The Republic of Malawi is a landlocked country bordered by Zambia to the west, Tanzania to the north, and Mozambique to the east and south. Malawi covers an area of 118,480 km2, which is about one-third the size of Japan. The population of Malawi is 13.2 million, according to the 2008 Malawi National Population Census. The population is therefore just higher than that of Tokyo in Japan.
Geography
Malawi contains an abundance of pristine nature. The Great Rift Valley runs through the country from the north to the south. Beautiful Lake Malawi, the third largest lake in Africa and the 10th largest in the world, covers 20% of the area of the country. The tallest mountain in the country is Mount Mulanje, which is about the same height as Mt. Fuji, at 3,002 meters.
Climate
Malawi has a sub-tropical climate. The wet season is typically from November to April. Average rainfall during this period is from 725mm to 2,500mm. The cool-dry season is from May to August during which temperatures range between 17 and 27 Degree Celsius. The hot-dry season occurs between September and October, when temperatures range between 25 and 37 Celsius. However, the climate seems to be changing over time, probably due to global warming.
Governance and Structure.
The Republic of Malawi has a five year presidential government since 1994 through democratic elections with total separation of powers amongst the executives, legislative (parliament) and judiciary. However, the structure for public governance is divided into central government and local government through decentralization policy. The latter include the city assemblies, town assemblies and district assemblies. They are local government authorities empowered under Malawi constitutional law to form by-laws in various departments through the assistance of the three arms of government at city assembly, town assembly and district assembly levels.
Health Profile of Malawi.
Malawi is among the Sub-Saharan African (SSA) countries with worst health indicators (Table 1). The majority of disease burden remains communicable diseases including malaria, tuberculosis and HIV/AIDS.
Table 1: Malawi Health and Development Indicators
Characteristic Value
Total population (2008) 13,066,320
Annual population growth rate% (2008) 2.8
Life expectancy at birth (male/female) (years) (2006) 49/51
Infant mortality rate (per 1000 live births) (2006) 69
Under-five mortality rate (per 1000 live births) (2006) 118
Total fertility rate (2006) 5.7
Maternal mortality ratio (per 100,000 live births) (2006) 804
Stunting in under-five children (%) (2006) 19
Gross national income per capita (2006) (US$) 720
Population living below US$1 a day (%) (2004) 20.8
Human development index (2007) 0.493
HIV prevalence rate (%) (2006) 12
Prevalence of tuberculosis (per 100,000) (2006)5 322
| HIV prevalence 15-49, 2007/20085 | 11.9% |
| Tuberculosis death rate | 97/100,000 population |
| Prevalence of tuberculosis per 100,000 population, 2000 | 539 |
| Prevalence of tuberculosis per 100,000 population, 2004 | 501 |
| % Tuberculosis detection rate under DOTS, 2001 | 41 |
| % Tuberculosis detection rate under DOTS, 2004 | 40 |
| % Tuberculosis treatment success rate under DOTS, 2000 | 73 |
| % Tuberculosis treatment success rate under DOTS, 2003 | 74 |
Malaria mortality rate in under five (per 1,000) (2006) 2
Per capita total expenditure on health (international
dollars) (2006) 64
Sources: [NSO (2008), WHO 2006 database]
Bacteriological, immunological and pathogenic aspects of TB
Most cases of TB worldwide are caused by Mycobacterium tuberculosis. Other mycobacteria, e.g. Mycobacterium bovis, are of minor importance. About 75-80% of TB involves the lungs (pulmonary TB) and 20-25% occurs in other organs3.
Tubercle bacilli are most often transmitted by inhalation of droplets produced by a patient who has pulmonary TB, through coughing, talking or spitting. Those whose sputum is positive on direct smear are much more infectious than those with sputum positive only on culture3. Chemotherapy rapidly reduces infectiousness. That is why the combination of diagnosis of sputum positive patients and complete treatment is the most effective method of TB prevention in the population3.
Whether someone develops disease is dependent on the size of the infecting dose and on the level of host defences. In non-immunocompromised populations, only about 5% of infected people develop the disease within a year and a further 5% during their lifetime. TB in most adults is due to reactivation of organisms seeded during primary infection3.
Clinical TB is classified as “primary TB” and “reactivation TB”. Primary TB is typically seen in childhood infection, but does also occur in adults, particularly in association with HIV infection3.
Clinical Manifestation of TB
Clinical presentations of TB in adults and in children are relatively different with thin line in between. It is of epidemiological importance to know the minor differences.
