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Care in the community? TB treatment in rural Swaziland

Tuberculosis (TB) infection is increasing rapidly in Swaziland, largely due to widespread HIV infection. This has exposed weaknesses in the National TB Control Programme (NTCP). How should the Programme respond to this increasing burden?

A health needs assessment by the UK Nuffield Institute of Health in the rural district of Lubombo found that the weak control programme and poor health education contribute to the worsening TB burden. The authors recommend a shift towards home-based TB control strategies.

Successful TB treatment requires effective medication, direct observation of drug taking and monitoring of treatment results through sputum smear tests. This forms the basis of the World Health Organisation (WHO) recommended DOTS strategy. However, DOTS requires daily supervision of treatment. How can this be achieved with limited resources and poor infrastructure?

The two-month study involved one district hospital and two health centres. Researchers found that:

The number of registered TB cases rose from 151 per 100,000 population in 1987 to 280 per 100,000 in 1997, reflecting the rising HIV incidence. Two-thirds of registered cases are among men.
All patients are put on a six-month course of therapy. Drug distribution functions well under the NTCP.
Patients receive intensive treatment in hospital for 60 days. This is very resource-intensive, and the hospital has bed occupancies of between 150 and 225 percent.
When patients are discharged, there is no system for direct observation of treatment in the community or for active tracing of patient contacts and treatment defaulters.
Records show that around a quarter of patients finish treatment. The WHO target is an 85 percent cure-rate.
People do not understand the link between TB and HIV, and in general know less about TB than HIV/AIDS.

These results highlight the need to develop a service that can deliver high treatment completion rates despite the rapidly rising case load. The authors recommend a transition to a community care model using WHO-recommended treatment schedules and sputum smear testing. To achieve this transition, health planners should:

encourage greater ownership of evaluation processes by health workers
appoint and train TB liaison nurses to manage the programme and educate patients
develop systems for supervising discharged patients and tracing treatment defaulters
prescribe ethambutol tablets rather than streptomycin injections in new drug treatment schedules, to enable community-based care
identify and train supervisors within the community to oversee treatment
minimise hospital stays when the community-based system has been established
transport newly-discharged patients to an initial meeting with a community supervisor
improve communication between patients and health centres
raise awareness of TB and its symptoms through health education
establish a working relationship between community health workers and traditional healers to encourage referrals of TB patients to healthcare facilities.

Since this health needs assessment, the authors have successfully implemented community-based DOTS throughout Lubombo region, in collaboration with Dr A. Philip and the TB team of Good Shepherd Hospital and the regional health office.

Source(s):
'Tuberculosis in Swaziland: a health needs assessment in preparation for a community-based programme' by S. Pushpananthan, J. Walley and J Wright, Tropical Doctor 30 (2000)

Funded by: unknown

id21 Research Highlight: 28 June 2001

Further Information:
Suresh Pushpananthan
Nuffield Institute for Health
71-75 Clarendon Road
Leeds
LS2 9PL
UK

Tel: +44 (0)113 233 6963
Fax: +44 (0)113 233 6997
Contact the contributor: ugm5sp@leeds.ac.uk

Nuffield Institute for Health, University of Leeds, UK

John Walley
Division of Public Health
Nuffield Institute for Health
71-75 Clarendon Road
Leeds
LS2 9PL
UK

Tel: +44 (0)113 233 6941
Fax: +44 (0)113 246 0899
Contact the contributor: j.d.walley@leeds.ac.uk

Views expressed on these pages are not necessarily those of DFID, IDS, id21 or other contributing institutions. Unless stated otherwise articles may be copied or quoted without restriction, provided id21 and originating author(s) and institution(s) are acknowledged.

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