Annual report for 2016

Transcription

1 The United Republic of Tanzania Ministry Of Health Community Development, Gender, Elderly and Children The National Tuberculosis and leprosy Programme National TB and Leprosy Programme (NTLP) Department of Preventive Services Ministry of Health, Community Development, Gender, Elderly and Children a

2 Table of content 1 GENERAL BACKGROUND Demographic and social economic profile Summary of health services Summary of NTLP activities Financial Support 2 2 HUMAN RESOURCE DEVELOPMENT Staff establishment Capacity building: Training and coordinative meetings 5 3 TUBERCULOSIS CONTROL SERVICES Tuberculosis case notification in Tuberculosis treatment outcome for cohort notified in TB/HIV Services Paediatric TB MDR-TB 14 4 LEPROSY CONTROL SERVICES Leprosy Case Notification Leprosy treatment outcome Activities related to acceleration of leprosy elimination efforts Activities related to prevention of disabilities (POD) 24 5 LABORATORY SERVICES Laboratory workload Culture analysis External Quality Assurance of Drug Resistance TB Laboratory Network 33 6 PROGRAMME SUPPORT ACTIVITIES Procurement and Supply Management of Anti-TB and Anti-Leprosy Medicines Community empowerment activities Advocacy, Communication and Social Mobilization (ACSM) activities Public and Private Partnership (PPP) 37 i

3 6.6 Quality Improvement in TB case detection Supportive Supervision Data Quality Assessment (DQA) 40 ii

4 List of Table Table 1: NTLP Source of Funds Table 2: Summary Training Provided during Table 3: Tuberculosis cases notified in Tanzania Table 4: TB treatment outcome of new and relapses TB cases notified in Table 5: Treatment outcomes of previously treated (except relapse) cases notified in Table 6: Interim Outcomes, Table 7: leprosy cases reported in 2015 and Table 8: New leprosy cases detected by indicators in 2016 by regions 19 Table 9: Endemic districts with prevalence rate greater than 1/10,000 Population in Table 10: Treatment outcome of PB leprosy reported in Table 11: Treatment outcome of MB leprosy notified in Table 12: The number of targeted index cases and contacts screened in the project districts 24 during August 2015 December 2016 Table 13: Leprosy cases started treatment with corticosteroid in Table 14: Number of leprosy admissions in hospitals Table 15 : Protective Footwear distributed/ produced to PALs in regions by type in Table 16: Materials distributed for fabrication of special and local shoes production per 28 region in 2016 Table 17: Number specimens received in Table 18: Summary analysis of the Xpert MTB RIF in Table 19: Total Isolates for LPA 32 Table 20: Summary Participation of EQA for CTRL 33 Table 21: stocks of anti-tb and anti-leprosy drugs distributed in the country in Table 22: Trend of community contribution (%) in TB case notification in Tanzania from iii

5 List of Figures Figure 1: Distribution of TB cases notified by regions in Figure 2: Age and Sex distribution of new and relapse TB cases notified in Figure 3: Notification rate TB new and relapses cases notified by region for Figure 4: Trends of Previously Treated TB cases notified form 2006 to Figure 5: TB Notification rates by regions Figure 6: Trend of TB patients counselling and testing for HIV, initiated CPT and ART: Figure 7: HIV testing among TB patients in 2016 by regions 13 Figure 8: Distribution of MDR/RR-TB cases enrolled on treatment by regions in Figure 9: Trends of treatment Success rate of DR-TB enrolled for MDR-TB treatment: Figure 10: Distribution of leprosy cases notified by region in Figure 11: Trends of new leprosy cases reported: Figure 12: Trends of MB cases, children and females among new leprosy cases: Figure 13: Trend of disability grade 2, percentage among new cases and rates per 20 1,000,000 populations Figure 14: Trends of new leprosy cases detected and registered: Figure 15: Culture analysis at CTRL Figure 16: Showing Mbeya Quarterly TB notification comparison for quarters 1 and 2 of and 2016 (intervention facilities) Figure 17: Dodoma referral regional hospital Monthly TB case notification, iv

6 List of Annexes Annex 1: List of DTLCs Annex 2: Change in Case Notifications by regions between 2015 and Annex 3: Comparison of Case notifications Rates by regions between 2015 and Annex 4: Contribution of pediatric notification by regions between 2015 and Annex 5: Regional Community contribution 50 Annex 6: contribution from private health facilities with the proportion of health facilities 51 Annex 7: TB/HIV cases notified in v

7 TB burden at a glance vi

8 Leprosy burden at a glance Trends of new leprosy cases reported from 2006 to 2016 Distribution of leprosy cases notified by region in 2016 vii

9 Acknowledgement The successful completion of this Annual report for the year 2016 was made possible by joint efforts from a number of dedicated individuals at facility, regional and national level. 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 officers. First, I want to thank the Monitoring and Evaluation Unit within the central level for their dedication in ensuring accuracy of the reported data. I also like to thank the health workers at regional and health facility levels who by recording and timely reporting of TB and leprosy data to the central level has made possible the contents of this report. To them I say keep up the good work and dedication to the call for a healthy Tanzania nation. The focal persons from all the TB and leprosy service and diagnostic sites are especially thanked for their immense contribution to the work of the program. I extend my gratitude to the Government of Tanzania particularly the Ministry of Health Community Development Gender Elderly and Children and the President office for Regional administration and local governments for the dedicated commitment to TB and leprosy control and mobilization of resources from development partners to support the programme. I would like to recognize, in particular, the 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) United State Agency for International Development (USAID), Novartis Foundation (NF), Global Drug Facility (GDF), ITECH, International Organisation for Migrant (IOM) and 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 Programme Manager (NTLP) September 2017 viii

10 1 GENERAL BACKGROUND The National Tuberculosis and leprosy Programme 1.1 Demographic and social economic profile The population of Tanzania in 2016 was projected to be 50,055,411 based on 2012 national census. According to projected population, female make up is 51% (25,528,260) of the total while male are 49% (24,527,151) 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 1,424,689 with a growth rate of 2.8%. Agriculture is still a major source of livelihood for majority of the population in Tanzania. 1.2 Summary of health services The Health care delivery system in the country is well established with more than 7,992 health facilities.tb control is fully integrated into the primary health care services. 49% (3,911) of the facilities provide TB treatment services while 1199 (15%) provide TB diagnostic services. The Government is the major provider of health services owning and/ or run 69% of the health facilities including the face based facilities which are Designated District Hospitals (DDH). On leprosy services there are 1,500 health facilities that provide leprosy treatment services and have a leprosy unit registers, these health facilities are known as MDT centres. 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 5.3% 1 in the population aged years. TB has continued to be among the top ten cause of death and among admission aged five years and above in the country. 1.3 Summary of NTLP activities In the period of January December 2016, NTLP continued to implement its 5th Strategic plan ( ). All activities conducted focused on addressing the NSP 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 1 Tanzania HIV/AIDS and Malaria Indicator Survey

11 TB and Leprosy prevention and care (vi) reducing new Leprosy cases with disability grade 2 (vii) collaborating with internal and external partners in conducting relevant operational research. 1.4 Financial Support The Ministry of Health Community Development, Gender, Elderly and Children through National Tuberculosis and Leprosy Program (NTLP) received approximately USD 7,713, through government consolidated funds, external grants and loans in year Government resources channeled through the program for program management and support the health system and infrastructure maintenance as well as staff remuneration at all levels. Direct cash was received from Centers for Disease Control and Prevention (CDC) grant, The Global Fund-NFM grant, German TB and Leprosy Relief Association (GLRA) grant and World Health Organization (WHO) grant as detailed below. Other key stakeholders were active partners/collaborators in various Program interventions through different grants. These include Implementing partners such as KNCV-Challenge TB,local research institutions, academia, private sector organizations and community based Civil Society Organizations (CSSOs). Table 1: NTLP Source of Funds 2016 S/N Source of Funds Amount in US$ 1 Government Contribution - 2 Germany Leprosy Relief Association GLRA 206, Centre for Disease Control and Prevention CDC 1,221, World Health Organization TDR (carried forward from 22, previous period) 5 GFATM (carried forward from previous period) 6,251, World Bank (IDA) 11, TOTAL FUNDS 7,713,

