TB or Tuberculosis being a bacterial disease is highly infectious but it has its cures and measures. The disease is a major point of concern in South Africa, especially in the areas of Western Cape. It is so common among them that one out of ten people develop this disease and if not treated in a timely and effective manner the infected person can affect 20 other people or more in a year. According to the World Health Organization’s (WHO’s) Global TB Report 2009, South Africa ranks fifth among the 22 high-burden tuberculosis (TB) countries. South Africa had almost 460,000 new TB cases in 2007, with a frequency rate of a projected 948 cases per 100,000 population – a major raise from 338 cases per 100,000 population in 1998. (Source, (World Health Organization Statistics, 2009).
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A Synopsis of TB
Tuberculosis being a bacterial disease is caused by micro-organism, a bacilli scientifically, Mycobacterium tuberculosis which enters the body by inhaling through the lungs. From where they can spread to other parts of the body through the blood, lymphatic system via airways or by direct transfer to other body organs. It develops in the body in two stages: Tuberculosis infection in which an individual breathes in the TB bacilli and becomes infected but the infection is contained by the immune system. The other stage is when the infected individual develops the disease himself.
Out of those people who do become infected, most will never develop the disease unless their immune system is seriously damaged for instance by stress, HIV, cancer, diabetes or malnutrition. The bacteria remains dormant within the body if the patient is BCG injected. BCG immunization at the time of birth provides up to 80% protection against the progression TB infection to take form of a disease. A basic sign of TB is consistent cough of two weeks, so the earlier the patient goes to the clinic to get a check up, the more curable it is. Other severe signs are bleeding in cough, night sweating, weight-loss and short-breathing.
TB in South Africa
Africa and southern Africa
In their 1997 reports on the tuberculosis epidemic and on anti-tuberculosis drug resistance in the world, the WHO paints a bleak picture of the global failure of health service providers to deal with the burden of tuberculosis. In the 216 reporting member countries of the WHO, representing a total population of 5,72 billion, there were an estimated 7,4 million new cases of tuberculosis in 1995. This represents a rate of 130 cases among every 100 000 persons.
In Africa the case rate is 216 per 100 000. The 11 countries of the Southern Africa subregion contribute approximately 275 000 cases every year to the total case load in Africa. Almost half of these come from South Africa. In an analysis of tuberculosis trends and the impact of HIV infection on the situation in the subregion, it is estimated that by 2001 the smear positive case rate would have increased from 198 per 100 000 population for the region as a whole, to 681 per 100 000 if tuberculosis control efforts are not optimised. To aggravate the situation, 69% of these cases would be directly attributable to HIV infection.1
A serious complication of the tuberculosis problem in Southern Africa has been the emergence of multi-drug resistant (MDR) strains of the organism causing the disease. Patients infected with MDR require prolonged chemotherapy with very expensive medication which will at best cure only half of them. Such treatments cost at least 100 times as much as the cost of curing an ordinary tuberculosis patient infected with drug-sensitive bacteria. Very few countries can afford this additional burden.
In order to determine the magnitude of the MDR problem in Southern Africa, and the implication for National Tuberculosis Programmes (NTP’s), surveys are being conducted in various countries as part of the activities of the WHO/IUATLD Global Working Group on Tuberculosis Drug Resistance Surveillance. So far, information is available for four countries in southern Africa: Botswana, Lesotho, South Africa, and Swaziland.
Results confirmed that initial resistance to first-line drugs is relatively low in southern Africa compared to some other regions in Africa and Asia where the problem is up to 5 times more common. Resistance rates range between 4% and 12% for isoniazid, and between 4% and 7% for streptomycin. For rifampicin it is 1% and for ethambutol 1%; MDR is fortunately still low at 1%, indicating that resistance strains are not commonly transmitted from person to person. On the other hand, rates for acquired resistance, that is resistance which has arisen in patients previously inadequately treated for tuberculosis, are at least three times higher than in patients not previously exposed to anti-TB medications. The high rates of acquired resistance point to a failure of control programmes to effectively manage case-holding and treatment adherence.
The full course treatment time can stretch up to eight months with consistency as a major factor. People who stop treatment develop a multi-drug resistance which makes the disease more complicated. TB can prove fatal if not treated.
The treatment is in two phases:
The intensive phase consists of taking four different drugs for five days a week, for two to three months.
The continuation phase consists of taking two drugs for five days a week for four to five months.
Sputum tests are regularly taken every two months for keeping a check on the progress.