As if it’s not enough, TB in adults presents also differently if it is primary TB or reactivation TB. The former in adults causes fever, often lasting weeks, retrosternal discomfort or pain due to mediastinal lymph node enlargement and pleuritic pain. The most common radiographic manifestation is hilar lymphadenopathy. Pleural effusions occur in a third of adults. Pulmonary changes are present in most patients within 3 months of infection, most commonly involving the perihilar areas. Occasionally lower lobe TB may occur and may be mistaken for pneumonia. Acute miliary TB following primary infection in adults has increased due to HIV. On the other hand, reactivation TB in adults presents with symptoms varying from a gradual insidious onset with anorexia, weight loss, fatigue and low-grade fever to acute onset with fever, night sweats, productive cough and dyspnoea. Sputum is often blood streaked, and rarely massive haemoptysis may occur. However many patients with active pulmonary TB may be completely asymptomatic. The chest X-ray in reactivation TB typically shows upper lobe infiltrates with or without cavitation. Miliary TB in adults is usually due to reactivation and results in cough, progressive dyspnoea and fever. The chest X ray shows a miliary pattern at presentation in half of cases, but may initially appear normal. It is also of public health importance to diagnose Pulmonary TB in adults into sputum smear positive PTB and smear negative PTB for transmission prevention purposes.
TB in children differs from that in adults in a number of ways. The younger the child, the greater the risk of developing active disease following infection3. Lymphatic and blood spread occurs more commonly, resulting in greater risk of extrapulmonary TB (EPTB) especially miliary TB or TB meningitis in the young. Although PTB is the most common manifestation in children, cavitation is unusual and sputum is usually smear-negative.
It is of epidemiological importance to note that the diagnosis of TB in children is difficult and is further compounded by HIV infection. Children usually present with pulmonary symptoms and the diagnosis is based on clinical features, chest X-ray (CXR), tuberculin skin test (TST) and a positive history of close contact with an adult or older child with smear-positive PTB. Children rarely cough up sputum, so confirmation by smear examination is often impossible. The most common forms of EPTB in children are lymphadenopathy, pleural effusion, spinal disease and pericardial disease3.
Diagnosis of Tuberculosis (TB)
The most important diagnostic test for TB is identification of tubercle bacilli. Microscopic examination of sputum smears using the Ziehl-Neelsen staining method has a reasonable diagnostic yield (about 40 % in non-cavitatary and up to 80 % in cavitatary disease)3. The optimal number of specimens is 3, preferably collected first thing in the morning. Culture improves the yield. In resource-poor settings like Malawi, the standard examination of the smear is by the Ziehl-Neelsen method. Culture is only possible in research labs and in the reference laboratory in Lilongwe and priority is given to relapse cases, defaulters, treatment failures and any patient going onto a retreatment regimen. Unfortunately microscopy of pleural and ascitic fluid is rarely diagnostic and specimens should be cultured, should this be possible. Culture of pleural biopsy material is positive in over 90 %, and granuloma (pathological feature but is not a pathognomonic sign for TB) are often seen on microscopy. In TB lymphadenitis needle aspiration of superficial lymph nodes is positive for acid-fats bacilli in over 70 % of cases. Cerebro-spinal fluid (CSF) in tuberculous meningitis is similar to partially treated bacterial meningitis, fungal meningitis or syphilitic meningitis. There is often a CSF lymphocytosis and an elevated CSF protein. CSF glucose may be normal, and is rarely as low as it is in bacterial meningitis. Microscopy and culture of CSF are seldom diagnostic3.
X-ray films should be obtained if possible in suspected cases (presents with gibbus deformity) of smear negative PTB or EPTB, especially Potts Disease (TB spine)3
Intestinal and peritoneal TB although uncommon, may be more likely in HIV positive individuals and should be considered in the differential diagnosis of unexplained abdominal symptoms, weight loss or ascites3. However, Gastric aspiration for culture is positive in 40% of children with pulmonary TB and is the procedure of choice in children younger than 10 years3. Gastric aspiration is performed first thing in the morning after an 8 hour fast.
Finally, it is epidemiologically important to take note that turbeculin skin test (TST) is of little diagnostic value for TB in adults in endemic areas like Malawi but is useful in children. The Mantoux test is the most reliable and, in children at high risk (contacts of smear positive adults, HIV positive, or with clinical features of TB), 5 mm induration should be considered
diagnostic. Currently in Malawi, this remains one of the guidelines for TB diagnosis in children.
Organization of Public Health Services in Malawi
The Ministry of Health (MOH) in Malawi has the overall responsibility for health care provision in Malawi. The Public Health Delivery System in the country is divided into three levels of administrative cost centers, namely, the Headquarters, 5 Central Hospitals and 28 District Hospitals through local assembly authorities.
At the central level structure, there is a Secretary for Health, who is assisted by Director of Finance and Administration who is responsible for the financial and administrative affairs of the MOH. The MOH has seven technical directorates: Clinical Services, Nursing Services, Reproductive Health Services, Preventive Health Services, Planning & Policy Development, Financing & Administration and Central Monitoring, Evaluation and Research Development.
