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  • Title: The point of view of a high prevalence country: Malawi.
    Author: Nyangulu DS.
    Journal: Bull Int Union Tuberc Lung Dis; 1991 Dec; 66(4):173-4. PubMed ID: 1687509.
    Abstract:
    The National Tuberculosis Programme switched to short-course chemotherapy for smear-positive cases when the IUATLD started to assist in 1984. Treatment results in smear-positive cases improved from a 50-55% cure rate to an 87% cure rate in new cases (and 89% in retreatment cases). The hope of reducing the tuberculosis problem was then challenged by the occurrence of HIV-related cases of tuberculosis which are now considerably over-stretching services. Smear-negative cases and extrapulmonary tuberculosis now represent almost two thirds of all patients. For them, standard chemotherapy has now been changed to 2 R3H3Z3/2 HE(or TH)/4H in order to try and save money on syringes, needles and water for injection as well as prevent transmission of HIV through injections. This regimen will also enable the programme to depart from hospitalization since patients will take medication on an ambulatory basis. It may also give more time to district tuberculosis officers for the supervision of health centers. The Malawi National Tuberculosis (TB) Control Programme switched its main means of controlling TB from the standard regimen to a short course chemotherapy (intensive phase=2 months in the hospital for new cases and 3 months for retreatment cases) in 1984. It 1st introduced the new treatment into 3 districts and TB patients throughout the country were on the short course therapy 2.5 years later. The program had created demonstration centers countrywide to demonstrate the new regimen's effectiveness. The program obtained its data from the District TB Register and the Laboratory Register. It monitored smear positive cases using bacteriology, evaluated their situation every 3 months using cohort analysis, and followed them 15-18 months after initial therapy even though they had completed treatment. The program separated TB patients into new smear positive, smear negative, relapses, and extrapulmonary TB cases. Cure rates prior to 1984 ranged from 50% to 55% but from 86% to 87% for new smear positive patients in 1984-89 and from 89% to 91% for relapsed cases. Since cure rates of retreatment cases basically matched those of new cases, program managers assumed that acquired resistance to rifampicin and isoniazid tended not to occur. Failure rate for retreatment was only 3%. HIV entered the population of Malawi around the mid-1980s resulting in increased TB incidence which hampered TB control efforts. HIV-infected TB patients did respond to treatment as well as those not infected with TB, however. Since HIV incidence was growing and health workers must use syringes and needles to administer streptomycin, it was the most difficult drug because sterilizing syringes and needles and injecting streptomycin required much time. About 66% of all TB cases in Malawi were smear negative and extrapulmonary cases. They received 15 mg ethambutol/kg/body weight/day orally on an ambulatory basis.
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