Implementation of Home-Based Care; Status Report on Cholera, Malaria and Meningitis: briefing

Meeting report

SOCIAL SERVICES SELECT COMMITTEE
23 October 2001
IMPLEMENTATION OF HOME-BASED CARE; STATUS REPORT ON CHOLERA, MALARIA AND MENINGITIS: BRIEFING

Chairperson: Ms L Jacobus

Relevant Documents:
Presentation on the Implementation of Home Based Care in South Africa (awaited)
Status Report on Cholera in South Africa (Appendix 1)
Status Report on Malaria
Status Report on Meningitis

SUMMARY
The Committee was informed by the Department that malaria transmission is seasonal with the majority of infections developing between October and May. During the year 2000, South Africa recorded the highest number of malaria cases that is 61,934 for the past 50 years and that mortality rate of between 0.6% has been recorded for the previous seasons. During the 2000/01 season, the mortality rate has dropped to 0.5%.
The Committee was also informed that a study of the previous cholera epidemic had shown that it re-emerges to epidemic proportions every 8-10 years during which period it shows seasonal trends. There is an increase in the number of cases during rainy season starting in August or September and reaching a peak in December and January noting that areas showing more than 600 mm of rain are more affected.
With respect to home-based care it was concluded that attention needs to be given to capacity building and training priorities

Status Report on Malaria
Mr Devanand Moonasa (Vector Borne Diseases: Department of Health) noted that malaria occurs in the low altitude areas of the Northern Province, Mpumalanga and the north-eastern parts of Kwazulu-Natal. He said that occasionally limited focal transmission might develop in the North-West and Northern Cape provinces along the Limpopo and Orange Rivers.

Malaria transmission is seasonal with the majority of infections developing between October and May. During the year 2000, South Africa recorded the highest number of malaria cases - 61,934 - in the past 50 years and a mortality rate of up to 0.6% has been recorded for the previous seasons. For the 2000/01 season, the mortality rate has dropped to 0.5%.

Mr Moonasa said that Plasmodium Falciparum is responsible for over 95% of locally acquired infections and that high levels of resistance to sulfadoxine-pyrimethamine have been found among plasmodium falciparum infections in Northern Kwazulu-Natal.

Resistance has been reported from Mpumalanga province and the high levels of resistance in Kwazulu-Natal were partly responsible for the massive increase in malaria in the province. This resistance necessitated a change in the first line of treatment in Kwazulu-Natal from sulphadoxine-pyrimethame to co-artmetre.

In 1999, a mosquito vector, Anopheles Funestus, was found in northern Kwazulu-Natal and subsequent studies have shown that these mosquitoes are resistance to pyrethroid and may also be resistance to carbamates. He added that the presence of insecticide-resistant anopheles funestus necessitated the reintroduction of DDT.

Mr Moonasa said that population migration from neighbouring countries into South Africa continues to pose problems. He noted that many migrants are semi-immune and that up to 20% have been found infected without displaying any signs of illness.

These asymptotic carriers are responsible for local outbreaks of epidemics resulting in an increasing number of cases occurring in the low risk malaria areas.

During the past few years, increasing prosperity has resulted in the contents of dwellings changing from a minimal sleeping mat and clothing box to rooms full of furniture and furnishings, providing more mosquito resting sites which reduces the effective application of insecticides.

Travel for work, drug resistance, insecticide resistance and human and vector behaviour contribute and influence the transmission of malaria.

Mr Moonasa said that during the past season, rapid diagnostic tests were introduced at all health facilities in the province. These tests would now complement the microscopic examination of blood, which is in place at some of the health facilities.

Patients with severe malaria infections are admitted to hospital and treated with quinine orally or intravenously together with supportive treatment. Infected children less than one year of age and pregnant women are referred to hospital for treatment with quinine as well.

Mr Moonasa noted that spraying of residue insecticide in South Africa has proven to be one of the most effective methods of controlling malaria vectors that feed indoors. The dwellings are sprayed before the main transmission season, commonly before the end of December, with mop-up spraying conducted if warranted.

The Malaria Control Programme in Kwazulu-Natal procured 82 000 nets through emergency funds. These nets are presently sold for R20 but pregnant women receive free bed-nets from the health institutions on their first visit. He added that the sale of bed-nets is through community committees and the committees, as an incentive, retain part of the money.