The Directorate of Preventive Health Service (DPHS) is responsible for setting national standards for primary health care including disease surveillance, health promotion, health inspection programs and environmental health, expanded program of immunization, specific disease control programs, epidemiology and epidemic/emergency preparedness programs as well as multi-sectoral collaboration with other health partners in preventive health initiatives. On the other hand, the Directorate of Clinical Services (DCS), Directorate of Nursing Services (DNS) and Directorate of Reproductive Health Services (DRHS) are directorates largely responsible for clinical or therapeutic care including secondary and tertiary prevention services.
The Directorate of Planning and Policy Development is responsible for health policy development, setting national health goals, mission statement and vision statement, devising formulae for justification of health resource distribution countrywide and also responsible for provision of standardized health strategic planning tools of health activity itemized costing and health financing to all health cost centers in Malawi. As such there is a thin line between this directorate and other two directorates, Directorate of Finance and Administration (DOFA) and Directorate of Central Monitoring, Evaluation and Research Development (CMERD) in setting national governance standards, monitoring, supervision, reporting, evaluation of all health programs as well as responsible for health research promotion and development.
Below the central level there were three health regional offices for overseeing health activities at regional level until 1998 functional review which led to their abolition, with monitoring and supervision responsibility shifting back to the central level. This proved unsuccessful, with the result that the MOH in 2002 had rescinded the decision by establishing five health zonal support offices which are extensional arm of DPPD, each providing technical and facilitative supervisory support of health decentralization to district local authorities, EHP planning and implementation, and inter-district collaboration amongst five or six districts, but not having any management responsibilities.
Administratively, the country’s health system is divided into 28 districts. Each district has a District Health Officer (DHO) who leads a District Health Management Team which is accountable to the Local Government Financing Committee through district assemblies and answerable to the Principal Secretary of MOH. The DHO and District Health Management Team (DHMT) run the District Hospital and the peripheral health units which consist of health centers, dispensaries, health posts and mobile clinics and coordinate with district health partners including Public-Private Partnership (PPP) and Service Level Agreement (SLAs) with Non-Governmental Organizations (NGOs) especially mission health facilities under the umbrella of Christian Health Association of Malawi (CHAM). DHMT is responsible for the district health planning, coordinating district health partners, itemized budgeting of district health activities, execution, monitoring, supervision, evaluation and reporting of all district health activities.
The Malawi National TB Control Program.
The Malawi National Tuberculosis Program has historically been implemented as a vertical program and has been implementing the WHO recommended Directly Observed Treatment Short Course (DOTS) strategy since 196412. The DOTS strategy has five elements; government commitment, case detection through passive case finding, administration of standardized short course chemotherapy to at least all confirmed sputum smear positive cases of tuberculosis under proper management conditions; establishment of system of regular drug supply; and establishment and maintenance of a monitoring system8. In the first half of 2005, in response to the development of the Malawi Joint Health Sector Wide Approach Program of Work (POW) the Malawian National Tuberculosis Control Program began the process moving away from a vertical program and realigning its planning, approach and budgeting to be in line with the SWAp.
Gigure 2: TB Control Implementation Cycle
Figure 2.
At the central level, there are National TB Officers headed by the Director of TB Control Program. Their principle responsibility is mainly to set national standards in TB control in the country through research and quality control. In a decentralized health political structure, there are Zonal TB Officers, who are solely for strengthening the district health management teams (DHMT) in terms of planning, implementing, diagnostic, quality control, monitoring and evaluation of all TB control activities at district level. Each Zonal TB Officer is responsible for four to five or six districts and reports directly to the National TB Office. At the district level, the DHMT headed by the District Health Officer (DHO) is responsible for resource mobilization and partnership coordination as well operation research in TB control activities at district level. On the other hand, the DHMT is responsible for appointing a District TB Officer whose duties are to coordinate all the TB control activities at individual, village, community and district level on behalf of the DHMT. The District TB Officer supervises the clinicians, nurses, laboratory assistants, community health nurses, environmental health officers (health inspectors) and health surveillance officers (HSAs). Clinicians, nurses and laboratory assistants are involved in diagnostic and management of TB at health facility level which ranges from outreach clinic, dispensary, health post, health center, rural hospital, community hospital to district hospital. On the other hand, environmental health officers, community health nurses and HSAs are involved at village and community level in community surveillance (passive) of TB, health education and health promotion as well as follow-ups of TB suspects and TB patients. There is a well coordinated structure in which the villagers and communities themselves are directly incorporated actively as village health committee members, health facility committee members or as volunteers in TB activities. Reporting and feedback of TB control activities follow the same ladder in the reverse direction through Health Management Information System (HMIS) (see Figure 2).