The Department of Health in South Africa has implemented the World Health Organizations’ DOTS (directly observed treatment short course) technique to make sure patients adhere to treatment. DOTS have been implemented in a good number of clinics in the Western Cape. An essential element of the strategy is the support and back-up offered to TB patients for the entire six to eight-month treatment phase, where they are directly observed taking their medication at the clinic.
The DOTS strategy is embedded in the following principles.
The support of the national and provincial Heads of the Department of Health has significantly helped
South Africa to implement the DOTS strategy. This support is essential because DOTS requires
significant changes of approach and tends to challenge old practices. Although the strategy offers
the least expensive way of tackling TB, often it requires substantial redirection of funds and this
cannot happen without the political commitment and support of key decision makers.
Directly Observed Treatment Short-course as a global initiative, is a breakthrough that is increasingly
providing solutions to the control of the TB epidemic in South Africa. However, it is a new strategy
and as such may seem at first complicated and confusing. This merely shows the need to effectively
and adequately reorientate our resources and train health staff and treatment supporters to this
strategy. This means that each one of us from all sectors has a major role to play. TB is everywhere
and as such effective TB control should be practised everywhere. Good TB control is part of good
2.2 Identifying Infectious Patients
TB is a bacterial disease and bacterial tools should be used to manage it. The TB Control programme
is moving away from chest x-rays as a primary method of diagnosis. A crucial element of
DOTS is to use microscopes to ensure that infectious TB is reliably and cost -effectively diagnosed.
The first priority and the key issue in the new programme is to cure infectious patients at the very first
attempt to slow down the epidemic.
The over use of x -rays is discouraged as the primary means to confirm the diagnosis of TB because
it does not tell whether a patient is infectious, and it is difficult to distinguish between active TB and
other lung diseases or scarring. This leads to over diagnosis so that health workers could be treating
many patients that do not have active TB and are not sick with TB. More importantly, the TB epidemic
in South Africa is approaching uncontrollable levels and energies should be concentrated on curing
infectious TB patients to stop the spread of this disease. Only bacteriology identifies infectious
2.3 Direct Observation of Treatment
The implementation of DOTS ensures that every TB patient should have the support of another
person to ensure that they swallow their medication daily. The treatment supporter does not have to
be a professional health worker, but can be any responsible member of the community. Employers,
colleagues and community members can act as treatment supporters. Using family members is often
problematic but has been successful in exceptional cases. This person should know the signs and
symptoms of TB, side effects of TB drugs and the importance of taking TB medication regularly for
the patient. They should also motivate and empower patients and their families and provide them
with a better understanding of TB and the importance of cure.
Treatment supporters are best recruited as part of a community based system which is reviewed
annually and its results documented. Treatment supporters should work closely with local health
Because of the length of time, the patient has to take treatment, completing TB treatment is a special
challenge and requires an unyielding sense of commitment. This may be easy to sustain while the
patient feels sick. However, after a few weeks of taking treatment, patients often feel better and see
no reason for continuing their treatment. It is thus essential for health workers or treatment supporters
to be supportive and use the initial period to bond with the patient. This will enable them to build
a strong relationship in which the patient believes and trusts advice given by the treatment supporter.
2.4 Standardized Drug Combinations
A daily dose of a powerful combination of medications is administered to TB patients for five days a
week. Combination tablets simplify treatment and ensure that drugs are not given separately and
therefore decrease the risk of drug resistance.
2.5 Reliable Reporting System
A reliable recording and reporting system is necessary in order to monitor progress. Sputum results
should also be recorded to document smear conversion. This gives an accurate measurement of
performance and one can identify areas which need support.
The First Step to Filling the Country with DOTS:
Setting up Demonstration and Training Districts (DTDs) in 1997 was one of the first crucial steps in
the implementation of the DOTS strategy. In South Africa at least one Demonstration and Training
area was identified in each province where all the elements of DOTS would be adopted in the management
of TB services. Initially these areas would receive the necessary resources and support to
ensure that they function well. When these districts demonstrate success in implementing DOTS
they can be used as examples and training points to expand DOTS provincially and country-wide.
Everyday TB kills nearly 5000 people, which is one person every 20 seconds. (WHO, Global TB Report, 2009). There is a presence of numerous barriers while accessing TB care especially in the poor communities:
Economic Barriers – Delay in seeking health care occurs due to lack of money for transport plus the time lost working.
Socio-cultural Barriers – Lack of awareness and stigma about TB.
Geographical Barriers – Long distances from health care facilities and TB diagnosis and treatment centers.
Health System Barriers – Delays in diagnosis as a result of knowledge lapse among health care workers.
