Leader in TB treatment

Faced with the HIV/AIDS epidemic, deepening malnutrition as a result of a serious food shortage and abject poverty, Malawi has managed to become a model for sub-Saharan Africa in treating tuberculosis (TB), a disease that kills two million people annually. Dr Felix Salaniponi, Programme Manager of Malawi's National TB Programme (NTP) told PlusNews that the country, which boasts a 69 percent TB cure rate, was proud of its successes. "Most countries have a cure rate of 40 percent or 50 percent and very few go above 50 percent," Salaniponi said. The World Health Organisation (WHO) in 1993 declared TB, which kills two million people each year, a global emergency. The International Union Against Tuberculosis (IUAT) has set a global target cure rate of 85 percent and detection rate of 70 percent by the year 2005. But the spread of HIV/AIDS, with an estimated 28 million people infected in sub-Saharan Africa, has seen a breakdown in health services and the emergence of multi-drug-resistant TB, which has worsened the impact of the disease. In Malawi HIV/AIDS, first recorded in the country in 1985, kills 70,000 people every year, and 850,000 are said to be living with the HI virus. Treatment for TB cases has been complicated by the fact that 75 percent of the patients are HIV positive. Salaniponi said TB was first reported in Malawi in 1964. By the 1970s, 4,000 cases were officially recorded each year and 90 percent of the cases were successfully treated. "From 1989, we saw that those excellent results were eroded by the advent of HIV," he said. Within 10 years the number of TB cases had risen to 20,000 annually and TB cases became a strain on the health care sector. The mortality rate rose from 5 percent in 1985 to 22 percent in 1998. The large urban centres of Blantyre, Zomba and Lilongwe suffered the greatest. "When combined, they made up to 50 percent of all cases [in hospitals]. Congestion [in hospital beds] rose to 300 percent and 400 percent of bed occupancy in extreme case," Salaniponi said. Malawi's success in the fight against TB started in 1984 with the establishment of the new structure of the TB programme. TB manuals were also distributed and served to guide clinical officers in dealing with the disease. The country also adopted a WHO recording and reporting system "which produced good data". The TB programme also decided to decentralise its system, despite protests from WHO and independent consultants. "We insisted we would do it the Malawian way. Two years later, WHO says we're a leader and mentor in the region," Salaniponi said. The cure rate was now 69 percent, a real achievement "taking into account the big challenge of HIV". Malawi recorded 27,000 TB cases in 2001. All cases are treated with anti-TB drug regimens lasting from eight to 12 months. In 1996 WHO started providing technical assistance, equipment, training and operational research to the government of Malawi. "We made it clear that we were going to [be bent] on operational research. At that time the cure rate was 60 percent, and with technical assistance it rose to 65 percent," Salaniponi said. The decentralised system - in which patients are treated from home - reduces the cost from US $250 to US $100 per patient. Salaniponi said people like the system because it is user friendly, sociable, cheaper and culturally acceptable. The introduction of decentralised TB treatment has also reduced the mortality rate by one percent, he observed. But Salaniponi was quick to point out that "this is just an instant observation". Bed occupancy has also reduced from 400 percent to 60 percent. "The beds are empty," he said adding that even mortality rates in big hospitals had gone down. Malawi has also come up with a regimen for treating patients with multi-drug resistant TB, which it expects to begin administering within the next four weeks. "These patients will be treated for 18 months in total," Salaniponi said. The first four months are the most critical and intensive because each patient will be allocated a health officer responsible for treatment each day. The subsequent 14 months will see patients being treated normally. Malawi has eight officially recorded cases of multi-drug resistant TB patients. Drug-resistant TB is caused by inconsistent or partial treatment, such as patients not taking all their drugs regularly for the required period because they start to feel better, or when doctors and health workers prescribe the wrong treatment regimens or the drug supply is unreliable. In 1999 the NTP, in collaboration with the Liverpool School of Tropical Medicine, developed several projects aimed at devising holistic approaches to TB treatment. The Knowledge Programme, for example, aims at harnessing knowledge from operational research on issues such as: multi-drug resistance; gender equality and equity; poverty and TB; quality assurance; and pharmacokinetics (the way drugs behave in the body). The Knowledge Programme's core objective is to establish the link between poverty and TB and to inform policy on access for the poorest.