The United Republic of Tanzania

Transcription

1 The United Republic of Tanzania Ministry Of Health Community Development, Gender, Elderly and Children National Tuberculosis and leprosy Programme, Annual report for 2014 National TB and Leprosy Programme (NTLP) Department of Preventive Services Ministry of Health Community Development, Gender, Elderly and Children 6Samora Machel Avenue P. O. Box 9083,1147 Dar es Salaam Tanzania Tel/Fax: Web:

2 Table of Contents List of tables... 4 List of figure... 5 List of annexes... 6 List of abbreviations... 7 Acknowledgement GENERAL BACKGROUND Demographic and social economic profile Summary of health services Summary of NTLP activities Financial Support HUMAN RESOURCE DEVELOPMENT Staff establishment Tuberculosis and Leprosy Central Unit (TLCU) Regional Tuberculosis and Leprosy Coordinators (RTLCs) Training activities, meetings and conferences Trainings Meetings TUBERCULOSIS CONTROL SERVICES Tuberculosis case notification Tuberculosis treatment outcome for cohort notified in New and relapse cases Treatment outcome of previously treated TB cases notified in TB/HIV case finding Management of Pediatric TB Childhood TB notifications Childhood TB/HIV notifications Management of MDR-TB LEPROSY CONTROL SERVICES Leprosy Case Notification

3 4.2 Leprosy treatment outcome Treatment outcome of PB leprosy Treatment outcome of MB leprosy Activities related to acceleration of leprosy elimination efforts Conducted one leprosy elimination campaign (LEC) at Mkinga DC. The campaign was one of the activities during the commemorations of world leprosy day in Tanga region. In one week, 22 new cases were actively found and initiated on MDT Started preparatory activities to introduce leprosy post-exposure prophylaxis (LPEP) in Tanzania in three pilot districts of Kilombero, Liwale and Nanyumbu. Through this programme, family members of the index case will be screened to rule out leprosy disease and being given a single dose rifampicin. The intervention will largely contribute to efforts to detect leprosy disease early and cut down the transmission chain Activities related to prevention of disabilities (POD) People with leprosy related disabilities Leprosy reactions Specialized care of people with disabilities Footwear Programme LABORATORY SERVICES Summary of services PROGRAMME SUPPORT ACTIVITIES Procurement and Supply Management of Anti-TB and Anti-Leprosy Medicines Community empowerment activities Advocacy, Communication and Social Mobilization (ACSM) activities Logistic Support Transport Public and Private Partnership (PPP) TB in Mining sector Supportive Supervision Data Quality Assessment (DQA) TB epidemiological and Impact Analysis NTLP External Programme Review

4 List of tables Table 1: Source of Funds in 2014 Table 2: Tuberculosis cases notified in Tanzania Table 3: Tuberculosis treatment of all forms of TB new and relapses notified in 2013 Table 4: Treatment outcomes of previously treated cases notified in 2013 Table 5: Treatment outcomes of MDR TB enrolled for treatment, Table 6: New leprosy cases detected by indicators in 2014 by regions Table 7: Districts with prevalence rate greater than 1/10,000 Population in 2014 Table 8: Treatment outcome of PB leprosy reported in 2013 Table 9: Treatment outcome of MB leprosy notified in 2012 Table 10: Leprosy cases started treatment with corticosteroid in 2014 Table 11: Number of leprosy admissions in hospitals 2014 Table 12: Materials and tools distributed for fabrication of special and local shoes production per region in 2014 Table 13: Total number of specimens received at the CTRL Table 14: Number of Specimens Received per Month per Case Table 15: Number of Specimens per Case category by Regions Table 16: Culture results Table 17: Microscopy-Culture correlation Table 18: DST 1st LINE profile Table 19: DST 2nd LINE profile Table 20: DST Profile key Table 21: Molecular method Table 22: Molecular method Table 23: Xpert MTB/Rif results per type of specimen Table 24: Xpert MTB/Rif results per Quarterly comparison Table 25: The table below summarizes the stocks of anti-tb and anti-leprosy drugs distributed in the country in

5 Table 26: Community contribution to TB control and Patient care for 2013 and 2014 List of figure Figure 1: Distribution of TB cases notified by regions in 2014 Figure 2: Age and Sex distribution of new bacteriologically confirmed TB cases notified in 2014 Figure 3: TB notification rate (new and relapses) by region for 2014 Figure 4: Trend of Previously Treated TB cases notified form 2005 to 2014 Figure 5: Treatment outcomes of previously treated cases notified in 2013 Figure 6: Trend of TB patients counseling and testing for HIV, initiated CPT and ART: Figure 7: HIV testing among TB patients in 2014 by regions Figure 8: MDR TB patients enrolment by Year Figure 9: Age and Sex distribution of MDR TB cases enrolled on treatment in 2010 Figure 10: Distribution of MDR-TB cases enrolled on treatment by regions in 2014 Figure 11: MDR TB outcomes in Figure 12: The contribution of regions of new cases detected in 2014 Figure 13: Trend of new leprosy cases reported: Figure 14: Trend of MB cases, children and females among new leprosy cases: Figure 15: Trend of disability grade 2, percentage among new cases and rates per 1,000,000 populations Figure 16: Trend of new leprosy cases detected and registered: Figure 17: Trend of leprosy cases completed treatment: Figure 18: Total specimen received at CTRL in 2014 per month per case Figure 19: smear culture results, 2014 Figure 20: Map showing Xpert sites in the country Figure 21: Xpert MTB/Rif results per type of specimen 5

6 List of annexes Annex 1: Tuberculosis patients (all forms) notified in Tanzania by region in 2014 Annex 2: Age and sex distribution of new and relapse TB cases notified in 2014 Annex 3: Treatment results of new and relapse TB cases notified in 2013 Annex 4: Treatment results of all re-treatment TB cases except relapse notified in 2013 Annex 5: Tuberculosis and HIV positive patients notified 2014 Annex 6: Leprosy Patients reported by regions in 2014 Annex 7: Age and sex distribution for newly detected leprosy patients in 2014 Annex 8: Disability grading of newly detected leprosy patients by region in 2014 Annex 9: Leprosy Patients Registered by region at the end of

