J.21_Annual_TB_Program_Report_2018.pdf

MONITORING AND EVALUATION

Monitoring and Evaluation Unit Strategic Information Department

SIY I NQ A B A

KINGDOM OF ESWATINI

MINISTRY OF HEALTH

Annual Program

Report

ANNUAL TB

PROGRAM

REPORT

Acknowledgements

The report is based on the calendar year Jan 2018 - Dec 2018

The primary aim of this report is to share information on progress made in TB control in Eswatini (2018). The successful completion of the NTCP 2018 Annual Report has been made possible by the joint efforts of dedicated NTCP staff both at National and Regional level. The successes of the program are a result of a close collaboration between the National TB program and develop-ment and implementing partners. Our appreciation goes to the M&E unit both at the national and regional level for their tirelessly efforts in producing high quality data used in this report. We also extend our heartfelt gratitude to the health workers at the regional and health facility levels who recorded and reported all data, which has been aggregated in this report. The program also appreciates IHM for both technical and financial assistance during the analysis and report writing period.

This report would not have been a success without the following individuals at the NTCP:

Sanele Masuku M&E Advisor Makhosazana Matsebula M&E Officer Lindiwe Dlamini-Mdluli National TB/HIV Coordinator Dr Debra Vambe PMDT Technical Advisor Nonhlanhla Dlamini PMDT Coordinator Philile Mndzebele DOTS Focal Person Njabu Hlophe ACSM Coordinator Sisi Dube Paediatric Focal Person Goodwill Matsebula Laboratory Focal Person Dr Welile Sikhondze Clinical Scientist/ Research Coordinator Tandzile Dlamini Audiologist Joyce Sibanda National Community Services Coordinator Herbert Chomutare National M&E Coordinator Tikhona Mkhabela Shiselweni Active Case Finding Coordinator

CONTENTS

CHAPTER 1: 8

LIST OF FIGURES 11

List of tables 11 Acknowledgements 12 Abbreviations and acronyms 12

1.1. Background 8

1.3 Purpose of the Report 11

Chapter 2: Program Description 12

2.1 Leadership and governance 12

2.2 Organization of TB services 13

3.1 Coverage of TB services 16

3.2 TB Screening 16

3.3 Case Detection 18

3.4 TB Case Notification 19

3.5 TB Case notification by Diagnosis status 21

3.6 TB/HIV collaborative activities 22

3.7 Sputum Smear Conversion 23

3.8 Treatment Outcomes 24

3.9 Treatment Outcomes for TB/HIV co-infected patients 26

3.10 Burden of paediatric TB in the country 28

3.11. Drug Resistant TB 31

3.12 Enrollment by Age Disaggregation 34

3.13 Multi-Drug Resistant TB Interim Outcomes 35

TB/HIV Achievements 40

4.2. DOTS 41

4.8. PMDT ACHIEVEMENTS 41

4.9. LABORATORY 42

4.10. RESEARCH 43

4.11. MONITORING & EVALUATION (M & E) 43

5.1. Conclusions 44

5.2. Action Points 44

Introduction

Program Description

CHAPTER 2: 12

PROGRAM RESULTS

CHAPTER 3: 16

Program achievements and challenges

CHAPTER 4: 40

Conclusions and Action points

CHAPTER 5: 44

List of figures Figure 1.1 Global Plan to END-TB Strategy 13 Figure 3.1: TB Screening through Intensified Case Finding, 2018 17 Figure 3.2: TB Case Detection through GeneXpert 18 Figure 3.3: Trends in TB Case Detection (2015-2018) 19 Figure 3.4 Trends in TB Case Notification 2011-2018 20 Figure 3.5:Trends in TB Notification by Sex, 2011-2018 20 Figure 3.6: TB Notification Trends by Age Group, 2012-2018 21 Figure 3.7: All Forms of TB cases by Bacteriological Confirmation Status 2011-2018 22 Figure 3.8 TB/HIV Collaborative Services, 2012-2018 22 Figure 3.9: Sputum Conversion Among Bacteriological Confirmed TB Cases, 2018 23 Figure 3.10: Sputum Conversion Among Bacteriological Confirmed Cases by Region 2018 24 Figure 3.11: Treatment Outcomes for All Forms of TB, 2018 24 Figure 3.12: Treatment Outcomes for all forms of TB, 2012-2017 cohort 25 Figure 3.13: Treatment Outcomes among Bacteriologically Confirmed TB cases, Jan-Dec 2018 26 Figure 3.14: Treatment Outcomes for HIV+ TB patient’s cohort, 2013-2018 27 Figure 3.15: Comparison of TB Treatment Outcomes by HIV status, 2018 27 Figure 3.16: Proportion of paediatrics TB cases notified, 2012-2018 28 Figure 3.17: Proportion of paediatrics notified by anatomical site of TB, 2018 29 Figure 3.18: Proportion of pediatric TB cases notified by case definition, 2018 29 Figure 3.19: Childhood TB/HIV Collaborative activities, 2012-2018 30 Figure 3.20: Treatment outcomes among all paediatric TB cases, 2018 31 Figure 3.21: DR-TB cases enrolled on DR-TB treatment regimen, 2013-2018 32 Figure 3.22: DR-TB cases enrolled on DR-TB treatment by type of resistance, 2013-2018 33 Figure 3.23: Trends in DR-TB patients enrolled by history of TB, 2013-2018 34 Figure 3.24: DR-TB patients enrolled on DR-TB treatment by age-group, 2018 (N=306) 34 Figure 3.25: TB/HIV Collaborative activities among DR-TB patients, 2013-2018 35 Figure 3.26: DR-TB Interim Outcomes, 2013-2018 36 Figure 3.27: DR-TB outcomes for all DR-TB patients, 2009-2015 cohort 37 Figure 3.28: DR-TB Outcomes by type of Resistance, 2018 38 Figure 3.29: Final Outcomes for Paediatric DR-TB patients, 2015 cohort (N=5) 38 Figure 3.30: DR-TB final outcomes by HIV status, 2018 39

