THE UNITED REPUBLIC OF TANZANIA MINISTRY OF HEALTH AND SOCIAL WELFARE NATIONAL TUBERCULOSIS AND LEPROSY PROGRAMME ANNUAL REPORT 2010

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1 THE UNITED REPUBLIC OF TANZANIA MINISTRY OF HEALTH AND SOCIAL WELFARE NATIONAL TUBERCULOSIS AND LEPROSY PROGRAMME ANNUAL REPORT 2010 National TB and Leprosy Programme Ministry of Health and Social Welfare P. O. Box 9083 Dar es Salaam Tel : Fax : tantci@intafrica.com Website: July, 2011 i

2 Table of Contents LIST OF TABLES LIST OF FIGURES LIST OF ANNEXES LIST OF ABBREVIATIONS III IV V VI ACKNOWLEDGEMENT IX 1. GENERAL BACKGROUND DEMOGRAPHIC AND SOCIO-ECONOMIC PROFILE SUMMARY OF HEALTH SERVICES: SUMMARY OF NTLP ACTIVITIES FINANCE SUPPORT FINANCIAL SUPPORT FROM DEVELOPMENT PARTNERS DOMESTIC FINANCIAL RESOURCES 3 2. HUMAN RESOURCE DEVELOPMENT STAFF ESTABLISHMENT TUBERCULOSIS AND LEPROSY CENTRAL UNIT (TLCU) REGIONAL TUBERCULOSIS AND LEPROSY COORDINATORS (RTLCS) DISTRICT TUBERCULOSIS AND LEPROSY COORDINATORS/ TB/HIV OFFICERS VACANT POSTS TRAINING ACTIVITIES, MEETINGS AND CONFERENCES ATTENDED BY NTLP STAFF 6 3. TUBERCULOSIS CONTROL SERVICES TUBERCULOSIS CASE NOTIFICATION TUBERCULOSIS TREATMENT OUTCOME FOR COHORT NOTIFIED IN COLLABORATIVE TB/HIV ACTIVITIES MANAGEMENT OF MDR-TB LEPROSY CONTROL SERVICES CASE NOTIFICATION REGISTERED PREVALENCE LEPROSY TREATMENT OUTCOME ACTIVITIES RELATED TO PREVENTION OF DISABILITIES (POD) LABORATORY SERVICES 30 i

3 5.1 LABORATORY WORKLOAD OTHER ACTIVITIES EXTERNAL QUALITY ASSURANCE OF DRUG RESISTANCE OPERATIONAL RESEARCH ACTIVITIES FIRST NATIONAL TUBERCULOSIS PREVALENCE SURVEY TB/HAART PROJECT EAST AFRICA PUBLIC HEALTH LABORATORY NETWORKING PROJECT (EAPHLNP) REDUCTION OF EARLY MORTALITY AMONG HIV-INFECTED SUBJECTS STARTING ANTIRETROVIRAL THERAPY (REMSTART) TRIAL PROGRAMME SUPPORT ACTIVITIES DRUG SUPPLY AND MANAGEMENT ADVOCACY, COMMUNICATION AND SOCIAL MOBILISATION (ACSM) ACTIVITIES COMMUNITY EMPOWERMENT ACTIVITIES PUBLIC PRIVATE PARTNERSHIP LOGISTIC SUPPORT SUPERVISION 43 ii

4 List of Tables Table 1: NTLP financing 2010 Table 2: Trainings conducted in 2010 Table 3: Tuberculosis cases notified in Tanzania Table 4: Age and Sex distribution of smear positive TB cases notified in 2010 Table 5: Treatment outcomes of new smear positive TB cases notified in 2009 Table 6: Treatment outcomes of re-treatment TB cases notified in 2009 Table 7: TB/HIV cases notified from 2007 to 2010 Table 8: Tuberculosis treatment outcome new smear positive TB and TB/HIV patients notified in 2009 Table 9: Interim treatment results of confirmed MDR-TB cases started on treatment Table 10: New leprosy cases detected in 2010 Table 11: Treatment outcome of PB leprosy reported in 2009 Table 12: Treatment outcome of MB leprosy reported in 2008 Table 13: Leprosy patients started treatment with corticosteroid in 2010 Table 14: Protective footwear distributed to PAL in regions by type in 2010 Table 15: Materials and tools used for fabrication of local produced shoes and special boots Table 16: Materials used on job training and fabrication of special boots at Sikonge Tabora Table 17: Number of surgeries, prosthesis fitted and repair in region 2010 Table 18: Culture and DST results Table 19: TB and Leprosy drugs distributed to regions by MSD in 2010 Table 20: TB and Leprosy drugs received in the country in 2010 Table 21: IEC Materials produced in 2010 by funding source Table 22: TV and Radio spots broadcasted in 2010 Table 23: TB groups established by former TB patients in 2010 iii

5 List of Figures Figure 1: Percentage distribution for Tuberculosis cases notified by region in 2010 Figure 2: Percentage of new smear positive TB cases of notified by region in 2010 Figure 3: Age and sex distribution of new smear positive TB cases notified in 2010 Figure 4: Trends of TB notification rate from for all-forms and new smear positive Figure 5: TB notification rate (all forms and new smear positive) by region in 2010 Figure 6: Treatment success rate for new smear positive TB cases notified in cohort of 2009 Figure 7: Trend of treatment success for cohorts notified from 1999 to 2009 Figure 8: Percentage distribution of treatment outcome for re-treatment TB cases notified in 2009 by category Figure 9: Trends of treatment outcome of re-treatment TB cases notified in 2002 to 2009 Figure 10: Trends of TB patients counselled and tested for HIV, initiated CPT and ART from 2007 to 2010 Figure 11: Trend of New leprosy cases detected in Tanzania Figure 12: Trends of MB cases, children, females and disability grade 2 among leprosy cases: Figure 13: Trends of new leprosy cases detected and prevalence in Tanzania Figure 14: Prevalence and case detection ratio of leprosy between 2004 and 2010 Figure 15: Distribution of leprosy prevalence and cases detection rates by regions in 2010: sorted against prevalence rate Figure 16: Quarterly monitoring of culture performance laboratory CTRL year 2010 iv

6 List of Annexes Annex 1: Tuberculosis patients (all forms) notified in Tanzania by districts in the year 2010 Annex 2: Age and sex distribution of newly diagnosed smear positive pulmonary tuberculosis patients notified in 2010 Annex 3: Treatment results of new TB patients (AFBP, AFBN, and Extra Pulmonary) diagnosed by districts in 2009 Annex 4: Treatment results of all re-treatment (Relapses, Return, Failure and Other) TB patients notified by districts in 2009 Annex 5: Tuberculosis and HIV patients notified by district in the year 2010 Annex 6: Leprosy Patients reported by districts in Annex 7: Age and sex distribution for newly detected leprosy patients in reported by districts in 2010 Annex 8: Disability grading of newly detected leprosy patients reported by district in 2010 Annex 9: Leprosy Patients Registered by districts at the end of 2010 Annex 10: List of DTLCs and TB/HIV officers in 2010 v