12 2 HUMAN RESOURCE DEVELOPMENT The National Tuberculosis and leprosy Programme The Programme is composed of both permanent and contractual employees at the central unit (TLCU) with focus on strengthening TB and Leprosy services in the country. Contract employees were recruited through various grant support including GFATM and CDC/ PEPFAR. 2.1 Staff establishment In this reporting year there were 42 staffs at central level and 30 Regional TB and Leprosy coordinators. At District level 196 DTLCs and 92TB/HIV Officers. In the councils which were not fully established, DTLCS from the mother councils continued to oversee and coordinate TB and leprosy control activities. One contract staff left the program at Central unit for other opportunities, one retired and five new officers joined the program. The list of TLCU staff by December 2016 was as follows: 1. Dr Beatrice Mutayoba - Programme Manager 2. Dr Liberatus Mleoh Deputy Programme Manager 3. Mr.Cornel Wambura Health Secretary 4. Mr Didas Kayumba Programme Administrator 5. Dr Johnson Lyimo - MDR TB Coordinator 6. Dr Deusdedit Vedastus Kamara Leprosy and TB care and Prevention Coordinator 7. Ms Diana Kasembe Training Coordinator 8. Dr Joyce Wanze Kohi - TB/HIV Coordinator 9. Dr Allan Tarimo Public Private Partnership Coordinator 10. Dr Zuweina Kondo-Sushy Monitoring and Evaluation Officer 11. Mr Emmanuel Nkiligi Data Manager 12. Mr Jumanne Mkumbo Pharmacist 13. Mr. Bariki Brown - Pharmacist 14. Mr Jirabi Masige - Pharmacist 15. Ms Lilian Ishengoma Community TB care Coordinator 16. Ms Agatha Mshanga ACSM Coordinator 17. Mr Paul Shunda Orthopaedic Technologist 18. Ms Donatha Koko Procurement and Supplies Coordinator 19. Ms Elda Magawa - Procurement and Supplies 20. Ms Basra Doulla Head, National TB Reference Laboratory 21. Mr Salim Bossy Senior Laboratory Technician 22. Ms Daphne Mtunga Laboratory Technician 23. Mr. Amri Kingalu National TB Reference Laboratory Manager 24. Ms Christine Chipaga - Data entry clerk 25. Ms Grace Tairo - Data entry clerk 3

13 26. Ms Khadija Kassim - Data entry clerk 27. Mr Mashaka Penza - Data entry clerk 28. Mr Abbakari Msafiri Data Analyst 29. Mr. Baraka Onjare ICT Manager 30. Mr Lugano Ross Accounts Assistant 31. Ms Sophia Temba - Accountant 32. Mr Joachim Kizzuri - Accountant 33. Mr. Augustus Machumi Accountant 34. Ms Amina Ponera - Secretary 35. Ms Martha Haule - Secretary 36. Mr Paulo Kalombora Office Attendant 37. Mr Raymond Shirima Data Analyst 38. Mr Eneas Mdika - Driver 39. Mr Abdallah Shabani Driver 40. Mr David Kanyandeko Driver 41. Mr Beno Tayari - Driver 42. Mr Komba - Driver Regional Tuberculosis and Leprosy Coordinators (RTLCs) During this period one RTLC from Singida region retired from the government employment. By the end of 2016 there were 30 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 Edna Ntulwe Arusha 2. Dr Ackim M. Mwandobo Dar Region 3. Dr Mrisho Lupinda - Kinondoni 4. Dr Mary Kenedy Chiryamkubi Temeke 5. Dr Seif Mbarouk Ilala I 6. Dr Ibrahim. Mteza Ilala II (Muhimbili & Private Hospitals, Dar es Salaam) 7. Dr Martin Massimba Dodoma 8. Dr Tecla Orio Iringa 9. Dr Mussa Ndyeshobora/Martin Mujuni - Kagera 10. Dr Festo Baranuba Kigoma 11. Dr Geoffrey Chelangwa Kilimanjaro 12. Dr Abasi Pegwa Lindi 13. Dr Martin Khan Mara 14. Dr Qamara Qawoga Manyara 15. Dr Yahaya Msuya Mbeya 16. Dr Emmanuel Tenga Morogoro 17. Dr William Byemelwa Mwanza 18. Dr Mohamed Kodi - Mtwara 4

14 19. Dr Aden Mpangile Pwani 20. Dr Dismas Buhili - Rukwa 21. Dr Xavier Mbawalla Ruvuma 22. Dr John Majigwa Shinyanga 23. Dr Mussa Kimala Singida 24. Dr Sebastian Honorati Pima - Tabora 25. Dr Sakeo Kiluwa Tanga 26. Dr Emmanuel John - Simiyu 27. Dr Deus Kalaso - Njombe 28. Dr Abdul Majid - Katavi 29. Dr Michael Mashalla - Geita 30. Dr Obed Mshana - Unguja 31. Dr Said Alli Hamad - Pemba See Annex I for a List of DTLCs 2.2 Capacity building: Training and coordinative meetings Trainings Trainings continued to be an integral part in ensuring quality delivery of services to the community. During this year several trainings were conducted to the healthcare providers on TB case detection (Quality Improvement in TB case detection), Collaborative TB/HIV Management activities, Comprehensive HIV/AIDS Management, Paediatric TB and TB/ HIV management and MDRTB management. In addition the providers were also oriented on the use of the new monitoring and evaluation tools which were rolled up in the previous year. Table 2: Summary Training Provided during 2016 S/N Name of the Training Regions covered No. of HCWs 1. QI in TB case detection 16 1, Collaborative TB/HIV management Comprehensive HIV/AIDS Management Paediatric TB Management Sputum fixing DTLC course TB/HIV induction course Sensitize prison authorities Laboratory Trainings Drug Dispensers - ADDO X-ray reading interpretation Pharmacovigilance TB/HIV to HCWs

15 S/N Name of the Training Regions covered No. of HCWs 14. Gene-Xpert TB & Lep Logistic system DR-TB Management Coordination Meetings The Quarterly regional meetings for the RTLCs and DTLCs were conducted in most of the regions. The NTLP Annual meeting was conducted in Dodoma in November 2016 which provided the platform to share the lessons learnt during the first year of the implementation of the 5th NSP. Main Resolutions which made were on: i. Improving Communications between TLCU,MSD,LMU and the Regional and District coordinators to ensure constant supply of medicines ii. iii. Implementing Partners coordination specifically planning and monitoring of key interventions Improve specimen referral by adopting other existing modalities in other programs in the districts e.g integrating with the Dry Blood Spot samples transportation iv. Continue to champion the budgeting of the program key activities in the Regional and Councils plans v. Plan for M&E capacity build to all coordinators 6

16 3 TUBERCULOSIS CONTROL SERVICES The National Tuberculosis and leprosy Programme 3.1 Tuberculosis case notification in 2016 A total of 65,902 cases of all forms were notified in 2016, which shows an increase of 5.6 % or 3507 cases compared to the year Among the cases notified, new and relapse cases were 64,404 (95.5%) of which 27,655 (39%) were bacteriological confirmed. Table 2 below shows the comparison of TB notification in 2015 and 2016 by TB classification groups. Table 3: Tuberculosis cases notified in Tanzania Indicators Change Cases % Cases % numb. % All forms 62,180 65,902 3, New Cases Bacteriological confirmed TB cases 24, , , Pulmonary Clinically diagnosed TB 22, , cases Extra-pulmonary Clinically diagnosed 12, , Total 59, , , Previously treated Relapse 1, , Treatment after Failure Return after lost to follow up Other previously treated Total 2, , Tuberculosis notification by regions Dar es Salaam city has remained as the major contributor of TB cases notification contributing making 20% of all cases notified. There was considerable regional variation as in the previous years with 50% of cases being contributed by only 6 regions - Dares-Salaam, Mwanza, Mbeya, Morogoro, Arusha and Tanga. The data indicated that 15 regions notified below the national average of 129 cases per 100,000 population. 7

17 Figure 1: Distribution of TB cases notified by regions in Tuberculosis case notifications disaggregated by sex and age The age-sex distribution of the new and relapse TB cases notified in 2016 shows that 39,2017 (61%) cases were males and 24,694 (39%) 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 6,351 (10%). 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 and relapse TB cases notified in

