Western Cape TB Response Plan

Meeting report

Dr Nousheena Firfrey, Western Cape Deputy Director: Health Service Priorities Coordination (SPC), gave an overview of TB-related services in the province pre- and post-COVID-19, the progress of the Provincial TB Response plan, the localised multisectoral approach and implementing society approach, funding initiatives and advocacy, health promotion activities and rural and metro perspectives.

Each time the province experienced a wave of COVID-19 infections, the testing for TB would decrease. Over time this trend started to stabilise. The longest period of increased testing was between March 2021 and November 2022. The gene tests have slowed down in 2023 compared to 2022 but it still remains above the median monthly rate prior to the pandemic. The graph depicted the TB cases that increased every year from 2019. Deaths during admissions in adults also increased. This showed that patients are presenting symptoms to the Department much later which resulted in the increased number of deaths from 2019 to 2021. The SPC needs to find the cases earlier to intervene in time to prevent these deaths at health facilities.

74% of the headcount at each facility were screened for TB, 3% of which were positive. An investigation was conducted on the screening, and 17% of those in the investigation were found to be TB-positive. Of the confirmed TB cases, 91% started treatment and there was an overall treatment success rate of 69%. The loss to follow-up rate was 26%, meaning these patients initiated treatment but failed to complete treatment. 3% of the patients who initiated treatment succumbed to the illness.

The BCG-vaccine is provided to all infants at birth which provides protection against severe forms of TB. In 2021 and 2022, the coverage ranged from 65% to 100% across all districts. The lowest coverage being the West Coast. Coverage decreased in the 2022-2023 period. Dr Firfrey indicated that there is still a need for TB vaccinations in children because these vaccines do not protect the children from all forms of TB. The decrease in coverage in 2022-2023 can be attributed to the lower number of births during that period.

There are four main features of the Provincial TB Response Plan: prevention, case detection, linkage to care and adherence to treatment and support. The prevention is made up of TB-preventative therapy which includes contact tracing and treatment regimens. Shorter treatment regimes have been implemented. New policies are in the process of being signed off and approved to improve these regimens. Health education is also included in the prevention plan. The TB Check App is a convenient way to screen for symptoms.

New guidelines are currently being rolled out for case detection to target universal TB testing. This will require more GeneXpert kits. Digital X-rays will also be used to detect the disease in asymptomatic clients.

SMS notification of results is one of the many initiatives of the linkage to TB care plan. A contact centre supports and follows up with patients who have tested positive for TB so they can be linked to care and treatment. A circular was recently sent out on community screening and testing which aims to strengthen the role of the community health worker to follow up on clients at community level. As for adherence counselling and support, earlier this year the counselling strategy was approved which aims to make every contact count. Every point where a patient enters the health system is an opportunity to engage and intervene with them.

The Department is focusing primarily on Targeted Universal TB Testing (TUTT) and TB Prevention Therapy (TPT), of which the TUTT provincial plan is still in the process of being finalised. The national implementation of TUTT and TPT have been approved. The implementation of TUTT will allow for testing of TB patients regardless of whether they have symptoms, including groups such as HIV patients receiving antiretroviral therapy, HIV patients who are pregnant, and newly diagnosed HIV patients. People who are within close contact of someone with TB within a period of 12 months will also be eligible for testing.

Dr Firfrey noted that the rolling out plans like TUTT are not as simple as testing patients. She explained the complexities of the support required to facilitate this level of testing, and the treatment that would need to be provided to these patients who test positive.

TB test screening and sputum collection standard operating procedure involves the training of community health workers to collect sputum, which is integrated in the community-level oriented approach. There is also a focus on hotspot areas, in turn making linkage and support to care a focus of this approach.

The interim guidelines of TB Preventative Therapy had specific guidelines, but new guidelines have created an expansion for people who require preventative treatment. A test-and-treat approach will be available to people living with HIV, adults and children alike. There are special groups that require special consideration, such as dialysis patients preparing for organ transplants and diabetics.

The government-to-government project looks at supporting innovations of TB case finding and contact tracing. This project aims to raise awareness of TB as the leading cause of death in the Western Cape, to reduce the number of infections and increase the number of diagnoses. The pilot project taking place in the metro and rural districts has led to the appointment of extra staff to assist with the conduction of GeneXpert tests. The Department has also received funding for additional GeneXpert tests through the Global Fund for two years for implementation support and digital resources. Provincial funding was received across the metro and rural districts. The Department is in the process of appointing additional staff in the metro to assist with TUTT implementation.

Dr Firfrey said that they had recently attended the South African AIDS Conference in Durban, where there was a focus on TB and the integration of TB and HIV. The Conference put emphasis on social behaviour communication strategies as part of the adherence support component of the recovery plan. There was a discussion about taking stock of the post-pandemic impact on TB and STIs and also evaluating the current funding of TB and HIV interventions.

Dr Danie Theron, Manager: Medical Services at Brewelskloof TB Hospital in Worcester and Dr Nosi Kalawe, Metro Health Services medical officer for the Northern and Tygerberg districts, presented the remainder of the briefing, focusing on the perspective of rural health services.

