to all diagnostic centres on a quarterly basis.
The M&E-related interventions in 2009 focused on ensuring data quality through
enhancing the capacity of health care workers on recording and reporting.
The main achievements include the following:
 Revision and printing of appropriate TB recording and reporting tools;
 Development and printing of appropriate MDR/XDR-TB surveillance registers,
treatment cards etc;
 Maintenance of the Electronic TB register (ETR.NET); and
 training of health care workers on ETR.NET and data entry
 Training health care workers on M&E and routine data quality;
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
Quarterly review meetings were conducted and each facility and regional teams
developed improvement plans based on priority activities and objectives that
addressed the core problems from the data that was presented.
4.1.6 Programme Management and supervision
Supervision is central to ensuring continuous support towards delivery of quality TB care
at all levels. Effective supervision reinforce and promote good diagnostic, treatment
practices in line with national guidelines, ensures skill development; assist in problem
solving; stimulate health worker team spirit and motivation; and provides opportunity for
technical advice and guidance to health workers. Quality improvement will be an integral
component of the supervision process. The NTP supervision is planned and executed by
both central and regional level of the programme on a quarterly basis.
The main achievements in supervision and programme management include:
 Training of NTP staff on programme management and supervision
 Revision of supervision tools
 Conducting supervisory visits from Central level to Regional level and to
Community level
 Maintenance of adequate logistic support to the programme
 Coordinating activities of partners activities
4.1.6.1
Partnership coordination
The national TB Control Programme collaborates with technical and financial partners
within and outside the country. The technical partners include the World Health
Organization, the University Research Corporation (URC), Italian Cooperation,
Medicens sans Frontiers (MSF) and the Royal Netherlands Tuberculosis Foundation
(KNCV). The NTCP has numerous implementation partners who recently transformed
into an umbrella body referred to as the Swaziland Stop TB Partnership.
4.1.7 Human Resource Development, Training and Technical Assistance.
Human Resource Development (HRD) in TB control is a key element of TB control to
ensure quality of service delivery as effective implementation of control activities
depends to a large extent upon availability of adequate numbers of competent staff,
supported by sufficient facilities, infrastructure, equipment, drugs and other commodities.
The main achievements in the area of HRD include the following:
 An preliminary assessment of the programme HR requirements, identification of
HR gaps started with support of KNCV;
 Filling of key vacant staff positions through GF support R8;
 A series of trainings were conducted in the country for TB. This includes the
following trainings;
a. Several Training of HCWs on TB/HIV integrated services,
b. TOT workshop for 30 HCWs on Three I’s was conducted March 2009
followed by nurses training facilitated by the TOT
c. Training of all clinic nurses in the region on TB/HIV integrated
management;
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
d. Training of 23 nurses from hospitals, health centres and clinics on
Infection and prevention control;
e. Training of TB and ART nurses on 3I’s;
f. Training of TB nurses on M&E
Recruitment and placement of Staff in TB settings
a. Recruitment of Lay counsellors for TB units to facilitate HIV testing and
counselling among TB patients and suspects.
b. Hiring of additional TB Nurse;
c. Hiring of Cough officers
d. Hiring of DOTS adherence officers
4.2 TB/HIV collaborative activities
A National TB/HIV Coordinating Committee (NCC) exists, which is co-chaired by the
National ART Coordinator and the National TB Programme Manager. The NTCP
participated in the quarterly meeting of the NCC to review progress in implementation of
TB/HIV collaborative activities. The NTP has designated a focal point person for
TB/HIV.
The NTCP scaled up collaborative TB/HIV interventions aimed at reducing the burden of
HIV among TB patients; as well as those aimed at reducing the burden of TB among
people living with HIV (PLHIV). The focus was on decentralization of services and
improving the capacity of health care providers to manage TB/HIV con-infection
according to national guidelines.
