COUNTRY XEPERIENCE AND RESPONSE TO MDR AND XDR TUBERCULOSIS

1. COUNTRY XEPERIENCE AND RESPONSE TO MDR AND XDR TUBERCULOSIS PRESENTED AT THE WHO TB/HIV PLANNING MEETING, ADDIS ABBABA, 11-12, NOVEMBER 2008 BY MS GUGU SHONGWE SWAZILAND NATIONAL TUBERCULOSIS CONTROL PROGRAMME

2. PRESENTATION OUTLINE • TB SITUATION IN SWAZILAND • COUNTRY RESPONSE TO M(X) DR TB • CHALLENGES

3. Country situation • Swaziland has a population of about 1.1 million with an area of 17 373 Km². • The country is divided into 4 regions which are Hhohho, Lubombo, Shiselweni and Manzini. • According to the WHO Global TB Report of 2008, the incidence rate of TB in Swaziland is the highest in the world OF 1155 PER 100,000 population. • The TB programme faces problems of poor diagnosis of cases, poor case holding and high defaulter rates. • The treatment success for new pulmonary smear positive was 42% while that for all cases (new and retreatment) was 34%. • In 2007, 9636 of TB cases were notified. • 79.6% of TB patients are co-infected with HIV

4. Country efforts to control TB: focus(1) • improving the quantity and quality of staff involved in TB control; • increasing TB case detection and treatment success rates with expanded DOTS coverage at national and lower levels; • scaling up access to counseling and testing for HIV among TB patients • scaling up interventions to manage TB and HIV together, including increased access to anti-retroviral therapy for TB patients who are co-infected with HIV; • Increase investment in laboratory infrastructures to enable better detection and management of resistant cases.

5. Swaziland Experience and Response: The Emergency Plan MDR/XDR-TB Task force was formed after XDR-TB was diagnosed in 2006 The Task force developed an Emergency MDR/XDR response plan in 2006 and the Objectives of the emergency response plan for drug resistant TB were: • To Conduct a rapid survey of drug-resistant TB to establish whether Swaziland has cases of Extreme Multi drug Resistant TB; • To build capacity of a critical mass of clinicians, Nurses and TB programme staff to effectively respond to M(X)DR-TB; • To Strengthen and expand current national TB laboratory capacity to deal with diagnosis for drug resistant TB; • To develop comprehensive DR-TB guidelines that incorporate collaborative TB/HIV activities • To Declare tuberculosis a national disaster.

6. Swaziland Experience and Response: Priority activities 1. Establishment of a case management plan for patients suspected of M(X) DR, once identified. • identification of a facility where these patients would be admitted/Isolated: a TB hospital has been built for this purpose • ensure the availability of N 95 masks to protect health workers from the infection: N95 masks were procured and health care workers trained on their use; • Fast-track drug susceptibility testing for 1st and 2nd-line anti-TB drugs for such suspects; DST capacity at the NRL was developed for first line DST and collaboration established with SA MRC for second line DST

7. Swaziland Experience and Response: Develop MDR-TB guidelines 2. Develop technical guidelines and train health workers on suspicion, management, follow up and discharge of Mdr/Xdr TB: Draft Drug Resistant TB guidelines are under finalization; 60 nurses and 45 doctors have been trained on MDR-TB in 2008 3. Implement case finding strategies for MDR-TB and expand the availability and use of culture and DST for: • Contacts of known MDR(X)TB patients, including health care workers; • All patients being retreated for TB; • All patients with sputum results remaining smear-positive at 2-3 months; • All patients failing to improve clinically;

8. Swaziland Experience and Response: Training on XDR/MDR-TB 4. Identify and build a data base on all MDR-TB that are currently under treatment in Swaziland, who are potential of developing XDR and could be promoting ongoing transmission; Printing of MDR-TB registers, treatment and patient cards has been done. Currently 98 MDR-TB patients are on treatment. 5. Conduct a rapid survey of drug-resistant TB: rapid survey on XDR-TB was conducted July-Aug 2007 using standardized protocols developed by WHO, CDC, SAMRC and URC to assess the presence of M(X) DR-TB in among high risk patients and contacts. 4 XDR-TB patients were identified. 2 died before initiation of therapy and the other 2 are still on treatment and doing well 6. Conduct BCC and IEC activities to enhance M(X)DR TB identification and management: Flyers and other IEC materials have been developed

9. Swaziland Experience and Response 7. Ensure strict control and proper use of first- and second-line anti-TB drugs by following WHO Guidelines in an effort to prevent emergence of further drug resistance: drug management focal person was appointed in the NTP in June 2007. • Health care workers were trained on management of TB pharmaceuticals and supplies in May 2007 8. Apply to the Green Light Committee for access to quality second-line drugs :Application submitted in September 2008

10. Swaziland Experience and Response: strengthen lab capacity 9. Strengthen and expand current national TB laboratory capacity: • Strengthening all aspects of TB laboratory processes,-. specimen collection and transport, smear microscopy, culture, drug susceptibility testing (DST), and information management; • Establish linkages with a supra national laboratory to harness capacity for rapid detection resistance to first second-line anti-TB drugs, and proficiency testing for first line drugs DST; MRC sends quarterly DST panels • Implement quality control and quality assurance of the TB laboratory network according to international guidelines; NICD has been contracted to support QA • Fast-track hiring and training of laboratory personnel to increase capacity for microscopy, cultures and DST and technical oversight: 2 lab technicians, 6 microscopists employed

11. Swaziland Experience and Response: Infection Control 9. Implement appropriate infection control precautions in health care facilities, with special emphasis on those facilities providing care for people living with HIV/AIDS: • Develop and implement appropriate institution-level infection control plans consisting of: Administrative control measures • Environmental control measures; respiratory personal protection equipment: N95 Draft infection control guidelines have been developed. A senior nurse attended a 3 day International training on Infection control in Botswana in November 2007 and was expected to conduct the in-country training

12. Swaziland Experience and Response: MDR-TB and collaborative TB/HIV activities 10. Implement TB/HIV collaborative activities: • Provide HIV testing for all TB patients including MDR-TB patients: Ongoing • Provide ART to eligible TB HIV positive patients including MDR-TB patients: ongoing • Provide cotrimoxazole for all HIV positive patients including MDR-TB patients: ongoing

13. Challenges • Inadequate follow up and support mechanisms for patients on MDR-TB treatment • Inadequate contact tracing mechanisms for contacts of MDR-TB patients • No protocols for doing cultures for the MDR TB and XDRTB suspects • Lack of capacity (human resource capacity) • Human resource: Numbers and skills and knowledge on XDRTB • No monitoring and reporting tool to the programme (surveillance system) • Pill burden creates high default rates and increase occurrence of side effects • Referral system between the two programmes is weak (collaborative TB/HIV at facility level still a challenge) • Health workers not utilizing N95 masks • TB has not been declared national disaster