Distribution of TB in Malawi
The NTP in Malawi collects its data through registers maintained at district level and kept up to date and verified by both the District TB Officer and District Health Management Information System Officer. The registers are of 3 types: A chronic Cough Register where details of patients who submitted sputa for examination are recorded, a laboratory TB register where sputum smear results are recorded and a TB register where diagnosed TB cases are recorded for commencement of treatment. District TB Officers collect data on a quarterly basis before forwarding it to Zonal TB Officers, who in turn send aggregated zonal summaries to the Central Unit of the NTP at the Community Health Sciences Unit3.
- Incidence of TB in Malawi
TNP uses passive TB case finding. Either the suspect presents himself/herself to the nearest health facility or is referred by the trained village volunteers, including trained grocery owners, HSAs or community health nurses. This results in incidence data being based on notified TB cases. Therefore, there is obvious problem of under-reporting of TB cases with this approach and many patients with active TB are undiagnosed. Since 1985, reported TB cases in Malawi have been on the increase. There has been a 45 % increase in prevalence of notified cases between 1994 and 2003, and a doubling in the number of
cases that have relapsed after treatment3. Multi drug resistance TB (MDR-TB) in
Malawi has remained low in the period from 1986-1998 with a good surveillance system. This is probably a reflection of the TB control performance in Malawi3.
Rate of smear positive TB diagnosed between 1999 and 2002, by sex and age group as attack rates (new cases per 100,000 population) in adults were highest in people between 25 and 44 years. The age and gender specific incidence rate was 1100/100,000 population for both males and females in age group 25-34 years while in age stratum of 35-44, males had incidence rate of 1300/100,000 population while their gender counterpart had 950/100,000 population. On the other hand, the diagnosis of TB in children is difficult, especially in HIV endemic areas like Malawi11, 14. The estimated rates of TB in children were 78/100,000 in children under one year, 83/100,000 in children aged 1-4 years and 33/100,000 in those aged 5-14 years3. Because half of Malawi’s population is aged below 15, despite these lower attack rates, children still formed 12% of all reported TB cases in 19993. In general the ratio of men to women among TB patients in Malawi from NTP data is 1.13,15.
- Prevalence of TB in Malawi.
The actual prevalence of TB in Malawi is not known. Modeling work done by the World Health Organization (WHO) predicts that Malawi only diagnoses around 48% of the prevalent TB cases and 36% of the prevalent smear positive TB cases13. Although passive case finding may lead to missing cases the WHO figures cannot presently be contested in the absence of a prevalence survey. Such a survey is currently being designed in Malawi3. One way of estimating the smear positive prevalence rate, the major source of TB infections, has been through calculating the Annual Risk of Infection (ARI). The average annual risk of infection is calculated from the proportion of 6 year-old children, who have not been vaccinated with BCG, who are tuberculin skin test positive in a particular area. This is done in form of a community survey3, 16. In Malawi, the only community survey was conducted in 1994 and it showed an ARI of 0.917. This meant a predicted prevalence of 45 smear positive cases per 100,000 population17. In 1988, Malawi reported 2665 new smear positive and 184 relapse TB cases while in 1994 there were 5988 new smear positive cases and 504 relapse TB cases reported. Assuming a country population of 8 million (1998 NSO Census) this translates into a smear positive TB prevalence of
36/100 000 in 1988 and 81/100 000 in 1994. However, interpretation should be based on condition that there was no other causes of gross immunodeficiency in general population. This is different with Sub-Saharan African Countries where HIV/AIDS is endemic and is increasing the re-emergence of TB disease burden. For instance, in a country like Tanzania where serial ARI surveys have been conducted between 1984 and 1995 the ARI has gradually declined while the number of reported cases has increased nationally (IJTLD, 2001). This emphasizes the impact of HIV on interpreting ARI.
Distribution of determinants for TB in Malawi
Every person in the community is at risk of TB infection because it is an airborne infection from sputum smear positive TB patients when they speak, sneeze and cough3. The risk of infection depends on the concentration of the expelled bacilli from the patient, the level of ventilation in households and the duration of exposure of the uninfected individual to the patient. The risks of developing disease, usually years after one is infected are known. Globally the TB epidemic re-surfaced in the last two decades due to increased poverty in the developing countries, increased overcrowding, increases in ageing populations, relaxed vigilance by countries to TB control and the impact of HIV/AIDS18. However, two of these factors do not apply to Malawi as a sovereign state because there is no increase in ageing population as the average life expectancy at birth was 38 (UNDP, 2003) and 54 in 2008 (NSO 2008 Census) while on the other hand, the NTP is one of the model programs in the world that has been following the DOTS strategy that is recommended for better TB control since 19841,2,3.