Noting that communities in high-risk areas own and use nets, Mpumalanga and Northern Province have each bought 50 000 and 30 000 bed-nets respectively.

Communities have been involved in application of larvicides in their immediate surroundings and they have also assisted in environmental management of areas in their immediate vicinity.

Continuous health education messages are being broadcast by local radio stations and that information on the distribution and prevalence of vector mosquito is essential for the planning and assessment of control operations

On the budget, Mr Moonasa said that the budget for malaria control for the National Department of Health and the three malaria endemic provinces was R82 million for the 2000/2001 financial year. During the past year, an additional R39 million was made available to the malaria control programme, and this was part of the disaster relief effort due to high rainfall in the eastern parts of the country.

Mr Moonasa said that through the re-introduction of the DDT and the bed-nets for impregnated women, a major decline was seen in the incidence of malaria. He also said that evaluation and introduction of rapid diagnosis tests at all health centres has borne some fruits.

Speaking on the constraints the Department is faced with, Mr Moonasa said that some of the malaria control officers in the province are not adequately trained on general aspects of malaria control task. A training course is planned to address this issue.

There is also a lack of entomological capacity for vector studies and monitoring of insecticide resistance and that incentives will need to be created for students to be trained on the medical entomology.

A malaria awareness week is planned for the first week of November 2001 and campaigns will be run throughout the country in all malaria risk areas. A database will be developed and linked to GCIS for vector distribution and vector operations. He added that it is also intended to link the Department of Health to the information system run in the provinces.

Status Report on Cholera and Meningitis
Dr Uma Nagpal said that the epidemic started in Kwazulu-Natal in mid August 2000 and has affected more than 105 000 people in the province. She said that the epidemic has also spread to Northern province, Mpumalanga and Gauteng and that the Eastern Cape, Free SATE, North-west and the Western Cape have only had isolated imported cases.

Dr Nagpal said that various documents on the management and control of cholera in South Africa have been developed which included Guidelines for Cholera Control, Strategy for Diseases, Outbreak Response and Epidemic Management in South Africa and strategy for Cholera Control in South Africa. Pamphlets and posters have also been designed to inform and educate communities.

General initiatives like reporting procedures and notification have been strengthened in provinces through epidemiological training provided jointly by the Directorates of Health Information and Research, Environmental Health, Health Promotions and the Communicable Disease Control.

Dr Nagpal informed the Committee that diarrhoea surveillance has been conducted throughout the country by SAIMR engaging in stereotyping of pathogens and assisting in gauging sensitivity patterns, thus enabling policy making in appropriate treatment regimes.

Outbreak response teams have been established at national, provincial and district levels and that co-ordinated action by the teams at all times of the year helps keep diseases from emerging. At another level, she continued, capacity building through training and attending or presenting at conferences or courses at national and international level is ongoing and is encouraged at all levels.

On specific interventions, Dr Nagpal informed the Committee that safe water supply in tanks and tankers, adequate sanitation facilities through building of toilets, health promotion activities through media, posters, pamphlets, video and health education regarding safe hygienic practices have been embarked upon.

Accessibility to health services by re-hydration tents in the affected areas and training of health personnel in proper management have gone a long way in keeping mortality to the minimal.

A World Health Organisation team visited South Africa during September 2000 and January 2001 and recommendations made were carried out at the provincial level. Following the WHO visit, a full-time epidemiologist has been seconded by the WHO in Kwazulu-Natal since March 2001 and that a WHO epidemiologist, Dr Mugero, made a presentation to the National Cholera Task Team after field visits and analysis of data.

Dr Nagpal observed that although cholera is on the decline, this might be due to seasonal trends as well as active interventions. Cholera is endemic in South Africa and Kwazulu-Natal reports about 30 cases per year.

A study of the previous epidemic has shown that it re-emerges to epidemic proportions every 8-10 years during which period, she said, it shows seasonal trends. There is an increase in the number of cases during rainy season starting in August or September and reaching a peak in December and January noting that areas showing more than 600 mm of rain are more affected.

In the case of meningitis, Dr Nagpal said that it occurs through out the year but shows seasonal trends and increases in winter months and peaks toward the end of the winter. The Western Cape has a higher number of cases annually in comparison to all other provinces, but has not reported an upward trend from last year. She said the expected number of cases per year is 190 to 220.

