Namibia is among the five countries worstly affected by tuberculosis (TB) with a notification rate of 465/100,000 in 2011. This paper describes how the National Tuberculosis Leprosy Program (NTLP) developed from a poorly performing TB control program in 2002 into a well performing program in 2011. The program achieved 85% treatment success for new sputum-positive patients, high coverage and performance on TB/Human Immunodeficiency Virus (HIV) collaborative program activities, and institution of Programmatic Management of Drug-Resistant Tuberculosis (PMDT) where this was absent before. Provision of significant short-and long-term technical assistance provided by KNCV Tuberculosis Foundation (KNCV) in the period 2002-2011 was catalytic in leveraging a total of U$ 80million of external funding in a stepwise approach balanced with absorption capacity, in combination with national policy review and support for its implementation on the basis of two consecutive costed national strategic plans. The technical assistance by KNCV, in partnership with other international technical agencies for specialized areas, proved to work very well in this context where Namibian human resources and funding for TB control were initially limited and the Ministry of Health and Social Services (MoHSS) welcomed extensive technical assistance.

In Malawi, it has been the practice for several years to obtain sputum for smear microscopy of acid-fast bacilli (AFB) from all patients with extrapulmonary tuberculosis (EPTB). We audited this practice, and determined in patients aged > or = 15 years (i) the proportion of EPTB patients who had sputum smears examined, (ii) the number of sputum smears examined per patient, and (iii) the proportion of patients with EPTB who had sputum samples smear positive for AFB. Forty-one hospitals (3 central, 22 district and 16 mission) performing smear microscopy and registering EPTB patients were visited in 1998 and 1999, and a retrospective and prospective study was carried out using TB registers and laboratory sputum registers. In the retrospective study, 1124 (69%) of the 1637 patients with EPTB had sputum smears examined; 988 (88%) of the 1124 submitted 3 sputum specimens. In the prospective study, 2026 (84%) of the 2411 patients with EPTB had sputum smears examined: 94% of the 2026 submitted 3 sputum specimens. In both studies, high rates of sputum submission were found in patients with pleural effusion, miliary TB, lymphadenopathy and pericardial effusion. In the prospective study, only 34 (1.7%) EPTB patients submitting sputum were smear positive, and the proportion who were smear positive exceeded 3% only in patients with lymphadenopathy, miliary TB and TB meningitis. As a result of this study, the Malawi TB Control Programme has changed its policy, and now only insists on sputum-smear examination if patients with EPTB have a cough for > 3 weeks. These policy changes will be audited by further operational research.

SUMMARY SETTING Namibia ranks among the 30 high TB burden countries worldwide. Here, we report results of the second nationwide anti-TB drug resistance survey. OBJECTIVE To assess the prevalence and trends of multidrug-resistant TB (MDR-TB) in Namibia. METHODS From 2014 to 2015, patients with presumptive TB in all regions of Namibia had sputum subjected to mycobacterial culture and phenotypic drug susceptibility testing (DST) for rifampicin, isoniazid, ethambutol and streptomycin if positive on smear microscopy and/or Xpert MTB/RIF. RESULTS Of the 4124 eligible for culture, 3279 (79.5%) had Mycobacterium tuberculosis isolated. 3126 (95%) had a first-line DST completed (2392 new patients, 699 previously treated patients, 35 with unknown treatment history). MDR-TB was detected in 4.5% (95%CI 3.7–5.4) of new patients, and 7.9% (95%CI 6.0–10.1) of individuals treated previously. MDR-TB was significantly associated with previous treatment (OR 1.8, 95%CI 1.3–2.5) but not with HIV infection, sex, age or other demographic factors. Prior treatment failure demonstrated the strongest association with MDR-TB (OR 17.6, 95%CI 5.3–58.7). CONCLUSION The prevalence of MDR-TB among new TB patients in Namibia is high and, compared with the first drug resistance survey, has decreased significantly among those treated previously. Namibia should implement routine screening of drug resistance among all TB patients.

No abstract

Human immunodeficiency virus (HIV) infection increases the risk of tuberculosis (TB) 21-34 fold, and has fuelled the resurgence of TB in sub-Saharan Africa. The World Health Organization (WHO) recommends the Three I's for HIV/TB (infection control, intensified case finding [ICF] and isoniazid preventive therapy) and earlier initiation of antiretroviral therapy for preventing TB in persons with HIV. Current service delivery frameworks do not identify people early enough to maximally harness the preventive benefits of these interventions. Community-based campaigns were essential components of global efforts to control major public health threats such as polio, measles, guinea worm disease and smallpox. They were also successful in helping to control TB in resource-rich settings. There have been recent community-based efforts to identify persons who have TB and/or HIV. Multi-disease community-based frameworks have been rare. Based on findings from a WHO meta-analysis and a Cochrane review, integrating ICF into the recent multi-disease prevention campaign in Kenya may have had implications in controlling TB. Community-based multi-disease prevention campaigns represent a potentially powerful strategy to deliver prevention interventions, identify people with HIV and/or TB, and link those eligible to care and treatment.