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Contact management as an effective strategy for finding missing TB cases in community settings in South Africa

Contact management as an effective strategy for finding missing TB cases in community settings in South Africa
Publication date: 
Apr 2019

Background 

According to the World Health Organization(WHO), Tuberculosis (TB) contacts are people who have close contact with patients with infectious TB and are therefore at high risk of TB infection.  WHO recommends that TB contacts should be investigated systematically and actively for TB infection and disease through a process called ‘tuberculosis contact investigations’. Many studies in countries with a high TB incidence have shown that the prevalence of TB among household contacts may reach 5 per cent or more. Even studies conducted in South Africa identified a high yield of TB cases among household contacts of TB patients and even higher in HIV infected contacts.

Goal 3 of the South African National Strategic Plan for HIV,  TB and STIs (2017-2022) focuses on reaching all key and vulnerable populations with customised and targeted interventions. Among the key populations for TB included in the NSP are household contacts of TB index patients. The NSP envisages intensified TB case-finding in the prioritised key populations, including among household contacts of people with TB disease, healthcare workers, inmates, and people living in informal settlements. It further recommends that people with diabetes, HIV co-infection and every child contact of an adult TB patient should be screened for TB. 

To strengthen efforts by the Government of South Africa to reach household contacts of TB index cases with targeted interventions, the USAID TB South Africa Project contracted 39 Local Non-Governmental Organizations (NGOs) to provide a comprehensive package of services which includes TB awareness and education, TB screening and intensified case finding, contact management, improving linkage to care and treatment initiation for diagnosed patients as well as treatment adherence support to improve TB outcomes.   Asymptomatic contacts of smear negative DS and DR-TB have contact management done after diagnosis and every 6 months for DR-TB. or when there are evident symptoms. HIV positive contacts are followed up every 6 months for 2 years and encouraged to reports symptoms as soon as they become evident. Between October 2017 and March 2018, the NGOs conducted contact management in 15 districts in South Africa (Cape Winelands, West Coast, eThekwini, Umkhanyakude, Fezile Dabi, Mangaung, Nelson Mandela Bay Metro, OR Tambo, Sarah Baartman, Ehlanzeni, Gert Sibande, Waterberg, Sekhukhune, Vhembe) in 7 provinces in South Africa.

TB Contact Management Results

Between October 2017 and March 2019, a total of 12,177 TB index cases were reached with contact management done for 43,602 contacts. Of the adult contacts reached, 98% (42,715) were screened for TB with 21% (8,836) presumptive for TB; and 89% (7,862) of presumptive cases were tested for TB. Of those tested, 9% (710) were diagnosed with TB and 97% (689) successfully linked to care. Additionally, 4,014 children were reached and 97% (3,896) were screened for TB with 35% (1,374) presumptive for TB; 56% (775) were tested for TB resulting in 92 children being diagnosed with TB and 92% (85) successfully linked to care.  Cumulatively, the contact management activities conducted by local NGOs led to the diagnosis of 802 contacts of TB patients with TB.

The results demonstrate that through contact management the yield is significantly above the incidence in the awareness campaigns. Through contact management the NGOs produced the yield of 1,684 per 100,000 population, as compared to the awareness campaigns yield of 399 per 100,000 population during the same period.

Conclusion

Contact management conducted through local NGOs is an effective strategy of TB case finding in community settings. Although included in the NSP for HIV/TB and STIs, a number of challenges hinder TB contact tracing efforts. These challenges can be attributed to but are not limited to the following:

  • Fear of stigma and discrimination: Concerns over confidentiality and privacy can negatively affect TB contact tracing especially when patients do not want to disclose to their relatives, peers or workmates that they have TB for fear of being rejected, or stigmatised.
  • Difficulty in accessing households: Some patients give the incorrect physical addresses to their healthcare providers, while other, especially mobile populations, relocate. This makes tracing and follow up extremely difficult.  
  • Language barriers in contact tracing: This challenge emerged when healthcare workers provided services to migrants. Most foreign nationals had little or no understanding of local languages, making it difficult for health care workers to communicate with them.