- 1. Biological determinants
1.1 Sex.
Globally it is known that beyond the age of 15 years there are more men reported with TB than women, and that in the pre-HIV era young to early-middle-aged women progressed to disease with greater frequency than men of the same ages19. However, in Malawi, sex is not a strong risk factor for being diagnosed with TB in Malawi even in the presence of the HIV epidemic20.
1.2 Age
The prevalence of TB in Malawi as discussed above shows that TB peaks in the age group between 25 and 34. There is a higher risk for young women than men20. This correlates with the HIV infection rates in this age group. However, the sex disparities due to HIV/AIDS is not reflected in TB incidence and prevalence as explained above.
1.3 Immune status.
Immunodeficiency is the strongest biological risk factor in TB infection and developing the disease. The most common cause of immuno-suppression in Malawi is HIV infection that leads to AIDS. HIV infection leads to rapid progression from TB infection to disease and increases the risk of re-activation of old infection into active disease. The lifetime risk of developing TB of HIV non-infected individuals is between 5 to 10% while that of infected individuals is between 30 to 50% or 5 to 15% per year21. Currently 11% of the adult Malawian population is estimated to have HIV infection (National HIV/AIDS Commission of Malawi, 2010 Report). The first AIDS case in Malawi was reported in 1985. From that year the rise in the estimated HIV national sero-prevalence follows the same upward trend as the TB case notifications. According to the two National TB-HIV surveys done in the past, HIV infection among TB patients was 63% in 1993 and 77% in 20019. HIV is associated with increased reported cases of smear negative and extra-pulmonary TB in Malawi22,23. Despite concerns of over-diagnosis of smear negative TB in Malawi, one broncho-aveolar lavage study has shown that among such patients sent for TB
treatment registration, TB is the most commonly confirmed diagnosis24. It has also been shown that in Malawi some febrile HIV patients have TB bacteraemia25.
- 2. Behavioural determinants.
2.1 Parental-Child Relatinship.
Children, who are usually household contacts, are the most vulnerable to new infections from infectious adults3. High frequency of TB cases has been shown in household contacts of index TB patients in Malawi20,26. NTP has a policy of treating any child that is breastfed during the period a mother has smear positive TB3.
2.2 Alcohol and smoking.
Currently there is no documented scientific evidence that alcoholism or cigarette smoking increases the risk of developing TB. However, behavior that predisposes an individual to high HIV infection risk is, in the long term, a risk factor for developing TB. Currently in Malawi no extensive studies on this has been done.
2.3 Occupational exposure.
In Malawi, certain occupations seem to be associated with the development of TB.
Health workers in Malawi have been shown to have a higher risk of developing TB than the general public27. However, within the hospital set up in Malawi, the front line health workers in outpatient department and general medical wards are regarded at higher risk than others. However, the DPPD has incorporated this factor in designing of new hospitals in Malawi through engineering controls (by striving to improve health facility building ventilation) and modification of work place practices advocated by directorates of nursing (DNS) and clinical services (DCS). In TB wards, the relative open TB is controlled with the anti-TB treatment such that transmission is halted. Another group, the author is hypothesizing to be at occupation risk are the prison warders in Malawi. Many studies have shown the high prevalence and incidence of smear positive TB amongst prisoners. Therefore, I think the prisoner warders should be studied to confirm this hypothesis.
- 3. Sociocultural determinants
3.1 Poverty.
TB is a disease related directly to poverty. Poor living conditions, poor nutrition, poor access to health services and co-morbidity with other diseases of the poor like Malnutrition and HIV/AIDS are regarded as factors predisposing one to TB disease. The majority of countries that have a heavy TB burden are classified as low income (GDP below 760 US $) and also within countries -even the richer industrialized ones- the prevalence of TB is higher among the poor28. Malawi is among the 10 poorest countries in the world (UN Development Report). The GDP is around US$200 per capita and 60% of the population lives below the poverty line (Table 1).
3.2 Overcrowding
Overcrowding is a known risk factor for air droplet infection like TB. Malawi has experienced urbanization and overcrowding in the last two
decades. About half of all TB cases in Malawi are reported from the urban districts of Blantyre, Zomba, Lilongwe and Mzuzu where most of the Malawi population is found, mainly living in slams in the peripherals of cities. This rise may be attributed to overcrowding although HIV sero-prevalence that is also higher in the urban areas is probably another contributing factor. As explained above both HIV and overcrowding are linked to poverty in a vicious cycle. High TB rates have been found in
Malawian prisons29,30,31 where overcrowding is a common problem.