7 List of abbreviations ACSM Advocacy Communication and Social Mobilization AFB Acid Fast Bacilli AIDS Acquired Immuno-Deficiency Syndrome BMRC British Medical Research Council CDC Centres for Disease Control CPL Central Pathology Laboratory CTRL Central Tuberculosis Reference Laboratory DDH District Designated Hospital DOTS Directly Observed Treatment Short Course DST Drug Susceptibility Testing DTLC District Tuberculosis and Leprosy Coordinator EQA External Quality Assessment ETH Ethambutol FDC Fixed Dose Combination FIND Foundation for Innovative New Diagnostics GFATM Global Fund to fight AIDS/HIV Tuberculosis and Malaria GLRA German Leprosy and TB Relief Association HFN High False Negative HFP High False Positive HIV Human Immunodeficiency Virus HMIS Health Management Information System IEC Information Education and Communication INH Isoniazid IUATLD International Union Against Tuberculosis and Lung Diseases KNCV Royal Netherlands TB Association LEC Leprosy Elimination Campaign LED Light Emitting Diode LFN Low False Negative LFP Low False Positive LPA Line Probe Assay MB Multi bacillary (leprosy MDR-TB Multi Drug Resistant Tuberculosis MNH Muhimbili National Hospital 7

8 MoHSW MSD MSH NGO NIMR NRA NTLP PALs PATH PB PCT PEPFAR PLHIV PoD RTLC QE RIF RR RSS SDC STR TB TLCU WHO Ministry of Health and Social Welfare Medical Store Department Management Science for Health Non- Governmental Organization National Institute for Medical Research Royal Netherland Association National Tuberculosis and Leprosy Program People affected by leprosy Programme for Appropriate Technology in Health Pauci bacillary (leprosy) Patient Centred Treatment President s Emergency Plan Funds or AIDS Relief People Living with HIV Prevention of Disabilities Regional Tuberculosis and Leprosy Co-ordinator Quantification Error Rifampicin Rifampicin Resistance Routine Surveillance System Swiss Development for International Cooperation Streptomycin Tuberculosis Tuberculosis and Leprosy Central Unit World Health Organisation 8

9 Acknowledgement This report is the work of different stakeholders involved in the control of tuberculosis and leprosy in the country. The data presented in this report is generated by the general health workers and compiled by the district TB and leprosy coordinators under the supervision of the regional and national levels. I take this opportunity to acknowledge their dedication to the control of the two diseases especially now when there is emergency of drug resistance tuberculosis (DR TB) and there is a global movement to eradicate leprosy as a public health problem. I would also like to thank the Government of Tanzania for the dedicated commitment to control the two diseases and for mobilising resources from development partners to support the National TB and leprosy programme. In particular, I would like to recognise the financial support from: Germany Leprosy and Tuberculosis Relief Association (DAHW/GLRA) World Health Organization (WHO) The Global Fund to Fight HIV/AIDS, Tuberculosis and Malaria (GFATM) Centre for Disease Control (CDC) International Union Against TB and Lung Disease (IUATLD) United State Agency for International Development (USAID) Funds for Innovative New Diagnostic (UNITAID/FIND) Novartis Foundation (NF) Management Science for Health (MSH) Global Drug Facility (GDF) The Netherlands Tuberculosis Foundation (KNCV) On behalf of the programme, I would like to express my sincere gratitude for the support and encouragement given to us by the Permanent Secretary, Chief Medical Officer and all of the directors. Dr Beatrice Mutayoba 9

10 Programme Manager (NTLP) October GENERAL BACKGROUND 1.1 Demographic and social economic profile In 2014 is Tanzania projected to have a population of 47,431, 812 with 51% of the population being female while male were 49%. This is based on the projection from the 2012 census. The population of urban inhabitant was 29.6 % of total population. About 52% of the population are the working age (15 64); 44% are young (0 14 years) while 4% are elderly (65+ years). The annual growth rate is estimated at 2.7% from 2002 to 2012 census. The population of Zanzibar is projected at 1,341,713 with a growth rate of 2.8%. Agriculture is still a major source of livelihood for majority of the population in Tanzania According to World Bank report, 2013 per capita income (GDP per capita) is US $ categorizing Tanzania as a low income country. However, in the past five years the country has enjoyed good progress in economic growth averaging above 6%. 1.2 Summary of health services Health care delivery system in the country is well established with more than 7,214 health facilities. 3,500 health facilities have at least one TB patients receiving TB treatment while 1,500 health facilities had at least one leprosy patient receiving treatment. The major provider of health services is the government, which own or run 69% of all the health facilities including the Designated District Hospitals (DDH). Tanzania is classified as one of the least developed countries, with total expenditure on health per capita of US$ 126 (WHO). Data from Health Information Management System (HMIS) of the Ministry of Health and Social Welfare shows that communicable diseases are still the major cause of morbidity and mortality in the country driven by HIV epidemic with national prevalence of 5.1% in the population aged years. TB has continued to be among the top ten cause of death and is ranked 6th among admission aged five years and above in the country. 1.3 Summary of NTLP activities In the period of January December 2014, NTLP implemented its annual plan in line with NSP IV ( ). All activities conducted focused on addressing six NSP 10