Discussion
Ms R Windvogel (ANC) asked what the reason was for the delay in establishing the legislature TB Caucus and what percentage of the deaths attributed to TB in the province are that of children. She asked what the success rate was of locating persons who have failed to collect their medication for TB treatment, in metro and rural areas.

Mr A van der Westhuizen thanked Dr Firfrey and her team for managing the TB situation. He noted that the Western Cape’s population has grown significantly in the last four years and asked how this has influenced the number of TB cases, as the statistics presented indicate that the number of cases have returned to that of pre-COVID-19. He asked what the position is on the provision of BCG vaccines and if there is sufficient stock available for babies. On migrant workers, he asked if there was a national database of patients so that in the event of workers returning to other provinces, the clinics would be able to look up the medical history of the patient.

Mr P Marais (FF+) pointed out that the briefing lacks the topic of poverty and its impact on the spreading of TB. He expressed his frustration that impoverished communities are exposed to malnutrition and overcrowding and that the Ministry has failed to address this. He asked what the consequences were if someone who tested positive for TB refuses to complete treatment, because this increases the risk of exposure and infection. What has been done to address the fact that 49% of TB cases in the Western Cape between July 2021 and June 2022 were found in the Tygerberg region? He was disappointed that the presentation did not touch on these matters.

Health Department response
Western Cape Minister of Health and Wellness, Dr Nomafrench Mbombo, explained that the aim of the legislature TB Caucus is to make TB part of a political wheel, meaning that the caucus has a structure at both national and provincial levels. Four provinces are already apart of this TB Caucus. She said that there should be a subsidiary committee to the Ad-Hoc Committee that focuses on the socio-economic aspects of fighting TB, which the Department of Health will not be able to do. She then went on to explain the complexities of implementing the TB Caucus and how it would interact with different levels of government.

The Chairperson thanked the Minister for her response and then gave Dr Kariem the opportunity to answer further questions.

Dr Saadiq Kariem Chief Operating Officer, Western Cape Department of Health, noted that he would provide the detailed breakdown of demographics to Ms Windvogel. The linkage to care programme is clearly beneficial and the loss to follow-up rates give a clear indication of the number of patients collecting their medication and completing their TB treatment. He explained to Mr Van der Westhuizen that the statistics displayed on the first few slides of the presentation do indicate that they are exceeding the numbers and that TB-specific testing has increased. This is a good thing because if the TB exposure cases do not increase, it means that they are not doing enough testing. The goal is to find these TB-positive patients and admit them into hospital so that they can receive the proper treatment.

Dr Kariem clarified that there is no BCG vaccine shortage at the moment as there is currently a nine-week supply. As for the national database, there is no system like that in place as yet. A tele-health initiative was started during the pandemic, and this will hopefully be expanded to TB, HIV and diabetes. It is not just a case of the SMS reaching people but there is a project that has been implemented with colleagues from the Gates Foundation that will eventually develop enough to phone people and inform them if they have tested positive for TB and then assist these patients with linkage to care. He did specify that the challenge with this would be that many cell phone numbers are not correct or still active, making it difficult to reach these people.

Dr Vanessa Moodley, Public Health Registrar for Service Priorities Coordination, noted that the loss to follow-up rate is a cause for concern. The approach has shifted from in-hospital treatment to treating people within their communities and so the onus falls upon the Department to ensure that these patients stay consistent with their treatment. Different methods of making treatment more accessible to patients are in the process of being trialled.

Western Cape Minister Mbombo recalled occasions when interventions were not available, such as in the Winelands and the West Coast. The solutions were not as easy in these areas. On the loss to follow-up, the unique patient identifier assists medical practitioners in identifying which patients still need to or are in the process of receiving TB treatment, regardless of where they are in the province. This has seen to be vital in cases where some patients are reluctant to approach for medical assistance in different areas because they would have had to restart their antiretroviral treatment. With the unique patient identifier, this is not necessary.

Mr Marais asked if the system of home carers is still in place, and if not, why not. Many people are not able to travel all the way to the nearest medical facility to receive their treatment, so while they may still want to undergo TB treatment, they are not able to. He asked what nutritional resources can be made available to impoverished people. If their immune systems are jeopardised, they are more at risk of contracting TB.

Dr Kariem explained that the community health workers do the screening for people who cannot come to the clinics in the province. There are roughly 3 800 community health workers in the Western Cape, metro and rural combined. The nutritional status of these people is a problem, and Dr Kariem noted that during a meeting last week, the nutritional programme would pick up on TB patients who are severely at risk of malnutrition. This programme places them on nutritional support with clinics and the Department of Social Development.

Dr Theron said that there is a unique patient identifier now that spans across all the provinces to track patients with drug-resistant TB. Information systems puts the Western Cape ahead of other provinces, but also makes it more difficult to track these patients because other provinces do not have the same information technology to keep track of these patients. Patients with TB who suffer from malnutrition do receive support from dietitians and when they are admitted to hospitals, they receive high protein diets to assist their immune system.

