Cape Town TB Control
•
A Partnership between the Provincial Administration of the Western Cape Metropole Region and the City of Cape Town
•
Progress Report 1997–2003
Cape Town
TB Control
A Partnership between the
Provincial Administration of the
Western Cape Metropole Region
and the City of Cape Town
Progress Report
1997–2003
Progress Report 1997–2003
•
A Partnership between the Provincial Administration of the Western Cape Metropole Region and the City of Cape Town
•
Cape Town TB Control
• CONTENTS
FOREWORD ........................................................................................ii
Acknowledgements ............................................................................. iv
List of acronyms .................................................................................. iv
1
INTRODUCTION ................................................................................ 1
2
BACKGROUND .................................................................................. 1
3
3.2
3.3
3.4
3.5
3.6
3.7
MONITORING AND QUALITY ASSURANCE ......................................... 2
Reporting............................................................................................ 3
National Electronic TB Register ............................................................. 3
Sub-District Reviews ............................................................................ 4
Training .............................................................................................. 5
TB Treatment Wheel............................................................................. 5
Community-based DOT Programme .................................................... 6
4
4.1
4.1.1
4.1.2
4.1.3
4.1.4
4.1.5
4.1.6
4.2
4.2.1
4.3
4.3.1
4.3.2
4.4
4.5
4.6
TB PROGRAMME PERFORMANCE ........................................................ 7
Case Finding Indicators ....................................................................... 7
Case Loads......................................................................................... 7
Incidence Rate (Case Detection Rate) ................................................... 9
Types of TB.......................................................................................... 9
Bacteriological Coverage................................................................... 11
Case Detection Initiative ................................................................... 13
New and re-treatment rates ............................................................... 14
Case Holding Indicators ................................................................... 15
Smear Conversion Rate ..................................................................... 15
Treatment Outcome Indicators ........................................................... 16
New smear Positive Cases.................................................................. 16
Re-treatment Smear Positive Cases ..................................................... 17
Community Dot Coverage ................................................................. 18
Voluntary Counselling and Testing for TB ............................................ 19
Sputum turn around times.................................................................. 19
5
TB AND HIV/AIDS/STI INTEGRATION................................................. 20
6
6.1
6.2
6.3
THE COST OF TB TREATMENT .......................................................... 21
Laboratory costs ................................................................................ 21
Drug costs ....................................................................................... 22
Total costs ......................................................................................... 22
7
CONCLUSION ................................................................................. 23
©2004
The information contained in this publication may be freely distributed
and reproduced as long as the source is acknowledged
and it is used for non-commercial purposes.
This publication is also available on the internet
http://www.hst.org.za
i
Progress Report 1997–2003
•
A Partnership between the Provincial Administration of the Western Cape Metropole Region and the City of Cape Town
•
Cape Town TB Control
•
FOREWORD
TB is one of the major contributors to the burden of disease in Cape Town with a
66 % increase in the number of reported TB cases over the last six years. Western
Cape Provincial Department of Health and the City of Cape Town are committed
to the effective control of TB, which is one of the key priorities. It is recognised that
HIV/AIDS epidemic does impact significantly on this increase. Notwithstanding the
increased incidence of TB, the TB Control Programme in the region has continued
to make improvements. This is being achieved by a concerted effort at every level
of the health services.
The high burden sub-districts, Khayelitsha, Nyanga and Oostenberg account for half
of the TB caseload and have contributed significantly to these achievements. In 2002
Athlone, South Peninsula and Tygerberg West sub-districts achieved cure rates of
above 80 %. Site B clinic in Khayelitsha treats over double the number of TB patients
than any other clinic in Cape Town and still managed to achieve a cure rate of
72 %, 2 % higher than the district average. This fine performance is proof that good
results can be achieved in spite of huge caseloads and should inspire other facilities.
Valhalla Park was the best performing clinic with a cure rate of 98 % for 2002.
The main reasons underlying the success of the programme include:
• A good information system that identifies problem areas and enables the
programme to focus its efforts
• Strong partnerships between City Health, Metro District Health Services, NGOs and
communities
• Dedication and commitment of health personnel and community-based workers
• Strengthening the capacity of the programme at facility level, including training
and support
Healthcare 2010 framework of the Department places a big emphasis on
strengthening the Primary Health Care services. There is also a great emphasis on
expanding community-based services. Senior management will continue to equitably
resource, encourage and support the high burden sub-districts in the year ahead.
The Integrated District Health Plan and the Integrated Development Plan (IDP) of
Cape Town includes HIV/AIDS and TB as a key priority and it is part of the strategy
to build cohesive, self-reliant communities.
The recent government decision to provide anti-retrovirals means a significant
investment in Primary Health Care and this provides an exciting opportunity to further
strengthen TB control. By exploring synergies with the HIV/AIDS programme, more
active TB case finding is one of the potential benefits.
TB is responsible for a third of all deaths in HIV infected people. In the light of a
dual HIV/TB epidemic, we cannot become complacent and allow our gains to be
reversed. The challenge for us all is to maintain the momentum and redouble our
efforts to increase case detection. This will require a higher index of suspicion and a
lower threshold for doing appropriate TB investigations. By bringing TB under control
an important contribution will be made to the fight against HIV/AIDS.
ii
Our congratulations and thanks go to all our staff, to the NGO’s who have assisted
us and to the community members who have contributed their time and effort.
Dr Ivan Toms
Director Health: City of Cape Town
Dr Lawrence Bitalo
Director: Metro District Health Services
Cape Town TB Control
•
A Partnership between the Provincial Administration of the Western Cape Metropole Region and the City of Cape Town
•
Progress Report 1997–2003
The challenge ahead is to continue to identify best practices that make the most of
our available resources and to integrate the provision of care. We remain focused on
our goals to strengthen performance management and to promote accountability.
iii
Progress Report 1997–2003
•
A Partnership between the Provincial Administration of the Western Cape Metropole Region and the City of Cape Town
•
Cape Town TB Control
• ACKNOWLED G E M E N T S
Appreciation is expressed to facility staff, TB NGO’s and community treatment
supporters for their co-operation and hard work, to the sub-district TB/HIV
coordinators for their commitment and dedication in improving TB Control and to
the clinical specialists for their continued technical support and guidance.
The support and leadership provided by City Health, Metro District Health Services
and Provincial Managers has underpinned these achievements.
