MSF's Dr Aoua Hima talks about TB in Swaziland

09 July 2008

Médecins Sans Frontières teams have been operating in Swaziland since November 2007. Swaziland, a small landlocked kingdom between South Africa and Mozambique, is badly hit by a double HIV/AIDS and tuberculosis (TB) pandemic. It has the world’s highest rate of HIV/AIDS infection with one in four of its people HIV positive. MSF launched a care programme that is integrated into the Shiselweni region public health structure. Dr Aoua Hima Oumarou, a tuberculosis consultant working in Nhlangano is giving details on MSF activities.

© China Donald Webber/AtlasPress

What are the conditions in TB clinics within the Shiselweni region public health care structure?
Swaziland is the country with the world’s highest rates of HIV/AIDS and TB infection. These two pathologies frequently affect the same people since HIV/AIDS weakens the immune system, thus paving the way for TB infection. Some 26 percent of young adults and 40 per cent of women tested in antenatal consultations are HIV positive, as for the number of TB officially reported every year it reaches 1,200 for 100,000 people, again the world’s highest rate. When we arrived here we were struck by the conditions: TB wards were often just a single small room, without proper ventilation, right in the middle of other wards. This close proximity increased the risk of contamination between patients already infected and patients waiting to be tested or awaiting test results. It also didn’t allow for the provision of proper waiting rooms to organise group information and counselling meetings on TB and its treatment for patients, and on protective measures for the families.

Additionally, there’s a dire shortage of qualified staff. People are fleeing this country and doctors have too many patients to treat. Many patients cannot move around owing to high transportation costs. They are often left to fend for themselves as if tuberculosis were still unavoidable, although the slogan “TB is curable” is clearly written on walls in care centres.

In order to relieve congestion in the limited number of care centres and to be closer to patients living in the most remote parts of the country, MSF has launched a programme aimed at decentralising diagnosis and the care of patients infected with HIV/AIDS and TB. This means that MSF medical staff is now working within the main public health care structures (the Hlatikulu hospital, the Matsanjeni and Nhlangano care centres) where specialised wards care for tuberculosis (“TB clinics”) and HIV/AIDS (“ART clinics”). MSF is also working in six community clinics set up in the most remote parts of the country in order to care for patients living in rural areas. The HIV/TB coinfection can be found at every level of care.

What has been MSF’s priority since it launched its cooperation programme with the country’s health care services?
There’s so much to do to ensure the care of patients infected with HIV/AIDS and TB that everything seems urgent to us. We had to start by devising a straightforward method so as to set out a number of parallel objectives allowing for the concurrent treatment by the same health care service or worker of both infections affecting a single patient.

To reduce the risk of developing a resistance to drugs, it became urgent to use drugs properly and match treatments to individual cases. This concerned more than half the patients being treated. We were startled to see patients receiving treatment for TB over 13 months or even longer for a number of reasons and without medical consultations, when six months only of proper treatment was needed. The damage is twofold: an excessively long treatment and the risk of developing a resistance to drugs. We had to sort out through a multitude of patients, both those following a treatment and those who had abandoned it. We also had to recruit staff to be specially assigned to TB services, and to decentralise consultations for patients completing their treatment. In order to do this we had to schedule consultations to end – or adapt – unnecessary or lengthy treatments. A schedule for each health care centre was set up, in full agreement with the doctors working there. Health care staff had to be trained to follow up patients and to ensure that sputum samples are systematically taken to assess precisely the patients’ clinical condition. This method, which allows a definitive diagnosis of tuberculosis, was rarely used before, although, it helps reach a more accurate diagnosis and achieve better follow-up care for the patient.

Our teams are substantially overstretched, as they are frequently alone to bear the burden of caring for this disease. Most of the time a single nurse is in charge of the tuberculosis service. In spite of these difficulties we achieved some promising results in the first six months of this programme. During this period we were able to cure 491 patients, to diagnose 1,121 new cases and to start treatment for 600 of these. A search for patients who suspended their treatment is also being actively pursued.

The detection rate for the pulmonary form of TB through the testing of sputum samples has gone up from 25 percent for the last quarter of 2007, to 60 percent for the first quarter of 2008. We’re thus getting closer to the 75 percent recommended by the WHO.

How can you explain the substantial number of drug-resistant TB cases?
Swaziland meets a number of conditions explaining this incidence of tuberculosis and, worse still, the large number of drug-resistant cases. This is a very contagious infection. According to the WHO a contaminated patient, if untreated, can infect up to 20 persons every year. Furthermore, the HIV/AIDS virus favours the spread of tuberculosis. Therefore in this HIV/AIDS pandemic situation, the number of TB cases can only increase. Additionally, with more than five per cent of patients abandoning their treatment and with more than eight percent resuming it, resistance to drugs is getting worse. This means that drugs are getting less and less effective against an illness that adapts, evolves and resists to drugs.