Minister Mbombo added that there are social determinants of health. Upstream factors need to be tackled by the other sectors because they end up in the healthcare system. Food is medicine, but due to poverty many people are unable to address lack of proper nutrition until their immune systems are so compromised that they become ill with diseases like TB.

Mr van der Westhuizen asked if a patient from a very rural community tested positive for TB, would the entire community be made a point of focus? He pointed out that in rural communities it is unlikely that an entire community would get tested for TB, but the likelihood of there being more than one person with TB is much greater if there are positive TB cases within the community itself. Would the Department then reach out to this community to test the people to identify other possible carriers of the disease?

Ms A Bans (ANC) asked if statistics could be provided of how many hospitals and clinics received training on drug resistance management integrated into primary healthcare, as well as how many TB-only clinics and hospitals there are in the entire province.

Dr Theron replied that mobile clinics are dispatched to treat and care for people in rural settings. These mobile clinics will have either clinical practitioners or professional clinical nurses and they drive either every two weeks or once a month to these areas. These mobile clinics screen for TB each time, and if there is a positive TB case, the family and close relations of that person are also screened as precaution. The relationship built between the communities and the healthcare practitioner in the mobile clinics is very special, more so than the relationship between patients and healthcare workers in metro hospitals. These clinics are not open on the weekends, but their feedback is vital to the primary healthcare system.

Currently there are six hospitals in the Western Cape that admit TB patients. The reason for the decentralisation is because when the number of TB cases was high, the hospitals could not admit all the drug-resistant TB patients so many received treatment from the sub-districts until beds were available. The new drugs for TB treatment that have become available have ensured much better adherence to the treatment and the outcome of these patients.

Dr Kariem said that the criteria for those who are screened has expanded as part of TUTT, which allows for a greater number of people to be screened for TB. Contacts are also screened along with people who fall into the other criteria.

Mr Marais asked if unemployment had an impact on volunteers and if crime impacted the number of TB cases. He asked if it would be possible to find out if benefits could be accrued to volunteers who visit sick people who have TB or HIV, such as the “danger allowance” that police reservists receive. He urged the Committee to approach the Premier about this.

Ms Windvogel asked for a breakdown of the vaccines in different regions so as to see why there were fewer vaccines administered in the West Coast. The province has struggled to achieve some of its annual TB targets and asked if this strategy would help improve the province’s performance with TB programmes.

Mr van der Westhuizen asked if there was a way of keeping track of babies that are unable to receive their BCG vaccine upon birth for reasons such as their mothers already having TB. Could these babies be vaccinated at clinics later on?

Dr Kariem replied that BCG vaccinations are closely monitored, but with COVID-19 there was a drop in vaccinations that were administered. The Road-to-Health card not only monitors malnutrition but also keeps track of vaccinations. Healthcare workers are trained to check on the vaccinations on the Road-to-Health card as part of standard screening procedure.

BCG-vaccines are administered up until the age of one year, explained Dr Theron. Unless the patients have immune deficiency or HIV, they all receive BCG vaccines. Previously there was stock-out of the vaccine and the Department had to list all the babies who did not receive the vaccine and then these babies had to be traced to ensure they did get the vaccine. The West Coast is made up of rural areas and there is a lot of migratory movement that takes place during various farming seasons. All these factors contribute to the lower rate of BCG vaccinations in that region. Sometimes patients are born in a Level-2 hospital, but they do not reside in the area, so the birth is registered but it is difficult to trace the patients thereafter.

Dr Firfrey noted that there is a big difference between population and live births in the Western Cape compared to other provinces, especially in the West Coast. Another reason why the West Coast could have lower rates of vaccinations is because the babies are born outside of the region but then immunised within the West Coast.

Mr Marais asked if the volunteers could receive some form of gratuity or life insurance for the work they do, as it can be dangerous. Could this request be elevated to the Cabinet?

Dr Kariem replied that the Department mostly makes use of community health workers who have undergone training, and it prefers working through them because they have the training required. Sometimes stipends have been provided to some volunteers, but he would happily take concerns Mr Marais has and follow up.

Dr Theron pointed out that, as Dr Moodley indicated, they do not trust the population figures. The denominator is usually too high, and thus they work on an estimated figure of the population.

Dr Kariem said that he is in the process of concluding a partnership with the Gates Foundation that would hopefully secure about $5 million over a three-year period, along with other donors for the fight against TB.

The Chairperson thanked the Department and Minister.

Mr van der Westhuizen suggested that the Committee invite one or two community healthcare workers to discuss their training and their role in the community. He suggested that more information be gathered about the SMS notifications sent out to people who test positive for TB. It would be beneficial is SASSA could be utilised to identify communities who are at high risk of malnutrition and infectious diseases such as TB.

Mr Marais suggested that the Committee discuss the link between poverty, malnutrition and the impact that a solution for this problem would have on TB-related matters.

The Chairperson led the Committee through two sets of minutes that needed to be considered. Thereafter, she thanked the members for attending the meeting and for their participation.

The meeting was concluded.