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Analytical summary - Tuberculosis

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In 2007 Namibia was the country with the fifth highest incidence of TB (WHO, 2009), the epidemic being fuelled by the generalized HIV/AIDS epidemic in the country. The case notification rate (CNR) and absolute number of TB cases have been on a downward trend since 2005, with a major (10%) reduction observed between 2007 and 2008. (MoHSS, 2010)TB prevalence gradually decreased from 1,287 per 100,000 in 1990 to 603 per 100,000 in 2010. (WHO, 2011)

The Government of Namibia has consistently provided high quality first- and second-line medicines for TB treatment, which are provided free of charge. Eight out of every ten health-care facilities offer diagnostic services for TB, though some regions have better coverage than others and the quality of service varies from place to place. (MoHSS, 2009HFC) Infection control is another area where significant efforts have been made to reduce the burden of the disease in the country. The recently adopted Second Medium Term Strategic Plan 2010-2015 aims to reduce TB prevalence to 50% of 1990 levels by 2015. (MoHSS, 2010SPTBL)

Currently less than half of funding for TB treatment, care and prevention comes from domestic sources (WHO, 2011); it is clear that Namibia needs to work towards taking a greater share of the responsibility for maintaining, improving and extending these programmes.

The community-based DOTS is a key strategy of the TB programme, providing treatment for TB/HIV and direct observation of intake of medication, dealing with drug-resistant strains of TB and working alongside other programmes to control the spread of TB. (MoHSS, 2010) By the end of 2008, Namibia had achieved a treatment success rate of 76% for new smear-positive pulmonary TB cases started on DOTS. (WHO, 2009)

The emergence of drug-resistant strains of TB is a serious threat to controlling the infection; drug-resistant, multi-drug resistant and extensively drug-resistant (DR, MDR, and XDR) forms of TB have been reported in Namibia since 2007, and incidence has been increasing. (MoHSS, 2010; WHO Namibia, 2009) The number of cases of confirmed MDR-TB in Namibia more than doubled between 2007 and 2009.MDR-TB and XDR-TB constitute a serious challenge for controlling the disease because of the higher mortality rate and the financial burden of more costly treatments. (MoHSS, 2010)

In Namibia the most frequent cause of progression to active TB disease is infection with HIV, because it reduces the immunologic control of TB infection. (MoHSS, 2010) While a person infected with only TB faces a 5%-10% risk of developing TB disease, a person with TB and HIV faces a 50-60% risk; consequently TB is now the most common cause of death in HIV-infected individuals in Namibia and worldwide. (MoHSS, 2010) In 2010, due partly to provider-initiated testing, 76% of all TB patients were tested for HIV, and of those 55% were HIV-positive. The TB treatment success rate among HIV infected people has been increasing over the years, from 70% in 2004 to 82% in 2008. (WHO, 2011)

Nutrition is an important aspect of TB prevention and treatment. TB makes malnutrition worse and malnutrition weakens immunity, thereby increasing the likelihood that active TB disease will develop. Many patients with active TB experience severe weight loss and may show signs of vitamin and mineral deficiencies; co-infection with HIV adds to the problem by increasing energy expenditure.

The Strategic Plan for Nutrition works to improve the nutritional status of the Namibian population, especially for those living with HIV and TB, in order to reduce morbidity and mortality associated with malnutrition. Nutrition planning to date has been based mainly on international recommendations, but more local data are needed for effective planning in Namibia. (MoHSS, 2011)

In regard to services for TB, the Primary Health Care Guidelines of 2009 spelled out the elements for the healthcare system: integration of services, promotion of community involvement in TB care, ensuring that all laboratory facilities in Namibia be monitored for quality control, ensuring that all TB treatment centres use standard treatment procedures, ensuring that all TB treatment centres have a regular supply of TB drugs and ensuring that all TB treatment centres receive regular and effective supervision and monitoring. All of these objectives require strong political commitment with sustained financing. (MoHSS, 2010)

Fortunately, Namibia has the minimum number of laboratories needed to provide culture and drug susceptibility testing services, which are essential for diagnosis of drug-resistant TB and smear-negative TB. (WHO, 2011)The 2008 review of the healthcare system found that in spite of progress made in the implementing Primary Health Care, the provision of health services did not extend beyond the clinics, although there were vast distances between health facilities, especially in the sparsely populated areas. (MoHSS, 2009HEW; MoHSS, 2009HFC)

The TB programme has achieved progress through the involvement of organizations such as CoHeNa and Penduka, who work closely with volunteer community healthcare providers to support and provide care to clients receiving TB treatment. One of the village-level targets is for all TB patients to complete their course of treatment. (MoHSS, 2009HEW)

The coordination of TB and TB/HIV control activities is the responsibility of the Public-Private Mix (PPM) sub-committee of the TB/HIV Technical Working Group and the Second Medium Term Strategic Plan 2010-2015 provides guidance for the implementation of PPM activities in the country. (MoHSS, 2010SPTBL)

All regions have functional community-based DOTS which is patient-centered. Community and patient empowerment are central to a human-rights approach to care of TB patients and prevention of the disease. Experience shows that activities that foster community and patient empowerment can have a positive impact on case detection and treatment outcomes. (WHO, 2009)The TB Road Show of 2011 saw two groups travelling throughout the country with a TB awareness campaign with two basic messages: 'Coughing for 2 weeks? Get TESTED for TB!' and 'On treatment for TB? COMPLETE it!' (WHO Namibia, 2011)

The surveillance systems currently in place have been identified as inadequate according to international health regulations, and the MoHSS is working to improve consistency and promptness in reporting cases. (MoHSS, 2011)

In 2010 two members of the National TB and Leprosy Programme attended a workshop on TB surveillance and epidemiology in Africa to better understand the methods used to produce the estimates of TB incidence, prevalence and mortality that are published in the WHO annual report on global TB control; to conduct in-depth assessment of the quality and coverage of surveillance data in participating countries; and to develop plans for improving estimates of disease burden via surveys of the national prevalence of TB disease.

In the area of research, WHO continues to assist the MoHSS through support for research to develop new diagnostic tools and medicines to speedup case identification and shorten the duration of treatment; a clinical trial for this purpose has been initiated for the first time in Namibia at UNAM in 2011. (WHO Namibia, 2009; UNAM, 2011). Another area which has been identified as needing research is to look into community perceptions, beliefs and practices relating to prevention, treatment and rehabilitation. (MoHSS, 2009HEW)