SWAZILAND: Spiralling TB cases overwhelm health sector
Swaziland's TB case load has quadrupled since 1990, largely as a result of the country's high HIV prevalence.
Manzini, 3 August 2007 (IRIN) - Swazi health officials are concerned that the nearly two thirds of tuberculosis patients who do not complete their treatment could spell disaster for containing the spread of drug-resistant strains of the disease, particularly in patients co-infected with HIV.
"TB treatment completion rates have dropped to 34 percent, which is far below the 85 percent generally required to control TB. This represents a major public health challenge," the Ministry of Health and Social Welfare reported in a new study assessing the impact of AIDS-related diseases on Swaziland's health sector.
"Once TB treatment is interrupted or discontinued, the drugs can lose their effectiveness. We are seeing a new strain of drug-resistant TB in the country as a consequence," Cesphina Mabuza, director of health services at the Ministry of Health and Social Welfare, told IRIN/PlusNews.
Mabuza said that if no improvement was detected in patients who had stopped taking their TB drugs, two months after they had resumed treatment, this was taken as an indication that the patient had developed a multidrug-resistant TB (MDR-TB).
Such patients are supposed to be isolated, but Swaziland's overburdened government hospitals and public health sector have been unable to cope with the demand.
Health workers contacted by IRIN/PlusNews blamed inadequate and short-staffed hospitals and clinics, and a rudimentary home-based care system, for the failure of so many patients to complete their TB treatment.
"In Swaziland, HIV/AIDS and TB are joined at the hip; it is natural that the same treatment problems occur with both," said Rose Dlamini, a nurse on the TB ward at Raleigh Fitkin Memorial Hospital in the central commercial hub of Manzini. "It's a challenge, ensuring HIV-positive people stick to a regimen of antiretroviral treatment. If they fall off treatment, it may not work for them any more. It is the same with TB."
Mumu Shongwe is an outreach officer with a non-governmental organisation that provides home-based care to TB patients. "The relatives are usually not trained to oversee ARV [antiretroviral] or TB treatments, or they may be absent much of the day, leaving the patient alone. Home-based care is used because there is no room at hospitals," she said.
Before 1990, Swaziland's TB rates had been declining but, according to the ministry's report, between 1990 and 2004 the number of TB cases increased by almost four times, from around 210 per 100,000 people to 820 per 100,000.
TB also accounted for 7.5 percent of all hospital admissions by 2002, a 50 percent increase over four years. Although the average length of a hospital stay for TB has fallen due to a policy change that encourages home-based care for TB patients, the length of stay for TB remained around 14 days, the longest of all major diseases.
Swaziland has the highest HIV prevalence in the world, with an estimated 33.4 percent of the adult population infected. People with HIV-compromised immune systems are 50 times more likely to develop active TB. Based on tests of TB patients, the World Health Organisation estimated in 2004 that 80 percent of Swazi adults with TB were HIV-positive.
"Some of the clearest evidence of HIV and AIDS impact is on TB-related services," the ministry's report commented. "Health workers widely reported a substantial increase in the number of patients with TB. Many also noted that TB in HIV-infected people is often more difficult to diagnose, and that relapse rates have increased markedly."
Noting the strong links between HIV/AIDS and TB, Khanya Mabuza, programme officer for the National Emergency Council on HIV and AIDS, described the need for a greater integration of services aimed at preventing and treating the two diseases.
Cesphina Mabuza, from the Ministry of Health, agreed. "In Swaziland, the information we have is that most hospital beds occupied by people with HIV are patients who also have TB. There is strong evidence that when we do clinical management we need to combine the two."
Moves in this direction are already underway, according to Khanya Mabuza. "The message is getting through. Look at our ART [antiretroviral therapy] programme. Now, when a person is screened for TB and he or she comes back positive, the person is also screened for HIV. Conversely, if a person has TB, there is a test for HIV. This is the beginning of the linkage we need to do."
jh/ks/he See also, PlusNews In-Depth
- The New Face of TB: Drug resistance and HIV