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Implementation of FAST Approach in South Africa

Implementation of FAST Approach in South Africa
Publication date: 
Aug 2019

The FAST Approach

The central pillars of the FAST Approach for tuberculosis (TB) management include Finding TB cases, Actively screening, Separating safely and Treating them effectively to reduce transmission and avoid deaths as a result of TB. The Approach is based on the premise that most transmission of TB occurs from patients with unsuspected TB or unsuspected drug-resistance and whose disease is, therefore, not being effectively managed. The most important aspect of halting the transmission of TB in health facilities is thus to control the period between when a patient presents with a cough or other symptoms of TB, is diagnosed with TB and subsequently initiated on appropriate treatment. It is crucial to find and diagnose TB and drug-resistant TB (DR-TB) patients quickly and accurately in order halt transmission.

The significance of implementing the FAST Approach

South Africa ranks third amongst countries with the highest number of new TB infections. The South Africa National Department of Health (NDoH) has developed the National Policy and Strategy for Infection Prevention and Control (2007) and National Infection Prevention and Control Guidelines for TB, MDR- TB and XDR-TB (2015) however implementation of TB infection prevention measures in most health facilities, remains suboptimal. This raises risks for healthcare workers, patients and visitors to health facilities from acquiring TB infection.

In 2016, the NDoH in collaboration with the USAID Tuberculosis South Africa Project, adopted the FAST approach to contribute to efforts aimed at strengthening TB services in health facilities in the country. The approach was first implemented in April 2017 and by September 2019 it had been implemented scaled up from 81 to 142 health facilities covering five provinces namely; Eastern Cape, Gauteng, Free State, KwaZulu-Natal and Limpopo. To successfully implement the FAST Approach, orientation and training workshops were conducted for healthcare workers (HCWs) at across various facilities in the identified provinces.

The USAID Tuberculosis South Africa Project began implementing the FAST Approach in South Africa in April 2017. By September 2019, the Approach had been scaled up from 81 to 142 health care facilities. The Approach was introduced in five provinces: Eastern Cape, Gauteng, Free State, KwaZulu-Natal and Limpopo.

To successfully implement the FAST Approach, multiple training and orientation workshops were convened for healthcare workers (HCWs) at various levels.

To support the implementation of the Approach, an implementation guide which outlines basic information on resources, processes and procedures needed for the successful implementation of FAST was developed. In addition, posters outlining the patient process flow and pamphlets aimed at educating patients and health workers were developed and disseminated to the facilities as shown below.

A National FAST workshop hosted by the USAID Tuberculosis South Africa Project to review guidelines and discuss barriers and challenges for implementing a standardized infection control initiative in health facilities was held on 17th – 18th August 2017. The workshop was attended by 150 managers working in TB and HAST (HIV and AIDS / STI / TB) units, infection control, quality assurance, hospital services and occupational health units across all nine provinces in South Africa.

Basic TB management and orientated on the following elements of IPC in health settings:

  • Fit testing for respirators
  • How to wear N95 respirators
  • Establishing Infection Prevention and Control (IPC) committees and roles of the committee
  • Conducting IPC risk assessments

A checklist to monitor compliance to IPC measures has been developed and is currently being implemented in FAST facilities.

Achievements of the FAST Approach

Between April 2017 and June 2019, the USAID TB South Africa Project increased TB screening 9-fold from 2, 92 518 / 6, 60 006 (44%) to 26, 144 66 / 29, 372 07 (89%), tested 59, 514, an increase from 10, 460 in 2017, diagnosed 7, 570 patients with drug susceptible TB (DS-TB) and 369 patients with drug-resistant TB (DR-TB) using GeneXpert. The patients were found in both inpatient and outpatient departments.

The intervention consistently achieved over 90% treatment initiation rate which is attributed to reduced time to diagnosis. Although the number of patients tested in 2018 is small, there are improvements in both median time (0.8 days) to diagnosis and treatment initiation rate compared to baseline of 4 days.

The decrease in the time to diagnosis and treatment initiation indicates that the approach has potential to contribute in effectively detecting unsuspected DS/DR-TB cases in health facility wards admitting key populations and other areas where screening is not routinely conducted. The TB positivity rate in wards admitting key population patients between 2018 annual to June 2019 was 2, 341 in 79 FAST sites.

Overall the turnaround time (TAT) has decreased from 4,0 days to 1,4 days in patients who were diagnosed through GeneXpert. In addition, the proportion of patients put on treatment increased from 61% to 85.6% within 1.4 days of sputum collection.

Implementation of Urinary Lipoarabinomannan (U-LAM)

The USAID TB South Africa Project has also supported the implementation of Urinary lipoarabinomannan (U-LAM) in facilities implementing FAST in Eastern Cape, Free State, Kwa-Zulu Natal and Limpopo provinces. U-LAM is a test to diagnose TB in people living with HIV. The table below (Table 2) represents data from FAST sites in KwaZulu Natal and Eastern Cape provinces. Of 1, 370 people living with HIV who have a low CD4 count (less than or equal to 100 cells/ul) and 1, 123 people living with HIV who are seriously ill (determined based on four signs, respiratory rate > 30/min; temperature > 390C; heart rate > 120/min; unable to walk unaided) and regardless of low CD4 count, TB was detected in 575/1, 846 (31%) patients and 90% of whom were initiated on treatment.

Lessons Learned

Through implementing the FAST approach in 142 facilities across 5 provinces, unsuspected TB and DR-TB cases were identified and initiated on treatment. These cases would have been undetected and untreated without this intervention. Several lessons have been learnt by the project and they include the following:

  1. Leadership buy in and support is a critical first step in implementing the FAST approach.
  2. The FAST approach is a team approach that should be integrated into existing health facility management systems, with the support of existing staff.
  3. During the introduction phase process indicators need to be identified and monitored weekly.
  4. During implementation and scale up, indicators need to be monitored monthly to evaluate impact.