The role of the Department of Health is to perform a supportive and monitoring function. On the other hand the Communicable Disease Control Co-ordinator is responsible for keeping track of the cases and ensuring that appropriate interventions are in place and to offer support to the provinces in case of need.

Dr Nagpal concluded that the provincial communicable disease control unit has an outbreak response team, comprising of the outbreak response co-ordinator, the environmental health officer and a health educator. She said most districts have similar teams to trigger a quick response.

Briefing on Home Based Care
Mr Cornelius Libilo said that Home Based Care (HBC) is defined as the provision of comprehensive services, which include health and social services by formal and informal caregivers in the home.

In June 2000, a joint team of Health and Social Development MINMECS decided that Departments should develop a cost integrated models for Home Based Care and Community Based Care programme.

He informed the Committee that in January 2001, the joint Health and Social Development Departments presented the HBC models and it was approved by the MINMEC. In June 2001, a national workshop was conducted with approximately 65 delegates including provincial representatives, national NGOs, traditional healers and traditional leaders and other departments.

He said that the purpose of the workshop was to obtain suggestions from the various stakeholders and to develop implementation plans for the roll out of the home based care programme. A decision was taken at the workshop to conduct a rapid appraisal of existing home based care initiatives country-wide with the purpose of establishing gaps in service delivery and strengthening existing initiatives based on a needs assessment of each initiative.

A tool was developed jointly with the Department of Social Development in conjunction with the provinces and the process is currently in progress of implementation. The countrywide report would be completed by mid-November wherefore a process of assessing the needs of existing initiatives will be undertaken.

Mr Libilo pointed out that the process of establishing new initiatives where none exists has already begun and that district-based approach is being adopted where a district will be selected as a central point of cluster of districts around it. He said that the central district will serve as a training site for the surrounding districts which, he clarified does not mean that implementation will be delayed in other districts.

He said that a series of provincial workshops have in the interim commenced and will be completed by the end of November. He noted that the workshops are complementary to the national workshop held in June this year and that they are intended for provincial stakeholders wherein the rollout plan for each province will be drafted.

Mr Libilo said that implementation of the HBC programme is currently occurring in terms of the National Integrated Plan for Children and Youth Infected and Affected by HIV/AIDS in the Eastern Cape’s Tsolo area, De Aar in Northern Cape and in Jouberton situated in North West province. Other areas are Polokwane, Maraba and Mashashane all in Northern Province, Tonga in Mpumalanga and Welkom in the Free State Province.

Provincial and local co-ordinating structure which have been established and all sites are providing services and social relief to beneficiaries.

Home based care suppliers are being provided and the partnership and pooling of limited resources is taking place while in the Free State province the four cluster approach with specific responsibilities such as support, IEC, HBC and counselling are provided. In all, the programme has impacted 21 300 beneficiaries.

Altogether 1350 caregivers have been trained and there is ongoing support, guidance and monitoring provided in the existing projects. PWA is actively involved in the project and that co-ordinators have been appointed in six provinces. He pointed out that approximately 52 NGOs providing HBC services have so far been funded.

He said that the challenges facing implementation were mechanisms for integration between various stakeholders and the slow pace of country mobilisation. Institutional arrangements are not in place while the conditional grant option is accompanied by procedures that need to be understood well and adhered to before any progress can be made.

Mr Libilo concluded that the way forward was to give attention to capacity building and training priorities. The Department is currently in the process of continuing its train-the-trainer programme in home based care. It is also in the process of advertising a tender for home based care suppliers.

Discussion
A member asked for an explanation of what constitutes a team and how their could be involvement in NGO activities.

Mr Cornelius Libilo said that there is an ongoing effort to get the provincial legislator to assist with the decimation of information to the people. There is a policy document available on what constitutes a team and a whole range of other guidelines on NGO work initiatives. He said that basically one needed to first establish a secretariat, appoint a Co-ordinator and care givers who report to the Co-ordinator. He added that most of the Health Care programmes have been implemented by NGOs with government support. The Department had trained ten master trainers and he promised to supply the Committee with their names and contact address.

A Member said that people complain that there are delays in the processing of their applications. Why was this the case?