List of tables Table 3.1: TB Basic Management Units and TB Diagnostic Sites 16 Table 3.2: Trend in TB Screening Conducted, 2012-2018 17 Table 3.3: TB Screening through Active Case Finding (Door to door vs Contact Tracing), 2018 18 Table 3.4: Number of facilities providing DR-TB services, 2018 32

ABBREVIATIONS

AND ACRONYMS

ACF Active Case Finding IPT Isoniazid Preventive Therapy

ACSM

Advocacy, Communication and Social Mobilization LPA Line Probe Assay

AFB Acid-Fast Bacilli MDR-TB Multi-Drug Resistant TB

AIDS Acquired Immuno-deficiency Syndrome MoH Ministry of Health

ANC Ante natal clinic MTP Medium-Term Plan

ART Anti-retroviral therapy MS Medical Stores

ARV Anti-retroviral medicine MSF Medicins San Frontiers

CBNAAT Catridge Based Nuclei Acid Amplification Test NERCHA National Emergency Response for HIV and AIDS

CBO Community-Based Organization NGO Non-Governmental Organization

CDC

Centre for Disease Control and Prevention, Atlanta, USA NSP National Strategic Plan

CHAI Clinton Health Access Initiative NTCP National TB Control Programme

CPT Cotrimoxazole Preventive Therapy NTRL National TB Reference Laboratory

DOT Directly Observed Treatment OPD Out Patient Department

DST Drug Sensitivity Testing PHC Primary Health Care

EGPAF

Elizabeth Glasier Peadiatric AIDS Foundation PLHIV People Living With HIV

EQA External Quality Assurance PSM Procurement and supply chain management

FDC Fixed-Dose Combination PTB Pulmonary Tuberculosis

GDP Gross Domestic Product QA Quality Assurance

GFATM Global Fund to Fight AIDS, TB and Malaria

SACU Southern African Customs Unit

HDI Human Development Index SADC Southern African Development Community

HIV Human Immuno-deficiency Virus SDGs Sustainable Development Goals

HF Health Facility SHI Social Health Insurance

HPI Human Poverty Index SNAP Swaziland National AIDS Control Programme

HR Human Resources TB Tuberculosis

HRD Human Resource Development TB/HIV HIV-related Tuberculosis

ICAP International Center for AIDS Care and Treatment Programs URC University Research Co.,LLC

IHM Institute of Health Meausrement URSA University Research Southern Africa

6 Tuberculosis Control Program_2018 Annual Report

EXECUTIVE SUMMARY

The Ministry of Health (MOH) through the National TB Control Program (NTCP) has made a great stride in controlling TB in Eswatini in the past years. The rising notification of TB cases in Eswatini has been halted through increased invest-ments in TB control by the Kingdom of Eswatini (GKoE).

Key interventions that the TB program has implemented in order to curb TB include among others, decentralization of TB services from 86 BMUs in 2013 to 130 BMUs in 2018, strengthening collaboration between the TB and HIV programmes through the National TB/HIV Coordination Committee (NCC), intensified case finding, active case finding, strengthen contact tracing, expanding access to TB treatment and ensuring un-interrupted supply of quality-assured first and second line anti-TB drugs.

According to the WHO Global TB report (2018), the country’s estimated TB incidence has decline from 398/100 000 popu-lation in 2017 to 308/100,000 population in 2018, TB-related mortality rate for HV- TB patients has dropped from 19/100,000 to 10/ 100,000 population and TB mortality rate among HIV+ TB patients has also decline from 84/100 000 population in 2017 to 44/100 000 population in 2018. In terms of TB case notification rate the country is at 260/100 000 population translating to 84% in case detection rate.

Major milestones achieved since implementation of the TB National Strategic Plan (2015-2019), among DS-TB patients, a remarkable improvement in TB treatment success rate has been noted, increased from 73% in 2013 to 86% in 2018 though still below the 90% recommended target by WHO. Great progress has also been made in TB/HIV collaborative activities, HTS uptake has increased from 95% in 2014 to 99% in 2018, ART uptake increased from 79% in 2014 to 98% in 2018 and CPT uptake constantly doing exceptional well from 98% in 2014 to 100% in 2018.

The Kingdom of Eswatini has also implemented numerous interventions to improve management of Drug resistant tuberculosis which includes but not limited to; roll out of Xpert MTB/RIF to improve DR-TB case detection, decentraliza-tion of Gene Xpert MTB/RIF testing capacity to peripheral laboratories, universal access of first-line and second-line Drug Susceptibility Testing (DST), introduction of first-line & second-line line probe assay (LPA), introduction of new drugs and shorter MDR-TB regimen and further decentralized DR-TB treatment services to 13 sites.

These efforts have been accompanied by a decline of DR-TB cases from 495 in 2014 to 306 in 2018 and a significant increase in DR-TB treatment success rate from 54% in 2010 to 74% in 2018.

However, despite the above-mentioned achievements, Eswatini is still experience some challenges with high mortality among TB patients and a drastic decline in paediatric TB diagnosis. These challenges pose threats to the achievements already made in TB control in the country.

Tuberculosis Control Program_2018 Annual Report 7

PERFORMANCE INDICATORS

Thematic Area Indicator Baseline 2011 Target for 2018

Achievement Progress Status

Case detection

Case detection rate 46% in 2013 80% 84%

Case detection rate 867/100 000 _ 260/100 000

DS-TB % of TB patients initiated on ART

35%

90% 98%

Treatment Success( All Forms)

73% 90% 86%

Success( All Forms)

72% 90% 85%

DR-TB % of TB patients initiated on ART

78% in 2013 90% 97%

Success rate

18% (2008 cohort) 90%

74% ( 2015 cohort)

Legend

Target off-track, requires action

Target on-track, likely to be achieved

Target achieved.