7 List of Abbreviations AFB Acid-Fast Bacilli AIDS Acquired Immuno-Deficiency Syndrome CHAI Clinton HIV/AIDS Initiative CDC Centre for Disease Control (America) CTRL Central Tuberculosis Reference Laboratory DCI Development Cooperation for Ireland DDH District Designated Hospital DGIS Directorate General for International Cooperation (Netherlands) DHMT District Health Management Team DMO District Medical officer DOTS Directly Observed Treatment Short Course DRS Drug Resistance Survey DTLC District Tuberculosis and Leprosy Coordinator E Ethambutol EH Ethambutol and Isoniazid EP (TB) Extra-pulmonary (Tuberculosis) ETR Electronic Tuberculosis Register FDC Fixed Dose Combination FIDELIS Funds for Innovative DOTS expansion through Local Initiatives to Stop TB GCP Good Clinical Practice GDP Gross Domestic Product GLRA German Leprosy and TB Relief Association GLP Good Laboratory Practice GFATM Global Fund to fight AIDS/HIV Tuberculosis and Malaria H Isoniazid HAART Highly Active Antiretroviral Therapy HBC Home Base Care HC Health Centre HIV Human Immunodeficiency Virus HMIS Health Management Information System HSR Health Sector Reform HW Health Workers IEC Information Education and Communication ISTC International Standard of TB care IUATLD International Union Against TB and Lung Disease KNCV Royal Netherlands Tuberculosis Foundation LEC Leprosy Elimination Campaign MB Multi bacillary (leprosy) vi

8 MDR-TB MNH MOHSW MSD MUCHS NGO NACP NIMR NMC NTLP OPD PALs PATH PB PCT PM PMTC PoD PRS PTB+ PTB- PZA R RACC RCHS RLT RMO RNE RTLC S SDC SOPs TB TDR TFDA TLCU ToTs UCSF VCT Multi-drug tuberculosis Muhimbili National Hospital Ministry of Health and Social Welfare Medical Store Department Muhimbili University College of Health Science Non- Governmental Organization National AIDS Control Programme National Institute of Medical Research National (TB/Leprosy) Management Committee National Tuberculosis and Leprosy Program Out Patient Department People affected by leprosy Programme for Appropriate Technology in Health Pauci bacillary (leprosy) Patient Centred Treatment Programme Manager Prevention of Mother to Child Transmission Prevention of Disabilities Preventive and Reconstruction Surgery Pulmonary Tuberculosis, Smear positive Pulmonary tuberculosis, Smear negative Pyrazinamide Rifampicin Regional AIDS Control Coordinator Reproductive and Child Health Section Regional Laboratory Technologist Regional Medical Officer Royal Netherlands Embassy Regional tuberculosis and leprosy Co-ordinator Streptomycin Swiss Development for Cooperation Standard Operating Procedures Tuberculosis UNICEF/UNDP/WORLD BANK/WHO Special Programme for Research and training in Tropical Diseases Tanzania Food and Drugs Authority Tuberculosis and Leprosy Central Unit Training of Trainers University of California, San Francisco Voluntary Counselling and Testing (for HIV) vii

9 WHO Z World Health Organization Pyrazinamide viii

10 Acknowledgement This annual report is a concise description of activities implemented by the National Tuberculosis and Leprosy Programme (NTLP) under the Ministry of Health and Social Welfare for the year The purpose is to share this information with stakeholders interested to know progress made in the control of leprosy, tuberculosis and TB/HIV interventions in the country. On behalf of the programme, I would like to express my sincere gratitude to the management of the Ministry for the support and encouragement given to us especially the Permanent Secretary, the Chief Medical Officer and all the directors in the different departments. A wide range of partners and stakeholders have greatly contributed to this report. I would like to extend my appreciation to the regional TB and leprosy coordinators for supervising the quality of this information, district TB and leprosy coordinators, TB/HIV officers, and all health workers, who generated and compiled data presented in this report Special appreciation is directed to TLCU staff that reviewed, edited and made possible the writing of this report. Last but not least, I would like to recognise the financial and technical support given to the Programme by development partners. In particular, I would like to commend the support from the following: Germany Leprosy and TB Relief Association (DAHW/GLRA) The Global Fund to Fight HIV/AIDS, Tuberculosis and Malaria (GFATM) The Centres for Disease Control and Prevention (CDC/PEPFAR ) Programme for Appropriate Technology in Health (PATH) United States Agency for International Development (USAID) UNITAD The Netherlands Tuberculosis Foundation (KNCV) USAID through TBCAP Funds for Innovative New Diagnostics (FIND) World Health Organization (WHO) Novartis Foundation for Sustainable Development (NFSSD) Global Drug Facility (GDF) under the Stop TB Partnership World Bank - IDA Dr. S.M. Egwaga Programme Manager National TB and Leprosy Programme Ministry of Health and Social Welfare June, 2011 ix

11 1. GENERAL BACKGROUND 1.1 Demographic and socio-economic profile In 2010, the Tanzania mainland population was projected to be 41,914,311 based on 2002 census with 51% of the population being females. The population of urban inhabitant was 23 % and those living in rural areas were 77%. About 65% of the population are estimated to be below 25 years of age giving a broad-based population pyramid with a relatively young population. The annual population growth rate is estimated at 2.9. The population of Zanzibar is projected at 1,273,512 with a growth rate of 3.1%. Agriculture is still the major source of livelihood for majority of the population in Tanzania. 1.2 Summary of Health Services: Health care delivery system in the country is well established with more than 72% of the population living within 5km of a health facility. The major providers of health services are the government, parastatal institutions, non-governmental organisations including faith based and private for profit. In 2010, there were 5,972 health facilities of which 3,895 or 69% were government owned or District Designated Hospitals (DDH). Tanzania is classified as one of the least developed countries, with government per capita spending on health was US$ 14.7 against WHO recommended $34 (Public Expenditure Review Report 2009/10; Ministry of Health and Social Welfare) 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 5.7% in the population aged years. Tuberculosis accounts for about 8% of the burden of diseases and 6 % of all deaths in the country for people aged 5 years and above, primarily due to HIV/TB co-infection. 1.3 Summary of NTLP activities During the year 2010, the programme implemented various activities based on the annual plan. This ranged from DOTS expansion by recruiting new staff, provision of quality assured first line anti-tb drugs, laboratory supplies and equipment; initiating treatment of MDR-TB patients at Kibong oto National TB hospital; scaling up national -wide collaborative TB/HIV activities, scaling up involvement of more private health care providers; empowering patients and community members to take active participation in TB prevention and care; collaborating with internal and external partners in conducting relevant operational research. The programme also focused on elimination of leprosy by actively conducting targeted leprosy elimination campaigns in districts with high prevalence of the diseases and strengthening Prevention of Disabilities (PoD) among people affected by leprosy (PALs). Targeted leprosy elimination campaigns were conducted in Kilombero district in Morogoro region and Masasi district in Mtwara. 1