Mr Cornelius said that the question of delay had two sides to the coin. The process has to start with the community, which must in the first place acknowledge that it has a problem then approach the Department for assistance. Projects have to start from point zero and establishing the necessary structures can and do take considerable time. The question of timing, really, differs from community to community and from resource to resource.

Ms Vilakazi (IFP) said the meningitis epidemic is recurrent and show no signs of abating. What causes the virus and is there an effective master plan to eradicate it?

Ms Lubidla (ANC) asked Dr Nagpal to explain the different type of meningitis and show the strain that is related to the HIV/AIDS pandemic.

Dr Nagpal replied that there were three different types of meningitis namely, viral, fungal and bacteria. The first type of meningitis was not a serious strain while the second one was serious but non-life threatening and that it was the one related to HIV/AIDS. The third type was the most lethal one and that it can cause instant death if no treatment is accessed immediately.

She explained further that the bacteria meningitis afflicts the brain and it was the main cause of opportunistic infections. This type requires immediate access to antibiotics to avoid sudden death. Dr Nagpal said that there has been a drastic decline in reported cases of meningitis and that steps have been taken to educate communities on how to handle an outbreak.

Mr Tlhagale (UCDP) said that Dr Moonasa had mentioned that climatic conditions were related to the outbreak of meningitis. If this position were true then what makes the Gauteng province susceptible to the epidemic yet its climatic conditions were more or less like other non-meningitis-prone provinces?

Dr Nagpal replied that some strains of meningitis were caused by weather conditions but that generally there was no defined character for the distribution as such. Some of the epidemic is attributable to life styles and not climatic conditions as such.

The Chair said that Mr Libilo had referred to new sites and asked whether there were news sites created in addition to the existing ones. She also wanted to know the process, which those interested in participating in NGOs, are expected to undertake.

Mr Libilo replied that the new sites are the ones the Department is concentrating on but that there were other related initiatives spread out in the provinces.

People are in dire need of information around the issue of NGO work in order to understand the underlying process. He said that people have been submitting applications for funding but that the Department has directed them to first indicate how many care givers they marshalled for the project before funding is made available. Once a project is accepted the Department gives R 500 per month, which is only a subsidy, and that the NGO has to top up on this.

He said that any NGO is free to apply so long as they can indicate that they have competent people who can provide services to the home care programme. He added that the onus was entirely on the NGO to set up the structure of the programme. The Department is currently putting up a policy on control of funding.

The Chair said that the data information Mr Cornelius had referred to very useful and that he should try to avail it to Members.

Dr Nel (NNP) observed that the malaria parasite differs from region to region. He then asked whether the Department supplies doctors with the necessary guidelines on the treatment regime.

Mr Moonasa replied that in South Africa plamonium specie of malaria was the most prevalent. The Department was still redefining the appropriate intervention and that treatment guidelines are in the process of being made available to practitioners.

Ms Vilakazi (ANC) said that the incident of cholera was very high in Kwazulu-Natal but that there has been some decline in recent past. She then asked what the present status of cholera was in the province.

Dr Nagpal agreed with Ms Vilakazi that there has been a marked decline in cholera incidents in the Kwazulu-Natal province. He attributed this to a relentless prevention and curative campaign that involved several combined intervention measures. She referred Ms Vilakazi to the data graph for the current status of Cholera in the province.

Mr Tlhagale (UCDP) noted that malaria was most prevalent in the eastern region of the country and this was mainly due to the movement of people across the border. He asked whether people on the other side of the border are vaccinated before they enter the country.

Mr Moonasa replied that there was no known vaccine for malaria but that there were treatment regimes that would minimise chances of infection. The border problem was that people from the neighbouring countries were immune to the malaria virus whilst they were carriers. He said the issue of cross border control was an explosive political landmine, which must be handled at the highest level of government.

Ms Vilakazi (IFP) said that in 1998 when the use of DDT was stopped the malaria epidemic more than trebled in Kwazulu-Natal province and many people died as a consequence. Why was this measure discontinued in the first place only to be re-introduced later?

Mr Moonasa replied that from 1946, South Africa was using the DDT successfully but it contains pesticide that does not decompose in the soil and so it poses a serious environmental danger and that is why it was discontinued.

