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Analytical summary - Tuberculosis

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Tuberculosis constitutes a one of the major public health problems currently confronting the Kingdom of Swaziland. Compared to a 1990 level of 267 all forms of TB cases per 100,000 population, the incidence of the disease has increased five-fold (Fig 1). Within the same period, the incidence of infectious sputum smear positive TB cases has more than tripled. Currently tuberculosis accounts for about 10% of in-patient morbidity in the country.

The country is among those with an estimated TB incidence of 1,198 per every 100,000 population. TB-related mortality has increased from 76 per 100,000 in 1990 to the current level of 317 per 100,000 populations. This 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. Current MOH statistics show that 20% of in-patient deaths are attributable to tuberculosis.

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Fig. 4.2.1: Trend of TB notification rate in Swaziland 1990 to 2009

The country faces a significant challenge of Multi-Drug Resistant TB. It is estimated that about 200 cases occurring annually, 10% of which may be the extensively drug resistant (XDR-TB) strain. The country has detected 317 MDR-TB 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 of becoming MDR or XDR-TB cases.

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Fig. 4.2.2: Trend of MDR-TB Cases diagnosed in Swaziland 2006 to 2009

The Ministry of Health re-established a National TB Control Programme in 2007 at both national and regional levels, allocated budget line for TB control, funded procurement of quality-assured first and second line drugs, provided personnel and constructed a national TB hospital. The National TB programme developed appropriate strategic documents, plans and guidelines for effective management of tuberculosis.

The Directly Observed Treatment Short-course (DOTS), which is at the core of the Global Stop TB Strategy, is currently implemented in all the 4 regions of the country. 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 74% in 2010, the treatment success rate improved from 42% in 2003 to 68% in 2007 cohorts. However, a lot still needs to done in view of 70% minimum target for case detection and 85% minimum for treatment success in line with WHO recommendations.

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Fig. 4.2.3: Swaziland’s performance in sputum smears positive TB Case Detection

Fig. 4.2.4: Swaziland’s performance in successful treatment of infectious TB cases

Implementation of collaborative TB/HIV activities have been scaled up with more than 80% of detected TB cases tested for HIV, 90% receiving preventative therapy with Cotrimoxazole (CPT), and about 25% initiated on anti-retroviral therapy (ART). Programmatic management of Drug Resistant tuberculosis has been introduced. The accreditation of the WHO Green Light Mechanism (GLC) has been obtained.

However, the increasing number of MDR and XDR-TB cases being detected presents a disturbing trend in the face of limited Human Resources and infrastructure to cope with the demand. Tuberculosis Infection control in health care, communities and congregate settings still remain a challenge in terms of the infrastructural and financial resource constraints.