1. NATIONAL TB PROGRAM ANNUAL REPORT 2012 Presented by: Ndumiso Mlotsa Ministry of Health NTCP

2. Report Layout & Structure Chapter 1: Program Services & Outcomes Chapter 2: Analysis of the 2012 TB Work-plan Chapter 3: Conclusions, Challenges & Recommendations

3. TB Situation In Swaziland, the World Health Organization estimates that; – There are 1317/100,000 incident TB cases occurring annually which is by far among the highest per capita TB burden in the world. – There are 854/100,000 prevalent TB cases occurring annually – There are 53/100,000 TB deaths (excluding HIV related) occurring annually Testing for HIV among TB patients remains high at 92% among new patients and 95% among all patients The TB/HIV co-infection rate remains around 80% which is among the highest co-infection rates in the region

4. TB Situation… The ART uptake among HIV positive TB patients has always been low with significant increases noted only in 2011, however; the improvements were sustained in 2012 as 66% were started and or continued on ART. There were remarkable improvements in TB treatment success rate from 68% in 2009 to 73% in 2012 which though still below the 85% recommended target by WHO, to hit the 70% mark for Swaziland is significant. MDR-TB cases increased from 332 in 2011 to 613 in 2012. MDR-TB Treatment Success rate improved from 18% in 2011 (2008 cohort) to 57% in 2012 (2009 cohort).

5. Program Description

6. Policy Formulation & Guidelines All NTCP activities regulated through the STOP-TB Strategy adapted in the NTCP Strategic Plan 2010-2014 To operationalize the Strategy the following policy documents & guidelines were enacted; – The National TB Control Programme Manual 2012, – The Drug-Resistant TB Management Guidelines 2012, – The TB Infection Prevention and Control Guidelines 2012 – The TB/HIV policy guidelines 2010 Revised in 2011 – The PMDT Plan, 2011-2016 – The TB Emergency Response Plan 2010-2013 – The TB M&E Plan 2011-2015

7. Organization of TB Services The NTCP Manager is responsible for the overall program activities reporting to the MOH Directorate NTCP Thematic area heads or coordinators responsible for strategic leadership and expert advise in their thematic areas National Regional coordinators are responsible for implementation of TB activities in the 4 regions Regional TB Focal Nurses are responsible for providing of TB services at health facility level Facility

8. Decentralization of TB Services & Infrastructure Improvements RegionPublicPrivateNGOMissionIndustryTOTAL Hhohho122210 17 Manzini85240 19 Lubombo50033 11 Shiselweni201230 26 TOTAL458611373 Table 5: Facilities that are providing TB Treatment initiation Services by Ownership 2012 Source: TB Program Annual Report, 2012

9. Decentralization of TB Services & Infrastructure Improvements… Figure 1.TB hospital upgrading of the mechanical ventilation system installed with support from URC Figure 2: Renovations at Mpuluzi TB clinic including reroofing and construction of the patient waiting area supported by MSF in the Manzini region Figure 3: Renovations at Dvokolwako TB/HIV clinic including reconstruction of the patient waiting area supported by URC in the Hhohho region

10. Continue….. Mankayane Hospital TB ward with Support from (MSF). Hlathikhulu TB ward to admit DR-TB patients. TB Centre Clinic to have a fully fledged laboratory with the Support from URC. Accreditation of Sphofaneni lab to provide diagnostic services for surrounding Health Facilities in the Lubombo region. Decentralization of TB Services & Infrastructure Improvements…

11. New TB Diagnostics & Lab Strengthening FacilityInstallation Date Number of. Gene- Xpert Machines 1. Mbabane Laboratory25.05.122 2. Good Shepherd Hospital Laboratory23.04.121 3. Piggs Peak hospital Laboratory21.05.121 4. RFM Laboratory28.05.121 5. Sithobela HC Laboratory24.04.121 6. Siphofaneni Laboratory30.07.121 7. TB Hospital Laboratory16.07.122 8. Matsapha MSFOct-112 9. Mankayane LaboratoryNov-111 10. Hlathikhulu LaboratoryAug-121 11. Nhlangano LaboratoryAug-122 12. Matsanjeni Laboratory Nov-121 13. TB CentreNov-122 TotalBy end of 201218 Table 4: Facilities that have GeneXpert Installed in 2012

12. New TB Diagnostics & Lab Strengthening Figure 5: 4 module GeneXpert machine installed at TB centre. Figure 6: LED microscope placed at TB Hospital laboratory. More LED microscopes were bought through support from MSF and FIND installed at TB centre. Figure 7: MGit machine used to run samples for culture and DST at the National Reference Laboratory in Mbabane.

