BOX 2-1Problems of Dealing with Drug-Resistant TB in Mozambiquea

The experience of Mozambique illustrates the problems facing many areas of southern Africa in dealing with the epidemic of drug-resistant TB, according to Zimba. Almost constant warfare during the three decades from 1965 to 1994 created severe disruptions in the country's health care system, just as political instability elsewhere in southern Africa has hampered health care delivery. Only 45 percent of the population has access to health care. Of Mozambique's 22 million people, 12.5 percent of adults are estimated to be infected with HIV (UNAIDS, 2008) (see the discussion of TB and HIV coinfection later in this chapter).

Southern Africa has adopted the WHO guidelines for diagnosis and treatment of TB, using microscopy as the standard for diagnosis and follow-up of TB cases. In Mozambique, the national TB control program was launched in 1977. The country has seen some success in expanding Directly Observed Treatment Short course (DOTS) to the community (community-based DOTS [C-DOTS]) and improving access for people in underserved areas (USAID, 2009). However, drug resistance has proven to be a great problem in the country.

There are 255 laboratories in Mozambique that can diagnose TB using microscopy. But there is only one National Reference Laboratory that conducts culture and drug susceptibility testing for first-line anti-TB drugs. Samples for diagnosis from the district and provincial laboratories are transported to the National Reference Laboratory in the capital city of Maputo. Three months can pass before those laboratories receive feedback and the patient is informed of the diagnosis.

A 1998–1999 nationwide survey of 709 culture-positive TB cases in Mozambique found that 3.4 percent of new cases were MDR (Mac-Arthur Jr et al., 2001). Drug resistance was more common among those with a history of prior treatment. A 2002–2003 report from the Mozambique national TB program similarly indicated that 3 percent of new TB cases were MDR (Nunes et al., 2005). In 111 samples from HIV-infected patients, 9 percent were found to have MDR TB. About 6 percent of new TB cases in patients infected with HIV, as well as 16 percent of TB cases among previously treated patients, were MDR.

In 2009 there were an estimated 1,700 cases of MDR TB among notified pulmonary TB cases in Mozambique (WHO, Global Tuberculosis Control 2010; Annex 3). According to Zimba, however, it is known that the Mozambique national TB program has in the past seriously underestimated the numbers of new cases of MDR TB. The actual number of cases of primary MDR TB in Mozambique remains unknown.


This box is based on the presentation of Tomás Zimba, Maputo Central Hospital, Mozambique.

From: 2, The Incidence of Drug-Resistant TB in Southern Africa

Cover of The Emerging Threat of Drug-Resistant Tuberculosis in Southern Africa
The Emerging Threat of Drug-Resistant Tuberculosis in Southern Africa: Global and Local Challenges and Solutions: Summary of a Joint Workshop.
Institute of Medicine (US) Forum on Drug Discovery, Development, and Translation; Academy of Science of South Africa.
Washington (DC): National Academies Press (US); 2011.
Copyright © 2011, National Academy of Sciences.

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