The NTP participated actively in the joint National Coordinating Committee (NCC),
which is the collaboration mechanism between NTCP and the Swaziland National HIV
and AIDS Programme (SNAP). The main achievements in implementation of
collaborative TB/HIV activities:
The implementation of TB/HIV collaborative activities was scaled up in all Regions. This
includes training of health care workers on TB/HIV, partnership strengthening, HTC
services to all TB patients, provision of CPT and ART to HIV positive TB patients. In
2007, 6517 TB patients received HIV testing of which 5,252 (80.6%) tested positive. Of
the 5,252 HIV positive TB patients, 4,987 (95%) were receiving CPT and 1,014 (19.3%)
were started on ART.
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Figure 16:
%
Trend of TB/HIV collaborative activities 2006-2009
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
% on CPT
% On ART
% HIV tested
2006
2007
2008
% on CPT
88%
90%
94%
% On ART
19%
24%
20%
% HIV tested
20%
60%
91%
Year
4.2.1 TB Infection Control
Infection control in TB and HIV care and treatment facilities is an essential component of
TB Control to reduce the risk of nosocomially transmitted TB, multidrug-resistant TB
(MDRTB) and XDR-TB infections to health care staff, other patients and visitors.
The priority of the NTCP is to develop infection control policies and plans that include
congregate settings e.g. the penitentiary institutions, barracks and other public places.
Main achievements include:
 Development of draft infection control guidelines;
 Infection Control Assessments in 15 TB Diagnostic sites
 Trainings on Infection Control in collaboration with Stellenbosch University;
 Infrastructure – prefabricated TB clinics with appropriate ventilated waiting areas
(in Pigg’s Peak, Mbabane, RFM, Matsenjeni, Emkhuzweni)
 Assessment of the TB Hospital by infection control specialists (Clean Room)
4.3 MDR/XDR-TB prevention and control
MDR/XDR-TB currently constitutes a major threat to the control of TB in the country,
and needs to be addressed timely and effectively. The priority of the NTP is to implement
an effective programmatic management of drug resistant TB in line with WHO
recommendations. This includes development of a sound MDR/XDR-TB technical
guideline, training of health care staff and ensures access to quality-assured second line
anti-TB drugs through the Green Light Committee mechanism.
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In 2009, NTCP developed a plan that aims to establish a DOTS-Plus project with
approval of the Green Light Committee (GLC). In May 2009, GLC granted Swaziland
approval to commence with an initial cohort of 50 patients. The plan includes
strengthening the capacity of the Central Laboratory to support the diagnosis of multidrug resistant TB (MDR-TB) as well as building the capacity for clinical management of
patients at the National TB Hospital. However, the national TB Hospital was not
operational. At inception, an anti-TB drug resistance survey (DRS has been planned with
collaboration of WHO, URC, MSF and the US Centres for Disease Control (CDC) to
establish the level of drug resistance in the country. Furthermore, the development
process for a national DR-TB management guideline has been initiated. The MOH has
requested WHO’s technical assistance to develop the guidelines. A surveillance system
for MDR/XDR-TB has not been fully established.
The main achievements in this area include:
 Operationalization of the National TB Hospital to enhance clinical management
of DR-TB cases;
 Development and printing of the national guideline for management of drug
resistant TB;
 Conducted DRS funded by MSF and in collaboration with WHO, URC and other
partners,
 The programme has successfully obtained Green Light Committee (GLC)
approval that enables the country to access quality-assured second line drugs at
concessionary prices, as well as technical assistance to ensure effective
implementation according to WHO recommendations;
 Procurement of additional second line drugs by the Swaziland Government;
 Training of 45 Medical Doctors and 60 Nurses was conducted recently (Feb/08
and Aug/08) by the NTCP and URC, training of key staff in clinical and
programmatic management in Lesotho by Partners in Health in Feb 09.
 Revision of recording and reporting tools for DR-TB (DR-TB register and patient
cards);
 Programme staff had orientation on best practices available on MDR-TB Program
(Lesotho and RSA).
