BLANTYRE, 18 September 2007 (PlusNews) - When the first cases of
extremely drug-resistant tuberculosis (XDR-TB) were reported in
South Africa in 2006, the World Health Organisation (WHO) urged
other countries in the region to improve their laboratory
capacity and implement infection control measures, but Malawi
still cannot test for the virtually untreatable TB strain.
Multidrug-resistant TB (MDR-TB) strains cannot be treated by at
least two of the main first-line TB drugs, while XDR-TB is
resistant to most first and second-line drugs, severely limiting
Patients usually develop MDR-TB as a result of not completing
treatment for an earlier bout of TB. Failure to complete lengthy
MDR-TB treatment creates the risk of developing XDR-TB.
In 2006, at the height of fears that XDR-TB would spread to
Malawi, health and population minister Marjolie Ngaunje told the
nation that according to surveillance done by the WHO there was
no evidence that any extremely resistant strains had reached the
country. She added that XDR-TB still posed a threat to Malawi
because of its relatively close proximity to South Africa.
Henry Chimbali, a spokesperson for the National TB Control
Programme, explained that Malawi could not test for XDR-TB
because it lacked the anti XDR-TB drugs needed to test cultures
(samples of TB bacteria cultivated in a special liquid). He
added, however, that testing of cultures from patients with
recurring TB was routine and would alert them to the emergence of
The Central Reference Laboratory in the capital, Lilongwe, which
coordinates all TB testing, reported that between 1995 and 2005,
there were 71 MDR-TB cases in a total of 95,116 TB patients.
Malawi currently has 15 MDR-TB patients undergoing treatment that
can take up to two years.
Ngaunje pointed out that Malawi was in a strong position to avoid
an XDR-TB outbreak because guidelines for treatment of the
disease were being adhered to, with only about four percent of
patients failing to complete their six-month course of first-line
While MDR-TB cases remain rare, poverty and a 14.4 percent HIV
prevalence have increased the incidence of TB in Malawi to about
27,000 diagnosed cases a year. According to the National TB
Control Programme, the disease is now the biggest single cause of
adult illness and death, killing about 22 people a day and 8,000
annually. In March 2007, the Malawian government declared TB a
national emergency and a number of strategies were put in place.
"Health workers are on high alert to pick up all suspected TB
patients at the earliest time possible. Community awareness
campaigns have been intensified, and we are opening up more
diagnosis and treatment centres with the aim of improving the
accessibility of these services," said Dr Ibrahim Idana, deputy
director of the National TB Control Programme.
People with immune systems compromised by HIV are 50 times more
likely to develop active TB, but the sputum tests most commonly
used to detect TB often fail to recognise it in HIV-infected
Idana said only about 30 percent of TB cases in Malawi were
diagnosed using sputum tests. Health workers have to rely on
other screening tools such as x-rays and biopsies for the 40
percent of TB patients who are sputum-negative, and the 23
percent who have TB in other organs besides the lungs. For TB
patients who were on treatment before and are experiencing new
episodes of the disease, culture samples are sent to the Central
Reference Laboratory in Lilongwe to check for drug resistance,
Idana told IRIN/PlusNews.
Despite the obvious links between HIV infection and TB, in most
cases, co-infected patients still have to attend two seperate
clinics to access treatment. Adamson Muula, a lecturer in
community health at the College of Medicine in Blantyre, Malawi's
commercial capital, explained that while TB clinics could be
manned by health surveillance assistants (Malawi's lowest
qualified cadre of health workers), HIV clinics had to be manned
by a clinical officer or doctor. "There are few clinical officers
and medical doctors to provide both TB drugs and ARVs
[antiretroviral drugs], compelling patients to attend two
clinics," he said.
Treatment under one roof
At Chiradzulu district hospital, about 40km outside Blantyre, the
government, in collaboration with international medical relief
organisation, Medecins San Frontieres (MSF), is providing medical
services to scores of TB and HIV patients from surrounding
districts. Some even come from urban Blantyre, where the shortage
of health workers at Queen Elizabeth Central Hospital, Malawi's
largest infirmary, has limited capacity.
MSF provides human resource support and equipment to existing
government programmes aimed at TB and HIV prevention and
treatment. "Our collaborated efforts have helped TB patients who
are also HIV positive to get all the treatment they need at one
site," said Gerald Zomba of MSF France.
Chiradzulu has a 40-bed in-patient facility in the TB ward, but
so far only two cases of MDR-TB have been identified, according
to Zomba. Last year, the programme achieved a 78 percent
treatment success rate, not far behind the target of 85 percent
recommended by the WHO.
Similar programmes are being put in place at Blantyre's Queen
Elizabeth Central Hospital, at Kamuzu Central Hospital in
Lilongwe, and several other district hospitals around the
Chimbali, of the National TB Control Programme, said the HIV/AIDS
Unit in the Ministry of Health was working with his organisation
to ensure the success of joint TB/HIV programmes. All patients
diagnosed with TB were encouraged to test for HIV.
However, "Most TB patients who are also HIV positive have
problems accessing ART [antiretroviral therapy], just as is the
case with TB patients having problems accessing counselling and
testing services [for HIV infection]," he said.
Health workers also ran the risk of becoming infected with TB in
spite of precautionary measures taken while treating patients. A
nurse at a TB clinic in Blantyre said it was easy to become
infected. "It's a challenge that government has to look into,"
Muula said limited resources and a lack of pressure from health
workers to push authorities to provide safer working environments
was jeopardising their health. "There is evidence from the
Ministry of Health's own reports that health workers have a high
incidence of TB."