18 3.1.3 Tuberculosis notification rate The notification rate of new and relapses TB cases was 129 cases per 100,000 population which was slightly higher compared to that of 2015 that was 125 per 100,000 population. Dar es Salaam region had the highest TB notification rates in the country at 244 cases per 100,000, Kigoma region has the lowest TB case notification rate of 45 cases per 100,000, followed by Unguja (46) and Katavi and Rukwa at 59. Ten regions has notification rate of above national average are: Dar es Salaam; Iringa; Pwani; Arusha; Manyara; Njombe; Lindi; Mtwara Kilimanjaro and Mbeya. The notifications rates for Unguja and Pemba have been presented separately but in comparison to administrative regions in the Mainland. The figure below shows notification rate of TB cases by regions and Zanzibar. Figure 3: Notification rate TB new and relapses cases notified by region for Previously treated cases of Tuberculosis Previously treated TB cases notified in 2016 were 3,051 cases which is 4.6 % of all cases notified in the country. Among them relapse cases contributed 58% of all previously treated cases. 9

19 Figure 4: Trends of Previously Treated TB cases notified form 2006 to 2016 Figure 5: TB NOTIFICATION RATES BY REGIONS

20 3.2 Tuberculosis treatment outcome for cohort notified in New and relapse cases The National Tuberculosis and leprosy Programme Analysis of the 59,293 TB cases notified in 2015 shows that the overall treatment success for new and relapse cases was 90%. 3,531 (5.8%) died while still on treatment, 106 (0.2%) failed treatment and 1,091 (2%) 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 1,602 (2.6%). The treatment outcomes for individual groups of TB vary from 90% treatment success rate for new smear positive TB to 81% of TB relapses. The table below summarizes treatment outcomes of groups Table 4: TB treatment outcome of new and relapses TB cases notified in 2015 Treatment Outcomes B. Confirmed Clinically diagnosed Pulmonary Clinically diagnosed -Extra Pulmonary Relapse All forms - new and relapse number % number % number % number % number % Cured 19, , Treatment Completed 2, , , , Treatment Success 21, , , , Failure Died 1, , , Lost to follow up ,091 2 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 91% in 2014 and consistently maintained above 85% since Similarly the death rate has progressively been declining since 2006 from 8% to 6% in Treatment outcome of previously treated TB cases notified in 2015 In 2015, 1,292 previously treated TB cases excluding the relapse were notified, 1,200 (93%) cases their treatment outcomes are available. Among the evaluated cases: 1,037 (80%) were treated successfully; 14 (1.1%) failed treated while 103(8%) cases died while in still on TB treatment almost similar proportions as for the year Number of TB cases lost to follow up were 46 (4%) of all previously treated cases. Table 4 and figure 5 below summarizes the treatment outcomes for each category of the re-treatment cases. 11

21 Table 5: Treatment outcomes of previously treated (except relapse) cases notified in 2015 Treatment Outcomes Treatment after Failure Treatment after Loss to follow up Other previously treated All forms number % number % number % number % Cured Treatment Completed Treatment Success , Failure Died Loss to follow up Evaluated , Notified , TB/HIV Services TB/HIV case finding 2016 In the year 2016, 63,753 (97%) of all TB cases notified had their HIV test results recorded at time of notification, which was slightly higher than that of 2015 data which stood lower at 93%. Among those who tested for HIV, 21,720 (34%) cases were found to be coinfected with HIV. The co infection has slightly decreased compared to 2015 whereby the co infected cases were at 36%. Furthermore, analysis shows that among co-infected cases 20,709 (95%) cases were registered at HIV care and Treatment clinics (CTCs) for care and treatment services. Furthermore 20,895 (96%) were put on Co-trimoxazole Preventive Therapy (CPT) while 19,814 (91%) were initiated ART in at both TB clinic and CTCs. Figure 5 below summarizes the trend of TB/HIV indicators in the country from 2007 to 2016 with significant gains in the proportion of those initiated ART especially after the year Figure 6: Trend of TB patients counselling and testing for HIV, initiated CPT and ART:

22 3.3.2 Regional performance on HIV testing and counselling and ART uptake HIV counselling is entry point for accessing HIV care, treatment and preventive services. In 2016 the national average was 97% which is still below the WHO target of 100%. The majority of the regions are above the national average and Unguja in addition to few regions are below the average which included: Dar Kinondoni, Dodoma, Geita, Kigoma, Lindi, Mara, Mbeya, Morogoro, Njombe, Dar Ilala II, Kilimanjaro, Mwanza, Simiyu and Rukwa. Figure 7: HIV testing among TB patients in 2016 by regions TB treatment outcomes of TB/HIV case notified 2015 Analysis of the 21,232 co-infected TB/HIV cases notified in 2015 shows that treatment success rate of all forms was 83.2% which is almost similar to the rest of other notified TB cases. 1,908 (8.4%) died and 419 (1.8%) 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 1443 (6.4%) 3.4 Paediatric TB Childhood TB notifications 2016 In 2016, 6351 (10%) of the new and relapse TB cases notified were children under the age of 15 years. Among children (under 15 years) notified, 3,054 (48%) were children under 13

23 the age of 5, while 1,674 (26%) cases were children between age group of 5-9 years and 1,679 (26%) were children in the age-group years Childhood TB/HIV notifications 2016 Testing and counselling for HIV is also done to children (under the age of 15) attending the TB clinics. In 2016 data shows that 6,194 (96%) of notified children were tested for HIV and 1,687 (27%) were HIV and TB co-infected cases. Among all the co-infected children notified, 1,663 (99%) were started on CPT and 1,589 (94%) were on or started ART at time of diagnosis IPT provision to Children All children younger than 5 years in contact with a sputum smear-positive PTB patient are investigated for TB. Children with signs and symptoms suggestive of active TB are registered and treated with a full anti-tb course. If there are no signs of active TB, the children are put on preventive treatment with isoniazid for six months. In the year 2016, a total of 6,311 children in contact of smear positive TB cases were provided with IPT. 3.5 MDR-TB In 2016 a total of 196 MDRTB cases were notified country wide among which 158 (82%) were started on MDR TB treatment from 21 regions. The enrollment is an increment of 28% compared to that of As in previous years, the majority of MDR TB cases detected and enrolled on treatment were from Dar es salaam (41%) followed by Mbeya (9%), Geita (7%), Mtwara (6%), Morogoro (5%) and Simiyu (5%). The graph below shows number of MDR/RR-TB patients started second line treatment in 2016 Overall, there is improvement in enrollment as compared to last year with an increase of 35 cases. This could be due to the kick off of the decentralization of the services to other facilities. This is implemented guided by the Decentralization plan (2015) of which by Dec 2016 a total of 22 sites 2 had already begin offering initiation of the MDRTB treatment Among the enrolled patients, a male predominance continued to be observed with 88 (71%) being male. As in the previous year, the age groups bearing the brunt of MDR TB among, was the younger, economically active age group from Kagera (Bukoba Hospital 1,Rubya1 and Ndolanga Hospitals1),Dar es salaam (Sinza Hospital 8, Rangitatu3 Hospital, Ukonga Dispensary 10,Tambukareli Dispensary2 and Amana1),Geita(Bukombe1 and Mbogwe Hospital1),Mtwara (Newalla Hospital1),Mbeya (Mbeya regional1 and Ruanda Dispensary1 ),Pwani (Bagamoyo Hospital1),Tanga (Ngamiani Hc 1),Morogoro (Sabasaba HC1,Kibaoni Hospital 1,1Kilosa and 1 malinyi) Zanzibar 1 in Unguja,1Tabora at Utete Hospital and 1 Kigoma at Kibondo 14

24 Figure 8: Distribution of MDR/RR-TB cases enrolled on treatment by regions in 2016 End of Treatment Outcomes for 2014 Cohort: A total of 143 patients were enrolled in 2014, with age of enrolled cases ranged from 2 to 84 years old with a median age of 39 years old. Those aged from yrs were the most affected with MDR TB disease. Among MDR patients 38% (35) were HIV co-infected, while 62% (57) were HIV negative. Of all enrolled 143 patients 108 (76%) were successfully treated (cured + treatment completed). Those with unfavorable outcome include; 25 (17%) patients died, 10(7%) patients defaulted and 2 (1%) were not evaluated. A review of trends of treatment outcomes from 2009 (figure 11) showed the treatment success rate to have dropped in 2013 with the most contributory factor being a spike in mortality. Further review of the mortality data revealed that most deaths occurred at older and younger groups, in more males than females and patients who had been in treatment for less than 6 months. HIV status was not a significant contributor as most deaths occur among the HIV negatives 14 (78%) than the HIV positives 4 (22%). The extreme of age groups and the early timing of deaths may be a result of lack of monitoring tests for second line drugs toxicities since most of these reagents are out of stock at the admitting hospital and peripheral decentralized sites. The programme should mobilize funds to ensure that all enrolled MDR-TB patients have access to these tests. 15