The ever existing barriers to the success of the targets involve overlooking of TB control by government, lack of monetary and human resources to provide regulation and quality control, weak and stigma health systems, poorly managed TB control health centers, poverty in majority of communities, population escalation and a significant boost in drug-resistant TB (particularly MDR-TB) and the recent, extensively drug-resistant TB (XDR-TB). Lack of new diagnostic tools has impeded progress in TB control programs. Perhaps the greatest challenge to achieving the TB targets, however, has been the ever-growing HIV outbreak and the resultant increase in HIV-associated TB.
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A regional emergency was once declared in the large parts of this region due to unrestrained epidemic of HIV-associated TB. The start of such an epidemic as the TB/HIV one has seriously compromised even historically firm national TB programs working globally. TB programs are weighed down by this increasing volume of HIV-associated TB cases and by the necessity to manage cases and ensure treatment completion. in addition, TB is the leading source of death among HIV-infected persons, and HIV is the strongest forecast of progression from dormant TB infection to active disease. Thus, TB programs that were almost up to the mark by WHA-set global TB targets have seen their treatment and completion rates plummet.
The TB/HIV combination has also had a remarkable impact on human resources. In a labor force that has remained the same or shrinked, the increased overall number of TB patients has damaged TB programs’ infrastructure and amplified poor TB results such as treatment default, death and the emergence of XDR-TB. The HIV-associated TB epidemic has led to an escalating rate of smear-negative and extra pulmonary TB; these forms of TB do not add to the case-detection targets and are more difficult to identify. Moreover, smear-negative TB has a worse prediction than smear-positive TB amongst those who are also HIV-infected.
TB and HIV
The HIV outbreak has led to a massive increase in the number of fatal TB cases. TB is not accountable for a third of all deaths in HIV infected people. People with HIV are far more vulnerable to TB infection, and are not as much able to fight it off. Recent studies by Wood, (2007) in a region with an approximate HIV prevalence of about 20% in Cape Town, calculated that the pulmonary TB-warning rate among HIV-infected persons in that area amounted to 5,140 cases per 100,000; and that the rate amongst HIV-uninfected individuals in the same area was 953 cases per 100,000. Using these statistics, the determinable fraction for TB among HIV-infected individuals in that area aggregated to 82 percent.
Conclusion & Recommendations
The overall purpose of the project is to identify risk factors and make appropriate recommendations based both on the available evidence and the studies that stem from this project. As such, recommendations are structured in terms of the conceptual framework of this document. Nevertheless, the existing evidence from current data and literature reviews allows us to pinpoint areas where interventions are clearly required. On these grounds, we can make certain recommendations.
Introduce epidemiologically-led behavioural interventions
Reference has been made to the heterogeneity in HIV prevalence in the province (Shaikh et al, 2006). This unevenness is also apparent in the provincial TB profile. It is therefore important to identify the geographical focal points for interventions according to this disease distribution that has been identified by routine surveillance. Populations at high risk for infection may be identified according to geographical area, as well as according to other demographic factors such as age, sex and socio-economic status. By raising awareness in populations at high risk and targeting specific high risk behaviors, interventions will be more effective in lowering the incidence of new infections.
Target hotspots first
Once populations at risk have been identified, geographically discrete regions should be selected for resource allocation and focused interventions. An implementation of interventions based on the known and expected burden of disease will prioritise the roll out of a prevention strategy. Prevention efforts that address HIV infection should identify areas and populations where there are certain risk factors and areas of high HIV prevalence must apply concentrated intervention of TB programmes.
Identify and manage at-risk groups earlier
Behavioural and communication strategies for highest risk groups must be pro-active in their efforts, and target the false sense of security that exists regarding the risk of HIV infection. At-risk populations should include vulnerable groups such as women, and also specific groups such as prisoners, commercial sex workers, mobile persons and labour migrants. Awareness of the risk of TB among HIV infected people must be raised both in communities and within the health service.
Integrate prevention and treatment
While evaluating the effectiveness of prevention programmes within an epidemiological context, the potential future impact of treatment of both HIV/AIDS and TB needs to be examined.
Adapt relevant public services
Goal-directed partnerships between social-cluster group departments should be actively pursued. Resource allocation must be rationalised within a broader spectrum than only the health services. The high burden of TB must be taken into account in this process, and be assigned equal importance as the efforts against the spread of HIV. In addition to intersectoral collaboration towards intervention for both these infectious diseases, more effort must be made to integrate the management of HIV/AIDS with TB.
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