12 During this period, a number of programme staff attended workshops, training courses, meetings and conferences both inside and outside the country including the union and TSRU meetings. 1.4 Finance support Financial support from Development Partners In year 2010, the National Tuberculosis and Leprosy Programme NTLP actual funding for TB,TB/HIV and Leprosy control activities provided from different sources amounted to about $16,594, which include domestic and external support both in liquid cash and in kind through materials and services including technical assistance. The Programme received direct financial support from a number of partners including Global Fund Against AIDS, TB and Malaria, Round 6 (GFATM6), WHO/TDR, German Leprosy and TB Relief Association (GLRA), Centers for Disease Prevention and Control (CDC) under PEPFAR, and USAID through PATH.Novartis Foundation for Sustainable Development (NFSD) and Global Drug Facility (GDF) under the Stop TB Partnership provided first line anti-tb drugs. Other support includes cash from Basket Fund under SWAP, technical support and training from International Union Against Tuberculosis and Lung Diseases (IUATLD), WHO-Afro, Netherlands TB Foundation (KNCV) and TBCAP. 2

13 Table 1: NTLP financing 2010 Planned intervention/ Service delivery area Actual financing Government Global Fund Other External Sources First-line TB drugs Staff working for TB control (central unit staff and sub national TB staff) Routine programme management and supervision activities Laboratory supplies and equipment for smears, culture and DST PAL (Practical Approach to Lung Health) PPM (Public-Public, Public Private Mix-DOTS) 2,510, ,830-2,309,580 6,402,220 5,473, , ,660 2,767,680 88, ,890 1,895, , , ,600 18, ,540 Collaborative TB/HIV activities Second-line drugs for MDR-TB Management of MDR-TB (budget excluding second-line drugs) Community involvement ACSM (Advocacy, communication and social mobilization) Operational research Surveys to measure TB burden and impact of TB control 1,168, ,430 1,027,180 47,400 47, , , , , ,800 32, , , , ,000 57,000 57,000 All other budget lines for TB (e.g., technical assistance) 680, , ,670 TOTAL (calculated automatically) 16,013,050 5,795,566 2,362,200 7,944,880 The financing shows the existing health system to implement as opposed to absolute requirement for TB, TB/HIV and leprosy control interventions Domestic Financial Resources The Government s own sources include consolidated fund disbursed under Medium Team Expenditure framework (MTEF) and domestic partners contribution in kind. This covered to a large extent the institutional overheads and personnel costs for staff working for TB programme at national and sub-national levels as well as routine programme management and supervision. 3

14 2. HUMAN RESOURCE DEVELOPMENT The programme recruits regular and contract staff through government procedures, both at the central unit (TLCU) and councils with focus on strengthening TB/HIV services in the country. The contract staffs have been recruited through various project grant support including GLRA, the GFATM and CDC/PEPFAR. During this reporting year, the programme embarked on building capacity of staff in TB, TB/HIV, MDR-TB and leprosy control services according to the national and international guidelines. The programme implemented various training activities with funding sources from the different partners. All together there is 37 staff at central level, 24 at regional level (RTLC), and 263 at district level; 197 DTLC and 97 TB/HIV officers. Below is a detailed description of staff establishment for Staff establishment Tuberculosis and Leprosy Central Unit (TLCU) During this reporting year, two accounts staff; Ms. Evaline Mapunda Assistant Accountant, Ms Biem Abeid - Accounts Assistant, joined the Programme. At the same time two senior staff members retired from public service; Mr. Timothy M. Chonde - Principal laboratory technologist and Mr. Messiah Mgoba - Assistant Orthopaedic Technician. One staff Dr. Irinei Myemba Human Resource Officer left the programme for other opportunities outside the Ministry. The list of TLCU staff by December, 2010 was as follows:- 1. Dr. S. M. Egwaga - Programme Manager, 2. Dr. D. Kamara Programme Officer 3. Dr. M. Nyamkara - National TB/HIV Coordinator 4. Mr. B. Msuya - Programme Accountant 5. Mr. W. Lugano - Accounts Assistant 6. Ms. K. Kadege Assistant Accountant 7. Ms. E. Mapunda Assistant Accountant 8. Ms. B. Abeid - Accounts Assistant 9. Ms. B. Doulla - Head, National TB Reference Laboratory 10. Dr. J. Lyimo MDR-TB Coordinator 11. Ms. D. Kasembe Human Resource Officer 12. Mr. J. Ngowi Programme Pharmacist 13. Dr. R. Mtandu Medical officer Laboratory 14. Dr. S. Matiku Monitoring and Evaluation officer 15. Dr. A. Tarimo PPP Coordinator 16. Ms. L. Ishengoma Community TB care Coordinator 17. Ms. A. Mshanga ACSM Coordinator 18. Mr. S. Bossy Senior Laboratory Technician 19. Ms. D. Mtunga Laboratory Technician 20. Mr. R. Shirima Data Analyst 21. Ms. D. Semu Prevention of Disabilities Coordinator 22. Mr. P. Shunda Orthopaedic Technologist 4

15 23. Ms. F. Mallya Supplies Officer 24. Mr. D. Kayumba Health Administrator 25. Mr. E. Nkiligi Data Manager 26. Ms. C. Chipaga Data Entry Clerk 27. Ms. J. Goodluck Data Entry Clerk 28. Ms. K. Kassim Data Entry Clerk 29. Ms. G. Tairo Data Entry Clerk 30. Mr. N. Mwangaba Data Analyst 31. Mr. M. Penza Data Entry Clerk 32. Ms. M. Sindano Secretary 33. Ms. A. Ponera Secretary 34. Mr. P. Kalombora Office Attendant 35. Mr. E. Mdika Driver 36. Mr. A. Shaban Driver 37. Mr. D. Kanyandeko Driver Regional Tuberculosis and Leprosy Coordinators (RTLCs) There are 24 Regional TB and Leprosy coordinators who coordinate TB and Leprosy control services at regional level in Tanzania mainland and 2 RTLCs from Zanzibar. Their names and regions are shown below:- 1. Dr. E. Ntulwe - Arusha 2. Dr. J. Msangi - Kinondoni-Dar es Salaam 3. Dr. N. Kapalata - Temeke-Dar es Salaam 4. Dr. A. Swai - Ilala-Dar es Salaam 5. Dr. I. Mteza - Muhimbili-Dar es Salaam 6. Dr. M. Massimba - Dodoma 7. Dr. F. P. Mhomisoli - Iringa 8. Dr. I. Abdulrahman - Kagera 9. Dr. D. N. Leonard - Kigoma 10. Dr. M. Chelangwa- Kilimanjaro 11. Dr. A. Pegwa - Lindi 12. Dr. M. Khan - Mara 13. Dr. Q. Qawoga - Manyara 14. Dr. J. Kabalika - Mbeya 15. Dr. E. Tenga - Morogoro 16. Dr. W. Byemelwa - Mwanza 17. Dr. R. Mnandowa - Mtwara 18. Dr. N. A. Singano - Pwani 19. Dr. P. Yamsebo - Rukwa 20. Dr. W. N. Mtumbuka - Ruvuma 21. Dr. M. Sahali - Shinyanga 22. Dr. M. Kimala - Singida 23. Dr. R. Hussein Tabora 24. Dr. L. Kijazi Tanga 25. Drs. J. Mohamed/J.Mshana Unguja 26. Dr. H. Said Pemba 5