11 strategic objectives i.e. (i) Achieve universal access to quality DOTS and MDT services in both public and private sectors. (ii) Reduce the burden of TB/HIV and drug resistant TB with special emphasis on vulnerable populations. (iii) contribute to health system strengthening based on primary health care (iv) scaling up involvement of more private health care providers (v) empowering patients and community members to take active participation in TB prevention and care (vi) collaborating with internal and external partners in conducting relevant operational research. Other major activities that were implemented includes: conducting Tanzania National Tuberculosis and Leprosy Programme External Review; Development of new National Strategic Plan for Tuberculosis and leprosy control ( ); and TB epidemiological and impact assessment. Leprosy elimination activities were conducted by performing a number of leprosy elimination campaigns in targeted areas. 1.4 Financial Support The Ministry of Health and Social Welfare through National Tuberculosis and Leprosy Programme (NTLP) received US$ 8,125, through government consolidated funds, external grants and loans in year Government resources channeled through the programme for programme management and at lower levels to support the health system and infrastructure maintenance as well as staff remuneration for staff working (nurses, clinicians and lab staff a lower levels we made a full time equivalent approximation) for TB. Direct cash was received from Centers for Disease Control and Prevention (CDC) grant, The Global Fund (GFR6 TFM & BF) grant, The World Bank (IDA) loan, German TB and Leprosy Relief Association (GLRA) grant and World Health Organization (WHO) grant as detailed below. Many other local research institutions, academia, private sector organizations and community based Civil Society Organizations (CSSOs) not herein mentioned were also active partners/collaborators in various TB interventions: Table 1: Source of Funds S/N Source of Funds Amount in US$ 1. Government Contribution 2,083, Germany Leprosy Relief Association GLRA 385, Centre for Disease Control and Prevention CDC 2,677, World Health Organization TDR (carried forward from previous period) 9, GFATM (carried forward from previous period) 2,655,

12 6. World Bank (IDA) 33, Basket Fund 280, TOTAL FUNDS 8,125, HUMAN RESOURCE DEVELOPMENT The Programme is composed of both government and contract employees at central unit (TLCU) with focus on strengthening TB/HIV and Leprosy services in the country. Contract employees were recruited through various grant support including GFATM and CDC/PEPFAR at the central level. TB/HIV Officers who were recruited through PATH support had to be absorbed in the government payroll through district councils following phasing out of the organization. During this reporting year, the programme strengthened its effort in building capacity of staff through various trainings such as TB/HIV, Paediatric TB, ACSM, community TB, DHIS2 user training and Laboratory with funding sources from WHO, GF and CDC PEPFAR according to the national guidelines. 2.1 Staff establishment In this reporting year there were 33 staffs at central level and 30 staffs at regional level identified as Regional Tuberculosis and Leprosy Programme Coordinators (RTLC). New RTLCs were recruited for Katavi, Geita, Tabora, Kigoma, Mtwara, Rukwa, and Iringa. New DTLCs were also deployed in the district councils. For those regions and councils which were not fully established, RTLCS and DTLCS from the mother regions and councils continued to oversee and coordinate TB and leprosy control activities in the newly established regions and district councils until when they are fully fledged to own their coordinators. During this period, Dr Beatrice Mutayoba was appointed to be the Programme Manager, four staff were transferred to other units within the Ministry namely Mr Jerome Ngowi, Ms Evaline Mapunda, and Ms Grace Hatibu. Mr Jumanne Mkumbo, Ms Neema Voniatis, Ms Elda Magawa, and Mr. Joachim Kizuri joined the Programme as a transfer also within the Ministry Tuberculosis and Leprosy Central Unit (TLCU) The list of TLCU staff by December 2014 was as follows: 1. Dr B. Mutayoba - Programme Manager 12

13 2. Dr L. Mleoh Deputy Programme Manager 3. Dr M. Nyamkara TB/HIV Coordinator 4. Mr B. Msuya Head Accountant 5. Mr L. Ross Accounts Assistant 6. Mr J. Ngowi Programme Pharmacist 7. Mr J. Mkumbo Programme Pharmacist 8. Mr B. Bariki Programme Pharmacist 9. Dr J. Lyimo - MDR Coordinator 10. Mr D. Kayumba Administrator 11. Ms D. Semu Prevention of Disabilities Coordinator 12. Mr P. Shunda - Orthopaedic Technologist 13. Ms D. Kasembe Training Coordinator 14. Ms B. Doula Head, National TB Reference Laboratory 15. Ms L. Ghasia Health Secretary 16. Mr S. Bossy Senior Laboratory Technician 17. Ms D. Mtunga Laboratory Technician 18. Dr A. Tarimo PPP Coordinator 19. Dr V. Mboneko Programme Officer 20. Ms L. Ishengoma Community TB care Coordinator 21. Ms A. Mshanga ACSM Coordinator 22. Mr E. Nkiligi Data Manager 23. Mr N. Mwangaba Data analyst 24. Ms K. Kadege Assistant Accountant 25. Ms E. Mapunda - Assistant Accountant 26. Ms C. Chipaga - Data entry clerk 27. Ms J. Goodluck - Data entry clerk 28. Ms G. Tairo - Data entry clerk 29. Ms K. Kassim - Data entry clerk 30. Mr M. Penza - Data entry clerk 31. Ms A. Ponera - Secretary 32. Ms M. Haule - Secretary 33. Mr P. Kalombora Office Attendant 34. Mr E. Mdika - Driver 35. Mr A. Shabani Driver 36. Mr D. Kanyandeko Driver 37. Mr B. Tayari - Driver 13

14 2.1.2 Regional Tuberculosis and Leprosy Coordinators (RTLCs) At the end of the reporting period, there were 28 RTLCs who coordinated TB and Leprosy control services at regional level in Tanzania mainland and 2 RTLCs from Zanzibar. Their names and respective regions are listed below: 1. Dr E. Ntulwe Arusha 2. Dr M. Lupinda - Kinondoni 3. Dr M.Chigwire Temeke 4. Dr S. Mbarouk Ilala I 5. Dr I. Mteza Ilala II (MNH & Private Hospital Dar es Salaam) 6. Dr M. Massimba Dodoma 7. Dr T. Orio Iringa 8. Dr M. Ndyeshobora - Kagera 9. Dr D. Leonard/Dr F. Baranuba Kigoma 10. Dr M. Chelangwa Kilimanjaro 11. Dr A. Pegwa Lindi 12. Dr M. Khan Mara 13. Dr Q. Qawoga Manyara 14. Dr Y. Msuya Mbeya 15. Dr E. Tenga Morogoro 16. Dr W. Byemelwa Mwanza 17. Dr. M. Kodi - Mtwara 18. Dr A. Mpangile Pwani 19. Dr D. Buhili - Rukwa 20. Dr W. Mtumbuka Ruvuma 21. Dr J. Majigwa Shinyanga 22. Dr M. Kimala Singida 23. Dr P. Pima - Tabora 24. Dr S. Kiluwa Tanga 25. Dr J. Mshana Unguja 26. Dr S. Hamad Pemba 27. Dr E. John - Simiyu 28. Dr D. Kalaso - Njombe 29. Mr. J. Mollel - Katavi 30. Dr M. Mashala - Geita 14

