A Programme Plan for the Control of Tuberculosis in Swaziland TB Problem
Tuberculosis (TB) is potentially dangerous infectious disease caused by different strains of mycobacterium, usually Mycobacterium tuberculosis. In most cases, TB affects the lungs. Infected people may spread TB bacteria to others through spitting, sneezing, and coughing respiratory tiny droplets. Most TB infections do not have obvious symptoms and tend to be latent. However, asymptomatic TB may progress to an active status over time and cause death if not treated.
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People with strong immunity systems may have bacteria that cause TB, but they may not display symptoms. Hence, there are latent TB and active TB infections. Latent TB infection is inactive, and it does not cause any observable symptoms. Active TB is contagious and dangerous.
Today, there are several strains of TB, which are drug resistance and difficult to treat. People infected with TB require a combination of medications for a given period (usually up to eight months) in order to destroy TB bacteria and eliminate possibilities of developing drug resistance cases.
TB was rare in developed countries. However, after the HIV/AID epidemic, it became rampant among people with HIV/AID because of the weakened immunity system of the body. As a result, TB and HIV have remained major concerns for many countries, particularly developing countries. This is a programme plan for controlling the TB epidemic in Swaziland as one of the developing countries with highest prevalence of TB infections in the world.
TB Problem in Swaziland
The Government of the tiny Kingdom of Swaziland declared that TB as a national emergency as it intensified the fight not only against the ancient disease of TB, but also against the now well established link between TB and HIV (2). The kingdom faces a health emergency crisis in large proportions.
The United Nations Swaziland observes that the country has the highest TB incidence in the world (1198 per 100,000 population), and it has the highest TB/HIV co-infection rates where 80% of incident TB cases are already HIV positive (2). TB kills more than 2,780 people in the country every year.
This number consists of the most productive population in Swaziland. Swaziland’s prevalence of MDR TB is at the rate of 7.7 percent as new cases while 33 percent represents past cases. The country has recorded increasing cases of drug-resistant TB strains (nearly ten percent of diagnosed cases are resistant to TB medication). As a result, life expectancy in Swaziland has dropped from 60 years to 41 years today.
There are ongoing efforts to control the spread of TB in Swaziland. For instance, the Ministry of Health and Social Welfare works together with Médecins Sans Frontières (Doctors without Borders) implemented an integrated model of HIV/TB in different locations.
Many factors could be responsible for the rise of TB cases in Swaziland. The emergence of the drug-resistant TB has created treatment challenges for many TB patients. The National TB Control Programme of Swaziland noted that health care facilities have reported poor success rates in treatment.
Moreover, in 2008, the World Health Organisation (WHO) observed that failure rates were high with up to seven percent in new cases and 11 percent in retreated cases (3). Still, Swaziland borders South Africa at the Province of KwaZulu-Natal where majorities cross the border to mining zones. In 2005, an outbreak of TB was reported with high numbers of HIV infections. This is where many miners work. There are common cases of occurrences of TB and HIV infection among the most susceptible populations.
High HIV rates in Swaziland have also played a role in the increasing number of TB infections. In most cases, people living with HIV (co-infection) also have TB infections. However, any association between the drug-resistant TB infection and HIV infection has remained controversial (2). Some studies have indicated that malabsorption outcomes of anti-TB drugs have association with HIV-positive patients. This situation increases the risk for acquired rifampin resistance.
Many scholars have linked HIV and TB infections with high socioeconomic challenges in Swaziland. This state of poverty has contributed to patients’ vulnerability, poor treatment adherence, and lack of access to proper treatment, which result in the development of drug resistance cases among TB patients. People with HIV/AIDS may also interact with others who have MBR TB infections.
People who have MDR TB conditions require several visits to health care facilities for effective management of the condition. These frequent visits may expose and increase chances of people with HIV getting TB bacteria from TB patients. This is nosocomial transmission of multidrug-resistant TB strain to other patients, who may be vulnerable to TB bacteria, especially HIV patients (1). TB infections in people with HIV progress fast. This is most likely to lead to other infections due to reduced immunity of the body.
Swaziland’s national TB control programme developed the Directly Observed Treatment Short Course (DOTS) in order to curb the rapid spread of TB infections. However, high prevalence of HIV infections in Swaziland has undermined the DOTS programme. Moreover, few health care outlets, lack of proper equipment, MDR TB and Extensively Drug Resistant TB (XDR TB) have also hampered the fight against TB in Swaziland.
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All TB initiatives and programmes in Swaziland require consistent supports in order to ensure that such initiatives are successful. Any programme should focus on delivering effective DOTS, combating TB/HIV infections, and MDR TB cases in Swaziland.
Given the escalating cases of new TB and HIV infections, Swaziland requires urgent interventions in several ways.
- The country needs sustained prevention, treatment, and care to TB and HIV patients. There is a need to introduce effective integrated programmes for managing both HIV and TB infections. These programmes should also focus on prevention of malaria and effective support to malaria patients because malaria kills many pregnant women and children fast.