25 Figure 9: Trends of treatment Success rate of DR-TB enrolled for MDR-TB treatment: Available 6 month interim results for 23 patients enrolled in quarter two 2015 showed the target of loss to follow at 6 months as met (Table 5), also for these patients the early trend data still showed a higher than normal mortality rate that is partly contributed by lack of toxicity monitoring test. Table 6: Interim Outcomes, months interim outcomesindicator Target Results%(n ) Target achieved? The percent of patients who default within the first six month of treatment <10% 0% (0) MET The percent of patients with an unknown <15% 4.3% (1) MET culture and smear status The percent of patients with culture >=80% 78.3% (18) NOT MET conversion within the first six months The percent of patients dying within the first six months <10% 17.4% (4) NOT MET 16

26 4 LEPROSY CONTROL SERVICES The National Tuberculosis and leprosy Programme 4.1 Leprosy Case Notification In years 2016, a total of 2,164 leprosy cases (all forms) were notified and reported in the country, which shows a decline of 258 cases or 11% compared to the year Among the notified leprosy cases, new leprosy cases were 2,047 (95%), relapses were 60 (3.2%) cases while return after defaulter were 57 (1.8%) of all reported cases of leprosy. 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. In the year 2016, over 50% of notified relapse cases were reported from in six regions of Morogoro (15%), Lindi (9%), Tanga (7%), Mtwara (6%), Kigoma (6%) and Rukwa (6%) as shown in figure 9 below. Table 7: leprosy cases reported in 2015 and 2016 Leprosy Classification Change Cases % Cases % cases % All forms 2,422 2, New cases MB 1, , PB Total 2, , Re-treatment Return after default Relapse after MDT Relapse after DDS/Others Total

27 Figure 10: Distribution of leprosy cases notified by region in New leprosy cases notified in 2016 In 2016, a total of 2,047 new leprosy cases were detected in the country, the annual notification rate (case detection rate) was calculated at 4.1/100,000. These figures show that, Tanzania continue to be one of the leprosy high burden countries in the world which notify more than 1000 cases a year. The data shows that Lindi region had the highest leprosy notification rates in the country at 21 cases per 100,000 population. Arusha has the lowest leprosy notification rate of 0.2 cases per 100,000, followed by Kilimanjaro (0.4) and Simiyu (0.5). Ten regions with notification rate of above national average were: Lindi; Rukwa; Mtwara; Morogoro; Pwani; Tanga; Unguja; Katavi; Ruvuma and Kigoma. Among the new cases notified, 1,793 (88%) were MB. Females were 781 (38%) giving a female to male ratio of 1:1.5 suggesting that being male continues to be suggestive of risk factor. The number of children among the new cases was 38 or 2% like those reported in New leprosy cases notified with disability grade II were 267 or 13% which was slightly higher than the previous two years, indicating that many cases continue to be detected late. Table 8 below summarizes indicator data on new leprosy cases notified in 2016 by regions and those having disability grade II according to WHO classification. However, the trend of new leprosy cases detected for the past 10 years shows tremendous decline country wide as is displayed in figure

28 Table 8: New leprosy cases detected by indicators in 2016 by regions The National Tuberculosis and leprosy Programme Figure 11: Trends of new leprosy cases reported:

29 Since 1,990, the proportion of new MB cases detected annually has been slowly increasing from 68% to over 88% while the proportion of females and children detected has been declining slowly from 44% down to below 38% and 10% to 2% 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. Figures 11 and 12 summarise the above findings for the past 10 years. Figure 12: Trends of MB cases, children and females among new leprosy cases: During this reporting period, the proportion of disability grade 2 among new detected cases has remained higher at 13%, however, there has been a gradual decrease in rates due to change and growth of population as shown in figure 12 below. Figure 13: Trend of disability grade 2, percentage among new cases and rates per 1,000,000 populations 20

30 4.1.2 Registered prevalence Overall, the prevalence of leprosy has showed a steady decline since The registered leprosy prevalence rate for years 2016 was 0.43/10,000 population as it was last year The prevalence detection ratio has remained around 1 since 2004 suggesting that patients are timely removed from the registers after completing their MDT treatment. The 2016 data shows that, there are still 20 districts with prevalence rates higher than 1/10,000. These endemic districts were yet to achieve elimination targets and came from 9 different regions as shown in table 9 below. Lindi and Morogoro had most of their districts still endemic and remain at high risk of increased disease burden. Figure 14: Trends of new leprosy cases detected and registered: Table 9: Endemic districts with prevalence rate greater than 1/10,000 Population in 2016 S/N District Region Population Registered cases Prevalence Rate 1 Liwale District Council Lindi 94, Nkasi District Council Rukwa 318, Ruangwa District Council Lindi 135, Nanyumbu District Mtwara 158, Council 5 Shinyanga Municipal Shinyanga 175, Council 6 Kilombero District Council Morogoro 448,

31 S/N District Region Population Registered cases Prevalence Rate 7 Mafia District Council Pwani 50, Pangani District Council Tanga 58, Mvomero District Council Morogoro 343, Masasi Town Council Mtwara 107, Lindi District Council Lindi 201, Kilwa District Council Lindi 197, Mpanda Town Council Katavi 116, Nachingwea District Lindi 184, Council 15 Rufiji District Council Pwani 237, Korogwe District Council Tanga 338, Mkinga District Council Tanga 128, Ulanga District Council Morogoro 291, Morogoro District Council Morogoro 314, Chato District Council Geita 414, Leprosy treatment outcome Treatment outcome of PB leprosy The treatment outcome of PB leprosy cases who started treatment in 2015 shows that, 344(84%) completed treatment while 6 (1%) were transferred out, 1 cases (0%) died while receiving treatment and 8 defaulted from treatment as shown in 10 below Table 10: Treatment outcome of PB leprosy reported in 2015 Treatment outcomes New cases Relapse after MDT Relapse after DDS/Others Total number % number % number % number % Treatment Completed Died Out of Control Transferred Out Evaluated Notified

32 4.2.2 Treatment outcome of MB leprosy Treatment outcome of MB leprosy cases notified in 2014 shows that, 1,632 (93%) completed treatment while 11 (1%) patients died during treatment period. However, the data also shows that 96 patients did not complete their treatment due to various reasons: 46 (3.0%) defaulted from treatment and 50 (3%) cases were transferred out during treatment. Table 11 below summarizes treatment results of MB cases notified in Table 11: Treatment outcome of MB leprosy notified in 2014 Treatment outcomes New cases Relapse after MDT Relapse after DDS/Others Total number % number % number % number % Treatment 1, , Completed Died Out of Control Transferred Out Evaluated 1, , Notified 1, , 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 per year. The planned activities to accelerate leprosy elimination efforts include; elimination campaigns in targeted areas, leprosy post exposure prophylaxis (LPEP) and implementation of the Bangkok declaration special fund (BDSF). During this reporting year, only LPEP continued to be implemented with financial and technical supports from Novartis Foundation (NF) and Germany Leprosy and Tuberculosis Relief Association (GLRA). Towards the end of the year, NTLP received approval note of BDSF grant from WHO-AFRO Leprosy Post Exposure Prophylaxis (LPEP) The Leprosy Post-Exposure Prophylaxis (LPEP) is a study project implemented in three districts of Nanyumbu, Liwale and Kilombero to demonstrate the impact of PEP added to contact tracing activities as a strategy to interrupt transmission of leprosy. The LPEP study is a multinational exercise implemented in seven countries across Asia, Africa and Latin America and Tanzania is representing the Africa continent. The three year project in Tanzania was launched in August, The project involve identification of index case households and the corresponding health facility, contact tracing, leprosy screening and provision of a single-dose rifampicin (SDR) to those who screen leprosy negative and eligible. The study involve all new leprosy cases diagnosed in and is 23