This publication has been made possible through the combined efforts of the
Metropole TB Working Group and the Metropole TB/HIV Information Task Team.
Our grateful appreciation to Dr Neil Cameron from Community Health Department
at University of Stellenbosch for his support and clinical expertise in refining the
content of this document.
We thank Natalie Leon and Peter Barron from Health Systems Trust for the final
editing and for facilitating the publication of this document.
• LIST OF ACR O N Y M S
AIDS
ARV
BCH
COCT
CPD
DOTS
DOT
DPM
ETBR
HIV
INH
IUATLD
LA
MDHS
MDR
WC-NACOSA
NGO
NHLS
NTCP
TB
PGWC
STI
VCT
WHO
Acquired immuno Deficiency Syndrome
Anti Retroviral
Brooklyn Chest Hospital
City of Cape Town
Continued Professionl Development
Directly Observed Treatment Strategy
Directly Observed Treatment
DP Marais Hospital
Electronic Tuberculosis Register
Human Immuno Deficiency Virus
Isoniazid
International Union Against Tuberculosis and Lung Disease
Local Authority
Metro District Health Services
Multi Drug Resistance
Western Cape -Networking Aids Community of South Africa
Non-Governmental Organisation
National Health Laboratory Service
National TB Control Programme
Tuberculosis
Provincial Government of the Western Cape
Sexually Transmitted Infection
Voluntary Counselling & Testing
World Health Organisation
iii
Cape Town TB Control
•
A Partnership between the Provincial Administration of the Western Cape Metropole Region and the City of Cape Town
•
Progress Report 1997–2003
•
MAP OF CAP E T O W N M E T R O A R E A
29
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Progress Report 1997–2003
•
A Partnership between the Provincial Administration of the Western Cape Metropole Region and the City of Cape Town
•
Cape Town TB Control
1. INTRODUCTI O N
The reported incidence of tuberculosis (TB) in the Western Cape, particularly in
Cape Town, continues to be amongst the highest in the world, complicated and
exacerbated by the HIV/AIDS pandemic. Effective management of TB remains one of
the key principles of Provincial and Local Government health services. The increasing
recognition that HIV is fuelling the TB epidemic in high HIV prevalence populations
and that TB is a leading cause of HIV-related morbidity and mortality, has led to
broad multisectoral strategic plans to guide the response to both pandemics.
!
In Cape Town, TB Control has improved significantly. This report
provides an overview of TB control from 1997 to 2003.
The purpose of the report is:
• To document the progress of the TB Control Programme in the
district over the past seven years
• To acknowledge the outstanding contribution made by all involved
in the TB Control Programme, particularly the staff working on a
daily basis with people suffering from TB
• To highlight the resources and systems required for the provision of
adequate TB services
• To stimulate discussion with other interested parties who can
contribute and enrich our efforts to improve TB Control in South
Africa
• To inform and influence health policy and planning decisions in TB
control.
It is intended that future reports will be integrated to include HIV/AIDS and STI
indicators. This will be the last TB report according to the eleven sub-districts and
future reports will be according to the new eight sub-districts, which means that subdistrict profiles will change.
The Metropole TB Working Group would welcome discussion on this report and
invites readers to e-mail responses to:
• Judy Caldwell (jcaldwel@pgwc.gov.za)
• Virginia Azevedo (Virginia.Azevedo@capetown.gov.za).
For detailed sub-district data, please contact the authors.
2. BACKGROUN D
The Provincial Administration (PGWC) funds primary health care services rendered
by Local Authorities (LA), which includes earmarked funding for TB laboratory
investigations, TB drugs, NGO Community DOTS programmes and partial funding
of sub-district TB/HIV co-ordinators’ salaries.
PGWC Metro District Health Services (MDHS) has overall responsibility for
supporting, monitoring and evaluating the TB Control Programme. HIV/AIDS, STI
and TB activities have been integrated in all eleven-health sub-districts in the region.
1
Progress Report 1997–2003
•
The National Health Laboratory Service (NHLS), situated in Green Point is responsible
for all TB bacteriology services. TB diagnostic services are provided at almost all
points of contact with health professionals. The key tool for evaluating diagnosis,
treatment and outcomes of TB patients is the TB register. TB patients are registered at
100 reporting units: 96 LA Clinics; two TB hospitals, Brooklyn Chest Hospital and DP
Marais Hospital, and two correctional facilities, Pollsmoor and Goodwood Prisons.
TB treatment is supervised at 121 treatment points, with additional community-based
support provided through a network of community DOTS supporters managed by
three TB NGOs.
The new National TB Control Programme Guidelines were introduced in June 1996.
A National Electronic TB Register (ETBR) was introduced in January 2003, replacing
previous reports.
!
PROGRAMME OBJECTIVES
The five essential elements of World Health Organization’s DOTS
Strategy have been expanded to include HIV-related and drugresistant forms of TB.
a. A commitment at both political and service level to strengthen the
human and financial resources to make TB control effective
b. Access to sputum bacteriology for case detection among persons
with symptoms of TB
c. Standardized treatment under direct observation, which includes
harnessing support in the community and workplace
d. Uninterrupted supply of fixed dose combination drugs, free of
charge to all TB patients
e. Recording and reporting system enabling assessment of the
outcomes of each patient and the programme at district level
(Source: An Expanded DOTS Framework for Effective Tuberculosis
Control, WHO/CDS/TB 2002.297)
The DOTS strategy focuses primarily on improving the cure rate in new infectious
patients, but the experience is that outcomes for all categories of TB patients improve
in the process. DOTS is now accepted worldwide as the gold standard for the
management of TB, given current tools. DOTS has been shown to:
• Reduce TB mortality and morbidity
• Prevent the development of drug resistance
• Accurately measure and improve TB programme performance.
Cape Town TB Control
•
A Partnership between the Provincial Administration of the Western Cape Metropole Region and the City of Cape Town
Sixteen sub-district TB/HIV/STI coordinators have been appointed to provide training
and mentoring to facility staff; and to monitor and evaluate the quality of services.
3. MONITORIN G A N D Q UA L I T Y A S S U R A N C E
The programme is monitored according to World Health Organization (WHO)
and International Union Against Tuberculosis and Lung Disease (IUATLD) accepted
definitions. These definitions include case finding, case holding and treatment
outcome indicators.