1.1. Background

The Kingdom of Eswatini is an absolute landlocked monarch. It is the smallest country in the southern hemisphere, covering just more than 17 000 sq km and with a limited area of 193 km from North to South and 145 km from east to west. Bordered in the North, West and South by the Republic of South Africa and by Mozambique in the East, the kingdom wherein altitudes range between 120 and almost 2 000 metres above sea level presents a mosaic of vistas and climates. The Kingdom’s geography is a microcosm of Africa’s widely varied and scenic terrain. It is divided into four administrative regions: Hhohho, Lubombo, Manzini, and Shiselweni and further administratively subdivided into 59 Tinkhundla (constituencies) and 385 chiefdoms. The estimated population of the country is 1,093,238 people (2017 census). An estimated 78 % of the population lives in Rural Swaziland. The country is classified as a Low-Middle Income Country with an income per capita of US$3914.02 in 2017.

1.1.1. Development challenges

Domestic economic activity remains weak and is estimated to have declined by 0.4 percent in 2018, triggered by the current fiscal challenges and the frail external expectation which dampened growth for the country’s exports. Economic growth in the medium term is expected to gradually pick-up, but remains below 2 percent, driven by anticipated improvements in the agriculture and manufacturing sectors. Growth is forecasted at 1.8 per cent in 2019.

The Kingdom of Eswatini continues to face daunting fiscal and economic challenges. Government revenues and expenditures are continuously moving in opposite directions, driven by volatile receipts from the Southern African Customs Union (SACU) and ballooning government expenditure. The expansionary fiscal position has surpassed sustainable levels, resulting in the accumulation of arrears, increased depletion of reserves and constrained economic growth. The nation is concerned that the SACU receipts have been decreasing over the last few years.

The primary development challenge for the country is to address the high rate of poverty and inequality. The weak economic environment, together with persistent drought conditions has a huge bearing on the lives of the people. A majority of Emaswati live in rural areas and depends on agriculture as their main source of livelihood. As a result, the adverse weather conditions have limited poverty reduction, with the poverty rate at the international extreme poverty line of $1.9 per day in 2015 stagnating at 39.4 percent, compared to 39.5 percent in 2014. Poverty is strongly correlated with unemployment which is about 26.4% overall and 54.78.4% among the youth according to 2017 statics. Poverty is also associated with the high burden of communicable diseases. The HIV/AIDS prevalence of 27% among adults 15 years and older of the population is the highest in the world and life expectancy has fallen to approximately 58 years.

1.2 Introduction

Tuberculosis (TB), still recognized by the World Health Organization (WHO) as the world’s leading pandemic causing ill-health to approximately 10 million people each year, continues to be a cause for concern. However, the major concern is that TB is still the leading cause of death among people living with HIV despite newer modalities for TB diagnosis and treatment.

Even though effective TB diagnosis and treatment has saved 54 million lives between the year 2000 and 2017, over 1.3 million TB deaths were recorded in 2017. This included approximately 0.3 million deaths among people living with HIV.

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INTRODUCTION

An estimate of 161, 000 people were exposed to Drug Susceptible TB (DS-TB) and some developed multidrug-resistant TB (MDR-TB). Despite WHO’s roadmap for reaching zero TB deaths among children, an estimated 1million children became ill with TB and a further 292, 000 died of TB in 2017 (WHO Global Report 2018).

The country adopted the End TB Strategy which was approved by The World Health Assembly in 2014 aimed at ending the global TB epidemic, with targets to reduce TB deaths by 95% and to cut new cases by 90% between 2015 and 2035 and to ensure that no family was burdened with catastrophic costs due to TB.

1.2.1 The burden of TB in the Kingdom of Eswatini

Tuberculosis remains one of the major public health concern(s) currently faced by the Kingdom of Eswatini. The coun-try’s estimated TB incidence is 308 cases per 100,000 population, TB-related mortality rate has shown a decline from 19 cases per 100,000 population, to 10 cases per 100,000 population among HIV negative individuals. Similarly, the same trend was noted amongst PLHIV which also declined from 91 cases per 100,000 population to 44 cases per 100,000 population.

In 2018, the total notified TB cases were 2,845 out of the estimated 3667 incident cases for 2018. This showed a 84% case detection rate presenting a significant improvement from 59% in 2016. Among the notified cases; 1729 (61%) were bacteriologically confirmed, 742 (26%) clinically diagnosed and 374 (13%) were extra-pulmonary cases.

Major milestones have been noted since the implementation of the NTCP strategy (2015-2019). This include a significant improvement in the TB treatment success rate, from 73 % in 2013 to 86% in 2018, which is above the 80% set target in the strategic plan. TB/HIV co- infection rate declined from 70% in 2015 to 66% in 2018. Through collaborative activities the country is at 95% ART coverage from 73% in 2013.

Childhood TB Childhood TB remains a challenge in the country, statistics show that childhood TB notification is currently at 6% which is lower than the WHO Standards and Benchmark (10- 15% among all TB cases). The country notified 162 cases in 2018 of which 156 (96%) were new cases 44 (27%) were bacteriologically confirmed, 96 (59%) were clinically diagnosed and 22 (14%) were extra pulmonary cases. The TB Program has intervened in several ways that include supplying health facilities with equipment for sputum induction in children, economic and social support for the improvement of children’s access to TB care services and improved children drug formulations among others.

