Tuberculosis in Mozambique

Situation analysis

WHO/Gary Hampton

Tuberculosis is a public health challenge for Mozambique that ranks the 19th among the 22 High Burden Countries in the world, with estimated incidence rate of 431/100.000 population (all forms) in 2007. The case detection rate (49% in 2007) for the registered new smear-positive TB cases is below the global TB outcome target. TB-HIV co-infections are increasing; in 2008 60.1% of TB patients tested for HIV were HIV-positive. The recent DRS survey was conducted in 2007/2008 and the results of the survey indicate that the prevalence of MDR-TB is 3.4% among new cases and 8.3% among re-treatment cases.

Tuberculosis is one of the priority programs in the Ministry of Health and the Minister of Health showed strong commitment toward TB control. In March 2006, TB was declared a national emergency and the 2007 TB plan of action included priority actions to address this emergency such as: improvement of diagnosis and treatment quality, expanded access to DOTS to people living in underserved areas, implementation of community based intervention and intensifying TB/HIV collaborative activities.

In 2008, the new National Strategic Plan TB 2008-2012 was adopted by the government. The new strategic plan focuses on the recommendations from the Stop TB Initiative. This National strategic plan aims at reducing the global burden of TB in line with the Millennium Development goals and the Stop TB partnership targets.

The main components of the National Strategic Plan are:

• Pursue high quality DOTS expansion and enhancement;
• Address TB/HIV, MDR-TB and other challenges;
• Contribute to health system strengthening;
• Engage all care providers;
• Empower people with TB and communities;
• Enable and promote research.

Nowadays, the main financial assistance is provided by the GFATM and TB CAP and technical support comes from the WHO, TB CAP, Health Alliance International (HAI), CDC, ICAP and others.

Challenges

• The last population-based prevalence survey was conducted in 1962. In order to get unbiased measures of tuberculosis burden and trends in Mozambique , the National Tuberculosis Control Program (NTP) intends to have the nation-wide population based TB prevalence survey in 2010 which will be a challenge in fact;
• The TB case detection is still below the global TB target;
• Tackling the burden of TB is constrained by poor access to health services which is estimated to be 50% of the population living more than 20 kilometers from the nearest health facility;
• Regardless of the introduction of CPT and ART , the case fatality rate among TB/HIV patients still remains unchanged in high HIV prevalence provinces;
• There is a need to improve TB case detection activities among HIV+ patients. The IPT program coverage needs to be expanded;
• Mozambique has only one laboratory (NRL) which performs DSTs on 1st line anti-TB drugs, therefore, MDR-TB suspects defined by the NTP policy have limited access to the diagnosis. The other challenge is to establish two functional provincial laboratories in Beira and Nampula;
• The implementation of GLC-supported MDR-TB project requires sufficient numbers of qualified health personnel;
• There is a need to strengthen a TB program planning, budgeting and management at provincial and district levels.

Achievements

• A comprehensive review of the National TB Program took place in February 2006;
• the number of professionals working at the central unit of the NTP has increased. Nowadays, four medical doctors who are responsible for various aspects of the TB control program are working in the central unit. The Unit is also supported by two consultant /specialists and two administrative officers;
• different Working Groups; MDR-TB, Monitoring and Evaluation, TB/HIV etc. are functional and contribute widely on and support activities of the NTP;
• the case detection rate among new smear-positive cases has risen from 45% in 2003 to 50% in 2008;
• the treatment success rate among new sputum smear-positive cases has increased from 76% in 2003 to 79% in 2007;
• rigorous efforts have been undertaken by the TB program to improve access of people living in underserved areas by the expansion of DOTS to the community and by the increase of the number of peripheral health facilities offering DOTS services. In 2006, 49% (666/1333) of health facilities (health posts are not included) offered TB treatment services; in 2008, this figure reached 96% (1351/1401). From 2007, Community DOTS has formally been introduced as a part of DOTS expansion initiative. Community DOTS Strategy was approved, numerous community volunteers, traditional healers and others were trained and actively involved in the detection of TB cases and follow-up of patients on treatment;
• a TB/HIV Task Force was established in 2006 aiming at involving all partners involved in TB and HIV control;
• the NTP trained all staff to provide voluntary counseling and testing to TB patients and systematically refers the HIV+ patients for HIV care and treatment. In 2008, 79% of TB patients were tested for HIV, showing a very good scaling up of the TB/HIV collaborative activities in the TB sector; 92% and 30% of them started CPT and ART, respectively; a Clinical TB manual and a laboratory procedures manual were updated; a MDR-TB manual is being finalized;
• the National Reference Laboratory and two regional laboratories in Beira and Nampula are being renovated;
• the number of microscopic units has been increased from 252 in 2008 and is expected to reach 348 in 2009, due to the expected number of laboratories providing services;
• since 2008, the training of clinicians in TB and TB/HIV management (396 health care workers (HCWs), MDR/XDR (22 HCWs), TB infection control measures (33 participants) has been organized;
• application to Round 7 of the Global Fund for AIDS, Tuberculosis and Malaria (GFATM) was approved;
• application to the Green Light Committee (GLC) in order to have access to reduced price, 2nd line drugs has been approved. The first batch of 2nd line drugs has been arrived in the country;
• countrywide DRS survey has been finalized and the report was produced;
• a National STOP TB partnership was established in 2008;
• various health education materials were developed, printed and distributed; two TV spots regularly provide essential information on TB on national broadcast channels.

Next steps

• promote the expansion of Community DOTS and introduce the Community MDR-TB program;
• support the laboratory on the introduction of the molecular line probe assay method for the identification rapidly the rifampicin resistance and the liquid method for culture and DST for 1st line drugs;
• support to improve EQA on microscopy;
• train managers, clinicians and laboratory staff for TB Control, including TB/HIV collaborative activities and control of MDR-TB;
• strengthen a TB Drug Management system;
• promote the strengthening of collaborative activities between TB and HIV programs, mainly focusing on implementation of the 'three I's';
• support the implementation of GLC – supported MDR-TB program;
• support the organization and implementation of the TB prevalence survey;
• support the organization of the next external review of national TB program in 2010;
• support the introduction of innovative approaches in order to improve case detection in country;
• assist the TB program to develop proposals to seek financial support from donors;
• support the TB program on TB program management, budgeting and planning at provincial and district levels;
• support to update TB- R&R forms and to improve the quality of data collected at different levels.