2
Locally, not only is progress of TB control evaluated on a quarterly basis according
to the defined indicators, but also through regular and timely feedback sessions to
staff, through sub-district programme reviews and ongoing training.
Cape Town TB Control
•
A Partnership between the Provincial Administration of the Western Cape Metropole Region and the City of Cape Town
•
Progress Report 1997–2003
The TB Control Programme is one of the health programmes where progress can
accurately be monitored and evaluated. There are defined indicators, clear end
points and a well worked out monitoring system that can be applied at facility and
sub-district level.
3.2 Reporting
Both MDHS and LA health services take an active interest in order to ensure that data
is accurate, complete and feedback to management and facilities is timely.
Over the last three years, quarterly reports have been completed and collated
for all eleven sub-districts within three weeks of the end of the quarter. Subdistrict TB/HIV coordinators present this information at the quarterly Metropole TB
Information Meeting, which offers an opportunity for immediate scrutiny, discussion
and feedback. This forum generates a better appreciation of the data amongst staff,
helping them to interpret and use the information to address the problems they
identify. Except for the Correctional Services information, good reporting rates have
been maintained. In 2003 the forum was expanded to integrate quarterly reporting
on HIV/AIDS and STI information.
The WHO DOTS Strategy aims at curing 85% of new smear positive cases, this is
the level at which the epidemic is brought into decline. The usual reaction from staff
was that the target was unachievable as they had little influence over the adherence
behaviour of patients.
When examining the outcomes by facility it became apparent that some clinics were
achieving rates of 80%+ whilst others were below 50%. On closer inspection, it was
found that factors like the level of poverty, gang activities and nurse workload did not
determine this difference in outcomes. It seemed that those nurses who were willing
to do whatever they could to keep patients on treatment (for example, trying different
tactics and not giving up) had much better results. Simple steps like getting sputum at
the end of treatment, moved a large percentage from treatment completed, to cure.
Finding out what happened to transferred patients and ensuring all patients had a
recorded outcome also tended to boost cure rates.
To encourage staff, a number of changes were introduced in 2000:
• Reports produced were automated and standardised (DHIS - TB Tool).
• A minimum number of key indicators were used to monitor progress, allowing
more time to be spent on analysis of the data down to facility level.
• Regular and prompt feedback given to clinic staff in each district with a system of
incentives to recognise achievements.
• Peer review and problem solving to address under-performance by setting clear
targets and identifying “quick-wins”.
3
Progress Report 1997–2003
•
A Partnership between the Provincial Administration of the Western Cape Metropole Region and the City of Cape Town
•
Cape Town TB Control
3.3 National Electronic TB Register
The ETBR was implemented in all sub-districts in Cape Town in January 2003, with
data backdated to July 2002.
There are advantages to the introduction of the ETBR namely:
• Standardisation of reporting, allowing comparability of data nationally and
internationally.
• Cohort analysis matching case finding, smear conversion and treatment outcome
reports.
• Patient listings are a useful programme management tool to trace patient
outcomes.
The ETBR also has drawbacks, mostly due to the software not being flexible.
• It does not allow for any changes, for example, adding and deleting of reporting
units or change of district boundaries.
• Standard reporting generators do not allow easy interface with other software
programmes. More advanced analysis requires the use of the Epi-Info statistical
package, which is a rare skill.
• Codes used are also limiting as patient listings do not allow for the separation
between failure, completion or cure.
• There are no smear conversion standard patient listing reports and no report on
smear negative/culture positive cases.
• The register is district based and does not allow focussing on individual clinics.
Detailed clinic-based performance reviews are essential for pinpointing areas to
improve the TB programme performance.
• Regional co-ordinators have no access to facility data in order to make
comparisons across the district.
The following should be considered for an updated version of the ETBR.
• More flexible software to allow local changes such as changing of district
boundaries, addition or deletion of reporting units
• Better interface with other software for more in-depth analysis
• Increasing the data elements which could be extracted for standard reports, e.g.
positive cultures, treatment commencement times
3.4 Sub-District Reviews
External sub-district programme reviews allow for a more in-depth evaluation of
programme activities, which is not possible through the analysis of routine data
alone. From 1999 to 2002 eight TB Programme sub-district reviews were conducted
for the purpose of:
• Identifying barriers to effective implementation of TB Control in the sub-districts
• Working with staff to propose solutions for the problems encountered
• Developing a shared vision and joint planning amongst all role-players in the subdistrict.
Initially facilities viewed these external reviews with much scepticism. At first staff
felt threatened, but with feedback provided in a positive manner, emphasizing
strengths, specific action plans and achievable targets, staff came to welcome the
interventions.
4
Progress Report 1997–2003
•
3.5 Training
District TB/HIV co-ordinators have been trained to understand the data and turn
it into meaningful information; this was later extended to include area and facility
managers. They learnt to prepare and implement action plans to strengthen the
programme based on available data.
PGWC Human Resource Department created a post for a trainer to take over all
clinical training for both TB and HIV/AIDS programmes. An integrated TB/HIV/STI
clinical course for all professional nurses is currently being developed.
Regular CPD accredited training sessions on the epidemiology and clinical
management of TB continued to be held to update knowledge and skills of general
practitioners and medical officers employed by health services. Ninety-six doctors
attended the four sessions conducted in 2003. The Paediatric and Community
Health Departments of Stellenbosch University made significant contributions to
these sessions.
3.6 TB Treatment Wheel
Research has shown that a well-informed patient is more likely to adhere and
complete treatment if adequately counselled and fully informed of what to expect
during the course of treatment. To assist with this task, a TB Treatment Wheel was
designed as an easy guide for staff to calculate the key dates for follow-up sputum
checks and to emphasise these to the patient. This facilitates the process of direct
interaction with the patient, by illustrating the “TB treatment journey” patients will
undergo to get to the end of treatment.
Cape Town TB Control
•
A Partnership between the Provincial Administration of the Western Cape Metropole Region and the City of Cape Town
The participation of TB/HIV co-ordinators in these reviews was an extremely useful
learning experience, which resulted in sharing of best practices across the subdistricts. TB/HIV co-coordinators continued to do internal reviews of their individual
clinics using the tools developed.