15 2.2 Training activities, meetings and conferences Trainings During this year, various trainings were conducted among health care workers. The trainings covered mostly TB/HIV collaborative activities, Pediatric TB management, Laboratory EQA, DHIS2 users and different trainings on surveillance of communicable diseases, TB included which were conducted in and outside the country. The purpose of these trainings was to build capacity of health care workers towards improving quality of care in those areas. These trainings were supported by CDC/PEPFAR, GF ATM and SADC Meetings Quarterly meetings were conducted for RTLCs and DTLCs in the regions and districts respectively. Various conferences were attended both in and outside the country where by Coordinators presented experience in the control of TB and Leprosy from Tanzania. 3 TUBERCULOSIS CONTROL SERVICES 3.1 Tuberculosis case notification 2014 A total of 63,151 cases of all forms were notified in 2014, which shows a decline of 3.9% or 2,581 cases compared to the year Among the cases notified, new cases were 60,575 (95.9%) and the retreatment cases were 2,576 (4.1%) which is almost the same proportions for the past three years. Among the new TB cases, 23,447 (37%) were bacteriologically confirmed, 23,587 (37%) were clinically diagnosed and 13,441 (21%) were extra-pulmonary TB. Table 2 below shows the comparison of TB notification in 2013 and 2014 by TB category groups. Table 2: Tuberculosis cases notified in Tanzania Indicators Change Cases % Cases % cases % All forms 65,732 63,151-2, New forms - Bacteriologic confirmed 24, , , Clinically diagnosed 23, , Extra-pulmonary 15, , , Total 62, , , Previously treated - Relapse 1,

16 - Failure Return to control others 1, , Total 2, , Tuberculosis notification by regions Although the proportion of cases notified in Dar es Salaam city is progressively declining, but the region has remained to be the major contributor with 22%, followed by Mwanza region-7% and Mbeya 6%. A list of regions which contributed more than 4% remained the same as for the past three year with some other major cities increasing their contribution. Figure 1 below shows individual regions contribution by percentage and it indicates that over 66% or two third of cases notified during the reporting year came from only 10 regions in the United Republic of Tanzania. The remaining 20 regions contributed only a third of all TB cases notified. The reasons for such huge variations in among the regions need to be explored and investigated. Figure 1: Distribution of TB cases notified by regions in 2014 Other regions 34% Dar es Salaam 22% Mwanza 7% Mbeya 6% Kilimanjaro 4% Tanga Manyara 4% 4% Mara 4% Arusha 5% Morogoro 5% Shinyanga 5% Tuberculosis case notifications disaggregated by sex and age 16

17 The age-sex distribution of the new and relapse TB cases notified in 2014 shows that 36,772 (60%) cases were males and 24,801 (40%) females with a sex ratio of over 1:1.5. The number of children aged 0 14 years old notified among new and relapse cases were 6,489 (10.5%). Age-sex distribution of the new and relapse cases also shows that, the highest number of TB cases notified was in the age groups of years and years for both males and females as summarised in Figure 2 below. Figure 2: Age and Sex distribution of new bacteriologically confirmed TB cases notified in 2013 Tuberculosis notification rate The notification rate of all forms of tuberculosis new and relapses was 130 cases per 100,000 population. Notification rate of all cases new and previously treated cases including the failure, other and return after lost to follow up was 133 which were smaller compared to 142 cases per 100,000 in Dar es Salaam region had the highest TB notification rates in the country at 272 cases per 100,000, Kigoma region has the lowest TB case notification rate of 34 cases per 100,000, followed by Pemba Island (42) and Rukwa region (44). The figure below shows notification of TB cases by region. 17

18 Figure 3: TB notification rate (new and relapses) by region for 2014 Tuberculosis re-treatment cases Previously treated TB cases notified in 2014 were 2,576 cases which is 4.1% of all cases notified in the country. For the past five years, gradual decline of previously treated patients have been noted. Most of the previously treated TB cases were in the categories of others 1,157 (45%) and relapse 998 (39%). The categories of loss to follow up and failure were 295 and 126 cases respectively. Relapses and other cases shows downward trends while return after lost to follow up and failure show a slender upward increase from years The figure 5 below shows the trend of re-treatment cases for the past ten years. 18

19 Figure 4: Trends of Previously Treated TB cases notified form 2005 to Tuberculosis treatment outcome for cohort notified in New and relapse cases Analysis of the 64,053 TB cases notified in 2013 shows that the overall treatment success for new and relapse cases was 90.3%, almost the same result as of 2012 cohort. 3,650 (5.6%) died while still on treatment, 118 (0.2%) failed treatment and 721 (1.1%) lost to follow up. During the same reporting year, the number of TB cases which were not evaluated due to being transferred out of their respective regions was noted still higher at 1,575 (2.6%) The treatment outcomes for individual groups of TB vary from 91% treatment success rate for new smear positive TB to 86% of TB relapses. The table below summarizes treatment outcomes of groups. 19