16 2.1.3 District Tuberculosis and Leprosy Coordinators/ TB/HIV Officers By 31 December, 2010, there were 166 District TB/Leprosy coordinators and 97 TB/HIV Officers distributed at district level including 35 recruited under PATH. The lists of names with their respective districts are as shown in annex Vacant posts Currently there are 31 vacant posts for TB/HIV Officers and five for MDR-TB nurse, TB training officer, nutrition nurse and drivers. These gaps are associated with increased turnover among health care workers but also as a result of establishing new districts by the government. These vacant posts will be filled through recruitment under CDC/PEPFAR and GFATM-R6 supports during coming calendar year (17 posts for each). 2.2 Training activities, meetings and conferences attended by NTLP staff Trainings Short training courses A number of TLCU staff, had the opportunity to attend training inside and outside the country to enrich their programme management skills on various disciplines. These included: Ms. G. Tairo - M& E Training- September 2010 (Nairobi, Kenya) Ms. K. Kassim - M& E Training- September 2010 (Nairobi, Kenya Ms. C. Chipaga - M& E Training - September 2010 (Pretoria, South Africa) Dr. A. Tarimo TB International Course -November 2010, Arusha Ms. B. Doulla - MGIT training 25th -28th May, 2010, in Nairobi, Kenya Mr. E. Luhanga MGIT training 25th -28th May, 2010, in Nairobi, Kenya Ms. B. Doulla participated in NTP program review Lesotho from 21st 30th October, 2010 as laboratory technical consultant Ms. B. Doulla participated in NTP Zambia review from 2nd 13th August 2010 as laboratory technical consultant Ms Daphne Mtunga, Mr. S. Bossy, Mr. R. Shirima, and Mr. B. Malewo attended training on Good laboratory practices 26 th -28 th January 2010, CEEMI Dar es Salaam Training activities conducted in various regions Training of staff during this reported year covered mostly TB, TB/HIV collaborative activities, comprehensive HIV/AIDS management, community based DOT, AFB and LED Fluorescence microscopy, and External Quality Assurance (EQA), MDR-TB management, supervision skills and footwear repair for PALS. Most of the trainings were supported by GFATM round 6, CDC/PEPFAR, USAID/PATH, USAID/TBCAP and GLRA. The main purpose was to improve quality of care for TB, TB/HIV and leprosy patients and to foster integration of these services into the health delivery system at facility level. Overall, the programme trained over 2,700 health workers on TB, TB/HIV and leprosy activities at 6

17 national, regional and district levels in varied cadres during this reporting period as summarised in Table 2 Table 2: Trainings conducted in 2010 Type of training Region TB Management TB/HIV collaborative activities TB Intensive Case Finding, HIV & AIDS management TB Infection control Community Based DOT AFB Microscopy/ Lab EQA /LED Fluor MDR-TB Management X-ray interpretation Supervision Skills Footwear ( Leprosy) Health communication skills Total No. trained Dodoma Tabora Tanga Kigoma Mara Manyara Kagera Iringa Arusha Morogoro Kilimanjaro Ruvuma D' Salaam Coast Mbeya Zanzibar Mwanza Lindi Tanga TOTAL ,693 Total Health care workers trained for 2010 in 19 regions = 2,693 7

18 2.2.2 Meetings and Conferences The Programme staff were supported to attend various meetings and international conferences relevant to programme services to enhance their capacity in provision of TB, TB/HIV, MDR-TB and leprosy control activities as shown below:- Dr. S. Matiku and Dr. R. Mtandu SADC ad hoc meeting on TB February 2010, Gaborone Botswana Dr. S. Matiku and Dr. D. Kamara Consensus building workshop on TB control in SADC region, March Gaborone Botswana Dr. S. Matiku Meeting on Centre of excellence for MDR TB in East African region, August Kigali, Rwanda Dr. S. Egwaga, Dr. M. Nyamkara, Dr. D. Kamara, Dr. S. Matiku, Ms F. Mallya, Ms. L. Ishengoma, Ms. B. Doulla and Mr E. Nkiligi - attended IUATLD annual conference in October 2010, Berlin, Germany Ms. Basra Doulla attended conference on laboratory TB/HIV in Rome, Italy 26th 30th October Programme coordination meetings The programme has scheduled coordination meetings, namely NTLP annual meeting, annual zone coordinators meetings and RTLC/DTLCs quarterly meetings. All these meetings were conducted as planned with the exception of annual zone coordinators meetings which were not done due to lack of funds under MTEF budget. The meetings that were conducted in this reporting year include:- Annual NTLP meeting which was conducted from 19 th -20 th April This involved all RTLCs, DTLCs, TB/HIV Officers, CTRL and TLCU personnel aiming at discussing/ harmonising issues related to programme activities implementation at all levels. RTLC/DTLCs quarterly meetings which are conducted to exchange patients information and discuss on the progress made on the implementation of planned interventions. Usually these meetings are conducted during the second week of the first month of the quarter. CDC/ PEPFAR and NTLP Annual Plan which was conducted in February 2010.This involved TLCU staff, RTLCs, TB/HIV Officers and some district planning officers. Quarterly TB/HIV coordination meetings which were conducted at all levels, namely national, regional and district. However, the districts under GFATM support could not conduct the meetings regularly as the programme was anticipating Round 6 phase II support approval. 8

19 3. TUBERCULOSIS CONTROL SERVICES 3.1 Tuberculosis case notification 2010 A total of 63,453 tuberculosis cases of all forms (new and re-treatment) were notified by the programme in the year The notified cases were less by 817 (1.3) compared to the notification of Among those notified, new tuberculosis cases were 59,668 (94%) and 3,785 (6%) were retreatment cases. Among the new TB cases, 24,769 (or 39.0% of all new cases) were new smear-positive cases. This is equivalent to 70% of the 35,530 WHO estimated incident cases. The number of new smear negative TB cases notified was 21,184 (33.4%) while new extra-pulmonary TB was 13,716 (21.6%). Table 3 below shows the comparison of TB notification in 2009 and 2010 by TB categories. Table 3: Tuberculosis cases notified in Tanzania Type notified Change Cases % Cases % num. % All forms 64,267 63, New forms - Pulmonary smear positive 24, , Pulmonary smear negative 21, , Extra-pulmonary 13, , Total 60, , Re-treatment - Relapse 1, , Failure Return to control others 2, , Total 4, , Notification rates (new and retreatment/ 100,000popn /yr) Notification rates (new sm+/ 100,000popn/yr) Tuberculosis notification by regions Distribution of TB cases by geographical areas shows that ten regions namely Dar es Salaam, Mwanza, Shinyanga, Morogoro, Tanga, Mbeya, Iringa, Arusha, Mara and Manyara contributed 71% of all cases notified. Dar es Salaam region remained to be the major contributor of TB cases notified in the country with 21.2%. Other major contributors were Mwanza - 8.9%; Shinyanga - 6.7% and Morogoro - 5.9%. The rest including Unguja and Pemba contributed only 29% of all cases notified. It is important to note however, that the contribution of Dar es Salaam has been declining consistently since 2005 when it notified 25% of all TB cases. Other regions which have been declining are Kilimanjaro, Tanga and Iringa. 9