- Swaziland TB prevention programmes require a special attention to MDR TB, XDR TB, HIV, and TB infections. Such programmes should emphasise the need to ensure equitable distribution of essential drugs and reasonable use by patients.
- TB and HIV infections require continued monitoring and evaluation in order to determine outcomes. Monitoring and evaluation programmes should also focus on observed changes in drug resistant TB, malaria, and HIV.
- Swaziland government is an important stakeholder in fighting TB epidemic in the country. As a result, the government should mobilise resources, show political commitment, and form partnership with other stakeholders to develop programmes that could effectively fight TB and HIV infections at all levels of the country.
It is also important to focus on knowledge and attitudes of TB patients in order understand their views. This process requires a well-designed study that can identify various causes and outcome of TB infections in Swaziland.
Studies from other regions of the world have shown that effective and sustained approaches to TB treatment and management have led to decline in cases of TB infections. Moreover, there are high success rates in treatment.
Unfortunately, Swaziland has registered high rates of defaulters, death rates, and transfer rates among HIV and TB patients (2). These situations have led to unfavourable outcomes in TB and HIV treatment and management. Hence, all stakeholders in fighting TB infections in Swaziland must improve their efforts and conduct follow-ups to evaluate patients after treatment.
TB Decentralisation and Integration in the Health System of Swaziland
Decentralisation and integration of TB management in Swaziland have taken some approaches to ensure that treatments are effective and successful.
Community-Based and Home-Based Approaches
Majorities of TB patients in Swaziland live in rural areas in small isolated villages. Normally, many TB patients cannot afford costs of travelling and long journeys to health care facilities.
As a result, health care service providers, such as MSF (Doctors without Borders), have developed decentralised and community-based programmes in order to combat TB and HIV infections. The MSF has trained some people in the community to take the roles of counsellors, who can also test both HIV and TB infections. The decentralisation effort aims to increase the number of people being tested for HIV and TB in Swaziland.
This is an initiative to start early treatment of both infections. In addition, decentralisation efforts would ensure that few people default treatment, improve their health, and ensure high success rates.
Decentralisation aims to support local clinics in poor, remote locations of Swaziland. As a result, these clinics are able to offer integrated programmes to treat both HIV and TB. They have increased the rate of testing patients every month. Moreover, patients on antiretroviral (ARV) have increased significantly.
This is also the case with TB treatments where many patients have registered for medication, including patients with multidrug resistant conditions. Many patients have regarded TB treatments as long and complex process, but decentralisation has ensured sustained treatments for these patients.
Swaziland has recognised that managing drug resistant TB strain is a major challenge in the health sector. In this context, MSF has provided support to decentralisation efforts in several health care centres in different parts of the country as a way of improving accessibility to health care services. In fact, MSF now constructs modern laboratories in such locations.
Decentralisation efforts require collaborative approaches with the Ministry of Health. In addition, this approach also aims to integrate both HIV and TB treatments in various parts of the country. The Ministry of Health alongside other stakeholders have rolled out national TB decentralisation programmes to focus on drug resistant strain of TB.
Decentralisation and integration efforts have also focused on patients who live in towns. Specifically, these approaches target people working in industries.
Research indicates that such programmes were effective in rural Swaziland. TB detection through intensified case finding (ICF) was feasible and aided in TB and HIV integrated care. The programme enhanced accessibility to underserved, rural TB patients. However, home-based care is effective in rural areas because patients lack adequate space in health care facilities as cases of TB increase and overwhelm care providers.
Swaziland desperately needs adequate health care providers and physicians. Inadequate training facilities have led to low number of nurses in the country. In this regard, it would be effective to train many nurses and allow them to tackle simple cases of TB infections, prescribe drugs, and provide required support.
Many patients have lived with HIV and TB for long in Swaziland. According the MSF, these are ‘expert patients’, who play critical roles in screening, advising, and informing new patients about HIV and TB medications. Moreover, these patients also conduct awareness campaigns in their communities.
The MSF has also organised several workshops in order to discuss the problem of increasing cases of new infections in Swaziland. The major aims of such workshops are to search for alternative and innovative method of offering effective treatments and supports to people infected and affected with HIV and TB in Swaziland. The country lacks health care professionals. On this note, workshop participants have developed health care programmes, which have provided care to patients at the village and local levels.
Despite these efforts to combat the spread of TB infections in Swaziland, there are new cases of infections. Swaziland tries to use integrated programmes to combat TB infections, which affect people with HIV/AIDS. This process requires a partnership with external professionals and other stakeholders.
The situation challenges the goals of eradicating TB as a communicable health problem globally by 2050. Cases of TB infections are rampant in people living with HIV/AIDS (2). This explains why most integrated intervention programmes focus on these two diseases together. Most TB patients are in Africa, and the WHO has attributed this state to high prevalence of HIV infections in the continent.