20 Table 3: TB treatment outcome of all forms of new and relapses notified in 2013 Treatment Outcomes new smear positive new smear negative Extrapulmonary Relapse all forms number % number % number % number % number % Cured 20, , Treatment 1,801 Completed , , , Treatment Success 22, , , , Failure Died 1, , , ,650 6 Out of Control Total Evaluated 23, , , , , Notified 24, , , , , The trend of treatment outcomes of the new and relapse cases for over decade, the treatment success rates have improved from about 80% in 2001 to 90% in 2013 and consistently maintained above 85% since Similarly the death rate has progressively been declining since 2006 from 8% to 5.64% in Treatment outcome of previously treated TB cases notified in 2013 In 2013, 1,679 previously treated TB cases excluding the relapse were notified, 1,585 (94.4%) cases their treatment outcomes are available. Among the evaluated cases: 1,334 (80%) were treated successfully; 21 (1.3%) failed treated while 165(9.8%) cases died while in still on TB treatment. Number of TB cases lost to follow up were 65 (3.9%) of all previously treated cases. Table 4 and figure 5 below summarizes the treatment outcomes for each category of the re-treatment cases. 20

21 Table 4: Treatment outcomes of previously treated (except relapse) cases notified in 2013 Treatment Outcomes Failure Return after lost to follow up Others all forms number % number % number % number % Cured Treatment Completed , , Treatment Success , , Failure Died Out of Control Total Evaluated , , Notified , , Figure 5: Treatment outcomes of previously treated cases notified in

22 3.3 TB/HIV case finding 2014 In the year ,151 TB cases were notified, among the notified cases 55,686 (88%) were counseled and tested for HIV status. The testing results shows that 19,890 (36%) cases were found to be co-infected with HIV which is less by 1% compared to the co-infection rate in Furthermore, analysis shows that of the coinfected cases 19,131 (96%) cases were registered at HIV care and Treatment clinics (CTCs) for care and treatment services. Among them 19,222 (97%) were put on Cotrimoxazole Preventive Therapy (CPT) while 16,437 (83%) were initiated ART in both TB clinic and CTCs within the three months reporting period after a two weeks tolerance period following starting TB treatment. There was a big improvement in the proportion of those initiated with ART from 73% in 2013 to 83% in The noted improvement would be contributed by the introduction of one stop-shop model in TB clinics since the year Figure 6 below summarizes the trend of TB/HIV indicators in the country from 2007 to 2014 Figure 6: Trend of TB patients counseling and testing for HIV, initiated CPT and ART: Regional performance on HIV testing and counseling and ART uptake 22

23 HIV counseling is entry point for accessing HIV care, treatment and preventive services. In 2014 the national average was 88% which is below WHO target of 100%. The majority of the regions are above the national average and few regions are below the average which included: Dar Temeke, Mtwara, Pemba, Dar Ilala I, Kilimanjaro, Mwanza, Iringa, Simiyu and Shinyanga. Figure 7: HIV testing among TB patients in 2014 by regions 3.4 Management of Pediatric TB Childhood TB notifications 2014 The 2014 data shows that of the 61,573 new and relapse TB cases notified, 6,489 (10.5%) were children. This notification has been increasing from the 2012 report which was at 8.6%. Among children (under 15 years) notified 3,078 (47%) were children under the age of 5, while 1,731 (27%) cases were children between age group of 5-9 years and 1,680 (26%) were children of the age-group years. The distribution of children under age of 15 notified according to forms of TB shows that new clinically diagnosed TB cases were 3,493 (53.8%) forming a larger part, followed by new extra-pulmonary TB cases that were 2,337 (36.0%) while new bacteriologically confirmed TB cases and relapse were 645 (9.9%) and 14 (0.2%) respectively. 23

24 3.4.2 Childhood TB/HIV notifications 2014 Testing and counseling for HIV is also done to children (under the age of 15) attending the TB clinics. In 2014 data shows that 5,543 (85%) of notified children were tested for HIV and 1,649 (30%) were HIV co-infected cases. Among all co-infected cases notified in 2014, children make up 8.3% of all cases. 3.5 Management of MDR-TB MDR TB enrolment A total of 143 MDR TB patients were enrolled to start second line treatment at Kibong'oto TB hospital in 2014, showing a 43% increase from the previous year, where by 95 patients were enrolled. Among enrolled patients, a male predominant continued to be observed as only 51 (35.7%) were women. Among enrolled cases, 65 (45%) were HIV positive which is an increase from previous years: 39% (2013), 27% (2012) and 19% (2011). The increase in HIV notification among the MDR cohort may be attributable to early detection of MDR TB cases obtained by the scale up of Expert MTB RIF technology in the country. Figure 8 MDR TB Patients enrolment by Year As in the previous year, the age-sex distribution of new MDR TB cases enrolled on treatment showed that most cases were males and were in the age group of

25 years, however, females were more predominant in the ages 0-24 years (Figure xxx below). Figure 9: Age and Sex distribution of MDR TB cases enrolled on treatment in 2010 MDR TB patients by region in 2014 A total of 22 regions notified MDR TB patients that were ultimately started on MDR TB treatment in 2014, an increment of 100% (11 regions) from the previous year. As in previous years, the majority of MDR TB cases detected and enrolled on treatment were from Dar es salaam (36%) followed by Kilimanjaro (8), Tanga (6%), Mbeya (6%) and Manyara (5%) as illustrated in figure 10 below Figure 10: Distribution of MDR TB cases enrolled on treatment by regions in

26 Treatment outcomes of MDR TB cases enrolled in 2012 In 2014, the programme continued to conduct quarterly cohort and expert review meetings. Cohort reviews aim at reviewing interim results of every patient enrolled in the targeted quarter and the reviews are conducted at 6, 12 and 24 months (final review) whereas expert review panels focus on problem solving for MDR-TB cases whose management is challenging. Final outcomes analysis was completed for on 45 patients enrolled in The results were; 32 patients (71%) were cured, seven patients (16%) completed treatment, two patients (4%) died during the course of treatment, three patients (7%) were recorded as lost to follow up and one patient (2%) was not evaluated. Overall, the treatment success rate (cured + treatment completed) for the 2012 cohort was reported at 87% which is higher than the global MDR TB treatment success target of 75%. Cumulatively, between 2009 and 2014, outcomes of 116 MDR TB patients initiated on treatment country wide were available and the cumulative treatment success rate was reported at 79.3 and the death rate at 10.3%. This is above the 75% globally recommended annual target for MDR TB treatment success rates. See table 5 Table 5: Treatment outcomes of MDR TB patients enrolled for treatment,