33 fully integrated into the national leprosy control program and district health care delivery system. Funding is provided by the Novartis Foundation. The project has completed 15 months of implemented and reports show high level of community acceptance with good performance of over 102.1% as shown in the table 8 below. Table 12: The number of targeted index cases and contacts screened in the project districts during August 2015 December Index cases/ households Targets Reached %age Kilombero % Liwale % Nanyumbu % Total % CONTACTS Targets Reached %age No. of New Cases detected Kilombero % 9 Liwale % 19 Nanyumbu % 11 Total % 39 Most of the planned index case households were visited, 2691 contacts screened and over 2380 people at risk given prophylaxis of a single dose rifampicin. At the same time, 39 confirmed new leprosy cases were detected from the 490 households visited Project to Implement Bang kok Declaration Special Fund (BDSF) Protocol to access funds to implement Bang kok declaration to promote early case detection and addressing challenges facing PALs with disabilities amounting US$ 161,450 was approved for the next three years starting The project will be implemented in three districts of Mkinga and Muheza in Tanga region and Chato in Geita region. The funds to implement the Bang kok declaration were donated by the Nippon Foundation of the Sasakawa Memorial Health Initiative and are being managed by the WHO Leprosy Global Programme (LGP). 4.4 Activities related to prevention of disabilities (POD) The programme continue to collaborate with key stakeholders, namely GLRA, social welfare commission, care centres, referral hospitals, MDT clinics and health management teams all around to strengthen efforts of preventing disabilities among people affected by leprosy (PALs). The main activities implemented during this reporting year include; regular assessments, management of reactions, care of wounds and ulcers, constructive septic surgeries, specialized eye care, provision of prosthesis and special boots. Other services included supporting shoe making workshops and referrals to consultant hospitals and 24

34 rehabilitation institutions People with leprosy related disabilities In 2016, a total of 893 people affected by leprosy (PALs) with disabilities were registered. A total of 1591(83.3%) were reviewed to assess their physical impairments and only 27(1.7%) PALs had their condition deteriorated and 373(23.4%) did not change on the course of their treatment Leprosy reactions A total of 936 leprosy patients were reported with reactions and started on corticosteroid treatment. Out of them, adults MB cases were 89.9% (842) and for PB 94 (10%). Of all the reported cases, only 93 required hospital admission 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. The district medical officers in all councils are reminded to include the requirement of prednisolone for PALs in their routine health facility drug need estimates and orders. Table 13: Leprosy cases started treatment with corticosteroid in 201 Region MB (A) MB ( C) PB (A) PB ( C) Total 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

35 Region MB (A) MB ( C) PB (A) PB ( C) Total Mtwara Mwanza Njombe Pwani Rukwa Ruvuma Shinyanga Simiyu Singida Tabora Tanga Mainland Pemba Unguja Zanzibar Tanzania Specialized care of people with disabilities During the year 2016, a total of 287 persons affected by leprosy (PALs) were admitted requiring some specialized care at different consultant hospitals in the country. Ulcers and wounds ranked high as the main reason for admission by 94 (32.7%) followed by reactions 133(46.3). Eye pathology ranked third and accounted for 27(9.4%). and the least was constructive surgery 13(4.5%). Eye pathology which was 27(9.4%). In addition to these, 23 PALs were fitted with prostheses. The table 14 below summaries the number of surgeries done, prosthesis fitted and prostheses repaired for people affected by leprosy in 2016 by regions. Table 14: Number of leprosy admissions in hospitals 2016 Number of leprosy admissions in hospital(s) Ulcers/wound treatment 94 Reactions 133 Indications for admission (Reconstruction) Surgery 13 eye pathology 27 Others 20 Number of Amputation done 2 Number of referred for rehabilitation outside the regions 4 Number of PALs given Prosthesis 23 26

36 4.4.4 Footwear Programme In 2016, a total of 3150 pairs of special boots were produced centrally and distributed to regions country wide. By the end of the year 2049 pairs of protective sandals were distributed to people affected by leprosy. This is only 65% of the protective sandals reaching PALs in need. To complement these efforts, 156 pairs of shoes were made locally in several regions by the local shoemakers. In the case of special boots 99 pairs were fabricated and 315 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 15 : Protective Footwear distributed/ produced to PALs in regions by type in 2016 S/N REGIONS Protective footwear distributed to region Protective footwear distributed to PALs per region Protective footwear on site produced Special boots Prostheses provided 1 Ilala I Ilala II Temeke Kinondoni Arusha Dodoma Iringa Kigoma Kilimanjaro Kagera Lindi Mara Mbeya Morogoro Mtwara Pwani Rukwa Ruvuma Shinyanga Singida Tabora Tanga Protective footwear repair 27

37 S/N REGIONS Protective footwear distributed to region Protective footwear distributed to PALs per region Protective footwear on site produced Special boots Prostheses provided 23 Manyara Mwanza Zanzibar Total 3,072 2, Protective footwear repair Table 16: Materials distributed for fabrication of special and local shoes production per region in 2016 Regions Leather MCR H.rubber GLUE L.Leather Thread S.Riverts Kigoma Morogoro Nazareth Tanga Misufini Mara Shirati Kagera Biharamuro Pwani Kindwitwi Tabora Sikonge Mwanza Bukumbi Ruvuma

38 5 LABORATORY SERVICES The National Tuberculosis and leprosy Programme The program continued to strengthen its laboratory services by increasing the number of diagnostics centres from 945 in 2015 to 1100 in 2016, Sensitize the use of the zonal laboratory culture laboratories and scaling up the use of the Gene Xpert in the country. In addition, during this year the second drug resistant survey has been initiated. 5.1 Laboratory workload In 2016, 3,895 specimens were received at the CTRL, out of these 42 (1.0%) were for studies/ projects and the remaining were from different parts of the country for AFB smear microscopy, culture and DST examinations. Of these specimens 2008(51.55%) were from Muhimbili National Hospital (MNH) for routine diagnostic examinations only and 1887(48.44.%) were set for culture and DST as part of MDR-TB routine surveillance system. However, culture was done on 1589 for sputum specimens of which 1219 (76.71%) were culture negative while 333(20.96%) were positive and some of these positive isolates (Retreatment cases) were set for DST. DST results were available for 381 isolates. Of these, 298(78.22%) of all isolates with DST results were sensitive to all four first line anti-tb drugs,.74 (19.4%) of the positive isolates had resistance to one or more anti- TB drugs and 45. Isolates were Multi Drugs Resistance (MDR), 130 specimens. Were subjected to second line drug susceptibility test and none was XDR. Table: 17 Number specimens received in 2016 Region N % Dodoma Arusha Kilimanjaro Tanga Morogoro Pwani Lindi Mtwara Ruvuma Iringa Mbeya Singida

39 Region N % Tabora Rukwa Kigoma Shinyanga Kagera Mwanza Mara Manyara Unguja Pemba Geita Njombe Kinondoni Ilala I Temeke Ilala II 2, Unknown Total 3, Culture analysis Percent of positive cultures that are smear positive (sensitivity) and the correlation smearpositive culture positive specimens (specificity) shows a lot of variations throughout the year. This ideally is measured for initial diagnostic specimens only; smears from patients already on treatment may be positive, but yield no growth on culture. The culture analysis shows an increase on smear negative/culture positives, a decrease on smear positive/culture positive. There was decrease of false negative during quarter 1 to three and an increase in quarter four of almost equal magnitude which came close to 50% towards the end of the year as can be seen in the figure below. 30

40 Figure:15 Culture analysis at CTRL Gene Xpert MTB/Rif Implementation Rapid DST Currently the program is in process of scaling up the use of Gene Xpert machines guided by the Xpert roll out plan launched during the last year. In 2016 total 5 health facilities were installed with GeneXpert machines making a total of 71 machines in the country. The GX Alert system continues to be a source of the information to analyse the operations of the machines in the country Table 18: Summary analysis of the Xpert MTB RIF in 2016 Values Grand Total Total # Xpert tests 52,583 Total # Xpert MTB- 40,213 Total # MTB+ RIF indeterminate 108 Total # MTB+ RIF sens 8,147 Total # MTB+ RIF res