5
3.7 Community-based DOT Programme
An important element of the WHO DOTS Strategy is the support and encouragement
offered to TB patients for the entire 6 – 8 month duration of treatment, where patients
are directly observed taking their medication. Non-governmental organisations
(NGOs) recruit, train and supervise members of communities to function as
treatment supporters for TB patients. Three TB NGO’s, TB Care, Santa Cape Town
and Santa Western Cape, deliver community-based treatment to TB patients in
Cape Town. PGWC and LA fund community-based DOT programmes according
to agreed funding norms based on TB caseloads per district and funding excludes
NGO infrastructure costs.
!
The main functions of treatment supporters are to:
• Observe treatment and record compliance
• Support and encourage patients to continue treatment
• Follow up on patients who do not attend for treatment
• Remind patients of clinic appointments and sputum checks
• Create awareness about TB in the community
• Refer TB suspect cases to health services for investigation
The quality of the relationships at a local level and the clarity with which roles and
responsibilities are articulated are key to the success of community DOT initiatives.
A clear model for managing community-based TB care had to be developed. This
included identifying the key treatment milestones of TB treatment, the necessary
quality checks, and monitoring and evaluation mechanisms to ensure standards.
City Health has funded WC-NACOSA, a networking and mentoring NGO, to assist
the NGO’s with capacity building in management, financial accountability and
supervision of DOTS supporters.
Workplace DOT, another form of community-based TB treatment, allow TB patients
to remain economically active whilst completing treatment, removes barriers to
treatment, reduces absenteeism and it reduces the risk of transmitting infection in the
workplace. A local NGO, TB Care, currently meets with employers, provides health
education about TB and acts as a link with the workplace treatment supporter.
Progress Report 1997–2003
Cape Town TB Control
•
A Partnership between the Provincial Administration of the Western Cape Metropole Region and the City of Cape Town
•
The TB treatment wheel is double sided, on one side of the wheel are the key
dates for first time TB patients while on the other side are the key dates for retreatment patients. Staff have found the treatment wheel very useful, especially as
it helps remind them to close the gap between completion and cure. As one staff
member commented: “The Wheel saves me valuable time and reminds me of all
the things I need to tell a TB patient.” (For copies of the Treatment Wheel, contact
jcaldwel@pgwc.gov.za)
6
Progress Report 1997–2003
LESSONS LEARNT
Cape Town TB Control
•
A Partnership between the Provincial Administration of the Western Cape Metropole Region and the City of Cape Town
•
• Accurate data, disaggregated to facility level, has enabled us to
identify problems and to address these quickly. A limited number
of key indicators were used to monitor progress, allowing more
time for analysis of the data at facility level.
• Quarterly information meetings are an opportunity not only for
presenting information, but also offers a conducive environment
for co-ordinators to interact, understand and internalise what the
data is saying.
• The changeover to the ETBR had to be carefully managed and it
included temporarily running a parallel paper system, to ensure
continuity in monitoring. The ETBR is not an end in itself, but
merely a tool to support districts and facilities to improve TB
Control.
• Where information officers are responsible for capturing TB data
electronically, partnerships with the TB/HIV co-ordinators need to
be enhanced to promote understanding of the indicators on the
one hand and of the software on the other.
• Programme reviews provide useful insight into barriers impeding
programme performance. These insights cannot be obtained by
only analysing routine data.
• The TB programme needs to clearly articulate quality standards
for community based DOTS programmes and assist in building
the capacity of NGOs. It requires strong management,
administrative and financial systems.
4. TB PROGRAM M E P E R F O R M A N C E
4.1 Case Finding Indicators
4.1.1 CASE LOADS
A total of 22,999 cases were reported in 2003 (Table 1). This is an increase of 66%
in seven years, reflecting a growing population, migration, improved case detection
and an increased burden of disease.
Table 1: Total Number of TB Cases Registered
1997 – 2003
YEAR
1997
New TB cases registered
13,870
CURE RATES
65%
1998
1999
2000
2001
2002
2003
14,970
15,769
17,244
18,361
20,950
22,999
66%
64%
70%
73%
70%*
**
*New definitions used for two quarters
**Cure rates for 2003 will only be available by the end of 2003
7
Figure 1: Case Load and Incidence Per Sub-district - 2003
Cape Town TB Control
•
Of the cases identified in 2003, three sub-districts - Khayelitsha (19%), Nyanga
(15%) and Oostenberg (13 %) carry almost half the burden. This translates to
Khayelitsha supervising 2,473; Nyanga 1,890; and Oostenberg 1,611 TB patients
on an average day. To make an impact on TB outcomes, these districts should receive
an appropriate share of resources and support.
Figure 2: Increase In Sub-district TB Caseloads
2000 - 2003
Patients
A Partnership between the Provincial Administration of the Western Cape Metropole Region and the City of Cape Town
•
Progress Report 1997–2003
As shown in Figure 1 the burden of disease is not shared equally between the
different sub-districts.
Increases in TB caseloads have been experienced across all sub-districts but mainly
where the HIV epidemic is highest. The highest increase in caseloads has been in
Khayelitsha with 66%, with a 30% increase in Nyanga. However, in Helderberg, the
sub-district with third highest HIV prevalence the caseload only increased by 15%.
The apparent high increase in South Peninsula and Blaauwberg in 2002 and 2003
can be attributed to the inclusion of data from the hospitals and correctional services
in these sub-district datasets due to the implementation of the ETBR.
8
In spite of 66% increase in the total TB caseload over the past seven years, when
population growth is accounted for, the TB incidence rate has only increased by 30%
over this period, with a high of 678/100,000 population in 2003 (Table 2).
Table 2: Incidence (Case Detection) Rate
1997 - 2003
Year
All TB*
1997
1998
1999
2000
2001
2002
2003
13,870
14,970
15,769
17,244
18,361
20,950
22,999
Case-detection Rate
/100 000 Population1
All TB
521
520
530
562
581
638
678
New Smear +
Cases
6,089
6,639
7,262
7,761
8,769
8,853
Case-detection Rate
/100 000 Population
New Smear+ TB
212
223
237
247
266
261
4.1.3 TYPES OF TB
The proportion of Pulmonary TB (PTB) cases appears to have remained fairly constant
at 72%. Primary TB decreased from 15% to 9% due to a change in definition of
primary TB from <13 years to < 7 years. Extra pulmonary TB (ETPB) has increased
from 12 to 16% over the last 4 years.