In the region where we are now operating, 15.6 percent of patients abandon their treatment in mid-course. Thirty-nine patients suffering from a drug-resistant form of TB were treated between the beginning of 2006 and April 2008, 21 of them following MSF’s arrival in November 2007. This variety of multidrug-resistant TB, also known as MDR, has been diagnosed in 26 patients, with one case of extensively drug-resistant tuberculosis or XDR TB. The patient suffering from this XDR TB was a cleaner working in the Hlatikulu wards. She was probably infected in the wards. Before MSF’s arrival in the region, the absence of precautionary measures for staff and patients alike helped spread TB infection within the very health care structure.

Finally, it must be said that the entire southern part of the kingdom borders the South African province of Kwazulu-Natal, where Africa’s first cases of XDR TB appeared. And with strong economic and cultural links between both countries, people are frequently moving across the border.

What is the current state of Swaziland’s national TB treatment programme?
This programme was launched in 1966. Its feature is an extremely centralised approach to the treatment of patients and suspected cases. To better treat patients, all care activities were brought under the same roof at the antituberculosis centre located in the economic capital Manzini. Before MSF’s arrival the decision to begin an antituberculosis treatment, when the presence of the BK bacillus could not be confirmed, rested with a single doctor or a number of nurses for the whole of the country. Likewise, this team alone could decide to halt the treatment for patients across the kingdom. Therefore, it was difficult to care for patients in a timely manner.

Drug supply to ensure patients’ treatment is also of great concern. Instances of untimely stock shortages are frequent and the quality and origin of drugs remain undefined. Therefore, MSF has temporarily replaced Swaziland’s health care authorities to ensure a clinical examination of patients at a regional level, improve the quality of lab diagnosis and to ensure treatment when required. MSF is also doing its best to improve the quality and supply of drugs needed to treat tuberculosis.

How are the admission and care conditions like for TB-infected patients in the hospitals and health care centres where you are working?
Our hospital beds are full of patients infected with HIV/AIDS and TB. The only encouraging factor for doctors is that it is possible to treat both infections at the same time. With such a high rate of HIV/AIDS and TB coinfection in the Swazi population, hospitals have become “TB hospitals” or “HIV/TB hospitals”. We carried out a random assessment of the kind of pathologies prevalent in a general medicine ward: we found out that 73 percent of in-patients had tuberculosis and that all were bedridden.

Over a six-month period 343 TB-infected patients were admitted to Hlatikulu hospital, they remain there for very long periods, between one and three months. Out of 100 patients who are admitted to hospital, 27 will die before being discharged. In the rural community clinics the majority of pathologies are HIV/AIDS-linked opportunistic infections, and all forms of tuberculosis represent the majority of these. This is precisely when we diagnose one of these opportunistic infections that we advise patients to be tested. Since all treatments are centralised, patients infected with TB who must be admitted to hospital are referred to Hlatikulu hospital. This resulted in a very high hospital bed occupancy rate, totally clogging up the system, to the detriment of patients.

There’s practically no precautionary measure or step to control contamination. Patients are not classified according to bacteriological test results. Non-contagious TB-affected patients with negative (pulmonary and extra pulmonary) sputum samples test results, suspected TB cases and general patients mix with contagious TB-infected patients with positive sputum samples test results. Patients suffering from drug-resistant tuberculosis are gathered together in a ward next to other wards, to the administrative wing and to the rooms reserved to health care workers.

The latter is frequently unaware of the risks posed by drug-resistant tuberculosis and the attention it requires in terms of care and prophylactic measures. This means, in particular, sorting out and isolating cases, and the need to wear masks to prevent a possible contagion. Patients are frequently admitted when already bedridden. This means a particularly intensive treatment, constant care and assistance, which cannot be given by the limited number of doctors. The consequence is that TB remains one of the main causes of morbidity and death in the country’s hospitals.

And today there aren’t enough hospitals in the country; it is necessary to decentralise treatment to smaller care units and communities. The Swazi government understands the need for this decentralisation now. In this framework, which we have been implementing since March 2008, only drug-resistant TB cases are admitted in Hlatikulu hospital, that is when there are free beds.

With a TB and HIV/AIDS coinfection rate of nearly 80 percent in Swaziland, what are the steps taken to meet the needs of patients?
With a coinfection rate of over 80 percent our approach has been to say: “One patient, two infections, one carer.” MSF staff is trained to be multiskilled. Each TB-infected patient is systematically screened for HIV/AIDS infection. Likewise, Each HIV/AIDS-infected patient is systematically screened for TB infection. The aim is to see all medical or paramedical staff have this reflex when a patient turns up at a care centre or treatment ward in a large centre or a smaller clinic. The treatment of patients coinfected with HIV/AIDS and TB is concurrent and is intervening at all levels of care. In coming months, MSF will concentrate its action on the screening for drug-resistant tuberculosis in communities. MSF will also try to increase the transfer of sputum samples collected in rural community clinics to care centres and hospitals equipped with labs. This should speed up the care of patients who live far from the main care centres but need treatment.

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