41 Total # error results 1,695 Average Error rate 4% Average Rate of Rif resistance 3% Average Rate of Xpert MTB positivity 12% Average Instrument capacity being utilized 29% Line Probe Assay (LPA) A total of 103 positive isolates were tested for LPA at CTRL of these 54 (%), were sensitive to both Isoniazid and Rifampicin, 9 (%) were resistant to both Isoniazid and Rifampicin, 1 (%) was resistant to Isoniazid only and 4 (%) were resistant to Rifampicin only. Total number of isolates tested for LPA was too small due to the reason that for a long time there was a stock out of LPA reagents. Table:19 Total Isolates for LPA Results New Previous Total Sensitive to Isoniazid and Rifampicin Resistant to Isoniazid and Rifampicin Resistant to Isoniazid Resistant to Rifampicin No MTB Detected Invalid results Total tests External Quality Assurance of Drug Resistance In 2016 CTRL participated in an External Quality Assurance of drug resistance organized by supranational laboratory (SLN) Antwerp, Belgium, CDC Atlanta and WHO in collaboration with NICD. The laboratory has received GeneXpert panels, Smear Microscopy panels, Culture & DST Panels. The table below shows participation of EQA for the CTRL. 32

42 Table 20: Summary Participation of EQA for CTRL PT Provider Proficiency Panel Survey # Date received Date results submitted Results / Score Acceptable / Unacceptable NICD/WHO Microscopy Jul-16 YES 95% Acceptable NICD/WHO Microscopy Feb Mar-16 90% Acceptable CDC/ATLANTA GeneXpert 2016-A 20-May My % Acceptable MTB/RIF CDC/ATLANTA GeneXpert 2016-B 05-Aug Aug % Acceptable MTB/RIF CDC/ATLANTA GeneXpert MTB/RIF 2016-C 01-Dec-16 YES 100% Acceptable UK NEQAS MTB culture Aug-16 4-Oct-16 8/8 (100%) Acceptable 5.4 TB Laboratory Network Tanzania TB Laboratory network comprise of 1100 diagnostic sites by 2016, five TB culture laboratory and the Central reference laboratory sites. Decentralization of Zonal TB culture laboratory was initiated on year By December 2016, five laboratory were recognized as TB culture laboratory which are Pemba Public Health Laboratory, Bugando Medical Centre Laboratory, Kibong oto Infectious Disease Hospital Laboratory, Mbeya Referral Hospital and Dodoma Region Referral Hospital. Accreditation process of the TB Laboratories has started since 2014.By the end of 2016 total of five culture laboratories were involved in Strengthening TB Laboratories Quality Management Towards Accreditation (TB SLMTA) with total of 15 Participants trained from six TB laboratories, among them eleven participants successfully completed from five laboratory as one laboratory excluded from the training programme. The program during this year has continued to use Tanzania Post Cooperation for transportation of samples from facilities to the Zonal TB culture laboratories and CTRL. 33

43 6 PROGRAMME SUPPORT ACTIVITIES 6.1 Procurement and Supply Management of Anti-TB and Anti-Leprosy Medicines Procurement of anti-tb and anti-leprosy medicines and commodities is done by the Government through the development partners such as; the World Health Organization (WHO), the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM). First line and second line for adults and children anti-tb medicines are procured by Global Fund grant through Global Drug Facility (GDF). On the other hand, the GF through Medical Stores Department (MSD) supports procurement of ancillary medicines and laboratory reagents, equipment and supplies. Ancillary medicines are used for the management of side effects in patients taking anti-tb second line medicines. Furthermore, the GF through GDF procures single therapy Isoniazid tables for INH prophylaxis among PLHIV. Leprosy medicines are procured through the World Health Organization (WHO) Stock status: National, and districts The Program is responsible for forecasting and quantification of anti-tb and anti-leprosy medicines and laboratory reagents. MSD, which is an autonomous institution of the Ministry of Health and Social Welfare is responsible for the procurement (ancillary medicines and laboratory reagents), port clearing, storage and distribution of pharmaceuticals and medical supplies. Monitoring commodity availability at point of service delivery remains to be core function of NTLP as well as overseeing overall resource mobilization for anti-tb and anti-leprosy medicines. NTLP has finalized roll out of The New Optimized TB and Leprosy Logistic System to all the regions including Zanzibar and Pemba. Using this system, facilities with TB and Leprosy patients are now required to fill in Facility Monthly Report Form (FMRF) every month indicating the number of patients in their facility, month of treatment and stock of medicines available at the facility in that respective month. This form is submitted to the district for them to be supplied with the required medicines. Each district compiles information from all the facilities and prepares quarterly order (District Quarterly R & R Forms) which is submitted to MSD for them to be supplied with medicines for specific quarter. Through thus optimized system, distribution of medicines solely depend on the demand of facilities. Medicines from MSD Central is transported to MSD Zones and Zones supplies all respective districts according to their order. The new logistic system does not cover distribution of Laboratory Commodities and MDR TB medicines, these commodities continue using the old system where MDR-TB medicines are sent directly to Kibong oto and Laboratory commodities are sent to the Regions through RTLC. NTLP is responsible for monitoring and supervision of anti- TB and leprosy drugs at all levels. 34

44 One of the challenges facing drug management in most facilities is improper filling of FMRP where data filled in the form are inaccurate. Most districts still supplies medicines to facilities without following the stipulated Tb and Leprosy Logistic SOP. In addition during roll-out, some health facilities were not trained since they did not have TB patients. During this period,(2016) the programme received through the MSD, consignments of Fixed Dose Combinations (FDCs) of anti TB drugs from the Global Drug Facility (GDF) and anti-leprosy blisters; MB Adult, MB child, PB adult and PB child from the WHO. The table below summarizes the Table 21:stocks of anti-tb and anti-leprosy drugs distributed in the country in S/No MEDICINE PACK SIZE QTY 1 Water for injection vial/100 2,196 2 RH 2FDC 60/ ,580 3 RHZ 3FDC 60/30/ ,503 4 E100mg 100 1,006 5 E400mg RHZE 4FDC 150/75/400/ ,929 7 RH 2FDC 150/ ,467 8 RHE 2FDC 150/75/ ,045 9 Streptomycin inj vial/100 2, Capreomycin Inj 1G VIAL 1, Cycloserine 250mg Ethionamide 250mg Kanamycin Inj 1G VIAL/ Levofloxacin 250mg 100 1, Levofloxacin 500mg Linezolid 600mg MBA BLISTER PBA BLISTER MBC BLISTER PBC BLISTER Community empowerment activities The implementation of the community based activities has been implemented by the Program in collaboration with LGA s, implementing partners, NGO s (6) and NSA s (2). The main focus was on community systems strengthening at all levels. Several activities such as organising a joint meeting with NACP, RHMT s and implementing partners to discuss the implementation of grant activities with specific focus on Global Fund, sensitization of unengaged CSO s on TB control, engagement of new CSO s (69) and their capacity 35

45 building took place at National level. Furthermore, a total of 247 CBO s (out of 400) were supported to provide community TB care and prevention together with provision of enablers. Training packages for CHW s, Sputum fixers and HCWs were reviewed along with the standard operating procedures for sputum fixers. At regional and district levels, training were conducted to capacitate the CHWs (including sputum fixers) with the skills of conducting contact tracing, active case finding and sputum fixation. A number of CHWs (ex TB patients) and sputum fixers are distributed to various regions (see annex.). The Program also printed and distributed M&E tools and operational guideline for community TB, TB/HIV and DR-TB interventions. The national average contribution from community was 9.7%, a decrease of 9.3% compared to 2015 (19%). This was contributed by the introduction of community TB referral component in the M&E tools where by most of districts were still using old TB registers of which did not accommodate this component. Other factors include lack of reliable financial support to some districts and inadequate capacity of HCWs to link TB cases contributed from community. Home Based DOT still continued to be the most preferred mode of treatment as 90.4% of TB patients in 2016 were treated under this modality. Among them,..% are successfully treated. Table 22: Trend of community contribution (%) in TB case notification in Tanzania from S/N Year Number of notified TB cases(all forms) contributed by community referrals % % % % % 6.3 Advocacy, Communication and Social Mobilization (ACSM) activities Advocacy, Communication and Social Mobilization (ACSM) activities are integral part of implementing TB activities in the country. The World Leprosy day and World Tuberculosis Day were marked on 31st January 2016 and 24th March 2016 respectively. Activities including sensitization campaigns and active case finding by screening of people for TB were conducted during commemoration period in 17 regions. The remaining regions did not commemorate due to lack of resources. Eighty three (83) members of parliament were sensitized on TB and TBHIV and MDR-TB. During the sensitization the Tanzania TB Caucus was also launched and endorsed by the Minister of MoHCDGEC and the Parliamentarians. 36

