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April 26, 2007

TB Day: a Zambian perspective

Is there anything awry with the response to TB or has the time come to re-strategise the way TB is being tackled? Violet Mengo, features reporter with the Zambia Daily Mail, reflects on what has been achieved so far and the way forward.

Tuberculosis is one illness that has spread to all the nine provinces in Zambia and the Ministry of Health is fast extending coverage of its programme. In its shadow, drug resistance is upping the pace.

March 24, each year, is observed and recognised as World TB day, a time when humanity is challenged to reflect on the way the disease has negatively impacted on the country and the world as a whole.

In Zambia, DOTS (Directly Observed Treatment Short Course), the internationally recommended TB control strategy that includes standardised case detection, treatment and patient support that requires consistent drug supply and effective monitoring systems is in place.

Zambia has adopted and implemented DOTS since 2000. Full national DOTS coverage was reported achieved at the end of 2006 with an estimated treatment success rate of 90 per cent.

But is it really time to focus on DOTS more intensively?

According to the World Health Organisation (WHO), drug resistant TB is a symptom of poor programme performance. If we hope to change the outcome and decrease the proportion of drug resistant TB, the DOTS model needs to be adapted or its implementation improved. More of the same might only compound the TB drug resistance threat.

Despite the recent DOTS coverage gains in Zambia, many communities in the rural areas are lagging behind due to a number of reasons. Rural settings, poor communities and mobile populations, for example are subject to social and economic factors that often lead to incomplete or inappropriate treatment. In addition, TB diagnosis is difficult in people living with HIV- a growing proportion of people with TB today.

Better strategies to make TB control programmes work more effectively for the most vulnerable and hard to reach communities are also essential to improving treatment adherence and, as a consequence reducing drug resistance.

The Ministry of Health 2006 annual report highlights Multi Drug Resistant TB (MDR-TB) as having been encountered in Zambia and its presence in HIV programme.

MoH spokesperson Dr Cannisius Banda said MDR-TB has been reported in almost every part of the country. In 2005, approximately 50 cases were reported.

The ministry has worked round the clock to ensure that MDR-TB is seriously addressed through sensitisation in all parts of the country.

“We can however, have a major impact on TB today, by rapidly identifying and curing patients with active disease. This approach is at the heart of the internationally recognised strategy for TB control (DOTS) which has proven remarkably effective in Zambia,” said Dr Banda.

TB has continued to be one of the major public health problems in Zambia and is among the top ten causes of morbidity and mortality.

However, the TB notification rate has increased from about 100 per 100,000 in 1984 to 500 per 100,000 in 2005.

TB has a profoundly damaging economic impact on patients and their families through spending on diagnosis and treatment, transport to the health facilities and time lost from work. Yet the disease can be cured with drugs that cost as little as US $14 to US $18 per patient.

The interaction of TB with the human immunodeficiency virus (HIV) infection has complicated and made the TB control programme difficult. TB has become the leading cause of death among people living with HIV/AIDS in Zambia today, while infection with HIV is the most potent risk factor for a latent infection to convert to active TB.

Recently, WHO launched yet another treatment - a new stop TB strategy that has six components of which DOTS is one of them.

The adoption of the new stop TB strategy is also in line with the Global plan to stop TB, in efforts to achieve the targets for the Millennium Development Goals (MDGs) by the year 2015.

The main objective of the TB programme is to reduce morbidity and mortality and socio-economic burden associated with the disease, therefore reducing the public health importance of TB. The new stop TB was planned for implementation in all districts countrywide in 2005.

In the same year (2005), international and local cooperation partners conducted a national TB Review. The findings and recommendations from the National Review formed part of the basis on which the National TB strategic plan was developed. The priority areas that the plan has addressed are:

- TB DOTS expansion and strengthening

- TB/HIV collaborative activities

- Community DOTS strengthening

- Public-Private Partnerships

- Health systems strengthening

- Health promotions

TB control programme aims at reducing the prevalence of and deaths by 50 per cent and eliminating the disease as a public health problem by 2050.

The control programme also targets to detect at least 70 per cent of the infectious TB cases and cure as least 85 per cent of them, to meet Millennium Development Goal (MDG) number 8 of stopping and beginning to reverse the incidence of TB by 2015.

Dr Banda expressed happiness at the pace the ministry was moving in addressing TB and the achievements scored so far.

He said there has been expansion in TB support visits that were carried out while the DOTS programme was expanded and strengthened.

A national TB/HIV coordination team was formed and health workers and community treatment supporters were trained countrywide.

The fight against TB can be won if the country had a good number of health staff. But the brain drain has hit the country badly that capacity building for the national TB control programme is limited.

The central unit has only two out of the five required staff establishment. There is high attrition of trained staff in the Ministry of Health (MoH) yet the workers’ manual has not been revised.

There is low HIV testing of TB patients despite a co infectivity rate of up to 70 per cent. The MoH says the patients are not counselled and tested for HIV infection so that they can be helped with drugs at early stages.

The 2006 annual reports says inadequate nutrition supplement for the TB/HIV/AIDS is high because many people in Zambia live below the poverty levels.

About 70 per cent of people living with TB are co-infected with HIV and this makes the fight rather difficult.

The enormity of the TB burden requires that TB diagnosis and treatment be taken beyond the health sector. The existing umbrella body for community-based organisations involved in TB control (Community Based TB Action Group- COBTAG) is limited and needs strengthening. The existing structures in Zambia for home-based care provide an opportunity to encourage communities to participate in TB and TB/AIDS activities.

Advocacy, Communication and socio (ACS) mobilisation has continued to be one of the weak components of the National Tuberculosis programme and needs to be prioritised.

Responding to the challenges of drug resistance and TB in general will require rebuilding the basics of the programme in a number of ways. Training and retaining health workers in sufficient numbers, strengthening diagnosis and laboratory facilities, maintaining continuous drug supplies (including second line drugs for treating drug resistant forms of TB would be essential in combating MDR-TB.