The tuberculosis control programme in the industry in Swaziland : a critical evaluation

Abstract

Background: Tuberculosis (TB) is a major public health problem in Swaziland aggravated by the escalating HIV epidemic. Health services in five of the major industries in Swaziland represent the potential for the highest quality of TB care in the country, arising from increased supervision and better case holding. The guidelines of the national TB control programme (TBCP) are mostly adhered to, but there is a tendency to rely on clinical and radiological parameters for diagnosis due to problems with sputum microscopy. Aim and Objectives: The aim of this study was to evaluate current TB management protocols by describing case management and treatment outcomes in these five industries. Specific objectives included the determination of quantitative outcomes (cure and treatment completion, smear conversion, treatment interruption and failure, and mortality). Patient knowledge of TB and its treatment as well as health worker practices were also assessed. Methods: Descriptive questionnaire survey. Results: The majority of TB patients (79%) were young (mean age 38 yrs) males. 81 % of patients were treated for TB for the first time. The HIV status of a third of patients was known, and 82.7% of these were positive. There were significant differences between the perceptions of health workers and patients on the delivery of TB care and the time lapse between diagnosis and treatment. Chest X-ray was the main diagnostic tool used. In more than 97% of cases the TBCP prescribed treatment regimen was used. Directly observed treatment was provided to 77.4% of patients. The majority of patients had some knowledge of TB and its spread. 73.4% of patients knew about available TB treatment, and 75% about treatment duration. Coughing was identified as an important symptom by 84.5% of patients. There was a significant difference between calculated and estimated adherence to treatment. In 55.6% of patients no sputum smear was done at two months. Treatment outcome was favourable in 83.7 % of patients, compared to only 62.1 % of TBCP patients in 2001. Outcome analysis showed that the participating industries had a highly successful TB control programme compared to the national TBCP, with outcome indicators meeting international standards. A serious deficiency detected was the lack of smear microscopy for diagnosis and treatment monitoring. Limitations: The possibility exists that patients presenting to the Health Centres were not registered sequentially. The usual limitations relating to questionnaires are applicable. Recommendations: Directly observed treatment coverage and supervision can be improved in industry as the patient group is well-defined and captive. Sputum microscopy should become the mainstay of diagnosis and monitoring. Health care providers should be primed to detect co-existing lung disease and HIV, and TB drug side effects. Accurate recording and reporting systems should be introduced without delay. Communication between the TBCP and the non-governmental health institutions in Swaziland needs improvement.