4.4 TB control among high- risk populations
The national TB programme aims to address TB in prisoners, miners, factory workers,
migrants, transport industry, and other special situations including mental health
institutions. This will entail development and implementation of effective policies,
addressing prevention and management of TB cases among inmates, including
supervision, monitoring and evaluation, according to the DOTS strategy. As a first step,
the programme established collaboration with the correctional services to establish DOTS
services in prisons.
The main achievements are as follows:
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
Site assessment of prisons has been conducted by URC/SNAP/PATH, no policy
yet on TB in coal and asbestos mines.
Training of personnel of Correctional services and military and police on TB and
HIV.
4.4.1 TB in Children
Improving diagnosis and treatment of childhood is a key and essential component of the
National TB Control Programme. Reducing the burden of TB in children requires
improving contact investigations and diagnosis and treatment of children with TB
mainstreamed as part of routine activities for pursuing high-quality DOTS Expansion and
Enhancement. The engagement of paediatricians and other clinicians is crucial, as well as
regular updating of the NTP recording and reporting system in line with WHO
recommendations. Operational research is crucial to establish how NTPs can best ensure
the delivery of effective prevention and care regarding childhood TB.
The main achievements in this area include the following:
 Successful negotiation of a GDF paediatric drugs grant;
4.5 Health Systems Strengthening (HSS) initiatives
The objective of health system strengthening is to actively participate in efforts to
improve system-wide policy, human resources, financing, management, and service
delivery and information systems.
The main achievements are as follows:
 Facilitating the negotiations of the HSS R8 Global Fund grant;
 Strengthening the national laboratory network including the transportation
system;
 Contribution to drug management issues
4.6 Engagement of all Care providers in TB Control
4.6.1 Public-Private Mix initiatives;
The National TB Programme, recognizing the enormous potentials of the private sector in
the health care delivery and TB control in particular, planned a systematic engagement of
the private sector. A strong Public-Private Mix (PPM)or partnership for DOTS that will
significantly increase access to quality-assured TB and TB/HIV care.
Private facilities have been involved in TB, TB/HIV management and have received seed
money to scale up TB services and are now operational, memorandums of understanding
between the ministry of health and relevant facilities have been signed. As a result of this
initiative TB activities have been decentralized to private facilities to be diagnostic and
DOTS sites. Muna health care services referral private health facility has been established
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to cater for all patients that receive TB services from private facilities. To ensure patient
support while on treatment, organizations that work in the communities were mapped and
will be incentivised upon successful treatment of patients.
Main achievements include the following:
 Engagement of 6 additional private providers for DOTS;
 Facilitation of the establishment and launch of the Swaziland stop TB partnership;
 Accreditation of private facilities for initiation of TB treatment;
4.7 Empowerment of people with TB, and communities
The main achievements include:
 Facilitation of the Swaziland Stop TB Partnership process
 Advocate for declaration of TB as an emergency
 Finalize and disseminate TB/HIV advocacy, communication and social
mobilization (ACSM) Strategy
 Improve communication amongst all TB stakeholders
 Strengthen community involvement in TB activities
 Establishment of a platform for dialogue with traditional practitioners for
treatment support and adherence
4.7.1 Community participation in TB Care
Community Care provision is well established in the country. According to programme
statistics, about 80% of TB patients are supported on treatment through community-based
approach. The National TB Programme, recognizing that an estimated 30% of Swazi TB
patients are managed by CBOs, FBOs and NGOs planned to strengthen the community
TB care initiative.
The community engagement includes a plan to sensitize community leaders on TB,
identify and train treatment supporters. A plan exists to elaborate this community-based
TB care for managing drug resistant TB.
The NTCP embraced community involvement in TB care with the aim of enhancing TB
case detection rate through increase awareness of the disease leading to stigma reduction,
and provision of treatment support to patients thereby increasing convenience, cost
reduction and reduced default. The programme intended to implement Community TB
care by building upon the other already existing community care initiatives e. g.
