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The reality of TB in Malawi

9 July 2009, 17:10

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by Charles Mkoka, Lilongwe, Malawi

TB is ranked as one of the top killer diseases in Malawi according to the technical division of the country’s National TB Control Programme (NTCP), together with malaria and HIV/AIDS. Annually an estimated 30 000 people are treated for TB in Malawi and 8 000 die of the disease.

Before the HIV/AIDS epidemic rates of infection were much lower, with public health facilities having to treat only 5 000 TB patients per year. The government declared a TB emergency on 27 March 2007 – since when the NTCP has been focusing on delivering ‘universal access’ to tuberculosis diagnosis and treatment, until the disease is no longer a public health problem.

However this initiative has been slow to take shape. Much more needs to be done to reach everyone, but with funding from the Global Fund to Fight AIDS, Tuberculosis and Malaria the NTCP intends to equip 135 health centres through out the country to carry out full time work on TB testing at local level.

One of the big challenges for TB has always been the cost and difficulty of transport, particularly for the sick, which has meant some patients don’t coming for testing, or fail to return for their results. “We have discovered through surveys that most people in villages are just not accessing health services – such as TB detection services – easily” a staff member of the NTCP, technical division, confirmed to EAGLES. Bus fares and other costs must be paid – by people the majority of whom survive on less than US$ 1 a day, according to the UN Development Programme.

In response the NTCP has established sputum collection centres in hard-to-reach rural areas that lack health facilities. And members of local communities are volunteering to collect sputum from people with TB symptoms, and take the samples to the collection centres.

NTCP is also encouraging voluntary home-based care services, delivered by community volunteers who observe and follow up on cases treatment for TB patients.

A good example of how communities are playing a participatory role in combating tuberculosis is Mtsiriza, a rural community on the outskirts of Malawi’s capital Lilongwe. Resident of Mtsiriza John Amos Phiri has been cured from TB due to the new centre in the area. “I was sick for about a year, and I haven’t been able to work at al” he said. I only got diagnosed with TB when a medical facility was set up here in my village.”

Phiri believes the NTCP initiative of bringing health care to the people, instead of expecting people to make their way to health facilities saved his life. “The testing service came to my area just in time to save me” he observed.

The community TB initiative also encourages all members of a household with a TB patient, especially children, to be tested, and home-based care using community “guardians” to observe and follow up with TB patients.

NTCP has also established walk-in centres in the country’s main health facilities, such as referral hospitals, to enable people to access TB testing services without having to join the long queues of patients requiring other hospital services.

According to former director of the NTCP Professor Felix Salaniponi, key targets include training of health workers at district and health centre levels on universal access strategies, the establishment of community based sputum collection points, establishment of walk-in programmes at health facilities, intensifying tuberculosis contact tracing with good record keeping, intensified case finding among high risk groups (prisoners, HIV-positive patients, and HIV treatment clinics among others), expansion of TB microscopy services for diagnosis, involvement of other stakeholders and strengthening of the monitoring and supervision of TB services.

Although the death rate among new, smear positive cases remained high at 13% in 2008, there has been a remarkable decline from the 2005 rate of 16%. Most of these deaths have been attributed to complications due to the HIV/AIDS pandemic. Default rates have stabilised at around 3%, although some treatment centres registered much higher rates.

Prisons in Malawi are very high risk places for the spread of TB. The NTCP therefore intensified TB control activities in all prisons, seeking to ensure that diagnostic and treatment centres are established in all major prisons to ensure that all TB positive inmates are properly cared for.

Although research is one of the main goals for the NTCP, according to the latest programme report in 2006 very little was achieved as a result of lack of capacity in the programme. However in January 2007, the department was reorganised and more research officers were deployed to assist in the planning and conduct of research activities.

Despite these plans and advances, the high HIV/AIDS prevalence in Malawi has had an impact on the success of the TB program.

A 2007 HIV sero-survey of antenatal clinics estimated a national prevalence of 12%, implying a total of roughly 900 000 Malawians living with HIV/AIDS. An independent, countrywide survey indicated that 72% of all TB patients were HIV positive, a much higher percentage than previous estimates. This finding is in line with the 2008 WHO estimate that 70% of new TB patients have HIV.

So NTCP now offers ‘active screening’ at its TB testing centres, which means that HIV testing is offered in combination with TB tests. This way, government tries to identify the large number of TB/HIV co-infections.

In 2008, an estimated 3.5% of new TB cases were multidrug-resistant, MDR-TB; extensively drug-resistant XDR-TB has not been reported in Malawi.

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