- 4. International Boundaries
Malawi as country is wrapped up by the Republic of Mozambique. The boundaries span from the north-eastern part of Malawi down to southern part and continuing up to the western side. Therefore, there are numerous entry/exit borders between two countries. Admittedly, her people share common daily activities including markets and health services. This can be a potential transmission of communicable diseases or cross-border diseases like TB. This prompted one public health specialist at College of medicine in Malawi to study the gaps in TB management by two different health systems. This resulted in the formation of networks of researchers and civil society organizations in 2001 called Malawi-Mozambique-Zambia International Disease Surveillance (MMZ-IDS)32. The studies had shown a significant number of Mozambican patients seeking for treatment in the Malawian health facilities. However, follow-ups of these patients remains a challenge as there are minor differences in community TB management between sister countries’ TB control programs. This is taken as a challenge in control and determinants of TB transmission in districts along the borders. More studies are recommended in this field of global health.
Impact of TB in Malawi
Mortality and Life Expectancy
Mortality among TB patients in Malawi has changed from less than 10% in early 1980s to present average of 20% among new smear positive TB patients and 30 to 50% among smear negative and extra-pulmonary TB patients3. One study showed that about 40% of TB deaths in Malawi occur in the first two months of treatment33. There is also evidence that high mortality amongst patients occurs months or years after TB treatment34. This may be due to HIV complications. However malnutrition among TB patients has also been shown to be associated with early patient deaths35. This has prompted the NTP and Directorate of HIV/AIDS and Nutrition to formulate a well concerted effort to mitigate this monster of TB/HIV/AIDS/Malnutrition through adult nutrition therapy called Chiponde in our vernacular language. Many partners in the country are supporting this cause.
Morbidity and Quality of life
Globally the DALY for TB has been calculated at 2.5% and 90% of this is due to death of a TB patient globally3. TB kills more patients from one single infection than all other infectious diseases combined3. Few studies have been published of assessment of quality of life among TB patients in Malawi. They are mainly on morbidity patterns according to TB notifications in Malawi (discussed above under prevalence).
Infant and Child Morbidity and Mortality in households affected by TB Disease.
The impact of adult TB disease on infant and child mortality or morbidity at household level in Malawi is an under researched area. Future research is needed to address this aspect of TB3.
Economic and Social.
Both the diagnostic pathway and treatment course of TB are long. The costs of accessing care are generally higher before than after diagnosis, because patients do not access the TB services straight away. Mann et al calculated that total direct costs and opportunity costs due to days lost before obtaining a TB diagnosis were 11 US$ and 4.6 US$ for poor patients and 17.7 US$ and 28.736. About one third of the direct costs were spent on transport and half on fees36 and drugs, probably before diagnosis. However, after diagnosis, the anti-TB drugs in Malawi remains free of charge and can be accessed at public health facilities, mission health facilities as well as at private health facility outlets with DTOs responsible for follow-ups in all facilities regardless of the owner. This has proved to be possible in Malawi due to the excellent coordination by the NTP which orders (procures), quantifies, distribute and monitor anti-TB drugs through all allied partners. The NTP was given an extra momentum by the Malawi Government when it was declared TB in Malawi as a Disease of an Emergency since November, 2007. This mandated all partners to put an extra gear in the combat against the disease.
Effective anti-TB Interventions and their Implementation in Malawi.
Biological Interventions.
1. Vaccination
Immunization during childhood with bacilli Calmette-Guérin (BCG) is likely to reduce the burden of severe forms of TB such as military TB and TBM among vaccinated children in some regions. The expanded program on immunization (EPI) policy in Malawi recommends that one dose of 0.1 ml of BCG vaccine be given intradermally to children soon after birth3. Studies done in northern Malawi published between 1986 and 1992 showed that BCG protects Malawians more against Leprosy than against TB37, 38. It is difficult to determine the influence of these estimates of relative efficacy of BCG on the current childhood and adult TB rates in Malawi. Besides, BCG is a live attenuated vaccine and it can cause disease in HIV-positive recipients. Research on new and more potent vaccines is in progress in humans, but results will not be available for at least a few years39. Indicators from the Malawi EPI itself show that that the coverage had risen from 72% in 1972 to 100% in 199840. Therefore, it is still routinely given but I am of the opinion that the cost involved could better be planned for other equally pressing health problems.
2. Isoniazid Preventive Therapy.
Isoniazid is recommended for the prevention of development of TB amongst HIV infected people41. The feasibility of using isoniazid at a large scale in Malawi is still being studied by the NTP. Isoniazid is also recommended for well children under 5 years who are close household contacts of people with smear-positive PTB. However, in practice, this rarely happens in Malawi3. It is also of epidemiological and public importance that Malawi Government regulates all the current used anti-TB drugs to reduce resistance. All pharmacies and private health practitioners comply with standards and guidelines set by the NTP, Medicines, Drugs and Poisons Board. With the policy of distributing drugs by NTP in conjunction with Malawi Central Medical stores and providing free of charge at all health facility outlets with vigorous emphasis on monitoring and reporting, private practitioners and pharmacies have no choice but to comply.