Figure 3: Patterns of TB
2000-2003
Percentage
Progress Report 1997–2003
•
4.1.2 INCIDENCE RATE (CASE DETECTION RATE)
Cape Town TB Control
•
A Partnership between the Provincial Administration of the Western Cape Metropole Region and the City of Cape Town
In 2003, approximately 2.3% (N = 539) of all newly registered TB cases were
initially treated in hospitals (BCH 1.6% & DPM 0.6%). Only, 0.5% (N = 112) of TB
patients were registered for treatment in correctional facilities. This does not reflect all
detected cases from Pollsmoor Prison due to non-submission of data. Representations
to those in charge at Correctional Services have to date not resulted in significant
improvement. This is of some concern, as TB tends to spread especially rapidly in
prison.
1
1996 Census Data, adjusted according to Dorrington
9
Figure 4: Primary TB Per Sub-district
2000 –2003
Patients
There are large variances in the percentage of children registered for treatment in
the different sub-districts. It is difficult to determine whether these variances are due
to an over or under-diagnosis of TB in children. With the exception of Khayelitsha
and Nyanga there seems to be a decreasing trend in the number of Primary TB cases
reported. The change in the primary TB definition (from TB <13 years to currently TB
< 7 years) has disrupted previous trends making it difficult to interpret changes.
Extra-pulmonary Tuberculosis
The numbers of extra-pulmonary TB cases have increased by 187% over the last
four years. As expected this trend reflects the HIV epidemic with the highest number
of reported cases being in Khayelitsha and Nyanga. The increases in Blaauwberg
and South Peninsula during 2003, is due to inclusion in the sub-district hospital data
(BCH & DP Marais respectively).
Cape Town TB Control
•
A Partnership between the Provincial Administration of the Western Cape Metropole Region and the City of Cape Town
•
Progress Report 1997–2003
Primary Tuberculosis
The high burden of childhood TB results from recent transmission and reflects the
level of TB within the adult population. The prevention of childhood TB disease
depends on early diagnosis and cure of infectious adult cases and chemoprophylaxis
of their contacts < 5 years. Recent audit of TB files in the Nyanga sub-district showed
that very few contacts <5 years are being traced and provided with prophylaxis. This
is an area that needs more attention.
10
Cape Town TB Control
•
A Partnership between the Provincial Administration of the Western Cape Metropole Region and the City of Cape Town
Patients
•
Progress Report 1997–2003
Figure 5: Extra Pulmonary TB per Sub-district
2000 –2003
Multi-drug Resistant Tuberculosis
The emergence of multi-drug resistant TB (MDR) is potentially the most serious aspect
of the TB epidemic. MDR TB refers to TB, which is resistant to the first line TB drugs,
Isoniazid and Rifampicin.
As with other forms of drug resistance, MDR TB is a largely a result of shortcomings
in the delivery of the TB Control Programme in the following areas:
• Prescription of chemotherapy
• Management of drug supply
• Patient management
• Patient adherence
In 1990 a specialist MDR clinic was established at Brooklyn Chest Hospital to
manage all MDR patients in the region.
It is gratifying to note that according to a recent survey conducted by the MRC in
2001, the Western Cape has the lowest rates of MDR TB in the country, with reported
rates at the same level as in 1995: 1% of new cases and 4% of retreatment cases.
MDR TB is difficult and expensive to treat, with success rates at best only just under
50%.
In 2002 the Western Cape adopted the DOTSPlus strategy and is enrolling MDR
patients on the National DOTSPlus study being conducted by the MRC. In 2003, a
total of 301 new MDR TB cases were identified in the district, with 107 of these being
enrolled in the National DOTSPlus study.
4.1.4 BACTERIOLOGICAL COVERAGE
Bacteriological coverage gives an indication of the basis for diagnosis. Up until
2002, over 90% of pulmonary TB cases were bacteriologically confirmed (80% smear
positive and 10% smear negative/culture positive); 1% of TB cases were started on
treatment with negative bacteriology and 5% of cases commenced on treatment on
clinical grounds without bacteriology being done.
11
Progress Report 1997–2003
•
Percentage
With the introduction of the ETBR, Primary TB is now included in the definition of
Pulmonary Tuberculosis resulting in a drop in the proportion of smear positive cases
and an increase in bacteriology “not done/no bacteriology” category.
Figure 7: PTB - Sputum Results prior to the initiation of treatment
2003
No smear
Smear -ve
Smear +ve
As from 2003, in line with reporting of results in other countries, only three
categories are accounted for bacteriology, prior to the initiation of treatment: smear
positive, smear negative and no smear. It is therefore unfortunately not possible to
distinguish the number of patients who were commenced on treatment due to a
positive culture as opposed to those commenced on treatment solely based on signs
and symptoms.
Cape Town TB Control
•
A Partnership between the Provincial Administration of the Western Cape Metropole Region and the City of Cape Town
Figure 6: PTB - Sputum Results Prior To Initiation Of Treatment
1998 – 2002
12
Percentage
Progress Report 1997–2003
•
A Partnership between the Provincial Administration of the Western Cape Metropole Region and the City of Cape Town
•
Cape Town TB Control
Figure 8: PTB - Sputum Results Prior To Initiation Of Treatment
Per Sub-district, 2003
An increase in the proportion of smear negative/culture positive TB in HIV negative
patients would indicate improved/early case finding. Looking at smear positive rates
across districts, it is noted that Helderberg has the highest smear positive rate of 73%
while Central and Athlone have the lowest rates, both at 57%.
4.1.5 CASE DETECTION INITIATIVE
WHO recommends that 10 smears for 1 positive (10% smear positive rate) should
be expected in a well functioning programme in HIV-negative patients. The MRC
survey 2001–2002 reported that an average 4,8 smears were analysed for every
smear positive case (21% positive rate).2 From data received from NHLS in 2002,
187,850 sputum smears were examined for TB bacilli, of which 30,681 smears
were positive, a rate of 6.1 smears to find one positive, (16.3% positive rate). Data
received for 2003 from NHLS reported a total of 218,088 sputum smears were
examined; 38,705 were positive. A rate of 5.6 sputum smears to find one positive
(17.7% positive rate).
The very high smear positive rates are indicative of poor case finding activities. This
is due to health workers’ delay in making a diagnosis (low degree of suspicion, lack
of integration of care with missed opportunities for diagnosis and strict application of
TB diagnostic algorithms), patients presenting very late in the course of their disease,
or a combination of all of the above.