Drug resistant TB Drug resistant TB is an emerging obstacle for effective TB control in the country. The results have showed that the prevalence of any form of drug resistance is 11%. The prevalence of Rifampicin resistant/Multi-drug resistant TB (RR/MDR-TB) among new TB cases is 6.8%, and 16% among previously treatment cases. These results compare favora-bly with the 2010 DRS which showed the prevalence of MDR-TB among new patients as 7.7% and among previously treated cases at 33.8%. In 2018 there were 306 registered DR-TB cases, of which 164 (54%) were new cases, 130 (42%) were previously treated with first line drugs, 12 (4%) were previously treated with first and second line drugs. Nonethe-less, specific measures are being taken within the National Tuberculosis Control Programme (NTCP) to address the DR-TB burden, through appropriate management of patients, strategies to prevent the transmission and dissemination of DR-TB. This further translates to the need for additional resources and investment into ensuring adequate care to cut the cycle of DR-TB transmission.

1.2.2. Political commitment and leadership

The country is in line with the Post-2015 Global TB Strategy launched at the 67th World Health Assembly in May 2014 as well as the UN General Assembly High level meeting on TB held in September 2018. His Majesty King Mswati III was amongst the world leaders who reaffirmed their commitment to ending TB in their countries. This resulted to a high commitment of Eswatini to foster coordination between health programmes by ensuring universal access to integrated prevention, diagnosis, treatment and care, emphasizing on community based health services.

Tuberculosis Control Program_2018 Annual Report 9

CHAPTER ONE: INTRODUCTION

Thus, the NSP objectives have been aligned to comprehensively embrace the Principles as well as the Pillars and Com-ponents of the Post-2015 Global TB Strategy:

Principles:

1. Government stewardship and accountability, with monitoring and evaluation

2. Strong coalition with civil society organizations and communities

3. Protection and promotion of human rights, ethics and equity

4. Adaptation of the strategy and targets at country level, with global collaboration

Sustainable Development Goals:

The Sustainable Development Goals (SDGs) continue to be the focus of global priorities for development cooperation and to guide national priorities in most countries. The END TB strategy calls for the e�ective use of existing tools to combat TB through universal health coverage to push down global incidence rates and the reduction of people who die from TB by 2025. Eswatini committed to the SDGs in September 2015 during the UN General Assembly. In line with this, the country has devoted to ending the TB epidemic by 2030, which is one of the targets under Goal 3; To ensure healthy lives and promote well-being for all at all ages.

1.2.3. TB Strategic Plan 2015-2019

In 2015 the country began implementing the new National TB Strategic Plan (TB-NSP) 2015-2019. The goal of the 2015-2019 TB National Strategic Plan (TB NSP) is to achieve a 35% reduction of TB prevalence rate by 2019 to 907/100,000.

The NSP is based on five objectives which are:

1. To increase TB case detection rates from 46% in 2013 to 70% in 2017 and 80% by 2019.

The country experienced a progressive decline in case detection in 2010, which saw the country introducing several strategies in intensifying case finding. Gene Xpert MTB/RIF was introduced, intensified case finding at facility level and community active case finding were implemented. Thus improvement on case detection was noted a few years later, currently case detection is at 84% from 59% in 2016. Furthermore, in 2018 the Program introduced gene Xpert Ultra to strengthen diagnosis particularly among presumptive peadiatric cases, PLHIV cases and to improve detection of resist-ant strains of TB.

The programme has also played a major role in implementing the Regional TB in the Mines project which aims to identi-fy and put on treatment miners and ex miners who are infected with TB and their immediate family members. In 2018, 49 miners and ex- miners were diagnosed and initiated on TB treatment.

2. To increase TB treatment success rates for all bacteriologically confirmed cases from 72.9% in 2013 to 90% by 2019 Eswatini has met and surpassed the WHO recommended TB treatment success target of 85% as it stands at 86%.

However, the NSP target of 90% is not yet met. Therefore, NTCP intends to strengthen its efforts towards attaining the 90% treatment success rate among all bacteriologically confirmed TB cases by 2019 through the use of lay cadre both at community and facility levels (Adherence Officers, Treatment Supporters, etc) and the introduction of the patient support program.

3. To implement and expand country-wide collaborative TB/HIV activities and management of co-morbidities by Eswatini is still listed amongst the high TB/HIV burdened countries in the world with a 66% co-infection rate in 2018.

There has been concerted efforts by the NTCP and Eswatini National AIDS Programme (ENAP) to address the dual epidemics through the development of the TB/HIV Integration policy which guides the implementation of TB/HIV servic-

es. The programme managers from the afore-mentioned two programmes co-chaired a functional National Coordina-

10 Tuberculosis Control Program_2018 Annual Report

CHAPTER ONE: INTRODUCTION

List of figures Figure 1.1 Global Plan to END-TB Strategy 13 Figure 3.1: TB Screening through Intensified Case Finding, 2018 17 Figure 3.2: TB Case Detection through GeneXpert 18 Figure 3.3: Trends in TB Case Detection (2015-2018) 19 Figure 3.4 Trends in TB Case Notification 2011-2018 20 Figure 3.5:Trends in TB Notification by Sex, 2011-2018 20 Figure 3.6: TB Notification Trends by Age Group, 2012-2018 21 Figure 3.7: All Forms of TB cases by Bacteriological Confirmation Status 2011-2018 22 Figure 3.8 TB/HIV Collaborative Services, 2012-2018 22 Figure 3.9: Sputum Conversion Among Bacteriological Confirmed TB Cases, 2018 23 Figure 3.10: Sputum Conversion Among Bacteriological Confirmed Cases by Region 2018 24 Figure 3.11: Treatment Outcomes for All Forms of TB, 2018 24 Figure 3.12: Treatment Outcomes for all forms of TB, 2012-2017 cohort 25 Figure 3.13: Treatment Outcomes among Bacteriologically Confirmed TB cases, Jan-Dec 2018 26 Figure 3.14: Treatment Outcomes for HIV+ TB patient’s cohort, 2013-2018 27 Figure 3.15: Comparison of TB Treatment Outcomes by HIV status, 2018 27 Figure 3.16: Proportion of paediatrics TB cases notified, 2012-2018 28 Figure 3.17: Proportion of paediatrics notified by anatomical site of TB, 2018 29 Figure 3.18: Proportion of pediatric TB cases notified by case definition, 2018 29 Figure 3.19: Childhood TB/HIV Collaborative activities, 2012-2018 30 Figure 3.20: Treatment outcomes among all paediatric TB cases, 2018 31 Figure 3.21: DR-TB cases enrolled on DR-TB treatment regimen, 2013-2018 32 Figure 3.22: DR-TB cases enrolled on DR-TB treatment by type of resistance, 2013-2018 33 Figure 3.23: Trends in DR-TB patients enrolled by history of TB, 2013-2018 34 Figure 3.24: DR-TB patients enrolled on DR-TB treatment by age-group, 2018 (N=306) 34 Figure 3.25: TB/HIV Collaborative activities among DR-TB patients, 2013-2018 35 Figure 3.26: DR-TB Interim Outcomes, 2013-2018 36 Figure 3.27: DR-TB outcomes for all DR-TB patients, 2009-2015 cohort 37 Figure 3.28: DR-TB Outcomes by type of Resistance, 2018 38 Figure 3.29: Final Outcomes for Paediatric DR-TB patients, 2015 cohort (N=5) 38 Figure 3.30: DR-TB final outcomes by HIV status, 2018 39