46 The program focus on increasing awareness of TB whre by Four TV and radio spots were developed and broadcasted in selected 8 media houses during this year. In addition panel discussions and talk shows were broadcasted by 14 media houses A total of 6 media personnel from different media houses were supported to document best practices on TB, TB/HIV and MDR TB in 2 regions of Iringa and Mbeya. Furthermore, review of Swahili training package on ACSM was undertaken and 30 TOT were trained and cascade trainings were done to 170 HCWs in 6 districts of Karatu, Meru, Kinondoni, Geita, Hai and Same. TB, TB/HIV and MDRTB messages for key affected population were developed and pre tested. The Programme in collaboration with partners managed to print and distribute IEC materials on TB, TB/HIV and MDR TB. Materials distributed include 3,490,000 leaflets; 71,968 posters; 1,500 wheel covers; 56 street banners; 2102 job aid for school health and 50,000 copies of Patient s Charter for TB care. 6.4 Public and Private Partnership (PPP) The contribution of private health facilities in TB case detection has not change significant in 2016 compared to that of 2015 where by in this year 7098 (11%) cases were notified from these providers. To strengthen the collaboration of between the Government and the private providers developed an action plan spearhead by honourable Minister of Health Community Development Gender Elderly and Children to be implemented for the coming next three years of the Program Strategic plan implementation ( ) were launched. The NTLP has continued to provide support to the implementation of TB services in private health facilities in terms of provision of free drugs and other commodities (lab. Reagents and supplies) and recording and reporting tools. Also provide trainings, mentorship and supervisions and sensitization activities. 6.5 TB in Mining sector TB in the mining sector (TIMS) initiatives continues to be implemented in the mining areas of in the the country. Among the interventions include: 1. Sensitization campaign and systematic TB screening activities in collaboration with implementing partners such as IOM and KNCV 2. Engaging mining companies in mobilizing resources for TIMS. 3. Conduct rapid surveys in North Mara Tarime and Geita to assess the current practices related to mining exploration and diseases vulnerabilities among key populations in these areas 4. Coordinate the multi sectorial Technical working group for of TB in the mining sector meetings aiming at reducing burden of TB in the mining. 37

47 6.6 Quality Improvement in TB case detection Basing on the Tanzania Quality Improvement Framework (TQIF), the NTLP has introduced an innovative approach focusing on improving the quality of TB, TB/HIV and DR-TB services at health facilities of various levels of health care system. The approach provides a direction for quality TB service provision to most vulnerable groups and those all in need at all levels in the country. To ensure it is well implemented, the programme has developed a toolkit to guide health facilities to efficiently utilize available resources and opportunities to strengthen TB screening and detect much more TB cases. The toolkit will also facilitate monitoring the impact and stimulate further innovations in service provision to stop TB transmission in the country. Some of key implemented activities include:- departmental working teams and health facility exchange working sessions and that is being delivered on regular planned days facilities during clinical meetings facility and different sections most appropriate position and time to institute TB screening to patients and clients at the clinic or ward facilities The NTLP is collaborating with GF to implement the initiative in the 16 phase I regions. During the first six months (January December, 2016) of implementation, the programme managed to conduct TB services assessment in Arusha, Zanzibar, Mbeya and Dar es Salaam, developed a training package and toolkit, presumptive TB register, job aides, posters and brochures and preparing a grant request to support implementation of key interventions. At the same time, 30 ToTs and 1228 health facility managers were trained. Dodoma and Mbeya regions were selected to be closely monitored and the initial results on the efforts to increase TB case notifications at the selected health facilities were very impressive as shown in the figures below. The monitoring activities in the past six months 38

48 were mainly conducted by consultants hired by GF. The phase II of implementation will start by mid next year, 2017 involving the remaining regions and the programme expects many other development partners like Boresha Afya-USAID to come in and support the initiative. Figure: 16 Showing Mbeya Quarterly TB notification comparison for quarters 1 and 2 of 2015 and 2016 (intervention facilities) Figure 17 Dodoma referral regional hospital Monthly TB case notification,

49 6.7 Supportive Supervision The NTLP supportive supervision is cascaded in three levels that are: central unit supervise regions at least once per year; regions supervise districts once in every quarter; and district supervise diagnostic centres every month and DOT centres each quarter. The Ministry conducted and coordinate supportive supervision to all 28 regions in as per the plan. Main strength identified include: 1. Good structured organisation and management to oversee the Program s activities at Regional and Local Government levels 2. Regional and Councils levels plans to control the diseases 3. Good Collaboration with the NGOs and CSOs in the implementation of activities Main weakness: 1. New Coordinators at Regional and Council level who are not yet trained Delayed submission of reports 2. Challenged EQA implementation 3. Poor capacity of the coordinators on data analysis and use Recommendations 1. Plan for the training of the new coordinators 2. Review EQA activity to strengthen implementation 3. Plan for mentorship by the experienced coodinators 4. Plan for the capacity on M&E 6.8 Data Quality Assessment (DQA) Data quality assessment was improved by reviewing the process and the tools. This resulted in the development of the guideline which was then oriented to the program coordinators. During this year the routine assessment was conducted in seven regions including an MDRTB data quality assessment which was conducted by the USAID. The following were the general main findings: 40

50 Strength An average of less than 2% variation between the reported values and re-calculated values Good systems for the data management : focal persons for data management who are trained and have working tools Weakness Recommendations Misclassification of cases : Understanding of new TB case definition among healthcare workers is still low, especially on groups of previously treated TB cases (relapse and other previously TB cases) Data quality checks are not performed at lower levels In appropriate use of registers Data management guideline is needed to be in place Ensure all treatment units in the region switch from using old to newly updated registers. POD register should immediately put in use for proper management of leprosy cases to prevent development of disabilities among registered cases. Review meetings should be essential in every region in order to discuss data management 41

51 Annex 1: List of DTLCs 2016 NAME LOCATION Dr. AMANI HAULE LUDEWA DC Dr. JONATHAN KITUNDU MAKETE DC Dr. JAIROUS NJIKU WANGINGOMBE DC Dr. JONATHAN SIHA NJOMBE DISTRICT Dr.ISACK LULINDI NJOMBE TC Dr.EMMANUEL F. KIWALE SONGEA MC Dr.KANGEKA NDAWANA SONGEA DC Dr.BRYSON MAPUNDA MBINGA DC Dr.MKASANGE KIHONGOLE TUNDURU DC Dr.ANTHONY NKWERA NAMTUMBO DC Dr.ATHANAS NDUNGURU NYASA DC Dr.MAXENCIUS KAYOMBO MADABA TC Dr.WENCE SLAUS SOCKY MBINGA DC DR MASANJA DWESE IGUNGA DC Dr.DAVID MLAKI NZEGA DC Dr JOHN BUSWELU SIKONGE DC Dr. SINDABAKIRA SEREJIO UYUI DC Dr.LUCAS MSANGI TABORA MC Dr. WILLIAM B. KAIJAGE KALIUA DC Dr JACOB KAMANDA URAMBO DC Dr.MADENI KIZINGI GEITA DC Dr.JEREMIAH NICANORY GEITA TC Dr. Jephter Zacharia BUKOMBE DC Dr.Polinatus Mwemezi Pantaline CHATO DC Dr.Samwel S. Nchunga MBOGWE DC Dr Phinias Ndaro NYANGHWALE DC Dr.ALLEN MASIMBA ARUSHA DC Dr.ELIPOKEA KAAYA MERU DC Dr.SULEMAIN BIROLI LONGIDO DISTRICT Dr.GODSON LEKASIO MONDULI DISTRICT Dr.PAULINA CHALLE ARUSHA CN ZONE Dr.THOMAS MGALULA KARATU DC Dr.MICHAEL KINGAZI ARUSHA CITY EAST ZONE Dr.JOEL MSUYA ARUSHA CITY WEST ZONE Dr.EMANUELLE MALLANGE NGORONGORO 42