In an effort to improve case finding activities, a new sputum request form was
implemented. With the NHLS as the single source of data, very useful information
about suspect investigations has emerged. For example, in 2003, in Khayelitsha
the smear positive rate for suspects investigated was 4.2 smears investigated to find
one positive (24% positive rate). Positive rates range from a low of 20% to a high of
35%.
2
MDR survey 2001-2002 Pre-final Report November 2002. MRC
13
In Khayelitsha CHC’s contributed only 15% towards suspect investigations, whilst
in South Peninsula CHC’s contributed only 7.7%. This is surprising, given that sick
adults usually access respiratory care at CHC’s. This indicates there are many missed
opportunities at CHC’s to investigate suspects and diagnose TB earlier.
Figure 9: Khayelitsha & South Peninsula: Percentage of Suspect Investigations
September 2003 – February 2004
Percentage
Progress Report 1997–2003
•
A Partnership between the Provincial Administration of the Western Cape Metropole Region and the City of Cape Town
•
Cape Town TB Control
By contrast, in South Peninsula sub-district, the smear positive rate for suspects
investigated was 7.8 smears investigated to find one positive (13% positive rate).
Nevertheless, two South Peninsula facilities had positive rates above 20%, which
shows that is important to look at variations between individual facilities within a
sub-district.
Khayelitsha has three times the incidence of TB and treats three times the number of
TB patients compared to South Peninsula, yet investigate fewer suspects. Feedback
has been provided to staff in Khayelitsha, designed to get them to have a higher
threshold of suspicion for investigating suspects (widening the definition of a TB
suspect). Trends will be monitored monthly to see if there are any changes in
practice. This initiative needs to be expanded to all sub-districts if rational differential
case finding targets are to be set.
4.1.6 NEW AND RE-TREATMENT RATES
About 33% of TB cases reported being previously treated for TB, a proportion that
has remained fairly constant until last year when the primary TB cases added to
pulmonary TB resulted in a 4% decrease of the percentage of retreatment cases.
Cape Town reported rates of retreatment cases (including relapses/reactivation and
re-infection) tend to be higher than reported for the rest of the country (14% reported
nationally in 2002 by TB registration system). International studies have shown that
a detailed history often reveals rates of retreatment comparable with rates reported
in Cape Town.
14
Progress Report 1997–2003
•
A Partnership between the Provincial Administration of the Western Cape Metropole Region and the City of Cape Town
•
Cape Town TB Control
Table 3: PTB New and Re-treatment Cases
Year
All PTB
New Cases
Re-treatment
1997
10,212
67%
33%
1998
10,986
65%
35%
1999
11,485
67%
33%
2000
12,558
67%
33%
2001
13,233
67%
33%
2002
16,394
68%
32%
2003
19,157
71%
29%
LESSONS LEARNT
• Sub-districts (and facilities) with the largest TB caseloads should
receive the appropriate share of resources and support.
• To prevent childhood TB, we need to trace children contacts
of infectious adult cases and provide prophylaxis to children
< 5 years.
• Closer co-operation is required with Correctional Services to
increase the effectiveness of TB control in prisons.
• Monitoring smear negative/culture positive TB will become an
important aspect of TB Control as the HIV epidemic matures.
• In areas with high TB incidence, staff should have a much higher
index of suspicion for investigating TB suspects. Budgets should
accordingly be allocated to facilities to support the increased
investigation of suspects.
• The cost of missed and delayed diagnosis in terms of epidemic
increase far outweighs the amount saved in limiting the budget
for laboratory investigations.
4.2 Case Holding Indicators
4.2.1 SMEAR CONVERSION RATE
Smear conversion rates are said to be a fairly accurate predictor of cure rates and
provide quicker feedback on programme performance than cure rates. Smear
conversion rates are reported at the end of the intensive phase (two or three months
of treatment). These results are available within 6 months of starting a patient on
treatment, whereas cure rates are only available after 12 months.
Poor smear conversion rates may reflect inadequate treatment and failure to convert,
but more commonly means that a sputum smear has not been taken or reported on
at the end of the intensive phase. The sharp drop in smear conversion rates from
Quarter 4 2002 is be attributed to the strict parameters set in the National ETBR.
The ETBR does not accept a result entered later than 70 days after commencing
treatment. This only allows staff 10 days leeway to send off specimens and receive
results to be reported on. By making staff more aware of these new and stricter
parameters, it is hoped that smear conversion performances will improve. The TB
Treatment Wheel can assist with plotting of sputum due dates.
15
Progress Report 1997–2003
•
Percentage
LESSONS LEARNT
• In order to improve smear conversion rates, sputum specimens
have to be obtained within 10 days of the due date.
• By ensuring conversion sputums are taken and results recorded
will result in closing the gap between cure and completion rates.
4.3 Treatment Outcome Indicators
4.3.1 NEW SMEAR POSITIVE CASES
During the period 1997 to 1999, despite considerable efforts made, little change
was noted in treatment outcomes with average cure rates of 65% and interrupter
rates of 21%. This caused both clinic staff and management to believe that 85% cure
rates were not possible in field conditions. With the new approach adopted in 2000
(see 3.Monitoring Quality Assurance) cure rates improved to 70 and 73%. Interrupter
rates decreased to 16% in 2000 and 14% in 2001.
In 2002 with the implementation of the new definitions of the ETBR, which now
includes ‘transferred out’ and ‘not evaluated’ in the denominator; there has been
a drop of 3% in cure rates. This drop can be attributed to 2.4% lost to ‘transferred
out’ and 2.5% ‘not evaluated’. The change in the definitions is also the reason
for accounting for outcomes in a much higher number of cases previously not
reported on (2002 = 9024 as opposed to 2001 = 7720). When looking at cure
and treatment completion rates, the 8% gap shows that a 78% cure rate was well
within reach. Of note is that these improved treatment outcome results were achieved
against a background of increased patient volumes and staff shortages.