List of tables Table 3.1: TB Basic Management Units and TB Diagnostic Sites 16 Table 3.2: Trend in TB Screening Conducted, 2012-2018 17 Table 3.3: TB Screening through Active Case Finding (Door to door vs Contact Tracing), 2018 18 Table 3.4: Number of facilities providing DR-TB services, 2018 32 tion Committee (NCC) which guide the successful implementation of the WHO recommended framework for collabora-tive activities. Regional Coordination Committees has been established in all the four regions of the country.

4. To provide treatment and support to all drug-resistant TB cases and reduce the MDR-TB prevalence rate amongst new TB cases to less than 5% by 2019 The prevalence of Rifampicin resistant/Multi-drug resistant TB (RR/MDR-TB) among new TB cases is 6.8%, and 16% among previously treatment cases. These results compare favorably with the 2010 DRS which showed the prevalence of MDR-TB among new patients as 7.7% and among previously treated cases at 33.8%. Based on guidance from WHO Recommendations the TB program adopted several recommendations such as the duration of INH mono resistance treatment regimen that changed from 12 months to 9 months, for longer duration treatment regimen, injectables are used for 6-7 months and also adopting the reviewed recording and reporting tools to capture new changes among others. Trained community cadres continue to offer treatment support to all DR-TB patients throughout the duration of treatment by offering health education and counselling as well as observing infection prevention control measures at household level.

5. To strengthen the capacity of the National Tuberculosis Control Program to effectively implement, coordi-nate and evaluate TB prevention, treatment and care interventions.

The aim of this component was to increase the capacity of the NTCP to be innovative, effective and efficient in the coordi-nation and management of TB prevention, care and treatment. The NTCP currently has a National TB/HIV Coordinator who coordinates TB/HIV service delivery at regional level; in the health facilities and communities through the Regional TB/HIV Coordinators. This team holds weekly technical update meetings to ensure the effective implementation and coordination of TB services in the country.

1.3 Purpose of the Report

The main purpose of this report is to share the Program’s progress in implementation of activities to the Ministry of Health and stakeholders. It also highlights achievements and gaps and areas for improvement in a bid to ensure effec-tive implementation of the National Strategic Plan.

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CHAPTER ONE: INTRODUCTION

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The National TB Control Program (NTCP) is responsible for the planning, implementation, monitoring and evaluation of TB services in line with the global and regional TB strategies. The goal of NTCP is to reduce morbidity, mortality, disease transmission and socio-economic burden of TB including the TB/HIV co-infection while minimizing the risk of drug resistance to such an extent that the disease is no longer a public health problem to the Eswatini nation.

2.1 Leadership and governance

The Kingdom of Eswatini has a centralized public health system which is under the Ministry of Health. The main respon-sibility of the Ministry of Health is to develop policies focusing on improving the health of the Eswatini population by providing leadership in the production, delivery and utilization of health services to increase their longetivity and quality of life. The Eswatini government as a World Health Organization member state ensures the development national strategic plans and formulation of health policies.

The health delivery system consists of formal and informal sectors. The formal sector comprises public and private service providers which include non-governmental organizations, missions, industrial health services and private prac-titioners. The public sector is administered by the Ministry of Health and the private service providers are for profit. The informal sector comprises of traditional based medicine which is offered by community healers and complementary or alternative health care providers.

The health delivery system consists of four tiers. The first tier is made of a network of community-based services provid-ed by Community Based Health Care Workers, who comprise of Rural Health Motivators (RHMs), TB Active case finders, Faith Based Health Care Providers, Traditional Healers, Traditional Birth Attendants (TBAs) and other volunteers providing home-based care, support and treatment. Health committees were also instituted to help with the general management of health facilities.

The second tier is made of primary health care facilities, consisting of clinics and Public Health Units (PHUs), as well as outreach services. Clinics are further classified according to availability of maternity services.

The third tier consists of Health Centers (HCs) and regional referral hospitals (RRHs) providing emergency, basic inpatient, outpatient, maternity, dental, minor surgery, some specialty, staffed by regional medical officers and nurses.

The fourth tier is made of national referral hospitals (NRHs), two of which are classified as specialty hospitals as they provide specialized care for tuberculosis and psychiatric services. Patients who can afford paying for health services are referred to South Africa where a higher level of medical care is available.