HIV/AIDS home based care.
The main achievements in this area are the following:
 Procurement of motorcycles with WHO support for adherence officers;
 Conducted mapping of CBO, FBO, NGO partners and resources operating in
various locations in the country, their scope work and area of competence.
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4.8 Programme-based operational research
The NTCP planned to develop capacity for conducting programme-based operational
research.
The main achievements include:
 1 TB KAP survey approved with budget through GF R8 grant to be conducted
internally through the Monitoring and Evaluation office of NTCP in quarter 4
2010.
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5. Regional scenarios
The regional TB control activities are essentially part of the regional health plan, which is
coordinated through the Regional Health Management Teams (RHMT) with the regional
TB Coordinators as focal points. The role of regional coordinator is to coordinate all TB,
TB/HIV and DR –TB activities in the region, under the theme of regional experience; it
will highlight the role played by each region in achieving strategic plan objectives.
5.1 Manzini region
In order to ensure adherence to treatment and to reduce the risk of development of drug
resistance TB patients are supervised by treatment supporters, The treatment supporter
card (yellow card) is used as a monitoring tool for standardized treatment with
supervision. Facility based DOT is done for admitted and re-treatment TB cases that are
on injection and community based DOT is conducted on new TB cases that were taking
treatment at home.
To facilitate community based DOT, a total of 7 groups of treatment supporters were
trained in 2009 in the Manzini region also the defaulter tracing system was strengthened
in the region be providing a motor bike and cell phone for tracing defaulters, These
played a vital role as it contributed to the increase in the treatment success rate for new
smear positive cases from 63% in 2008 to 68% in 2009, and significant decline in
defaulter rate from 17% in 2008 to 10% in 2009.
5.2 Lubombo region
In 2009 The Isoniazid Prophylactic therapy (IPT) Pilot study was conducted in the 15
Primary health clinics in Lubombo region which has enabled TB/HIV patients to receive
their INH treatment near to where they stay. All Pre ART and ART patients who come to
the clinic for refill and evaluation are first screened of TB symptoms using a 5
questionnaire validated TB screening tool to exclude any TB symptoms. All those
patients found free of TB symptoms are started on INH prophylaxis for a period of 6
months. Patients that did not show up the nurse was able to call the patient at home and
on the 30th day an adherence officer is able to visit the patient to note the reason for not
coming to the clinic and this gives the clinic nurse 2 days to intervene. The treatment
supporters attached at different clinics are assigned to TB/HIV patients to provide support
supervision on a weekly basis.
Out of the 518 patients, of both Pre ART and ART patients on IPT and only 8 patients
(1.5%) have defaulted INH treatment. The good adherence to INH treatment is a result
of decentralization of health services and constant patient support.
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5.3 Shiselweni region
Case notification for all TB cases increased significantly. The proportion of patients that
were diagnosed using smear among all pulmonary cases (bacteriology coverage) in 2009
stood 83%. This is as result of the some good initiatives. Usage of the new LED
fluorescent microscopy method has already started in all the regional TB diagnostic units.
Turnaround time varies between 24 to 48 hours. TB initiation has been decentralized to
peripheral clinics which are closer to the population in need of the services and these are
Mashobeni clinic, JCI clinic and Kamfishane in line with the decentralization process
motor bikes used in the transportation of sputum and blood samples from clinics to
diagnostic level four times a week.
Furthermore in a bid to ensure integration of TB/HIV services a one stop shop service
approach for patients; all TB patients and suspects who tested HIV positive are done CD4
count tests and initiated on ART in the TB clinic. Cotrimoxazole prophylaxis is also
provided to all TB/HIV co-infected patients in the same set up. Initiation of ART has
been decentralized to all the government clinics within the region. A total of three mobile
teams consisting of a doctor, a nurse, social worker, dispenser and a data clerk service
the entire region and this visits are done once a week.