27 Year enrolled Enrolled for treatment Cured completed treatment Failed Died Lost to follow up Not Evaluated % - successfully treated % - death Overall MDR TB treatment outcomes were also compared for 2009, to Overall, there was an increase of good outcomes such as; enrolment and cure rates and overall reduction in poor outcomes such as death and lost to follow up in the Tanzanian MDR TB programme over the period. Figure 11; MDR TB outcomes in

28 4 LEPROSY CONTROL SERVICES 4.1 Leprosy Case Notification A total of 2,153 leprosy cases (all forms) were notified in 2014, of which 2,037 (94.6%) were new cases and 67(3.3%) were relapses and 49 (2.1%) were return after default. The number of cases notified was 10 (0.5%) less than those in The number of relapses in Tanzania has persistently remained very high as of the past 15 years and this pose a challenge of whether the notified cases were all truly leprosy diseased. Both the annual national notification rate (case detection rate) and registered prevalence were calculated at 4/100,000 and 0.4/10,000 population respectively and remained almost the same as compared to those of the year Among new cases notified, 1,632 (81%) were MB and 387 (19%) were PB. Females were 701 (35%) giving a female to male ratio of 1:1.8 suggesting that being male continues to be suggestive of risk factor. The number of children among the new cases remained higher at 90 or 4% like those reported in New leprosy cases notified with disability grade II were 239 or 12% which was slightly lower than those reported 2013 at 12.9% indicating that many cases continue to be detected late. Table 5 below summarizes indicator data on new leprosy cases notified in 2014 by regions and those having disability grade II according to WHO classification. However, the trend of new leprosy cases detected for the past 20 years shows tremendous decline country wide as is displayed in table 6 below. Table 6: New leprosy cases detected by indicators in 2014 by regions Region New cases MB Female Children Disability grade II number % number % number % number % Dar Ilala I Dar Ilala II Dar Kinondoni Dar Temeke Dar es Salaam Arusha Dodoma Geita Iringa Kagera Katavi Kigoma Kilimanjaro Lindi

29 Region New cases MB Female Children Disability grade II number % number % number % number % Manyara Mara Mbeya Morogoro Mtwara Mwanza Njombe Pwani Rukwa Ruvuma Shinyanga Simiyu Singida Tabora Tanga Mainland 1,839 1, Pemba Unguja Zanzibar Tanzania 2,019 1, A figure 8 below summarizes the contribution of new leprosy cases by different regions. It shows that 72% of cases which were detected in 2014 were from only 10 regions. Figure 12: The contribution of regions of new cases detected in

30 Since 1990, the proportion of new MB cases detected annually has been slowly increasing from 68% to over 80% while the proportion of females and children detected has been declining slowly from 44% down to 36% and 10% to 4.6% respectively. The changes in proportion of MB cases and children notified annually suggest reduction in the prevalence of the disease in the country with reduced disease transmission. Moreover, the data also suggest that females could be utilizing less the available leprosy services compared to their male partners. This is summarized in the figures 9 and 10. Figure 13: Trends of new leprosy cases reported:

31 The trend of leprosy case notification over years shows a progressive decrease for both PB and MB from over 5,000 cases in 2003 down to just around 2000 in However, the proportions of MB cases remain high above 80% and have been on the increase while the number and proportions of PB cases were gradually declining as shown below in figure 10. This indicate that most of those diagnosed and brought into MDT treatment include old cases. Figure 14: Trends of MB cases, children and females among new leprosy cases:

32 During this reporting period, the proportion of disability grade 2 among new detected cases has remained higher at 12%, however, there has been a gradual decrease in rates due to change and growth of population as shown in figure 18 below. Figure 15: Trend of disability grade 2, percentage among new cases and rates per 1,000,000 populations Registered prevalence Overall, the prevalence of leprosy has showed a steady decline since The prevalence detection ratio has remained around 1 between 2004 and 2014 suggesting that patients are timely removed from the registers after completing their MDT treatment. There are still 18 districts from 10 different regions with prevalence rates higher than 1/10,000, as shown in table 8 below. These data show that the regions of Lindi and Morogoro had most of their districts still endemic and remain at high risk of increased disease burden. 32

33 Figure 16: Trends of new leprosy cases detected and registered: Table 7: Districts with prevalence or detection rate greater than 1/10,000 Population in 2014 S/N District Region Population registered cases prevalence rate 1 Liwale DC Lindi 93, South & Central Unguja Unguja 120, Nkasi DC Rukwa 299, Mkinga DC Tanga 123, Nanyumbu DC Mtwara 154, Lindi MC Lindi 80, Chato DC Geita 388, Ruangwa DC Lindi 133, Masasi TC Mtwara 359, Rufiji DC Pwani 226, Muheza DC Tanga 213, Tunduru DC Ruvuma 310, Newala DC Mtwara 210, Korogwe DC Tanga 324,

34 15 Lindi DC Lindi 197, Musoma DC Mara 141, Namtumbo DC Ruvuma 210, Shinyanga MC Shinyanga 168, Leprosy treatment outcome Treatment outcome of PB leprosy The treatment outcome of PB leprosy cases who started treatment in 2013 shows that, 368 (95%) completed treatment while 8 (2.1%) defaulted from treatment and there was no death reported. Table 9 below summarizes treatment outcome of PB leprosy cases notified in 2013 by region. Table 8: Treatment outcome of PB leprosy reported in 2013 Region Treatment Died Transferred Out of Total completed Out Control Reported in 2013 % completed Dar Ilala I Dar Ilala II Dar Kinondoni Dar Temeke Dar Es Salaam Arusha 0 0 Dodoma Iringa Kagera Kigoma Kilimanjaro Lindi Manyara Mara Mbeya Morogoro Mtwara Mwanza Pwani Rukwa Ruvuma Shinyanga Singida Tabora Tanga