The Government of Eswatini, through the Ministry of Health has aligned itself to the Global Plan to End TB (2016-2020) “The Paradigm Shift- End TB Strategy”. The NTCP has also aligned itself to the global vision of “A world free of tubercu-losis- zero deaths, zero disease and zero su�ering due to tuberculosis. Figure 1.1 indicate the global targets

2.2 Organization of TB services

2.2.1 Health workforce

The program is led by the NTCP Manager under the supervision of the Deputy Director Public Health (DDHS), who in turn reports to the Director of Health Services, who reports to the Principal Secretary in the ministry. At national level there is a DOTS coordinator, Pediatric TB focal person, TB/HIV Coordinator, Advocacy Communication and Social Mobi-lization Coordinator, National Community Services Coordinator , Laboratory Coordinator, National Monitoring and Evaluation Officer, Community Monitoring and Evaluation officer, Monitoring and Evaluation Advisor, Research Coordi-nator, Assistant Grants Coordinator, PMDT Technical Advisor, PMDT Regional Coordinators, Audiologist, IT O�cer, Pharmacovigilance Focal Person and Psychosocial Officer.

At the regional level, there are Regional TB/HIV Coordinators, Regional TB/HIV community coordinators, Regional Health Information Officers, Regional DOTs Officer. The Regional TB/HIV Coordinators directly supervise the TB focal Persons who are responsible for TB case registration and treatment in health facilities, while Regional TB/HIV commu-nity coordinators oversee the activities at community level and linking TB clients to the facilities. In addition, there are also regional health information officers who are responsible for data collection in facilities and in turn report to the national M&E Officer.

At community level there are TB active case finders, TB Treatment Supporter and Adherence Officers whose sole man-date is to promote health and influence community participation in the prevention and control of TB in the country.

Furthermore, at community level, various stakeholders including CSOs, NGOs, CBOs, FBOs and Traditional healers in their varying capacities deliver TB care in close collaboration with the Regional Health Management Teams (RHMTs).

Tuberculosis Control Program_2018 Annual Report 13

CHAPTER TWO: PROGRAM DESCRIPTION

GLOBAL PLAN TO END TB-STRATEGY

90% 90%90%

Reach at least As part of this approach, Reach at least Achieve at least

OF ALL PEOPLE

WITH TB

and place all of them on appropriate therapy - DS-TB, DR-TB & IPT as required

OF THE KEY

POPULATIONS

the most vulnerable underserved, at-risk populations (Children, miners,etc)

TREATMENT

SUCCESS

for all people diagnosed with TB through affordable tratment services, adherence to complete and correct treatment, and social support.

Figure 1.1 Global Plan to END-TB Strategy

2.2.2 Health Services

The TB Program aims at provide universal access to effective, safe, and quality TB services including proper diagnosis and placing TB patients on appropriate TB treatment.

Integration: In the Kingdom of Eswatini, the main driver of the TB epidemic is HIV which has a prevalence 66% co-infec-tion among TB cases. In response to the high TB/HIV co-infection rate the NTCP and ENAP developed the TB/HIV Integration Policy which guides the implementation of TB/HIV collaborative services in the country. This serves as a guiding document to ensure that PLHIVs infected with TB efficiently access ART and TB treatment as well as LTBI treat-ment for non TB infected PLHIV. The collaboration has further cascades to the community level, whereby ENAP trained ACFs on HIV and HIV self- testing in order to scale up HIV testing services at community level. Interventions are focusing on plummeting the burden of TB among PLHIV through intensified TB screening, Infection Prevention and Control (IPC) and implementation of TB Preventative Therapy (TPT) in facilities providing TB & HIV services. All TB patients put on treatment are tested for HIV and put on treatment.

Furthermore, to improve integration the TB Program introduced routine TB screening in MNCH particularly for preg-nant women and children under 5 years and has further strengthened routine TB screening among diabetic patients.

Similarly, NCDs screening has been incorporated in the clinical management of TB patients.

Accessible: The TB Programme continues to improve access to accurate and rapid TB diagnosis, prompt and appropri-ate treatment initiation as well as treatment monitoring and follow up. Concomitantly, decentralization and scale up basic management units (BMUs) increased from 125 in 2017 to 130 in 2018 providing TB services. As part of mitigating challenges that come with health services accessibility and utilization, the program engaged Active Case Finders to conduct door to door screening for TB, HIV and non-communicable diseases, thus bringing health services to the door step of the community members.

2.2.3 Medical Products and Technology

A good health system aims to deliver equitable access to essential medical products and technology of assured quality, safety, efficacy in a frugal demeanor to those in need. Supply chain management of essential health commodities, such as First -line anti-TB drugs, Second-line anti-TB drugs and antiretroviral (ARV) drugs, involves an array of activities that will ensure continuous availability of medicines from Central Medical Stores (CMS) to patients.

In a concerted effort to ensure an effective supply chain management system, the NTCP engaged a Pharmacy Techni-cian who collaborates with central medical stores (CMS), to ensure proper quantification, ordering and uninterrupted supply of TB drugs.

2.2.4 Laboratory

Effective laboratory services are critical for a successful TB control program. The national TB laboratory network consists of 28 peripheral laboratories which are under the leadership of the National TB Reference Laboratory (NTRL).

The TB program through the NTRL has collaborated with the Supra National Reference Laboratory (SRL) in Uganda to upgrade the country's BSL 3 reference laboratory to facilitate the provision of 2nd line DST services in Swaziland. The SRL also provides technical support to the NTRL and plays a pivotal role in the implementation of Laboratory Quality management system as per the requirements of the international organization for standardization (ISO 15189:2012).

The NTRL has developed the infra-structure and capacity for rapid molecular diagnostic testing with GeneXpert MTB/RIF, Line Probe assay (LPA) as well as mycobacterial culture and 1st and 2nd line DST (LPA, MGIT, solid culture).

Implementation of the GeneXpert MTB/RIF in all microscopy centers has improved the turnaround time for feedback of results to health facilities and has improved patient attrition between diagnosis and initiation into treatment. The NTRL also maintain national laboratory quality control through conducting External Quality Assessments (EQAs) and provide, mentoring and supportive supervision to all peripheral laboratories to enhance provision of effective laboratory services in the country. It is also the mandate of the NTRL to provide capacity building and training for laboratory staff and contri-bution to surveillance of TB, including drug resistance surveillance, and participation in epidemiological and operational research.