Stakeholders in the fight against HIV and TB have noted that people with HIV are prone to TB infections. As a result, these stakeholders have noted that it is effective to provide HIV Testing and Counselling (HTC) in TB clinics. These programmes also integrate TB-HIV services to the community.
According to the group of researchers (2), in Swaziland, about eight in ten individuals who have TB are HIV positive. However, URC launched an integrated strategy with TB clinics that offered HTC care to patients, but few patients received these services. Many TB centres referred TB patients to VCT centres to know their status. Swaziland has few centres, which implies that all VCT centres receive a large number of patients, which they cannot manage. Patients often face challenges in such overburdened facilities.
Hence, the quality of treatments and counselling may not meet the minimum threshold required.
Given such conditions, health care providers have recognised the need to address TB and HIV infections collectively and focus on underserved and underreported areas. Decentralised and integrated TB and HIV programmes work collaboratively with the National TB Control Programme alongside other stakeholders. These programmes aim to increase the number of TB and HIV clinics at the local levels.
Important Stakeholders of TB Problem
Swaziland has several stakeholders because of the unique nature of the problem. It is important to engage all stakeholders when developing an intervention programme for controlling and evaluating TB infections. Stakeholders are important for the day-to-day implementation of the TB control programmes, advocate for the programme, and support or authorise funding of the programme. There are three main groups of stakeholders in this programme.
- People involved in the programme operations
These include programme managers, administrators, staff, outreach staff, nurses, clinicians, and government health agencies
- People affected by the programme
These include patients, community members, families, visitors, and community planning boards
- Intended users of the evaluation outcomes
These include policymakers, health care providers, health educators, researchers, business communities, funding groups, and others.
The level of involvement among these stakeholders will differ considerably based on their roles in the project. Generally, there are priority stakeholders who will give the programme its credibility, implement it, and advocate for its improvement and funding.
The Approach for TB Problem and Evidence for Effective Strategies
The goals of this TB control programme in Swaziland are to break off and eliminate TB transmission, reduce cases of drug-resistant TB, lower death rates from TB complications, HIV-TB complication, and reduce challenges related to TB trauma, emotional trauma, social stigma, and TB ill health.
The control programme notes that TB is potentially dangerous, but preventable and treatable disease. The programme will focus on the most vulnerable members of the community, such pregnant women, children, older people, and HIV-positive patients.
This is a collaborative programme, which would include other stakeholders, such as health care providers, government agencies, research institutions, and funding organisations. TB surveillance would involve treatment, identification of latent and active TB infections, and managing existing conditions.
Swaziland TB Control Programme Activities
Creating awareness about TB and identifying all people, who have TB or suspected of having TB at the community levels. They should report to TB clinics and laboratories at community levels.
- Gathering and analysing TB risk factors in Swaziland
- TB testing
- Monitoring prescriptions and patients’ adherence to medication
- Offering DOTS and directly observed preventive therapy (DOPT)
- Analysing people exposed to TB and ensuring their protection through TB therapies
- Providing TB and HIV tests and conducting evaluation among vulnerable groups to prevent active TB
- The programme will work collaboratively with the local government health agencies, home-based programmes, and prison services.
How the Impact of the Programme will be Measured
Evaluation of the programme would focus on its effectiveness, assessment of the progress, identify optimal performing initiatives for replication, and help in redistribution of TB resources.
The process shall involve conducting surveys by gathering data from all stakeholders involved in the TB control programme in Swaziland. Data shall then be analysed and outcomes disseminated to interested stakeholders.
The programme outcomes would show the intended activities of the programme. However, the programme notes that it may or may not be possible to realise all its goals. The programme shall measure the desired changes in TB and HIV-TB patients, health care providers, and the community. The programme has short-term, mid-term, and long-term outcomes for evaluation. The focus of the programme would be on measuring:
- Changes in knowledge and attitudes of TB patients
- TB patients adherence to treatment
- The success of identifying patients contacts
- Patients use recommended drugs
- Patients complete treatments as scheduled
- Local cases of readmission
- Reduced cases of defaulting rates
- Low TB transmission
- Patients facilitate identification of contacts
- Reduced stigma
- Improved quality of TB-HIV patients lives
- Building trust
General health of patients
The programme measures shall indicate whether the programme would realise these outcomes. Stakeholders shall suggest various methods of evaluating and measuring these goals. For instance, open discussions with community members may indicate that stakeholders have built trust with other stakeholders. An outcome on stigma may indicate open discussions with friends and other contacts about the disease.
- Crudu V, Merker M, Lange C, et al. Nosocomial transmission of multidrug-resistant tuberculosis. The International Journal of Tuberculosis and Lung Disease. 2015;19(12):1520-1523.
- Mchunu G; van Griensven J, Hinderaker S, et al. High mortality in tuberculosis patients despite HIV interventions in Swaziland. Public Health Action. 2016;6(2):105-110.
- World Health Organization. Global tuberculosis control 2010. [Geneva, Switzerland: WHO]; 2010 [cited 2020 Feb 11].