3. Cotrimoxazole Adjunctive Therapy.
In 1999 two studies done in Cote d’Ivoire42,43 showed that cotrimoxazole reduced morbidity and mortality among HIV infected patients with positive acid fast bacilli smear TB, prompting the United Nations Joint Program on HIV/AIDS (UNAIDS) to draft this practice as recommended policy in sub-Saharan Africa. In Malawi cotrimoxazole has been shown to improve survival among HIV infected TB patients44 , improve TB treatment outcomes45 and its roll out to more hospitals in Malawi has been shown to be feasible46.
4. Behavioural Interventions.
Treatment of infectious TB patients is a main component of TB control as this leads to the cutting of chains of transmission in a community. Malawi uses passive case finding. The NTP has since 1999 developed an information, education and communication (IEC) strategy, which passes key messages to the community through several media e.g. print, radio, calendars, flyers. The key message is: “a cough of more than 3 weeks with little or no improvement on ordinary medication needs investigation to rule out TB”. This message encourages the community to seek a TB diagnosis for prompt treatment as for health promotion. The IEC strategy also involves providing continued messages to health workers for continued high suspicion of TB among patients with the key signs for prompt diagnosis and treatment. The impact of this strategy is yet to be demonstrated3. Recent studies have shown that with triple therapy of TB/HIV/AIDS/Nutrition therapies, people in Malawi are encouraged to change their health-seeking behaviours (NTP 2009).
5. Social Interventions.
The DOTS strategy is the most effective and efficient way of controlling TB. This strategy is recommended by WHO36. WHO advocates that it is envisaged that “a DOTS program that puts under treatment 70% of prevalent TB cases and is able to cure at least 85% of them will control TB and reduce it as a public health problem”. The NTP in Malawi has been using a DOTS program since 1984. DOT had taken place in hospitals during the 1 to 2 month admission period until 2001, after which DOT could be carried out either in hospital, at OPD, at health centers or by guardians at home, according to the patients’ choice47, 48. This approach has been shown to be cheaper to the health service and the community with maintained cost-effectiveness49.
The second social interventions, the NTP has embarked on worth recognition is involving the already existed grass root structures in health systems at community level. The village health committee members, health facility committee members, health volunteers have been trained in health TB health promotion together with grocery owners and private pharmacy store owners so that if one persons is seen to be coughing for three months or frequently coming to buy cough relievers, he/she is referred to the nearest health facility or the HSAs or community nurses will refer him/her accordingly. There are also outreach clinics where the trained HSAs are able to collect sputum at household level or during immunization programs in an integrated fashion. It is also of much epidemiological and public health importance that it is done routinely in outreach clinics for active TB case surveillance in hot TB spots including Prison Cells in all districts. This is what is currently done in Malawi (NTP 2009 Report).
The last but very important social intervention advocated by Malawi NTP is TB disease control in high risk groups. The recognized high risk groups in Malawi are children living with TB patients, health workers, prisoners and people living with HIV/AIDS (PLWHA). The World Health Organization has produced guidelines for TB control among health care workers50. This involves health worker training in infection control: patient education, early TB diagnosis amongst patients, safe processing of patient samples, encouraging out-patient TB case management, provision of preventive therapy to HIV sero-positive health care workers and isolation of multi-drug resistant TB patients. These guidelines are currently fully implemented in Malawi. However, public health surveillance of TB amongst health workers is not routinely done in Malawi. Robert H. Friis in his book entitled “Essentials of Environmental Health,” defines public health surveillance as “…..the ongoing systematic collection, analysis, and interpretation of health data essential to the planning, implementation and evaluation of public health practices, closely integrated with the timely dissemination of these data to those who need to know.” Therefore, this is a potential gap I can personally take it up and research upon. However, MDR-TB management remains a challenge. Although the number of cases is very small, some 872 cases of MDR-TB were reported in 2007, but extensively drug-resistant (XDR) TB has not been reported in Malawi because currently the management of MDR-TB is still done in the communities because the construction of specific MDR-TB hospitals are not yet finished (NTP 2009).
Control of co-morbidity of TB and HIV/AIDS in Malawi.
The government of Malawi has tried to respond to this challenge. Malawi was one of three African countries to pilot the WHO ProTEST initiative (1999–2002), which promoted HIV testing and counseling among TB patients as an entry point to HIV prevention, treatment and care services8. Subsequently, and with the support of bilateral and multilateral donors, a three-year TB/HIV plan (2003–2005) was developed and integrated into the five-year national TB control plan (2001–2005). The principal objectives were to scale up HIV testing among TB patients and, for HIV-positive TB patients, to provide cotrimoxazole preventive therapy and facilitate access to antiretrovirals.