14 Tuberculosis Control Program_2018 Annual Report

CHAPTER TWO: PROGRAM DESCRIPTION

2.2.5 Financing

The NTCP receives a bulk of its funding from the Global Fund (GFTAM) for implementing most of its activities and staff salaries through the TB/HIV grant currently being implemented. Additional financing also comes from government through the TB centre budget line and mainly covers human resource, office commodities, DS-TB /DR-TB drugs, supplies and commodities as well as fuel. The NTCP also receives additional financial support from development and implementing partners. For further detail please see Annex 1.

2.2.6 Information and Research

Health Information Systems ensures timely collection, collation, analysis, dissemination and use of reliable information on health determinants, health system performance and health status. The M&E unit continues to monitor and evaluate program performance to inform timely response to changing service needs and ongoing institutional adjustment of programme inputs in order to achieve key results.

2.2.6.1 Data collection, mining, reporting and source documents The NTCP M&E System is still using the paper based model of recording and reporting data from facility to regional and national level hence it remains a manual system which reports summary of patient aggregated data. However, the program collaborated with HMIS to incorporate TB module in the Client management system being implemented by the Ministry of Health. The TB module is currently being piloted in a number of facilities. The major sources of data for TB indicators included DS- TB treatment registers, DR-TB treatment registers, Contact Tracing register, Presumptive register, patient cards, Lab registers, screening tool and summary reporting tools, contact tracing logbooks, TB mortal-ity logbook and case review report, active case finding logbooks, community referral tool, national referral tool and community monthly reporting tools.

2.2.6.2 Information products, timelines and target audiences

Data is collected routinely and is used to generate different information products targeting different audiences who are part of the NTCP stakeholders. This Annual report forms part of the key information products that targets health man-agers and policy makers in the Ministry of Health and TB Control response to understand the TB epidemiology in the context of the environment under which services are provided. The Progress Update and Disbursement Report (PUDR) which measures performance of the TB grant and provide progress update on implementation of grant activities, SADC report, WHO Global TB report and the TB Epidemiological reports provided quarterly to clinicians and public health professionals to trigger new strategies and interventions based on epidemiological data are other information products produced by the program.

2.2.6.3 Data utilization

Data usage is encouraged at all levels of the health care system, from facility level to national level to inform decisions and policy developments and or adjustments. Semi Annual Review Meetings (SERMs), Regional Semi Annual Reviews(RESAR) and National Health Semi Annual Reviews (NAHSAR) are conducted to improve data quality and create demand for data use in evidence based decision making. These platforms create an opportunity to share best practices, lessons learnt and develop quality improvement projects to improve service delivery at facility and regional level.

Furthermore, the SERM meetings are also utilized as an opportune moment for capacity building for health care provid-ers in TB/HIV patient management.

2.2.6.4 Research

The NTCP as it aligns its activities with the NSP 2015-2019 objective 5 developed a research agenda to ensure that all activities for implementation are evidence based. Subsequently, two surveys were conducted in 2018 (drug resistance survey to determine the resistance pattern of TB and Prevalence Survey to determine the veracity of TB in the country).

The results of the two surveys are still pending at finalization phase. Additional surveys to be undertaken by the program include the Catastrophic cost survey as well as a study to understand the Factors associated with TB Mortality. Howev-er, these are heavily dependent on availability of funding

Tuberculosis Control Program_2018 Annual Report 15

CHAPTER TWO: PROGRAM DESCRIPTION

16 Tuberculosis Control Program_2018 Annual Report

Table 3.1: TB Basic Management Units and TB Diagnostic Sites

03C H

A P

TE

R

PROGRAM RESULTS

3.1 Coverage of TB services

According to SAM 2017, there are 327 health facilities out of which 130 are TB Basic Management Units (BMUs). The programme targets to have scaled up access to accurate TB diagnosis, treatment and close monitoring to 145 BMUs by 2019 and further align to the number of sites offering ART services. By the end of 2018 the TB programme had a total of 130 facilities providing TB services. It should be noted that the non-BMUs provide some TB services which include TB screening, sputum collection, TB Preventive therapy (IPT) initiation and refer presumptive TB patients to the BMUs.

Table 3. 1 below shows the distribution of the BMUs, Gene Xpert sites, microscopy and Culture sites across the four regions.

Region Number of Health Facilities

Number of BMUs Xpert TB diagnosis and microscopy sites

Culture facilities

Hhohho 100 28 5 1

Manzini 130 31 11 0

Lubombo 52 35 8 0

Shiselweni 45 31 4 1

National 327 125 28 2

3.2 TB Screening

TB screening is an essential component for TB detection especially in high TB/HIV burden countries including Swazi-land. The national TB control program started implementing intensified case finding in 2009 which aimed at expanding TB screening services to all health facilities and service entry points (departments) in health facilities including diabetes clinics, ART clinics, outpatient departments, antenatal clinics and prison clinics and proactively screen patients for TB.

A standard TB screening tool, which asks questions on major symptoms including cough of any duration, fever, night sweats and weight loss is used for screening TB patients.

Tuberculosis Control Program_2018 Annual Report 17

CHAPTER THREE: PROGRAM RESULTS

3.2.1 TB Screening through Intensified Case Finding(Facility)

Table 3.2: Trend in TB Screening Conducted, 2012-2018

Figure 3.1: TB Screening through Intensified Case Finding, 2018

Year Number screened

Presumptive cases Number diagnosed Number enrolled on

Rx % enrolled on

Rx

2012 294,611 16,140 1,671 1,428 85%

2013 294,590 12,001 1,281 1,239 97%

2014 286,073 9,744 838 715 85%

2015 240,051 11,641 1,139 958 84%

2016 1,075,077 18,980 1,682 1,596 95%

2017 1, 253,174 16,168 1,410 1,374 97%

2018 1,357,418 20,377 1,797 1,771 99%

NB: Please note that the number screened are screenings performed not the number of people screened.