20 Figure 1: Percentage distribution of Tuberculosis cases notified in Tanzania by region: 2010 Others 29.2% Dar es Salaam 21.2% Manyara 4.1% Mara 4.3% Arusha 4.4% Iringa 5.0% Mbeya 5.1% Tanga 5.3% Morogoro 5.9% Mwanza 8.9% Shinyanga 6.7% The number of new smear TB cases declined from 24,895 in 2009 to 24,769 in 2010 which is 126 (0.5%) fewer cases. Regions which reported decline were Tanga (18%), Kagera (14.5%), Ilala I (11%), Kilimanjaro (7.7%), Pwani (7.3%), Temeke (5%), Lindi (4.7%) and Morogoro (4%). Regions with notable increase in proportion of smear positive cases notified were Ruvuma (19.4%), Dodoma (19%) and Mwanza (13.4%). However, it is important to note that Ruvuma still had the lowest proportion of smear positive cases notified in the country. This could be attributed to increased screening of HIV infection among TB cases and extensive use of X-rays in diagnosing TB cases. The table below summarises distribution of proportion of smear positive cases notified by each region in Figure 2: Percentage of new smear positive TB cases notified in by region in Pwani Unguja Dar Ilala I Dar Lindi Pemba Mtwara Kagera Rukwa Kigoma Dar es Salaam Shinyanga Dar Temeke Tanzania Mbeya Mwanza Tabora Singida Mara Morogoro Manyara Dodoma Tanga Kilimanjaro Arusha Iringa Ilala II Ruvuma Tuberculosis case notifications disaggregated by sex and age 10

21 The age-sex distribution of the new smear TB cases notified in 2010 shows that 15,738 (63.5%) cases were males and females contributed only 9,031 or 36.5%.The ratio of males to females was 1.7:1 the same as in 2009 for age group 15 years and above. The number of children aged 0 14 years old notified was 480 equivalents to 1.9% of all new smear positive TB cases. A male to female ratio of 0.9: 1. However, among all forms the proportion of children notified was 8.7% which is still less than the WHO estimates Age-sex distribution of the new smear positive cases as in previous years 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 3 below. Similar patterns were observed among the new smear negative and extra-pulmonary TB cases notified. Figure 3: Age and Sex distribution of smear positive TB cases notified in 2010 TB cases 5,000 4,500 4,000 3,500 3,000 2,500 2,000 1,500 1, Female Male agegroup In 2010, the notification rate of tuberculosis (all forms) continued to decline from 154 cases per 100,000 populations to 147. Similarly, notification rate of new smear positive tuberculosis cases decreased from 59 per 100,000 in 2009 to 57. Dar es Salaam region had the highest TB notification rates in the country for both all forms and new smear positive cases at 432 and 196/100,000 people respectively. The trend of the notification rates for both new smear positive cases and all forms has been declining since 2005 as shown in figure 4 below. 11

22 Figure 4: Trends of TB notification rates from for all-forms and new smear positives All forms New SM+ Twelve regions had higher TB notification rates (all forms) than the national average and 13 others had notification rate below the national average. Regions with notification rates below 100/100,000 people were Pemba, Unguja, Kigoma, Rukwa, Tabora, Singida and Kagera. Pwani region had the second highest TB notification rate among all forms and new smear positive TB cases (190/100,000 popn and 102.9/100,000 popn) after Dar es Salaam. Figure 5: TB notification rate (all forms and new smear positive) by region in Dar Temeke Dar Ilala I Dar Kinondoni Pwani Manyara Iringa Morogoro Tanga Arusha Mwanza Mara Mtwara Tanzania Kilimanjaro Lindi AFP+ notification rates All Forms notification rates Mbeya Ruvuma Shinyanga Dodoma Kagera Singida Tabora Rukwa Unguja Kigoma Pemba 3.2 Tuberculosis treatment outcome for cohort notified in New smear-positive cases Analysis of the TB cohort notified in 2009 shows that the overall treatment success for new smear positive TB cases was 87.9%. This is the third consecutive year where treatment success rate has exceeded the global target of 87% by 2015 set by the Stop TB partnership Global Plan to Stop TB, and WHO target of 85% set in However, five 12

23 regions namely; Tabora (79%), Kilimanjaro (77%), Ilala I (84.4%), Ilala II (83.4%) and Kinondoni (84%) failed to meet the global target as shown in Table 6. Furthermore, the cohort analysis shows that 1,214 (4.9%) patients died during treatment. This is a decline by 35 patients compared to 2008 when 1,249 (5.2%) died. A total of 811 (3.3%) were transferred out, another 545 (2.2%) defaulted while on treatment and the remaining 62 (0.2%) failed treatment which was not different from the cohort report of Overall, the unfavourable treatment outcome was 10.6% which is below the WHO target of 15%. Figure 7, shows treatment outcomes of new smear positive TB cases treated in cohort of 2009 by region. Table 5: Treatment outcomes of new smear positive TB cases notified in 2009 Region Cured Treatment Completed Failure Died Out of Control Transfer red out Total Evaluated Report ed 2009 Dar Ilala I 1, ,833 1, Dar Kinondoni 1, ,136 2, Dar Temeke 1, ,649 1, Dar Ilala II Dar es Salaam 5, ,168 6, Arusha Dodoma Iringa Kagera 1, ,217 1, Kigoma Kilimanjaro Lindi Manyara Mara Mbeya 1, ,219 1, Morogoro 1, ,257 1, Mtwara Mwanza 1, ,038 2, Pwani 1, ,181 1, Rukwa Ruvuma Shinyanga 1, ,500 1, Singida Tabora Tanga 1, ,223 1, Mainland 20,238 1, , ,279 24, Pemba Unguja Zanzibar Tanzania 20,446 1, , , Treatment Outcomes- % Treatmen t Success 13