52 Dr. Ramadhani Makange Ukonga Dr. Eliah Mmbando Amana Dr.Linda Mutasa Mnazi Mmoja Dr.John Mkombachepa Tabata Dr.Salapion Mutagwaba Vingunguti Dr.Cyrilo Mapunda Buguruni Dr.Cristopher Mapunda Chanika DR AMBILIKILE MSHANI SUMBAWANGA MC Dr.FRANCIS MWASYEBULE SUMBAWANGA DC DR EVELADA SANANE NKASI UPLAND DR GODFREY MACHETA NKASI KIRANDO Dr.Festo Bernard Mpimbwe DC Dr.Festus Fliminus Mlele DC Dr.Jeremia Mollel Tanganyika DC Dr.Gabriel Karumuna Nsimbo DC Dr.Peres Ishengoma Mpanda DC Dr. JOHN MASANJA MKURANGA DC Dr.KASIMU SULEIMAN KIBAHA TC Dr.JUSTINE MYALA KISARAWE DC Dr.CHACHA DAUDI KIBAHA DC Dr.ROGGER NNARY RUFIJI DC Dr.JOAS MBAGA CHALINZE DC Dr.ABDALLAH BHAI MAFIA DC Dr.ALEX MLIGA KIBAHA TC Dr.STANLEY ALFRED KIBITI DC Dr.MWINYI KAMBI SALUMU B/MOYO DC DR. LAURENT MHEMBE SHINYANGA MC Dr.DANIEL SINGOLILE SHINYANGA DC Dr.PETER MAIGA MSALALA DC DR. PHILBRT NGWENDA KISHAPU DC DR. CONRALD B. WENCESLAUS USHETU DC DR. FREDRICK MALUNDE KAHAMA TC DR. JOYCE MGOHAMWENDE RANGITATU DR. SULTANI OMARI LUSAMBI MBAGALA DR. TULIKIFRI MBAGA WAILES 1 DR. SWALEHE KYONDA KIGAMBONI DR. SILVESTAR NGOWI WAILES 2 DR. NANGENJWA MRUTU YOMBO VITUKA DR. AMINA GAYAHIKA TAMBUKARELI 43

53 DR. MRISHO KAMKANGA KEKO PRISON DR. DISMAS NHANDULE MEATU DC DR. NICHOLAUS MBASSA ITILIMA DC DR. PETER HENRY BARIADI DC DR.ESTHER JOHN BARIADI TC DR. STEVEN MUNUBI MASWA DC DR. GEOPHREY OBEID SHANI LUGALO Dr. Elamu Malekano RUANGWA DC Dr.Victoria Kasanjala TBWRRD&PRIVETE HOSPITAL MUHIMBLI Dr. Sikujua Ally IDC -MuHIMBLI Dr.Marcelina Mlay MWAISELA_MUHIMBILI Dr Jackson Kileo Siha Dr.Alfonce Shirima Hai Dr Augustino Ngowi Moshi MC Dr Clif Mushi Moshi DC Dr.Ludovick Mashelle Rombo Dr Abdallah Kahuu Mwanga Dr.Alfred Seth Nyome Same Dr.Anita Mallya MAGOMENI Dr.Maliwaza Mganga MWANANYAMALA-1 Dr.Hawa Mtutu MWANANYAMALA-2 Dr.Theophilla Luhimbo TANDALE-1 Dr.Bertila Kimaro TANDALE-2 Dr.Maryam Mindu BUNJU Dr. Pius Mndowa SINZA Dr.Timoth Batram Kayuni MBEZI Dr.Sophia Kisoma MBURAHATI DR JAFARY THOBIASI;DTLC KILWA DC Dr. FILBERT JOHN NDUNGURU NACHINGWEA DC DR GAUFRID MTENDACHI LINDI WEST DR ALLUTUPHINA DAMARU LINDI EAST Dr. RICHARD KOMBA; LIWALE DC Dr. ESTHER JOSEPHAT MUCHUNGUZI MUSOMA MC Dr.REVOCATUS M. MUGETA BUNDA DC Dr.HAMAD OMAR HAMAD SOUTH PEMBA Dr. ABDUL M. MSUYA MAFINGA TC Dr.Wiston Kahumuza Kyerwa Dr. Abdiliian R Francis Muleba 44

54 Dr.Johannes Jason Karagwe Dr. Simon L. Mugera Ngara Dr. Pius Misunngwi Biharamulo Dr. Ruta Bachubila Misenyi DR. SUFIAN MBELWA TANGA URBAN DR. JOHN LUAMBANO MKINGA DR. RAPHAEL MUMBA TANGA RURAL DR. ELIGI MSECHU PANGANI DR.ERNEST KWINGWA KILINDI DR. BARAKA MBWAMBO KOROGWE DC DR. THERESIA MAUYA LUSHOTO DR. RASHID MHINA HANDENI DR. JASON KAMALA KOROGWE TC DR. EVANCE O.MATATA BUMBULI DR. ELIABU BWATARE KWIMBA DC DR. ATHANAS KASUBI SENGEREMA DC DR.GABRIEL MASSAM MAGU DC DR KANIKI TITTUS UKEREWE DC DR. ESTHER MICHAEL MWANZA URBAN NORTH DR. DANIEL MAZENGO MISSUNGWI DC DR. PIUS NTABO MWANZA URBAN EAST DR. NGELEJA KHAMIS DTLC MWANZA SOUTH Dr. Adam Masesa,, BUKOBA DC DR. Amani E Nkilingi Kilombero D.C Dr. Dominatha Rutta Kyela DC Dr. Mahuya M. Shibina Kasulu TC Dr. ESTHER BASHASHA MBOZI DC Dr. Mariam Msigwa MBEYA DC Dr. Emanuel E Nelson Babati TC Dr. KAWAMBWA KAWAMBWA KASULU DC Dr. Nicholas K.Mwaipyana Busokelo DC Dr. Musimu Makunja RORYA DC DR. SAID JUMANNE KITIKU IKUNGI DC DR. ATHUMAN STEPHEN SINGIDA DC DR.FERDINAND KUTIMWA MANYONI DC DR.EMMANUEL KATOSANI RUNGWE DC DR. JOHN SUNGI KONDOA DC DR. NOLASCO G. NGOLLOKA KILOLO DC DR. HERMAN KIMU SINGIDA REG. HOSP 45

55 DR. MSENGI GYUNDA DR. JAMES M. JUMANNE DR. FELIX M. BIGGI DR. JAMES MIGUNGA DR. EMMANUEL M. WANDETI DR. BONIFACE J. CHAPANGA DR. FARAJA S. MPOMBO DR. HAWA LESSO DR. LAUREAN A. KANAGANWA DR. JOSEPH KOMBA DR. EDWIN KONGOLA DR. CHARLES HILARY MBOTA DR. ANDREW P. MALELO DR. BONNY BANDA FERDNANDS FLACKSON M. KIBONA DR. GEOFREY MINZI DR. VEDASTUS P. LUMBALUMBA DR. ASELI A. PWELE DR. JOHN NADO MUSIBHA DR. JUMA KISINZA Dr. Obby Kavasha Alex Christopher Dr. Mussa Perment Dr. Ally Fupi Dr. Samweli Wilson Dr. PETER JENGELA Dr. SIMON KESSY Dr. VENANCE KIYEYEU Dr. Reuben Hebron Dr. Elias Mtungilwa Dr. Reuben Mfugale Dr. Boniface Manditi Dr. Mayunga William Dr. Thabit Kibika Dr. Said Muhombolage Dr. Emmanuel Chogo Dr. Chacha P. Maroa Dr. Sarah Sanze Dr. Samwel Matiko Peter IRAMBA KIGOMA DC KIGOMA UJIJI MC BAHI DC KONGWA DC KALAMBO DC CHEMBA DC MPWAPWA DC KIBONDO DC DODOMA MC CHAMWINO DC MAKAMBAKO TC BUSEGA DC MBEYA CITY ILEJE DC MBARALI DC CHUNYA MOMBA DC TARIME DC TARIME TC Babati DC Hanang DC Kiteto DC Mbulu DC Simanjiro DC Iringa DC Iringa MC Mufindi DC Morogoro DC Morgoro MC Gairo Dc Ifakara TC Mvomero DC Ulanga DC Kilosa DC Malinyi DC Serengeti DC Butiama DC Musoma DC 46

56 Annex 2: The National Tuberculosis and leprosy Programme Change in Case Notifications by regions between 2015 and