The table above shows an increasing trend in number of TB screenings conducted over the years from 294, 611 cases in 2012 to 1, 357, 418 in 2018. This upward trend can be attributed to the improvement in the strengthening of intensified case finding and implementation of active case finding strategy in 2016 which has enabled proactive TB screening of patients within health facilities and community door to door screening. Even though the number of TB screenings conducted has been increasing over the years, the yield has been constant ranging between 9-11%. In 2018, the number needed to screen (NNS) was 755 to get 1 patient with active TB. Figure 3.1 further illustrates.

No. screened Presumptive cases

1,357.41 20,377

1,797 1,771 Number diagnosed Enrolled on TB Rx

9% patients diagnosed with TB

99% enrolled in TB Treatment

3.2.2TB Screening through Active Case Finding (Community) Table 3.3 below show TB screening through active case finding strategy which uses two models of TB screening namely;

door to door and contact tracing. These two strategies are used to conduct TB screening at community level. In 2018, a total of 285 TB cases were enrolled on TB treatment through active case finding, and highest yield (95%) was through door to door TB screening even though a high number of individuals were screened in order to identify the 272 TB cases that were eventually enrolled on treatment. TB Contact tracing also remains an important aspect of identify TB cases at community level, even though the yield seemed very low when compared to door to door TB screening.

18 Tuberculosis Control Program_2018 Annual Report

Table 3.3: TB Screening through Active Case Finding (Door to door vs Contact Tracing), 2018

Figure 3.2: TB Case Detection through GeneXpert

Indicator Door to door Contact Tracing

Number screened 258 266 5779

Presumptive 11 669 1238

Tested 5 147 480

Referred for diagnosed 5 320 641

Enrolled on Treatment 272 13

Number Needed to screen 950 445

3.3 Case Detection

Case detection has remained one of the most critical components of TB control programme. It serves as an indication of the efficiency of NTCP to identify and diagnose TB cases and have these cases reported within the National TB Control surveillance systems. In line with WHO recommendations the NTCP adopted the rapid diagnostic techniques which include GeneXpert MTB/RIF, First Line Probe Assay (FLLPA) and Second line Probe Assay (SLLPA) to be able to detect tuberculosis early for prompt initiation of appropriate TB treatment. The country also has MGIT and LJ at NTRL for culture and phenotypic DST to assist with further diagnosis of other types of drug resistance. GeneXpert MTB/RIF is the first line diagnostic test for all presumptive TB cases and it has the advantage of detecting both mycobacterium tuber-culosis and rifampicin resistance as early as 2 hours. The country has also revised the diagnostic algorithm to include all available diagnostic techniques and universal access to genotypic and phenotypic DST.The patients are therefore requested to produce two samples of sputum, one for GeneXpert and the other for LPA, culture and phenotypic DST (using MGIT/LJ).

Total Tests Valid Tests MTB- MTB+ Rif- MTB+ Rif+ MTB+ Rif?

Jan- Dec 2018 28187 27893 25307 2265 182 139

10000

15000

20000

25000

30000

Number of Tests conducted through Gene Xpert (Jan - Dec 2018)

Tuberculosis Control Program_2018 Annual Report 19

Figure 3.3: Trends in TB Case Detection (2015-2018)

Trends in TB Case Detection (2015 - 2018)

The figure above depicts the total number of GeneXpert tests done between January and December 2018. A total number of 28187 tests were done, out of the total tests done, 27893(99%) tests were valid and 294(1%) were invalid. Out of the 27893 valid tests, 25307(91%) yielded ‘MTB not detected’ results, 2586 (9) yielded ‘MTB detected’ results. Out of the 2586 tests that yielded MTB detected results, 2265(88%) showed ‘Rif resistance not detected’ results, 182(7%) showed ‘Rif resistance detected’ results and 139(5%) showed ‘ Rif resistance indeterminate’ results.

56% 59%

74%

84%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

2015 2016 2017 2018

Estimated TB incident cases TB cases Case Detection Rate

There has been a steady decline in case notification as well the WHO estimates for TB prevalence and Incidence as shown in the figure above. The country has seen a closing gap between the WHO estimated incidence and the actual notified cases from 2016 which could be due to implementation of both facility and community active case finding.

According to the Eswatini National TB Strategic Plan the country aims to reach 80% TB case detection by 2019. There has been a considerable increase in TB case detection over the years, from 56% in 2015 to 84% by 2018 shown by figure

3.3 above. This further explains the gap between the incident rates as well as the notification rates that seem to be closing-in mimicking an epidemiology of a country that is experiencing a maturing epidemic.

3.4 TB Case Notification

TB Case Notification refers to the TB cases diagnosed and reported within the national surveillance system, and eventu-ally to WHO. The National TB program receives aggregate case-finding, TB/HIV, sputum conversion and treatment outcomes data for TB patients registered on a quarterly basis from all facilities providing TB services. The Program follows the recommended global method of cohort analysis for describing case finding and treatment outcomes. Timely data collection, reporting and dissemination remain key for monitoring the program’s performance.

20 Tuberculosis Control Program_2018 Annual Report

Figure 3.4 Trends in TB Case Notification 2011-2018

Figure 3.5:Trends in TB Notification by Sex, 2011-2018

Trends in TB Cases Notified (2011 - 2018)

TB Case Notification by Sex (2011 - 2018)

3226 2845

10000

2011 2012 2013 2014 2015 2016 2017 2018

No tif ic at io n ra te

TB

C as es

Total Notified Cases Case Notification Rate

Figure 3.4 above shows the number of TB cases notified in health…