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

PRESENTATION OUTLINE  TB SITUATION IN SWAZILAND  COUNTRY RESPONSE TO M(X) DR TB  CHALLENGES

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

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

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

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

Swaziland Experience and Response: Develop MDR-TB guidelines 2. Develop technical guidelines and train health workers on suspicion, management, follow up and discharge of Mdr/Xdr TB: Draft Drug Resistant TB guidelines are under finalization; 60 nurses and 45 doctors have been trained on MDR-TB in 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;

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

Swaziland Experience and Response 7. Ensure strict control and proper use of 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  Health care workers were trained on management of TB pharmaceuticals and supplies in May Apply to the Green Light Committee for access to quality second-line drugs :Application submitted in September 2008

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

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

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

Challenges Inadequate follow up and support mechanisms for patients on MDR-TB treatment Inadequate contact tracing mechanisms for contacts of 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