Namibia

Namibia, a southwestern African country with about two million inhabitants as of 2005, faces one of the most severe TB epidemics in the world, ranking no.1 in 2005 and number 3 in the 2006 Global TB report, after Swaziland and Botswana.  Notification rate in 2004 was 676/100,000 (all forms) corresponding to an average case detection rate of 822/100,000. Approximately 60 % of the reported TB patients are HIV positive. A low treatment success of 70% was reported in the 2004 cohort of smear positive patients.

Namibia introduced the DOTS strategy countrywide in 1996, but the National TB Control Program (NTCP) is still poorly equipped to implement the DOTS strategy effectively. Treatment success of patients treated with first-line TB drugs is poor, consistently showing high default rates (14 percent among new patients and 12 percent among re-treatment patients registered in 2002). High death rates are also common (nine and 12 percent of the two groups mentioned above, respectively), resulting in a treatment success rate of only 67 and 66 percent of new and re-treatment patients, respectively. Second-line TB drugs are available and in use since 1999, but no information is available on the number of patients treated for MDR-TB or their treatment outcome. The burden of TB is compounded by a severe dual TB/HIV epidemic, with 22 percent HIV prevalence in pregnant women (2002) and 45 percent HIV prevalence in TB patients (1998). As a result, TB is the main cause of morbidity and mortality in people with HIV infection, and HIV/AIDS is the most common complicating disease in people with active TB disease.

TB CAP Highlights Namibia

Fighting X/MDR-TB
Namibia is unique in several aspects. As big as Germany, this previous German colony has a population of just over two million people, sparsely distributed and of diverse socio-cultural attributes. The burden of TB is one of the highest in the world. Although it is a middle income country, human resources for health are one of the major problems, with an enormous shortage of Namibian nationals in the health system. The country has been managing MDR-TB using three second line TB medicines since 1999 when draft (second-line) treatment guidelines and drugs were distributed in the absence of a well functioning TB control program. These medicines included: ethionamide, amikacin, and ciprofloxacine; ethambutol and pyrazinamide were added to complete a standardized regimen. Thirteen regions have at least one hospital each and in these hospitals DR TB was being managed by different medical practitioners with different levels of experience and skills, in the absence of any form of formal training, supervision and reporting.

Since 2002 Namibia NTCP has received technical assistance from KNCV Tuberculosis Foundation and started receiving funding from PEPFAR and USAID since 2004, via the TB CAP mechanism. This assistance concentrated on the development of proper case-management and follow-up of new TB patients and on the improved management of patients with Drug Resistant TB (DR-TB) based on the latest WHO Guidelines.

The management of DR TB is a big challenge. In September 2007, the first confirmed case of XDR-TB was reported and since then XDR-TB is raising a lot of media attention resulting in the Ministry of Health and Social Services (MOHSS) holding press conferences to address the public concern. Since September 2007 seven emergency missions were called by MOHSS (conducted by CDC, WHO, Department of Health South Africa, KNCV) to advice on the emergence of X/MDR-TB, its management and TB Infection Control, every time when new XDR-TB cases were identified. TB CAP was closely involved in all the missions providing logistical and technical support. All missions identified similar weaknesses and explanations for the emergence of XDR-TB in Namibia. The missions also acknowledged progress that was being made to address the problem in terms of prevention, capacity building, laboratory diagnosis and surveillance. All advised that a more sustained and comprehensive approach is needed to address the fundamental causes of XDR-TB emergence and institute good clinical and public health practices. In May 2008, MOHSS placed an order for additional and new second line medicines to be procured as a matter of urgency through the regular commercial procurement channels. By 5 July all these medicines were already in the country except for PAS (mid July, 2008). In total 14 patients have so far been diagnosed with XDR-TB while over 300 patients have been identified with MDR-TB as of April 2008.

Based on the recommendations of the missions, TB CAP - working closely with the NTCP – conducted the following activities and achieved the following results:

• Training and re-training of over 120 medical officers and pharmacists in DR TB management
• Technical support to the development of a circular on the diagnostic criteria and standardized regimens for DR-TB (including XDR-TB), including new second line drugs replacing two existing ones (ciprofloxacin and amikacin) and adding 3 new ones (PAS, cycloserine, capreomycin)
• Support to the ordering of a new and expanded spectrum of second line medicines
• Development of TB Infection control guidelines
• A paper-based recording and reporting system for patients requiring treatment with second line TB drugs
• Expansion of an MDR-TB isolation ward in the MDR-TB hotspot of the country (Walvisbay)
• Support to the implementation of the first National Drug Resistance Survey
• Development of a Green Light Committee application
• An orientation visit of 3 Namibian doctors and a pharmacist to a DR TB referral hospital in South Africa

As a result of the above efforts renovations are currently underway in two of the main hospitals in preparation for improvement in IC and setting-up of one center of excellence with five satellites from where management of all DR TB patients will be coordinated and managed. Clinical case management committees have already been set up in each DR TB site, and patients are being started on the new second line medicines on a regular basis by trained health workers, and improvements are being made to recording and reporting of DR TB patients.

With support from TB CAP, Namibia is now well underway to the implementation of Programmatic Management of DR TB, which should eventually minimize the emergence and amplification of MDR- and XDR-TB, through adoption of proper diagnostic and case management practices of new and re-treatment patients, and provision of quality-assured second-line TB medicines. Many challenges still remain, and are being addressed through a coordinated effort of various TB CAP partners (KNCV Tuberculosis Foundation, CDC, WHO, The Union and MSH) and MOHSS, with funding from MOHSS, PEPFAR, USAID and Global Fund. The collaboration of NTCP with TB CAP is a combination of knowledge, experience and sheer enthusiasm; a weapon for success. Failure is not an option for the NTCP/TB CAP team.

The real success will be measured in the future when each patient with DR TB is properly diagnosed, treated and reported with good treatment outcomes and prevalence of DR TB has decreased to minimally low levels, evidenced by a sound DR TB surveillance system.

TB CAP Project Period (2005-2010)

Expected output(s)

1. Strengthened and expanded DOTS
2. Strengthened and Expanded TB and HIV/AIDS Coordinated activities.

TB CAP in Namibia is rapidly scaling-up DOT. Treatment success rate increased from 70% (2004 cohort) to 74% (mid-year report 2005 cohort). The percent of all registered TB patients who are tested for HIV rose from 16% to 24% (mid-year report 2006). During APA1, TB CAP offered national TB courses for 51 officers (18 men and 33 women). Forty volunteers (out of 100 targeted) trained on CB DOTS and are now engaged in providing DOT at various clinics. Five thousand copies of the NTCP guidelines printed and distributed to all regions and districts. Two medical officers were trained in MDR TB in Latvia.