35 Mainland Pemba Unguja Zanzibar Tanzania Treatment outcome of MB leprosy Treatment outcome of MB leprosy cases notified in 2012 shows that, 2,060 (93%) completed treatment while 8 (0.4%) patients died during treatment period. However, the data also shows that 83 patients did not complete their treatment due to various reasons: 50 (2.0%) defaulted from treatment and 33 (1.0%) cases were transferred out during treatment. Table 10 below summarizes treatment results of MB cases notified in Table 09: Treatment outcome of MB leprosy notified in 2012 Region Treatment completed Died Transferred Out Out of Control Total Reported in 2012 % completed Dar Ilala I Dar Ilala II Dar Kinondoni Dar Temeke Dar Es Salaam Arusha Dodoma Iringa Kagera Kigoma Kilimanjaro Lindi Manyara Mara Mbeya Morogoro Mtwara Mwanza Pwani Rukwa Ruvuma Shinyanga Singida Tabora Tanga

36 Mainland 1, ,065 2, Pemba Unguja Zanzibar Tanzania 2, ,151 2, Figure 17: Trends of leprosy cases completed treatment: Activities related to acceleration of leprosy elimination efforts Tanzania is among 17 countries in the world reporting high number of leprosy cases of more than 1,000 cases. It is also one of the signatories of the Bangkok declaration to accelerate leprosy elimination among the high burden countries and those at high risk of increasing disease burden. During this reporting year, the programme in collaboration with traditional partners like WHO, GLRA and Novartis Foundation has:- 36

37 Conducted one leprosy elimination campaign (LEC) at Mkinga DC. The campaign was one of the activities during the commemorations of world leprosy day in Tanga region. In one week, 22 new cases were actively found and initiated on MDT. Started preparatory activities to introduce leprosy post-exposure prophylaxis (LPEP) in Tanzania in three pilot districts of Kilombero, Liwale and Nanyumbu. Through this programme, family members of the index case will be screened to rule out leprosy disease and being given a single dose rifampicin. The intervention will largely contribute to efforts to detect leprosy disease early and cut down the transmission chain. Preparation of protocol to access funds to implement Bang kok decleration to promote early case detection and addressing challenges facing PALs with disabilities. The proposed protcol will mainly focus on active case finding efforts, promoting increased community involvment and social mobilization. The funds to implement the Bang kok decleration were donated by the Nippon Foundation of the Sasakawa initiative and are being managed by WHO leprosy global programme. 4.4 Activities related to prevention of disabilities (POD) People with leprosy related disabilities In 2014, a total of 1,836 people affected by leprosy (PALs) with disabilities were registered. Among them, 448 (24.4%) were staying in care centres. A total of 1,533 (83.5 %) were reviewed to assess their physical impairments and only 19 (1.2%) PALs had their condition deteriorated and 20.8% did not change on the course of their treatment Leprosy reactions A total of 572 leprosy patients were reported with reactions and started on treatment. Out of them, adults MB cases were 84.3% (482) and for PB 90 (15.7%). cases. Children from both types were 1.6% (9). Of all the reported cases, 97 were admitted because of severe reactions. The table below shows patients reported with reactions by region per category. The availability of sufficient prednisolone drugs for PALs in need at health facilities in the country remain a big challenge. 37

38 Table 10: Leprosy cases started treatment with corticosteroid in 2014 Region MB (A) MB ( C) PB (A) PB ( C) Total Arusha Dar Ilala I Dar Ilala II Dar Kinondoni Dar Temeke Dar es Salaam Dodoma Geita Iringa Kagera Katavi Kigoma Kilimanjaro Lindi Manyara Mara Mbeya Morogoro Mtwara Mwanza Njombe Pwani Rukwa Ruvuma

39 Region MB (A) MB ( C) PB (A) PB ( C) Total Shinyanga Simiyu Singida Tabora Tanga Mainland Pemba Unguja Zanzibar Tanzania Specialized care of people with disabilities During the year 2014, a total of 188 persons affected by leprosy (PALs) were admitted to different hospitals in the country. Ulcers and wounds ranked high as the main reason for admission by 98 (52.1%) followed by reactions 35 (18.6%). Eye pathology ranked third and accounted for 11 (5.8%), and the least was constructive surgery 4(.1%). Eye pathology which was 10 (5.6 %). In addition, 33 PALs were fitted with prostheses. The table 12 below summarises the number of surgeries done, prosthesis fitted and prosthess repaired for people affected by leprosy in 2014 by regions. Table 11: Number of leprosy admissions in hospitals 2014 Number of leprosy admissions in hospital(s) Ulcers/wound treatment 98 Reactions 35 Indications for admission (Reconstruction) Surgery 4 eye pathology 11 Others 40 Number of Amputation done 3 Number of referred for rehabilitation outside the regions 4 Number of PALs given Prosthesis Footwear Programme In 2014, a total of 3500 pairs of special boots were produced centrally and distributed to regions country wide. By the end of the year 1,537 pairs of protective sandals were distributed to people affected by leprosy. This is only 50% of the protective sandals reaching PALs in need. To complement these efforts, 211 pairs of shoes were made locally in several regions by the local shoemakers. In the case of special boots, 88 pairs were fabricated and 264 footwear repairs were done for PALs with foot deformities. The table below shows the amount of footwear distributed to people affected by leprosy by 39

40 region in This includes factory made sandals, locally produced shoes, special boots and repairs done. Table 12: Materials and tools distributed for fabrication of special and local shoes production per region in 2014 Regions Leather MCR H.rubber GLUE L.Leather Thread S.Riverts Zanzibar Morogoro Chazi Morogoro Nazareth Tanga Misufini Mara Shirati Shinyanga Busanda Kagera Biharamuro Pwani Kindwitwi Tabora Sikonge Mwanza Bukumbi Ruvuma

