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Finding Missing TB Patients Report

Finding Missing TB Patients Report
Publication date: 
Aug 2019

TB in South Africa

In 2017, South Africa notified 227,224 tuberculosis (TB) patients against the World Health Organisation’s (WHO) estimations of 332,000 patients in the same year.  This indicates that an estimated 104,776 TB patients were not diagnosed, notified or ever enrolled in the national treatment programmes. These TB patients have in essence been missed by the country’s health system are therefore referred to as “missing TB patients”. The missing TB patients include patients with undiagnosed TB in communities, or those missed by the health system at the time of diagnosis, treatment or reporting. These system constraints pose a major obstacle to achieving the END TB Strategy targets by 2035 and will require further effort and resources. Missing TB patients therefore remain an urgent priority to find and link to proper care.

The Government of South Africa (GoSA) had a set target to find 25% (40,000) of missing TB patients by September 2018, and 50% (80,000) of all missing TB patients by end of the government’s fiscal year in March 2019.  Activities to find missing TB patients are linked to the National Health Screening and Testing Campaign, which aims to diagnose people with HIV, TB, diabetes and hypertension as the first step to initiating them on appropriate treatment.  Approximately 60% of reported TB patients are co-infected with HIV and the link to the campaign is synergistic in finding missing TB patients. The USAID TB South Africa Project was given a target by the National Department of Health to find 15,000 missing TB patients by September 2018. The project  exceeded this target by reaching 15,603 patients. Comparatively, the Global Fund to Fight AIDS, Tuberculosis and Malaria found 2,575 patients and provincial health units found 1,171 patients.  As of June 2019, the Project has found 20,422 missing TB patients and linked 94% of them to care.

The National Department of Health (NDoH) has placed its Missing TB Patients strategy at the centre of its response (in addition to existing interventions) for the country to make meaningful progress in ending the TB epidemic as highlighted in the figure below.  Since there are multiple programmatic gaps in the cascade, various interventions are being applied to improve care as listed below.

Key NDoH interventions to address the gaps:

  1. Optimised TB screening 
  2. Efficient contact tracing of index cases
  3. Enhanced case detection among key populations
  4. Improving diagnostic yield through new diagnostic tools and revised algorithms
  5. Improved quality standards in recording and reporting and tracking patient transfers between facilities. 

USAID TB South Africa Project Support 

The United States Agency for International Development’s (USAID) Tuberculosis South Africa Project has the primary objective of providing technical assistance to the Government of South Africa (GoSA) to reduce the burden of tuberculosis (TB) in the country.  The objectives of the USAID TB South Africa Project are to: 

  • Reduce TB infections;
  • Increase sustainability of effective TB response systems; and 
  • Improve care and treatment of vulnerable populations. 

The Project supports 14 districts across six provinces, including eight of the districts prioritised by the NDoH in its Missing TB Patients strategy; eThekwini in Kwa-Zulu Natal, Nelson Mandela Bay Metro and O.R. Tambo in the Eastern Cape; Mangaung in the Free State; City of Johannesburg and Tshwane in Gauteng; Sekhukhune in Limpopo; and City of Cape Town in the Western Cape Province.
 
The USAID TB South Africa Project is implementing seven interventions aligned to the government strategies, targeting undetected TB patients at various levels from community to private and public health facilities. 

Finding Missing Patients Project Interventions

Interventions implemented by the project use a targeted approach to address missed opportunities for finding patients at community level as well as those missed by the health system, helping to bridge the multiple gaps in diagnosis, treatment and reporting.  

The FAST Approach

The FAST strategy, which stands for Finding TB cases Actively, Separately safely, and Treating effectively, is a quality improvement intervention aimed to reduce the spread of TB in congregate settings. FAST is primarily implemented in hospitals to strengthen TB services in the hospitals. Through FAST, all patients should be screened for TB at all hospital entry points. The FAST approach also aims to reduce the time from presentation to diagnosis using appropriate tests and initiation of treatment for patients with TB. As of March 2019, 143 hospitals are implementing the strategy of which 76 are directly supported by the project. The project expects further scale up to reach 189 hospitals by August 2019, of which 103 will be directly supported by the project. As of March 2019, the project has detected 7,478 TB patients through FAST interventions alone.

Contact Management

Through the Small Grants portfolio, the project funds community-based organisations who provide Directly Observed Treatment Support (DOTS) and contact tracing and management of identified index TB patients in project’s 14 directly supported districts. There are 31 funded NGO’s who provide contact management services to both DS and DR-TB patients which contribute to the missing TB patients target. As of March 2019, the project has identified 623 missing TB patients through contact management activities alone.

Targeted Active Case Finding

Additional community healthcare workers have been recruited from 22 project supported NGO’s to conducted targeted active case finding in identified hotspots. The community healthcare workers are placed both in communities and facilities to conduct TB screening, on-the-spot sputum collection (where possible) and linkage to care of diagnosed TB patients. This intervention alone has identified 3,530 missing TB patients as of March 2019.

Specialized Projects (key populations)

The project has a targeted and specialised intervention aimed at increasing TB case finding among certain a certain key population – migrant workers. The TB in Farms model of care intervention targets farm workers. The interventions strengthened efforts of patient identification, treatment, prevention and care of TB among the population. TB in Farms activities are being implemented in 4/14 supported districts namely, Sarah Baartman district, Eastern Cape province, West Coast district, Western Cape province, Sekhukhune and Waterberg district in Limpopo province. The project has identified 220 TB patients through this intervention alone as of March 2019.

Urine-LAM

Urine-LAM is a diagnostic test introduced to improve TB case detection among HIV positive patients. The test is currently specifically being used on HIV positive patients with a CD4 count of ≤100. The project is supporting roll out of Urine LAM in hospitals in the supported districts in Limpopo and KwaZulu-Natal provinces. As of March 2019, the project has identified 634 TB patients through U-LAM testing alone.

Linkage to Care – Initial Lost To Follow-Up (ILTFU)

Initial Lost to Follow up are patients who are diagnosed with TB but have not been initiated on treatment. The project uses lab results to track patients not yet initiated on treatment and link them back to care. The project has identified 956 missing patients as of March 2019 through this intervention alone.

Updating of records and Data clean up

This intervention refers to data management and strengthening the quality of recording, reporting and moving of patients between facilities. The intervention aims to have all diagnosed TB patients correctly registered into TIER.Net/ ETR, the TB reporting systems along all the referral pathways. Data audits alone have identified 6,129 missing patients through March 2019.

Results

The project implemented the above strategies to identify missing TB patients with the following results below as of June 2019. A total of 679 patients have been identified through contact management while 3,989 were identified through intensified case finding activities at community level. In the supported hospitals implementing FAST, 7,328 patients were diagnosed with TB and 1,071 patients were diagnosed with U-LAM in the hospitals. A total of 956 patients were traced and linked to care through the ILTFU  intervention  and, 270 farm workers were diagnosed with TB through project led key populations intervention. Data clean up exercises led to updating of 6,129 patients whose records were incorrectly entered leading to the underreporting of the TB patients in the supported districts.

Sustainability

The USAID Tuberculosis South Africa Project has made meaningful contributions towards finding missing TB patients in South Africa. Implementation of the various strategies demonstrated that applying customised targeted interventions yields good results. The project will continue to support the Government of South Africa to scale up efforts of finding the missing patients along the TB care cascade through these targeted interventions to bring more people into care, to better retain patients in the health system and to improve TB treatment outcomes.