Cape Town TB Control
•
A Partnership between the Provincial Administration of the Western Cape Metropole Region and the City of Cape Town
Figure 10: Smear Conversion Rate - New Smear Positive Cases
Quarter 4, 2001 – Quarter 3, 2003
16
Progress Report 1997–2003
Cape Town TB Control
•
Cure
Rate
Success
Rate
Interruption
Rate
Failure
Rate
Death Rate
(All Causes)
1997
N=4689
65
74
21
2.1
3.3
1998
N=5739
66
74
21
1.7
4.1
1999
N=6717
64
76
19
1.3
3.9
2000
N=7297
70
79
16
1.4
3.3
2001
N=7720
73
81
14
1.2
4.4
2002
N = 9024
70
78
13
0.9
3.6
Transferred
out
Not
Evaluated
2.4
2.5
Failure rates have also reduced significantly. Reported death rates are surprisingly
low given the HIV epidemic. However, it is quite likely that a significant number of
deaths have been categorised as “treatment interrupters” as patients have been lost
to follow-up and deaths not reported to clinics. According to a Cape Town Mortality
Report 2001 based on death data the deaths reported for TB were much higher
than reported in the TB register3. This is an important area for further research and
confirming deaths would give us a clearer epidemiological picture.
Figure 11 is an illustration of the challenge being set for health staff in each subdistrict to close the gap between completion and cure.
Figure 11: Gap between Cure and Success Rates
New Smear Positive 2002
Percentage
A Partnership between the Provincial Administration of the Western Cape Metropole Region and the City of Cape Town
•
Table 4: Treatment Outcome - New Smear Positive Cases
4.3.2 RE-TREATMENT SMEAR POSITIVE CASES
The cure rates for re-treatment smear positive cases have also improved over the
last six years, shadowing the trend for new TB cases. This indicates that although the
current focus is to improve the results of new smear positive cases, it resulted in better
outcomes for all smear positive cases. Interruption rates continue to decrease and
failure rates are less than half of what they were six years ago. The reported death
rates have remained stable and are almost double that of new smear positive cases.
This is largely due to the higher proportion of chronic lung damage and higher HIV
dual infection.
3
MRC, UCT & City of Cape Town November 2003
17
Progress Report 1997–2003
Cure
Rate
Success
Rate
Interruption
Rate
Failure
Rate
Death Rate
(All Causes)
1997
N=2095
50
57
32
4.9
6.5
1998
N=2780
50
56
32
4.0
7.8
1999
N=2185
47
57
33
3.5
6.1
2000
N=3107
55
62
29
2.5
6.3
2001
N=3187
59
66
24
2.7
6.8
2002
N = 3727
60
66
21
2.0
6.4
Transferred
out
Not
Evaluated
3.4
3.0
LESSONS LEARNT
• To improve programme performance, closing the gap between
cure and success rates is a potential quick-win.
• It is essential to ensure that follow-up sputums are done,
especially that end of treatment sputum is taken and results
recorded for each patient.
• The TB Treatment Wheel is a tool to facilitate the plotting of due
dates for sputum checks. It will assist staff to remind patients when
sputums are due.
4.4 Community Dot Coverage
An important element of the WHO DOTS Strategy is the support and encouragement
offered to TB patients for the entire duration of treatment, where patients are directly
observed taking their medication on a daily basis. Community DOT coverage for
the Metro Region in 2003 was 34%. A target of 40% for workplace and community
DOT was set for 2003/04.
Percentage
Figure 12: DOT Coverage 2003
Cape Town TB Control
•
A Partnership between the Provincial Administration of the Western Cape Metropole Region and the City of Cape Town
•
Table 5: Treatment Outcomes - Re-treatment Smear Positive Cases
18
Figure 13: VCT offered to TB Clients 2003
Percentage
Progress Report 1997–2003
•
As from Quarter 4 2003, with the exception of Blaauwberg, all sub-districts are now
reporting VCT offered to TB patients per TB cohort. In 2003, 59% of adult TB patients
(6970 adult cases) accessed VCT for HIV. Acceptance rates were relatively high at
86% and of people taking the test, 41% were dually infected. These figures include
patients where the HIV +ve status was previously known. A target of offering VCT
to 70% of adults registered for TB treatment for 2004 has been set. Although the
average co-infection rate for the region is 41%, it is noted that the range is very wide.
Khayelitsha and Nyanga have 65% and 69% co-infection rates, while Tygerberg West
has a low of 13%.
4.6 Sputum Turn Around Times
The NTCP requires services to monitor and report on a quarterly basis the time it
takes for sputum specimens to be processed by NHLS and results sent back at the
health facilities. In Cape Town, courier services and other communication networks
allows for good sputum turn around times. In light of this, it became increasingly
more important to measure the time it took services to recall patients and place
them on treatment once the results had been received. In an effort to monitor clinic
treatment commencement times, a random survey of patient folders was conducted
on a quarterly basis, to report on how many patients were recalled within 2 days,
between 3 and 5 days and more than 5 days. Feedback was provided to staff to
review recall mechanisms. Monitoring was discontinued as poor randomisation
skewed results. With adaptations to the ETBR, this information could be extracted on
all patients.
Cape Town TB Control
•
A Partnership between the Provincial Administration of the Western Cape Metropole Region and the City of Cape Town
4.5 Voluntary Counselling and Testing for TB
19
Progress Report 1997–2003
LESSONS LEARNT
Cape Town TB Control
•
A Partnership between the Provincial Administration of the Western Cape Metropole Region and the City of Cape Town
•
• Knowing the HIV status of a TB patient gives staff the opportunity
to provide better care and management thereby contributing to
the reduction of morbidity and mortality and postponing the need
for ARV therapy.
• Clinic treatment commencement times provided valuable
information on the ability of facilities to recall smear +ve patients
and commence them on treatment timeously
5. TB AND HIV / A I D S / S T I I N T E G R AT I O N
In Cape Town TB, HIV/AIDS and STI programmes have historically operated as
separate vertical programmes. Each programme focused on the key strategies within
its own respective domain. All three programmes are experiencing and placing
increasing demands on frontline staff and supervisors, therefore looking for synergies
has became an imperative.
In 2003 the region adopted an integrated TB and HIV/AIDS strategy. Currently, at
facility level this translates into using voluntary counselling and testing (VCT) as the
entry point to a package of HIV/TB primary health care. This package consists of:
• Cotrimoxizole chemoprophylaxis
• TB preventive therapy (INH) for those HIV +ve
• Access to early diagnosis of opportunistic infections
• Access ARV’s
The integrated strategy goes beyond finding and curing infectious TB cases and
includes:
• Intensified TB case finding amongst those HIV +ve
• TB preventive therapy for those HIV +ve, once active TB disease has been
excluded
• Behavioural, personal and social strategies aimed at reducing the spread of HIV
infection.