There had been some measured progress on this intervention between 2003 and 2005. From routine data collected and reported within the national program for TB and antiretroviral therapy, the proportion of TB patients tested for HIV increased from 15% in 2003 to 47% in 2005. During this time, the majority (90% or more) of HIV-positive TB patients started cotrimoxazole preventive therapy. In 2005, just over 20% of new patients starting antiretroviral therapy had active TB or a past history of TB2. It is pleasing to note that in 2007 when the Malawi Government declared TB in Malawi as an emergency, routine HIV testing for TB patients is mandatory on recommendation from the extensive researches done studying the triple co-morbidity of TB, HIV/AIDS and Malnutrition. Therefore, all patients qualifying this triple co-morbidity diagnosis are supplied with nutrition package on top of their usual anti-TB and antiretroviral drugs.
Figure3: Case Detection and Treatment Success Rates Under DOTS.
| Note: DOS treatment success rate for 2007 will be reported in the WHO Report 2010. Source: Global Tuberculosis Control WHO Report 2009. |
Partnerships in TB Control in Malawi.
- 1. National Partners:
- Malawi Government and her various departments.
- Christian Hospitals Association of Malawi (CHAM).
- Private Hospitals.
- Private Practioners and Private Pharmacies.
- Various Non-Governmental Organizations (NGOs).
- Various Civil Society Organizations in Malawi.
- 2. International Partners:
- Malawi-Mozambique-Zambia International Disease Surveillance (MMZ-IDS).
- Norwegian Agency for Development Cooperation (NORAD).
- U.K. Department for International Development. DFID).
- United States Agency for International Development (USAID).
- United States Center of Disease Control (US-CDC).
- Global Fund to fight for AIDS, Tuberculosis and Malaria.
CONCLUSION
Tuberculosis (TB) continues to be a public health problem in Malawi. According to the World Health Organization’s (WHO’s) Global TB Report 2009, there were an estimated 48,144 new cases of TB, but Malawi’s National TB Control Program (NTCP) estimates are around half that figure.
There are many extensive studies and researches done in TB in Malawi which most of their findings are transformed into public health policies of the day. In the epidemiology of TB in Malawi the strongest risk factors for developing disease are poverty, HIV infection, household contact with index case, overcrowding and younger age.
In fighting against TB, the NTCP is implementing DOTS, the internationally recommended strategy for TB control, since two decades ago. It has strived to achieve nationwide coverage which has included the provision of TB home-based care using community “guardians” to observe and follow up with TB patients. The other interventions in TB control in Malawi include BCG vaccination, IEC to improve health seeking behaviors, better clinical practice with isoniazid preventive therapy for people living with HIV (PLWHA) and children who are household contacts of smear positive PTB cases, cotrimoxazole prophylaxis to reduce morbidity/mortality among HIV-infected TB patients, safe TB case management within healthcare settings to prevent transmission to health workers and active TB case finding among high risk groups among others PLWHA and prisoners.
Despite these advances, the high HIV/AIDS prevalence has had an impact on the success of the TB program. Case detection has averaged 42 percent during the past five years (2003–2007), well below WHO’s target of 70 percent. The treatment success rate rose to 78 percent in 2006, after averaging 72 percent between 2002 and 2005, yet this is still below WHO’s target of 85 percent. About 72 percent of all TB patients in Malawi are HIV positive which is similar to the 2009 WHO estimates which was pegged at 68 percent for new TB patients to have HIV.
In striving to win the battle against TB in Malawi, the Malawi TB-HIV/AIDS Technical Working Group and NTCP in 2002 began implementing a three-year plan for joint TB and HIV/AIDS services, consistent with WHO/UNAIDS recommendations for policies and TB-HIV/AIDS collaborative activities. On the other hand, the Malawi Government became the second country in Africa to declare TB as a disease of emergency in 2007. About 872 cases of MDR-TB were reported in 2007, but extensively drug-resistant (XDR) TB has not been reported yet in the country.
The impact of TB disease globally accounts for 2.5% of the global burden of disease, mainly due to premature death. However, in Malawi TB patients spend 1.2-2.5 times their monthly income to obtain a TB diagnosis, claims a mortality of 20-50% of TB infected patients and TB causes higher disease rates among health workers and attrition due to deaths. On the other hand, treatment outcome among children diagnosed with TB is poor, especially among smear negative and very young children.
The Malawi National Tuberculosis Control Program therefore, is well established with a good reputation within the Sub-Saharan African Region. The program has attempted to be responsive to the needs of different social groups through the development of community based activities to intensify case finding amongst poor groups. Given increasing TB notification due to HIV co-infection, high numbers of missing cases, and a context of poverty and gender inequity there is need for further and continued program adaptation, innovation and operational research.
This is a successful story of a poor country in resource-constraint setting in Su-Saharan Africa striving in 360 degrees for holistic fight against the monster of 21st century, TB/HIV/AIDS/Malnutrition.
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