13. Drug Supply & Management Although none of the facilities reported stock-out of TB drugs in 2012 there were some erratic supplies that were a result of expired drugs being distributed from the central medical stores (CMS) however these did not amount to stock-outs as initiation of TB patients on treatment was not interrupted. There were approved changes with regards to the procurement, management and classification of treatment regimens for TB medicines as follows; – Streptomycin phased out as 1 st line regimen: only patients who were already on Streptomycin are continuing and new initiations has ceased already for this drug. – Also, the ordering and distribution of TB medicines have since been centralised and integrated to the normative Ministry of Health system i.e. it is now fully coordinated by the Central Medical Stores. This was complemented by the appointment of a dedicated pharmacist at the Central Medical Stores who is responsible for quantification, ordering and procurement of TB medicines and supplies. – Direct procurement of TB drugs has been approved by the Ministry of Finance which ensures uninterrupted supply of TB medicines.

14. Data Management & Reporting Institutionalized On-Site Data Verifications – NTCP received A2 rating on GF grant Reporting as a result of high quality data Regional QRMs for Experience sharing & learning – NTCP has been widely known for its effective quarterly data review meetings that bring TB nurses from all treatment sites to discuss progress made in service level indicators Information Products – Different information products generated from the routinely collected data sets targeting different audiences who are part of the NTCP stakeholders. – These includes; Progress Update and Disbursement Report (PUDR) for the Global Fund to Fight HIV/AIDS, Tuberculosis and Malaria (GFATM) and the TB Epidemiology reports provided quarterly to clinicians and public health professionals to trigger new strategies and interventions based on epidemiological data.

15. Research Developments In 2012 the TB programme published the study “Reducing TB diagnostic Delays in Swaziland” which revealed that there are still structural barriers to diagnosis as a result of continued low turnaround time for TB diagnosis results and inconsistencies with the sample transportation system. Additional research papers were presented by the National TB Control Programme in the National Health Research Conference in November 2012 included; – A study on Quantitative and Qualitative Analysis of Ambulatory Care for Multi-Drug Resistant TB in Swaziland: Clinical outcomes and Patient Experience which highlighted that there were no significant differences between clinical outcomes of patients managed under ambulatory care in the comfort of their families and those that are managed at facilities. – A paper on the Impact of GeneXpert rapid tests on TB Case finding in Swaziland which highlighted the contributions of the GeneXpect technology in reducing the number of smear negative TB cases being enrolled on TB and the number of Smear Not Done cases while detecting rifampicin resistance on the spot thus reducing the proportion of non-converters at 2/3 months after treatment enrolment. – Two additional papers were presented by the regions on successful scaling up of TB/HIV services in health facilities in the country and the role of partnerships in implementing TB/HIV collaborative activities in Shiselweni region. Both the papers highlighted the achievements of the National TB Control Programme in increasing coverage of TB/HIV services and bring the services closer to the people.

16. TB Epidemiology & Patient Outcomes

17. TB Incidence

18. TB Case Detection

19. TB Notifications Trends

20. Systematic TB Screening

21. TB Screening cont’d

22. TB Screening Cont’d

23. Declining TB Burden

24. CHILDHOOD TB NOTIFICATIONS

25. Estimated number of deaths 490,000 (range: 470,000–510,000) 327,000 Estimated TB Notifications The Global Childhood TB Burden -2011 Estimated Incident TB cases 64,000 (range: 58,000–71,000)

26. Swaziland Childhood TB Situation

27. TB Screening cont’d

28. TB Screening Cont’d

29. TB/HIV Services Among Childhood TB Patients

30. TB/HIV Services (All Forms)

31. CHALLENGES & RECOMMENDATIONS

32. Challenges I.Inadequate Attainment of Programme Outputs – The failure by the Global Fund to disburse monies in 2012 had far reaching effects in carrying out strategic activities directly linked to attainment of the targets outlined in the programme strategic plan 2010-2014. II.Poor results turn-around time (TAT) – The laboratory results turnaround time continued to be a challenge in 2012 as a result of inadequate maintenance of sputum transportation system including sub-standard communication between laboratory and facilities, unavailability of contingency & relief vehicles, uncovered routes and few vehicles to carry-out the task. III.Inconsistent supply of TB Drugs – Occasional stock outages of some second line TB medicines as a result of delays in the payment of suppliers and the previous arrangement which restricted 2nd line TB drugs to procurement with all other medicines. IV.Weak DR-TB Recording and Reporting – A major challenge in 2012 was the coordination of recording and reporting needs for DR-TB response as the services were being decentralized to other facilities beyond the national TB Hospital in Moneni while the guidelines themselves were being reviewed for adoption.

33. Recommendations Strengthen MDR-TB R&R by establishing an active DR-TB surveillance and notification system. Strengthen the supply chain for 2 nd Line TB Drugs in collaboration with the Central Medical Stores (CMS) to improve and reduce the delays in the Both 2nd line & 1st line drug procurement system. Strengthen research and evaluation activities by ensuring that a TB prevalence study as well as Client satisfaction survey are conducted. Strengthen collaboration between the NRL and facility labs to improve results Turn Around Time (TAT).

34. THANK YOU…