Department of Health on TB related cases and children’s vaccinations in province

Meeting report

Briefing by the Western Cape Department of Health on TB & Immunisation Services affected by COVID-19

Dr Krish Vallabhjee, Chief Director: Strategy and Health Support, Western Cape Department of Healt,h stated that in the past 10-12 weeks, the Department has been heavily preoccupied with trying to prepare for the service pressure related to the spread of COVID-19. As part of that preparation, there has been an intentional de-escalation of services in the Department at all levels to try and reduce capacity. He said that in the process of de-escalating services the question of what happens to services that are not related to COVID-19 became important, and the top management has recognised the importance of this issue. The month of April had already shown a significant drop in the services to non-COVID-19 patients. Dr Vallabhjee said that the Department has already put plans and strategies into action to remedy this challenge.

Ms Lesley Shand, Deputy Director: Information Management, Western Cape Department of Health, stated that the strategies that were implemented by the Department, alongside the National Government have also helped with the de-escalation of health services, especially with the regulations that came with the announcement of the National Lockdown in March. There was the closure of schools and public transport, as well as the constant communication by government with the citizens of the country with regard to sanitization and social distancing. The Department also implemented strategies that included the limitation of elective surgery to the minimum. The Department has prioritised COVID-19 and involved some of the Community Healthcare Workers in activities such as COVID-19 screening and testing in homes and in businesses. Ms Shand also stated that all these services have had an impact on other services that are not related to COVID-19, and some of the outcomes included the fear of the public to visit clinics, as well as the public’s inability to travel to health facilities due to the lack of transport. She said that the number of people over the age of five visiting public health facilities dropped by 56% in April 2020, in comparison to April 2019, where the number of those under the age of five dropped by 70%.

Ms Shand said that in terms of the Western Cape’s Immunisations Programme, in 2019 85% of children under the age of one year in the Western Cape were fully immunized in the Cape metro, which contributed up to 65% of immunisations in the Western Cape. The Department expects the numbers to decrease in 2020 unless interventions are put in place to catch up on missed immunisations. There was a general decrease in the number of all reported immunisations in April 2020 in comparison to the previous year. She also said that the annual average of immunisations that took place in public facilities have decreased by 36% from the 2019-20 average, while those that were done in private facilities have decreased by 10% from the 2019-20 average.

Ms Shand stated that the Department’s strategy for Immunisation remedial activities includes supporting services to deliver adaptive and responsive immunisation services whilst maintaining the safety of the health workers and children. She said that the Department’s vaccinations are free of charge and the mobile services will continue to work, while in some areas the Department has implemented staggered appointments in compliance with social distancing rules for situations where there is a small space to provide services. In terms of the Department’s communication strategy, it continues to strongly advise mothers to protect their children from infectious diseases by getting them vaccinated from birth to when they are 12 years old. Different types of media are used to communicate this message, including local radio talks, newspapers, social media groups, pamphlets and posters distribution as well as opportunistic education during the community screenings and testing. She said that the Department continues to monitor the vaccine supply, and there have not been any challenges in that regard so far. The Department also monitors the performance against targets especially in hotspot areas as well as disease outbreaks. In terms of people management, Ms Shand said that the Department applies management of staff shortages due to COVID-19 infections and supplies stock and upskilling and refreshers for professional nurses with community healthcare workers to immunize COVID-19 positive children outside facilities.

In terms of TB, Ms Shand stated that the Western Cape has adopted a National Strategic plan on HIV, STIs and TB 2017-2022, which is aimed at ensuring early diagnoses, successful treatment of TB patients and strengthening partnerships between local and provincial health authorities and citizens, to eliminate the threat of TB in the Western Cape by working better together. She stated that the impact of COVID-19 on TB has been that opportunistic screening and testing has decreased because there have been less people in the public health facilities, and some may have missed appointments because of the national lockdown, social distancing, lack of transport and stay at home messaging. Some patients have been provided with repeat medication so that they do not have to visit the health facilities. More people were screened in April 2020 than in 2019 and that is because most of the pharmacy attendances are being done outside of the facilities. The number of TB related visits to the public healthcare facilities since the COVID-19 outbreak have decreased in April 2020. She stated that the absolute number of TB screening has decreased by 36% in April 2020 in comparison to April 2019, and the absolute number of patients that started on TB treatment has decreased by 42% in April 2020. She also said that the remedial actions undertaken by the Department include the stable TB patients now receiving medication at home via the Community Healthcare Workers to avoid going to a facility or from quick pick up points outside of the facilities and only those that are at risk of acute decompensation continue to be seen at the facilities. She said that it should be noted that there is an overlap in the symptoms of COVID-19 and TB and that staff are reminded to consider TB as a possibility. There have been no changes to starting and closing times in public health facilities unless there is a need for temporary closure due to sanitisation of the facilities. The Department has implemented home deliveries of medication and has increased the services of the community healthcare workers as more of them are being appointed and requested to refer less to the facilities and handle as much as possible outside.