24 Figure 6: Treatment success rate of new smear positive TB cases notified in cohort of Kagera Dodoma Morogoro Pwani Mbeya Rukwa Singida Tanga Lindi Dar Temeke Manyara Unguja Kigoma Mwanza Pemba Tanzania Mtwara Mara Shinyanga Arusha Ruvuma Dar Ilala I Dar Kinondoni Iringa Dar Ilala II Tabora Kilimanjaro The trend of treatment outcome results for the new smear-positive patients in the past twenty years ( ) show that the success rate has increased consistently since 2001 from about 80% in 2001 to 88% in Similarly the mortality rate has been declining since 2006 from 8% to 4.9% in 2009 Figure 7: Trend of treatment success for cohorts notified between Percent Cured/Rx Compl. Failure Died Absc./Transfer Treatment outcome of re-treatment cases notified in 2009 Cohort analysis data is available for 4,121 out of the 4,217 re-treatment cases notified in 2009 giving case holding of 98%. Overall a total 3,501 (83%) of those evaluated were either cured or completed treatment resulting in treatment success rate of 83%. The treatment success among the different re-treatment categories was as follows; relapses - 82%, failures 76%, return after default 77% and others - 84%. The unfavourable outcomes were 15.1% represented by: - death (8.5%); failures - 31(0.7%); defaulted 112 (2.7%); transferred out 135 (3.2%). Figures 8 and 9 below summarises the treatment outcome for each category of the re-treatment cases. The trends of treatment success among re-treatment cases since 2006 has been consistently above 80% after introducing FDCs and DOT treatment supporters throughout the country. Similarly the unfavourable outcomes have declined significantly during the same period. 14

25 Table 7: Treatment outcomes of re-treatment notified in 2009 Treatment Relapses Failure Return Others All Forms Outcomes number % Number % Number % Number % Number % Cured 1, , Treatment Completed , , Treatment Success 1, , , Failure Died Out of Control Transferred out Total Evaluated 1, , , Reported/notified 1, ,416 4,217 Case holding Figure 8: Percentage distribution of treatment outcome for re-treatment TB cases notified in 2009 by category Relapses Failure Return Others All Forms Treatment Success Failure Died Out of Control Transferred out 15

26 Figure 9: Trends of treatment outcome of re-treatment TB cases notified in 2002 to Treat. Success Failure Died Out of Control Transferred Out 3.3 Collaborative TB/HIV activities TB/HIV case finding 2010 A total of 56,849 (90%) of the 63,453 TB cases notified in 2010 were counselled and tested for HIV status. This is above the 85% target of the Global Plan to Stop TB Of those tested, 21,662 (38%) were found to be co-infected with HIV which was 0.8% higher than the co-infection rate in 2009 of 37.2%. Among the co-infected cases in 2010, 17,103 (79%) cases were registered at HIV care and Treatment clinics (CTCs) for HIV care and treatment services. Similarly, 19,855 (92%) were put on Co-trimoxazole Preventive Therapy (CPT) and 7,572 (35%) were initiated ART in both TB and CTCs within the three months reporting period after a two weeks tolerance period after starting TB treatment. Table 7 and Figure 10 below summarises TB/HIV services in the country from 2007 to Table 7: TB/HIV cases notified from Year TB patients Tested for HIV TB patients Tested for HIV HIV positive TB cases Registered for HIV care Started CPT Started ART ,092 31,305 14,669 9,966 10,541 4, ,364 48,846 19,940 14,574 16,400 5, ,267 56,388 20,994 15,838 19,076 6, ,450 56,849 21,662 17,103 19,855 7,572 16

27 Figure 10: Trend of TB patients counselling and testing for HIV, initiated CPT and ART from % 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 72% 68% 50% 47% 31% % 90% 79% 38% 35% Tested for HIV HIV positive cases Enrolled into HIV care Started CPT Started ART Treatment outcomes of TB/HIV cases notified in 2009 Treatment outcome for new smear positive TB/HIV cases notified in 2009, shows that 5,255 (78.4%) were cured and 542(8.1%) completed treatment resulting treatment success of 86.5%. a total of 532 (7.9%) died while on TB treatment, 18 (0.3%) failed treatment, transferred out were 224 (3.3%) and 133 (2.0%) defaulted treatment. These results show that treatment success rate was slightly lower in HIV positive TB cases compared to HIV negative TB cases. Table 8 below summarises this information. Table 8: Tuberculosis treatment outcome HIV positive TB patients notified in 2009 Treatment outcomes HIV positive TB Cases TB/HIV Interventions in 2010 number % Cured 5, Completed treatment Treatment success 5, Failure Died Out of Control Transferred Out Total Evaluated 6, Development of guidelines/tools NTLP collaborated with National AIDS Control Programme (NACP) and other partners to implement TB/HIV activities with support from CDC/PEPFAR. This included support to 15 hospitals in the country in November 2010 to start implementing two of the three component of 3Is (Intensified TB Case Finding, and Infection Control). The third component - Isoniazid Preventive Therapy (IPT) will be introduced in May, The experience gained will inform the Ministry on how scale up of these interventions country wide. 17

28 In 2010 the programme also developed, printed and disseminated training materials on 3Is i.e. participants manual and facilitators guide including job aids on TB infection control. These materials are intended for training health workers implementing 3Is at service delivery level. The TB infection control guidelines have been developed in collaboration with a number of partners supporting TB/HIV services including NACP, ICAP, ITECH and WHO. NTLP also took a lead to develop IPT M&E tools in collaboration with partners. These tools included; - Form for assessing eligibility and monitoring of patients on IPT form - IPT register - Monthly and cohort report forms Support of X- ray costs to improve diagnosis of smear negative TB suspects All 13 hospitals included in the first phase implementation of 3Is were provided with funds to pay for X-ray costs for a total of 9,000 TB suspects who are smear negative who can not afford the costs. The social workers in each hospital have been directed to identify those who can not afford to pay the X-ray according to government exemption guidelines. 3.4 Management of MDR-TB MDR case management services continued at Kibong oto National TB hospital with financial support from the GFATM round 6 as planned. The first cohort of the 16 patients admitted in 2009 completed their intensive phase of treatment and were discharged from the hospital for ambulatory treatment at a health facility nearest the patients domicile. In order to ensure adequate management of MDR TB in the continuation phase, a system of training district TB coordinators and their respective DOT nurses was set up by the programme in collaboration with University of California San Francisco (UCSF). This included developing district MDR TB training materials followed by training respective health workers with financial support from PATH Tanzania. The National MDR-TB operational guidelines were approved by MOHSW in UCSF supported the programme to train 12 facilitators who in turn trained 38 DTLC 38 and DOT nurses in 3 phases of 12 people each. The participants came from the following districts - Babati (Manyara), Arumeru and Karatu (Arusha), Makete (Iringa), Temeke, Ilala and Kinondoni (Dar es Salaam), Hombolo (Dodoma), Chakechake (Pemba), Mkinga (Tanga), and Newala (Mtwara). In 2010, 17 new MDR-TB patients were admitted for treatment at Kibong'oto TB hospital making the total number of patients enrolled since 2009 to 33. The number of new patients admitted was small because of the ongoing construction within the hospital for a new isolation ward with bed capacity for 20 MDR-TB patients (10 males and 10 females). The wards have self-contained cubicles for 2 patients each thus minimizing nosocomial transmission of MDR-TB strains among the patients and to health care workers. In November 2010, the first interim analysis was done for the initial 16 MDR-TB admitted at Kibong oto TB National Hospital. The results were as follows: 18