5.4 Hhohho region
A series of sensitizations and TB awareness campaigns were conducted throughout the region:
 Sensitization of about 20 exam’s council staff at Ezulwini on TB, TB/HIV
 Sensitization of 15 Waterford Kamhlaba students on TB, TB/HIV.
 Sensitization of 100 Mhlatane High school students on TB, TB/HIV
 Conducting community awareness campaigns on TB, TB/HIV at Emvembili (1000
people), Esigangeni (300), Jubukweni (150), Kalamgabhi (150) and Ngwenya village
(200).
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6. Challenges and constraints
Tuberculosis rates in Swaziland remain higher than at any other time since 1990, and
higher than those in any other country in the world. Worst case scenario projections
indicate that if the current situation persists the country will be unable to maintain
essential services and requests for assistance will far exceed available resources. The
burden of TB will be such that it exerts pressure on local hospital admission rates and
outpatient clinics will fail to cope with the numbers infected each day. In light of these
projections the NTCP identified the following as major challenges in TB control in
Swaziland;
 Inadequate human resources for decentralization of TB diagnostic
and treatment services; though strides have been made in ensuring universal
access and affordability of TB treatment through decentralization of TB services
in the country there has not been an equal increase in the number of staff to
provide the TB services in the facilities. The one or two nurses at peripheral
clinics are no longer able to cope with the increasing numbers of TB patients
coming for treatment.
 Inadequate financial resource allocation to the TB Programme
Despite the increasing evidence that TB is now the major cause of morbidity and
mortality in adults in Swaziland the financial assistance from the government has
not improved over the years. This limits the ability of the NTCP to effectively
respond to the epidemic thus pulling down the country’s efforts in TB control.
 Administrative constraints in anti-TB drug procurement and HR
deployment; constant stock-outs of TB drugs has showed that the need to
explore other procurement methods for anti-TB drugs and redeployment of staff
to support and manage drug records is more evident now than before. The direct
procurement of anti-TB drugs is recommended in most countries and acceptable
to WHO where only WHO approved suppliers are contracted. For improved TB
patient management and timely enrollment on treatment these options remain
major challenges if not explored.
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7. Recommendations and priorities for 2010
7.1 Recommendations
The national TB programme is in the process of declaring TB as an emergency in the country
in line with the Maputo declaration of 2005 hence the key recommendations identified below.
 Allocation of financial resources to TB Control
As already alluded to Swaziland is the leading country among the fifteen countries of the world
with highest TB incidence and by such drastic and swift actions need to be undertaken to
improve case finding interventions and put TB patients on treatment early. In this regard, more
financial resources are needed to intensify communication and social mobilization
interventions and bring awareness to communities on TB.
 Provision of administrative waivers for the National TB programme.
The current TB situation in-country warrants that considerations in administrative processes
when dealing with TB related issues particularly anti-TB drug procurement be made. Such
considerations would allow the NTCP to timely and effectively respond to TB patients all over
the country and immensely reduce TB incidence rates.
7.2 Priorities for 2010
In its goal to reduce TB-related morbidity and mortality to such an extent that the disease
no longer a public health problem to the Swaziland the NTCP has identified the following
key priorities for the year 2010;
 Declaration of TB as an Emergency
 Expand TB diagnostic and treatment delivery mechanisms to all health facilities
 Improve treatment and care delivery for TB/HIV co-infection and drug resistant
tuberculosis
 Establishment of community DOTS system through hiring adherence officers & cough
monitors
 Develop and implement Advocacy, Communication and Social Mobilization strategy for
NTCP
 Implement intensified active TB case finding
 Prioritize operations research to inform programming
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8. Conclusion
The Government of Swaziland through the Ministry of Health is committed in the fight
against TB in the country and is in the process of declaring TB an emergency as per the
Maputo declaration of 2005. TB services remain free of charge and are accessible to all
persons. The NTCP will continue to work with partners to maximize TB and TB/HIV
control interventions.
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