Dr Vallabhjee concluded the presentation by stating that the main message from the presentation is that there has been a decline in services and with TB the concern is not on those patients that are already on treatment, assuming they are taking their treatment, rather the main challenge is on the screening, diagnosis and starting treatment of new patients.  

Discussion

Ms L Botha (DA) asked whether the Department’s strategy for the metro and rural areas stays the same. She also asked whether the Department has a communication strategy to warn TB patients about the dangers of defaulting their treatment, especially now that there is COVID-19 pandemic. Lastly, she asked whether the Department considered the homeless shelter that was created during the National Lockdown period for case finding for TB.

Ms A Bans (ANC) asked for clarity on what Dr Vallabhjee was referring to in terms of case finding. She also asked for clarity on the reasons for the decreasing statistics of the number of TB patients.

The Chairperson asked about the contributing factors to the 89% of TB patients who start their treatment as well as the contributing factors to the success rate of patients who start their treatment. She also asked what the Department’s projection are in terms of the spread of COVID-19 due to the fact that it is now winter and temperatures a likely to drop, which will result to people getting colds and flu, and what will the Department’s remedials be for those projections. Lastly, she asked in terms of immunisation what are the Department’s remedial measures on the success levels of tracking missed cases and what the Department’s outreach strategy is in terms of remote and rural areas within the province.

Dr Vallabhjee responded to the question about the strategies between rural areas and Metros by stating that the strategies are mostly the same in principle. He said that in rural areas the mobile service plays an important factor because of the distance. In response to the question about communication to patients about not defaulting treatment, he said that the Community Healthcare Workers visiting the homes of the patients are a key part of the Department’s strategy as they use the opportunity that comes with face-to-face communication in order to share the message of awareness and emphasize adherence to treatment. He said that the Department has employed more Community Healthcare Workers now during the COVID-19 outbreak, and as part of its remedial strategy in the near future, the Department’s intention is to use the Community Healthcare Workers’ home visits to patients to talk about different kinds of things, especially TB and Immunisation, and not only focus on COVID-19 awareness. He responded to the question about case finding by explaining that the patients that have already been screened, tested, diagnosed and have started treatment for TB if they are stable in taking their treatment, they become less of an issue. However, the bigger challenge is that the Department had implemented opportunistic screening of people who went to the health facilities which helped with case finding, but since the National Lockdown was implemented, the chance for opportunistic screening was limited and people were not going to health facilities, which led to the decrease of new cases found. He said that in some cases people do not follow up with tests because of different issues, which also leads to the inability of the Department to track down the new cases. He stated that it is a challenge that the Department is working on improving.

Dr Vallabhjee responded to the question of flu symptoms by stating that they expect that it will be difficult because the symptoms of flu, TB and COVID-19 are similar in many ways and that is where clinical judgement will be important, as there has been serious challenges in COVID-19 testing in the country, and at the moment the diagnostic decisions come from the primary healthcare nurses or the doctors. In terms of remedials with regard to the COVID-19 testing issue, the Department is using education, awareness and the Community Healthcare Workers to maximise the opportunity with each household visit.

Mr James Kruger, HIV/Aids, STIs & TB (HAST) Manager, Western Cape Department of Health responded to the question of homeless shelters by stating that the Department looks at the risks for setting up especially because COVID-19 just like TB requires physical distancing between people. In terms of Immunisations he said that the Department uses telephone calls to contact mothers in order to spread information on Immunisation campaigns.

Ms Shand added that another challenge that they face with the telephone calls is that sometimes the patients have changed their numbers which makes them impossible to reach.

Dr Vallabhjee said that the patients who are contacted via the telephone are regarded as an important risk because if they default treatment they become more prone to develop multi-drug resistant TB later on, which becomes hard to diagnose, and more difficult to manage, which is why the Department tries to make sure that patients do not default their treatment.

Ms R Windvogel (ANC) asked about the delivery of TB treatment to patients and whether the Department has a different strategy from the one it was using before the National Lockdown was implemented.

Ms Shand responded to Ms Windvogel’s question by stating that the Department in its remedial strategy has made use of Community Healthcare Workers to deliver the treatment to the patients’ homes and are also collaborating with Uber to assist in places where the distance to travel is long, as well as pick-up spots for the patients to go and collect their treatments, while some patients have been given repeat treatment.

The representatives from the Western Cape Department of Health left the Meeting.

Resolutions/Actions
The Chairperson asked the Members of the Standing Committee to raise their Resolutions and Actions to which all Members stated that they had none.

The Chairperson said if any of the Members did have Resolutions they should send them via email by 2pm today and if no resolutions were received, the meeting will be regarded as concluded. All Members agreed.

The meeting was adjourned.