He added that the use of DDT was reintroduced in 1999-2000 when malaria spiralled out of control. DDT is, however, used on a very limited scale in Kwazulu-Natal, Northern Province and in Mpumalanga.

The meeting was adjourned.

Appendix 1:
STATUS REPORT ON CHOLERA IN SOUTH AFRICA
Introduction

The epidemic started in KwaZulu-Natal in Mid August 2000 and has affected more than 105 000 people in the province. It has also spread to Northern Province, Mpumalanga and Gauteng. The Eastern Cape, Free State, North West and the Western Cape have only had isolated imported cases.

The provincial health departments have played an active part in the control of cholera along with other departments such as Water Affairs and Forestry, South African National Defense Force, Local Government and Education.

Actions taken by the health sector
Development of policies and strategies

Various documents on the management and control of cholera in South Africa have been developed. These included Guidelines for Cholera Control, Strategy for Disease Outbreak Response and Epidemic Management in South Africa and Strategy for Cholera Control in South Africa. Pamphlets and posters have also been designed to inform and educate communities.

Activities undertaken
General initiatives

The following activities have been performed:

Tally sheets, data collection and usage at district level has been re enforced.

Reporting procedures and notification have been strengthened in provinces through epidemiological training provided jointly by the Directorates Health Information and Research, Environmental Health, Health Promotions and Communicable Disease Control.

Laboratory support through referral laboratories as well as training conducted from time to time by referral laboratories and SAIMR.

Diarrheal surveillance has been conducted throughout the country by SAIMR engaging in serotyping of pathogens and assisting in gauging sensitivity patterns, thus enabling policy making in appropriate treatment regimes.

Outbreak response teams have been established at national, provincial and district levels. Coordinated action by the teams at all times of the year helps keep diseases from emerging. Teamwork during outbreaks helps achieve prevention of epidemics.
Capacity building through training and attending or presenting at conferences or courses at national and international level is ongoing and is encouraged at all levels.

Specific initiatives

Interventions in the form of safe water supply by tanks and tankers, adequate sanitation facilities through building of toilets, health promotion activities through media, posters, pamphlets, videos and health education regarding safe hygienic practices have been embarked on. Accessibility to health services by re-hydration tents in the affected areas and training of health personnel in proper management have gone a long way in keeping mortality to the minimum.

The national Department of Health played an active supportive role in all at-risk provinces by way of training, field visits, liaison with laboratories, national experts, international experts (WHO) and intra-departmental and inter-sectoral collaboration through a national Cholera Task Team. The national Department of Health also facilitated funding and redeployment of staff.

A World Health Organization team visited South Africa during September 2000 and in January 2001. Recommendations made then were carried out at the provincial level. A full time epidemiologist has been seconded by the WHO in KwaZulu-Natal since March 2001. A presentation was made by the WHO epidemiologist, Dr. Mugero, to the national Cholera Task Team after field visits and analysis of data.

His recommendations are as follows:

-Coordination of epidemic control
-Strengthen the Inter-ministerial Committee
-Review roles and linkages of different sectors involved in epidemic control.
-Involvement of all potential role players including community leaders, NGOs, local organizations, traditional healers etc. at district and sub-district levels.
-Rapid assessment of water and sanitation status in institutions (schools and farms); and ensure conformity to minimum standards.

Although Cholera is on the decline, this may be due to seasonal trends as well as active interventions. Endemicity of Cholera in South Africa is a fact.

Outcomes
Disease data

The latest cholera statistics (8 October 2001) in the country are as follows:

The new cases per day have reduced from over 1200 to approximately 10 per day which is indicative of a clear decline in the epidemic.

The case fatality rate of 0,22% is indicative of good case management as the world accepted figure for case fatality rate in cholera is 5%.

Cholera has been treated throughout the country by adhering to the national policy of "treatment without antibiotics except in very severe cases where ciprofloxaccin could be advised." This has not only led to a financial saving but also we could have lost the drug through development of resistance had it been used indiscriminately.

Trends

Cholera is endemic in South Africa. KwaZulu-Natal reports about 30 cases per year. A study of previous epidemics has shown that it re-emerges to epidemic proportions every 8-10 years. During the epidemic too it shows seasonal trends. There is an increase in the number of cases during rainy season. Starting in August or September and reaching a peak in December and January. Areas showing more than 600 mm of rain are more affected.