29 Table 9: Interim treatment results of confirmed MDR-TB cases started on treatment MDR-TB Patients Results at 5 months N % Converted at 5 months Died Not yet converted Defaulted Missing laboratory results Total At the end of 2010, the MDR TB programme was evaluated by the WHO GLC team and was found to comply with GLC recommendations. As a result, the programme was approved to expand the MDR-TB cohort from the initial 50 patients in the pilot phase to 150 MDR TB patients per year starting

30 4. LEPROSY CONTROL SERVICES 4.1 Case Notification Leprosy cases notified in 2010 were 2,499 cases (all forms), of which 2,349 (94%) were new cases and 88 (3.5%) were relapses and 62 (2.5%) were return after default. The number of cases notified was 305 (12.2%) less than those in The distribution of the relapse cases was as follows: after-mdt - 49 (1.9%) of overall total cases); DDS 39 (1.5%), The annual national notification rate (case detection rate) was 0.5/10,000 population which is less than was in 2006 (0.6/10,000). Among new cases notified, 1,899 (80.8%) were MB and 450 (19.2%) PB. Females were 893 (38.0%) giving a female to male ratio of 1:1.5 suggesting that the services provided are also accessible to females. The number of children among the new cases was 155 or (6.6%) which was less than 2009 (6.8%). New leprosy cases notified with disability grade II were 280 or 11.9% which was slightly higher than in 2009 when 11% were reported. Table 10 below summarises data on new leprosy cases notified in 2010 and those having disability grade 2 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 figure 11 below. 20

31 Table 10: New leprosy cases detected in 2010 Children cases Disability grade II Region All cases new cases MB cases Female cases No. % No. % No. % No. % No. % Dar Ilala I Dar Kinondoni Dar Temeke Dar Ilala II Dar es Salaam Arusha Dodoma Iringa Kagera Kigoma Kilimanjaro Lindi Manyara Mara Mbeya Morogoro Mtwara Mwanza Pwani Rukwa Ruvuma Shinyanga Singida Tabora Tanga Mainland 2,403 2, , Pemba Unguja Zanzibar Tanzania 2,499 2, ,

32 Figure 11: Trend of New leprosy cases detected in Tanzania ,000 6,000 5,000 PB MB Total number 4,000 3,000 2,000 1, Since 2004, the proportion of new MB cases detected annually has been slowly increasing from 68% to 81% while the proportion of females and children detected has been declining slowly from 44% to 38% and 10% to 7% respectively. The changes in proportion of MB cases and children notified annually suggest reduction in the prevalence of the disease in the country. However, the data may also suggest that females are utilising less the available leprosy services compared to their male partners. This is summarised in the figure below Figure 12: Trends of MB cases, children, females and disability grade 2 among leprosy cases: % MB cases % Children % Female % Disability grade II 22

33 Figure 13: Trends of new leprosy cases detected and prevalence in Tanzania ,000 6,000 5,000 percent 4,000 3,000 2,000 1, Registered Cases year New Cases 4.2 Registered prevalence In 2010, the national leprosy prevalence rate was 0.5/10,000 population which was less than 0.6 per 10,000 populations in This is below the WHO leprosy elimination target of 1 per 10,000 populations. Regions with prevalence rates higher than 1 per 10,000 has decreased from four in 2009 to two in These are Lindi (1.7) and Rukwa (1.6) while three regions have prevalence of 1.0/10,000 namely Ilala (Dar es Salaam), Morogoro and Mtwara. The remaining have already achieved the global target of 1/10,000 population. Overall, the prevalence of leprosy has showed a steady decline since Figure 14 and 15 below shows that the prevalence cases and detection ratio has remained about 1 between 2004 and 2010 suggesting that patients are timely removed from the registered after completing their treatment. Figure 14: Prevalence and case detection ratio of leprosy between 2004 and Prevalence/Detection Ratio

34 Figure 15: Distribution of leprosy prevalence and cases detection rates by regions in Tanzania: 2010 sorted against prevalence rate rate/10, Prevalence Detection Lindi Rukwa Dar es Mtwara Ruvuma Kigoma Tabora Morogoro Mwanza Unguja Pwani Tanga Mainland Tanzania Zanzibar Shinyanga Kagera Pemba Dodoma Mbeya Mara Singida Kilimanjaro Iringa Manyara Arusha 4.3 Leprosy treatment outcome Treatment outcome of PB leprosy Treatment outcome of PB leprosy cases notified in 2009 shows that, 490 (92.6%) completed treatment while three patients died during treatment period. However, the data also shows that 4 patients did not complete their treatment due to various reasons; 3 (0.6%) defaulted from treatment and 1 (0.2%) cases were transferred out during treatment. Table 11 below summarises treatment outcome of PB leprosy cases notified in 2009 by region. 24

35 Table 11: Treatment outcome of PB leprosy reported in 2009 Region Treatment Completed Died Transfer out Out of Control Total Evaluated Reported 2009 Completion rate-% Ilala I Kinondoni Temeke Ilala II Dar es Salaam Arusha Dodoma Iringa Kagera Kigoma Kilimanjaro Lindi Manyara Mara Mbeya Morogoro Mtwara Mwanza Pwani Rukwa Ruvuma Shinyanga Singida Tabora Tanga Mainland Pemba Unguja Zanzibar Tanzania Treatment outcomes-% Treatment outcome of MB leprosy Among the 2,651 MB leprosy cases notified in 2008, treatment outcome results are available for 2,449 or 96% of the cohort. Of those notified, 2,518 (95%) completed their treatment successfully and 11 (0.4%) cases died while still on treatment and another 22 or 0.8% were transferred out to other regions. A total of 65 (2.5%) cases defaulted while on treatment. Table 12 below summarises treatment results of MB cases notified in

36 Table 12: Treatment outcome of MB leprosy notified in 2008 Region Treatment Completed Died Transfer out Out of Control Evaluated Reported 2008 Completion rate-% Dar Ilala I Dar Kinondoni Dar Temeke Dar Ilala II Dar es Salaam Arusha Dodoma Iringa Kagera Kigoma Kilimanjaro Lindi Manyara Mara Mbeya Morogoro Mtwara Mwanza Pwani Rukwa Ruvuma Shinyanga Singida Tabora Tanga Mainland 2, ,562 2, Pemba Unguja Zanzibar Tanzania 2, ,616 2, Treatment outcomes-% Activities related to prevention of disabilities (POD) People with leprosy related disabilities At the end of 2010, a total of 3,346 people affected by leprosy (PALs) with disabilities were registered. Among them 476 (14.2%) were staying in care centres. Of the registered, 1,915 (57.2 %) were reviewed to assess their physical impairments. As a result of the assessment 26

