#Article (Archive)

Trends In Tuberculosis Control In The Gambia

Nov 11, 2009, 12:17 PM

(Tuesday, 10, November 2009 Issue)

In line with the Millennium Development Goal six (6) and targets which were endorsed by WHO Stop TB partnership, NLTP has set the following Goal and targets as outlined in the program's strategic plan (2008-2012).
The Goal is to reduce transmission, morbidity and mortality of TB so that it is no longer a public health problem in The Gambia

- Increase TB case detection rate to at least 70% by 2012 relative to the 2006 level of 64%. This implies that the TB control programme should strive to detect at least 70% of the estimated infectious TB cases in the country. TB case detection involves identifying infectious cases, mainly among adults attending out-patient or other health facilities for any reason with cough for two weeks or more, through sputum smear examination. Based on the current national TB notification data vis-à-vis WHO estimates, the TB case detection rate in the Gambia is 67%. Achievement of this target will require improvements in case detection of new smear-positive pulmonary TB cases in the country. However, the TB case notification for this category of patients has increased from 887 cases in 2001 to 1305 cases in 2008. The proportion of new smear-positive cases represents about 64% of all forms of TB registered during the year 2008 and 96 cases per 100.000 population (based on the 2003 national census). This rising trend is as a result of intensified TB case finding and the strong collaboration with partners such as Medical Research Council (MRC) in TB case detection. Identification of infectious cases is very significant in the context of public health since these are the patients who can transmit the TB infection in the community. However, infection transmission can be greatly minimised if such patients are detected early and promptly put on adequate chemotherapy under DOT. This constitutes the fundamentals of TB control in the Gambia.

Generally, the case notification for all forms of TB has also markedly increased in recent years. A total number of 2053 TB patients (all forms) was detected in 2008 in the Gambia. These include sputum smear-negative pulmonary TB and extra-pulmonary TB patients.        
- Achieve treatment success rate of at least 85% by 2012 relative to the 2006 level of 82%. Besides detecting the infectious TB cases, it is very important for the national TB control programme to put these patients on adequate anti-TB treatment which should be closely supervised (directly observed treatment or DOT). Treatment success rate is derived from a combination of cure and treatment completed. By definition, a TB case is said to be cured when the sputum smear is negative at the end of treatment and at least one previous occasion. Treatment completed means the patient has completed treatment but does not meet the criteria to be classified as cured or failure. With regard to this target, the TB programme of the Gambia has achieved 84% treatment success rate as indicated by the 2007 report on treatment outcomes:         
- Reduce death rate from 7% in 2006 to <5 by 2012. TB is a preventable, treatable and curable disease and as such the TB programme should ensure that the proportion of TB cases dying while on treatment out of all registered cases is lower that 5%. Like other unfavourable treatment outcomes such as default and treatment failure, high death rate is suggestive of weak TB programme implementation mainly as a result of late detection of TB patients, poor treatment adherence, weak implementation of DOT and failure of the TB programme to provide IEC. However, many TB related deaths are also associated with TB/HIV co-infection particularly if there is weak collaboration between the TB and HIV/AIDS control programmes where collaborative TB/HIV activities are not effectively implemented.
- Reduce defaulter rate (treatment interrupted for two consecutive months or more) in new smear-positive pulmonary TB cases from 4% in 2004 to 2% by 2012. The Gambia TB control programme is working hard to ensure case holding. The defaulter rate is currently maintained below 2%.

- Keep failure rate under 1%. Treatment failure occurs when a TB patient who, while on treatment, has sputum positive at five months or later. This can happen due to several factors including failure of TB programmes to supervise treatment properly and possible drug resistance. The current failure rate is less than 1% in the Gambia.  

- Maintain prevalence of multi-drug resistant TB (MDR-TB) at <1%. MDR-TB is a specific form of drug resistant TB which occurs when the TB bacilli are resistant to at least Rifampicin and Isoniazid, the most powerful anti-TB drugs. According to the routine MDR-TB surveillance report conducted by the National Reference Laboratory, no case of MDR-TB has so far been detected in the Gambia.
- Increase the number of TB patients counselled and tested for HIV from 50% in 2007 to at least 90% by 2012. As per the collaborative TB/HIV activities, the TB programme is determined to offer provider- initiated HIV counselling and testing (PICT) to at least 90% of the registered TB cases by the target year. This is very important as HIV counselling/testing is the entry point to care and support. Based on the results of the routine HIV surveillance among TB patients, the current PICT uptake stands at 82%.      

Scale up DOTS centres from 22 in 2007 to 40 by 2012. This is a very important target which ensures that TB diagnostic, follow-up and treatment services are brought closer to the communities. The number of DOTS centres has significantly increased from 11 in 2005 to 22 in 2008. When access to TB services is enhanced, it can lead to increased case detection and improved favourable treatment outcomes.