41 5 LABORATORY SERVICES 5.1 Summary of services In microscopy services, the Central TB Reference Laboratory (CTRL) trains, supervises and evaluates the performances as well as the External Quality Assurance (EQA) administration for all the AFB smear microscopy facilities in the country. The total number of AFB smear microscopy facilities in the country currently stands at 945. The Routine Surveillance System (RSS) operations involve performing microscopic examinations, culture and DST for specimens from all the regions. The CTRL is also responsible for supervision of the roll out of MTB RIF technique, a new diagnostic method using the Xpert MTB/RIF assay introduced recently. The Xpert MTB/RIF is a cartridge-based, automated diagnostic test that can identify Mycobacterium tuberculosis (MTB) DNA and resistance to rifampicin (RIF) by nucleic acid amplification technique (NAAT). In the year 2014, the total number of specimens received at the CTRL were 5,515 out of this 1,666 (30%) were from routine specimen from Muhimbili National Hospital (MNH), Apopo was 1,375 (25%) while specimen from up countries were 45% as summarized in Table 13 below. Table 13: Total number of specimens received at the CTRL Scheme N % MNH 1,

42 All other regions 2, Apopo 1, Total 5, Microscopy The CTRL performs smear microscopy using LED microscopes for the MNH specimens as well as those from other regions. In the year, 1,666 specimens were received from the Muhimbili National Hospital. It must be noted that specimens from new presumptive cases and are from sites without Xpert machines are tested using Xpert MTB/RIF technique while those from retreatment cases or from sites with Xpert machines or from the Kibong oto TB hospital undergo microscopy. All the specimens underwent culture except those from the MNH. The number of specimens received is detailed in table 14, Figure 14 and Table 15 below. Table 14: Number of Specimens Received per Month per Case Case Month New Retreatment Other Total January Feb March April May June July August September October November December Total 2,808 1, ,140 Figure 18: Total specimen received at CTRL in 2014 per month per case 42

43 43

44 Table 15: Number of Specimens per Case category by Regions Cases Region New Retreatment Other Unknown Total Arusha Dodoma Ilala I Ilala II 1, ,714 Iringa Kagera Kigoma Kilimanjaro Kinondoni Lindi Manyara Mara Mbeya 2 2 Morogoro Mtwara Mwanza Pemba Pwani Rukwa Ruvuma Shinyanga Singida Tabora Tanga Temeke Unguja Unknown Grand Total 2, ,140 44

45 Culture Culture is performed using both the liquid (BACTEC MGIT ) media and the solid (Löwenstein Jensen medium). The results are as shown in Table 16 below Table 16: Culture results Culture result N % CON NEG 1, TBC 1, Not for culture 1, Unknown Total 4, The relationship between microscopy and culture examinations at the CTRL for 2014 is summarised in Table 17 and figure 15 below. Table 17: Microscopy-Culture correlation Microscopy results Culture results Negative Positive Contaminated Unknown Total Negative ,001 Positive ,294 Not Done Total 1,133 1, ,474 Figure 19: Smear culture results,

46 DRUG SUSCEPTIBILITY TESTING (DST) Drug susceptibility tests are processed at the CTRL by proportional method for both first and second line drugs. The conventional TB drug susceptibility testing (phenotype), involving the culturing of M. tuberculosis in the presence of anti TB drugs in order to detect growth (indicating drug resistance) or inhibition of drug, (indicating drug susceptibility). The methods used are to perform direct or indirect tests on either solid or liquid media. It is also used for diagnosing patients after treatment failure and relapse. Table 18 and 19 below show the results of DST for 2014 Table 18: DST 1st LINE profile DST 1st Line Profile N % H HR HRE HRES HR-S R RES R-S Grand Total Table 19: DST 2nd LINE profile DST 2nd Line Profile N % OKUU UU Total

47 Table 20: DST Profile key Profile Letter Meaning - Susceptible H Resistant to ISONIAZID R Resistant to RIFAMPICIN E Resistant to ETHAMBUTOL S Resistant to STREPTOMYCIN O Resistant to OFLOXACIN K Resistant to KANAMYCIN U UNKNOWN Molecular methods At the CTRL, the HAIN test, which is an LPA used in Identification of the M. tuberculosis complex and its resistance to Rifampicin and/or Isoniazid from pulmonary clinical specimens or cultivated material, is done as confirmatory test. Sixty-one specimens were examined; results are show in Table 21 and 22 below Table 21: HAIN test results for Identification MTB Results N % MTB not detected MTB detected Total Table 22: HAIN test results for resistance to R&I Results N % Resistant to I & R Sensitive to all MTB not detected Total Apopo is a project looking at diagnosing TB using rats. The project received 1,375 specimens during the year (Table 1). These specimens are examined microscopically, both solid and liquid cultures, and would have an LPA and Rapid test as a confirmatory test. GeneXpert (Xpert) MTB/RIF Tanzania was an early adopter of the technology, with Xpert MTB/RIF testing commencing in However, the majority of sites became operational in 2011 and The NTLP introduced country Xpert focal person who oversees its activities in the 47

48 country. Therefore the NTLP requests sites the GeneXpert focal person at the CTRL be provided with monthly indicators from all sites undertaking patient testing with GeneXpert by the 7 th of each month. Figure 20: Map to show Xpert sites in the country. A summary of results for the Xpert both at the CTRL and for the whole country is shown in Tables 25 and 26 below Table 23: Xpert MTB/Rif results per type of specimen RESULTS NEW PREVIOUS TOTAL Xpert tests MTB negative ,129 Xpert tests MTB positive RIF sensitive Xpert tests MTB positive RIF resistant Xpert tests MTB positive RIF indeterminate Error results Invalid results No result Total 1, ,813 48