37 73.1% (1,401) showed improvements, 26.4 % (506) showed no change while the condition 43 (2.2%) deteriorated Leprosy reactions A total of 960 leprosy patients were reported with reactions and started on treatment. Among them, adult MB cases were 832 (86.6%) and 97 (10.1%) were PB cases. In the case of children 31 (3.2%) of them were started on reaction treatment. Among those still on treatment, 115 were admitted during reaction treatment. The table below summarises patients reported with reactions. Table 13: Leprosy patients started treatment with corticosteroid per region in Tanzania in Region MB (A) MB(C) PB(A) PB(C) Total Dar Ilala I Dar Kinondoni Dar Temeke Dar Ilala II Dar es Salaam Arusha Dodoma Iringa Kagera Kigoma Kilimanjaro Lindi Manyara Mara Mbeya Morogoro Mtwara Mwanza Pwani Rukwa Ruvuma Shinyanga Singida Tabora Tanga Mainland Pemba Unguja Zanzibar Tanzania

38 4.4.3 Footwear Programme In 2010, a total of 3,996 pairs of protective sandals were distributed to people affected by leprosy. Another 523 pairs of shoes were made locally in several regions by the local shoemakers. In the case of special boots 89 pairs were fabricated and 831 footwear repairs were done for PALs with foot deformities. The table below shows the amount of footwear distributed to people affected by leprosy by region in This includes factory made sandals, locally produced shoes, special boots and repairs done. Table 14: Protective Footwear distributed to PALs in regions by type in 2010 Region Ready made Locally Special Footwear sandals produced shoes boots repairs Dar Ilala I 29 Dar Ilala II 15 Dar Temeke 60 3 Dar Kinondoni 122 Arusha 0 Dodoma Iringa 37 Kagera 171 Kigoma 74 6 Kilimanjaro 33 2 Lindi 138 Mara Mbeya Morogoro Mtwara Mwanza Rukwa 65 Ruvuma 178 Singida Shinyanga Tabora Tanga Zanzibar Tanzania 3,

39 Table 15: Materials and tools Used for Fabrication of Locally produce shoes and special boots Leather MCR Micro Sand Pincer Oil Knife Regions (Sqft) (Sheets) sole(s) Glue(L) paper(m) stone Shinyanga Mwanza Coast Mara Morogoro Songea Tabora Zanzibar Total Table 16: Materials Used on job training and Fabrication of Special boots at Sikonge Tabora. CENTRES Leather (Sqft) MCR (Sheets) Micro sole (S) Glue (L) Vecro (R) POP Powder(B) POP Bandage(P) Sikonge/Training Total Specialized care of people with disabilities In the year 2010, a total of 540 persons affected by leprosy (PALs) were admitted to different hospitals in the country. Ulcers and wounds ranked high as the main reasons for admission of 315 (58.3%) cases. The second reason for admission was reactions 115 (21.3%) followed by surgery (SPRS) which accounted for 16.4% (89), and the least was eye pathology which was 4 % (22). In addition, PALs were fitted with prostheses. The table below summarises the number of surgery done, prostheses fitted and prosthesis repairs for people affected by leprosy in 2010 by regions. Table 17: Number of surgeries, prosthesis fitted and repair in regions 2010 Region Surgery Prostheses Prostheses repairs Dodoma 5 2 Manyara 1 Mara 4 Kilimanjaro 1 Kigoma 4 Morogoro Singida 2 1 Shinyanga 3 10 Tabora Tanga Zanzibar Total

40 5. LABORATORY SERVICES The program laboratory networking consists of three levels; one central reference laboratory at Muhimbili National Hospital also called the Central Tuberculosis Reference Laboratory (CTRL), two TB zone laboratories (Bugando Medical Centre and Kilimanjaro Christian Medical Centre) and 995 diagnostic centres at peripheral health centres levels. However, in 2010 the two zone TB laboratories did not perform any cultures on Mycobacterium tuberculosis nor drug susceptibility testing (DST) was because of lack of human resources. In 2010, CTRL continued to maintain Quality Assurance Programme in 13 regions in collaboration with external partners. CTRL has also introduced liquid culture technology using MGIT 960 which takes 2-3 weeks to get results. CTRL has also introduced rapid molecular methods for DST using the Line Probe Assay (LPA). In this regard one HAIN machine is currently undergoing validation for local use. CTRL has also established a proven capacity to routinely perform DST against all positive culture Mtb isolates for 4 first-line anti-tb drugs (streptomycin, Isoniazid, Rifampicin and Ethambutol). CTRL is also building capacity to do drug susceptibility testing for MTb isolated from re-treatment cases (relapses or failures) with results available usually in 4 weeks. The drugs covered are Kanamycin and Ofloxacin. 5.1 Laboratory workload Specimen AFB microscopy and solid culture In 2010, a total of 8,849 specimens were referred to the CTRL for AFB smear microscopy and culture examinations. Of these 5,961 (67.4%) were samples from Muhimbili National Hospital (MNH) for routine AFB microscopy examination only, 2015 (22.8%) were from different regions for culture and DST as part of MDR-TB surveillance while 873 (9.9%) were from TB HAART and other studies submitted for culture and DST. Overall, CTRL cultured 2,870 sputum specimens using solid culture method on Lowenstein-Jensen media of which 1,632 (56.9%) were positive isolates and were set for DST. DST results are available for 1,270 culture isolates. Of these, 712 (56%) of all positive isolates with DST results were sensitive to all four first line anti-tb drugs. In addition, 66 (5.2%) of the positive isolates had resistance to one or more anti-tb drugs and 77 isolates (6.1 %) were multi-drug resistant and 2 isolates were Mycobacterium Other than Tuberculosis (MOTT). The culture analysis shows that there is an increase in the rate of smear positive and culture positive which comes close to 90% towards the end the year which is the aimed target. However, the problem is false negative cultures (smear positive and culture negative) and a too low contamination rate of 1% annually. In addition, the CTRL managed to isolate tuberculosis from 20 to 30% smear negatives, increasing trend parallel with the smear positive from culture and DST 30

41 Table 18: Culture and DST results Source Sputum Submitted Culture done Positive Isolates DST Results Sens 4 drugs Mono Resist Poly Resist MDR Failure Pending Results Unkown Results MNH 5, Upcountry 2,015 2, TBHART Other studies Total 8,849 2,870 1,632 1, Figure 13: Quarterly monitoring of Culture Performance Laboratory by CTRL in Liquid culture using MGIT In 2010 CTRL started doing liquid culture using the MGIT machine. A total of 335 fresh sputum samples from new AFB patients were cultured using liquid media; of these 200 (69.7%) were positive, 30 (8.9%) negative and 35 (10.4%) were contaminated. A total of 105 (52.5%) of the positive cultures were set for DST using proportional method. The DST results revealed that 45 (42.8%) were susceptible to all the four fist line anti-tb drugs while 7(6.7%) were resistant to Isoniazid, 1 (0.9%) to Rifampicin, 3 (2.9%) to Streptomycin and 2 (1.9%) to Ethambutol. 31