This integrated approach has been extended to the integration of the quarterly
information meeting, district co-ordinators assuming dual responsibility for TB as
well as all HIV and STI programme activities. An integrated programme audit tool
was developed to compliment the use of routine data to evaluate the availability,
access and quality of services, focusing on integration of care. The integrated audit
tool was successfully piloted in the Nyanga sub-district.4 Programme and facility
managers found the results useful and were able to draw district and facility action
plans to improve the effectiveness of programmes. The tool has encouraged a shift
in mindset towards programme integration by making explicit the benefits of an
integrated HIV/TB/STI approach.
4
Unpublished data: Vera Scott et al 2003
20
Progress Report 1997–2003
•
A Partnership between the Provincial Administration of the Western Cape Metropole Region and the City of Cape Town
•
Cape Town TB Control
With the new integrated TB/HIV/STI approach, VCT counsellors will administer a
detailed questionnaire about TB signs and symptoms built into the VCT form as part
of the pre-test counselling. In the meantime TB diagnostic algorithms were reviewed
to include VCT for all TB suspects and a culture for HIV positive patients with a
negative smear.
LESSON LEARNT
• Integration of programme activities improves availability, access,
continuity of care, and most importantly minimises missed
opportunities in the delivery of quality health care services
6. THE COST OF T B T R E AT M E N T
TB diagnosis and treatment is free of charge to the public, leading to the
misconception that the TB service is not costly to provide. The reality is that TB is a
very expensive programme to run. In order to determine costs, estimates were made
on the number of new and re-treatment cases of patients diagnosed in the previous
year, using drug and laboratory costs. The estimated cost amounted to R15.57
million annually with an additional R2.6 million for suspect investigations, totaling
R 17.17 million. This estimated figure is remarkably close to the real expenditure in
2003/2004 which amounted to R9, 82 million for drugs and R7, 71 million for all
TB laboratory investigations, totaling R17, 54 million (excluding CHC expenditure
and LA staff costs).
It has already been noted that improved TB Programme performance results in
increased costs. Ideally a move needs to be made towards funding that is informed
by programme data.
6.1 Laboratory costs
The cost of laboratory follow-up monitoring of registered TB patients (managed as
per NTCP Guidelines) should be R 4,71 Million.
Table 6: Cases: Cost of TB Laboratory Follow-up Monitoring
Number of cases
Average cost of sputum
tests
Lab Expenditure
New cases
16,330
R 149,58
R 2,44 Million
Re-treatment
cases
6,670
R 340,71
R 2,27 Million
Total cases
23,000
R 4,71 Million
Current expenditure for case finding amounts to about R2, 6 million but if the
infectious pool of people was more adequately screened this would require a larger
budget as indicated in Table 7.
21
Progress Report 1997–2003
•
Cape Town TB Control
Ratio of TB Suspect: Positive
Sputum
Lab Cost
Current case-finding
5.6: 1 pos
R 2,60 Million
Improved case-finding
7: 1 pos
R 3,25 Million
Ideal case-finding
10: 1 pos
R 4.64 Million
6.2 Drug costs
At State tender prices the cost of drugs to treat the 23,000 TB patients registered in
the Cape Town during 2003 is R10, 86 million, excluding the cost of MDR drugs.
Table 8: Cost of TB Drugs
Number of cases
Average cost of regimen
Drug Expenditure
New Cases
16,330
R 391
6,38 Million
Re-treatment cases
6,670
R 673
4,48 Million
Total Cases
23,000
R 10,86 Million
The estimated MDR-drug costs accounts for a significant proportion of the TB
Programme budget, although MDR-drug costs have reduced significantly in 2003.
Table 9: Cost of MDR Drugs
No Cases
Per Patient
Cost
EMB Sensitive
253
R 4,211
R 1,065,383
EMB Resistant
48
R 16,103
R 772,944
TOTAL
301
R 1,838,327
6.3 Total costs
An economic evaluation study done in Guguletu in 1997 showed that total cost to
treat TB was approximately R3000 for a new an R5000 for a re-treatment patient.
Economic evaluations estimate the total cost of the Cape Town public health primary
care TB control programme between R90 and R120 million in 20035.
LESSONS LEARNT
• Knowing how expensive it is to treat TB patients has motivated
staff and management to improve the outcomes of the TB Control
programme.
• Improved TB programme performance leads to increased costs.
• Costing exercises demonstrated that good budget estimates can
be made, using programme data. This information should be
used in planning so that funding for TB programmes is based on
quality data and not merely historical data.
•
A Partnership between the Provincial Administration of the Western Cape Metropole Region and the City of Cape Town
Table 7: Suspects: TB Case-finding Laboratory Costs
5
Cost and Cost-effectiveness of Community-based Care for TB in Cape Town, South Africa, International
Journal of TB and Lung Disease, in press, E Sinanovich et. al.
22
Progress Report 1997–2003
•
A Partnership between the Provincial Administration of the Western Cape Metropole Region and the City of Cape Town
•
Cape Town TB Control
7. CONCLUSION
This report aimed to document the progress of the TB Control Programme in
Cape Town over the past seven years and to highlight the factors that have lead to
success.
On reflection, the key interventions that account for the improvements are:
• The investment in building capacity of staff, especially that of the sub-district TB/HIV
co-ordinators
• The ability of TB/HIV co-ordinators to analyse, interpret and use information
• Limiting the number of indicators for reporting
• Prompt feedback of performance and sharing of lessons learnt and best
practices
• Cross pollination of the lessons learnt and best practices across all sub-districts and
applying these to all sub-districts.
To conclude, we detail the main elements in the improvement of the TB control
programme in Cape Town.
!
REGULAR QUARTERLY SUPPORT MEETINGS with TB/HIV coordinators
are held to review data, and to provide immediate feedback and support.
Coordinators developed interpretive and data management skills and
acquired the confidence to work with clinic staff using the information
for action. This developed into a peer support structure where “best
practices” can be shared and learnt.
QUALITY HEALTH information remains vital for good management and
improvements in TB control require an investment in health information
systems. With accurate information the “real” problems can be identified
and appropriate remedial action taken.
FOCUSSING ON QUICK-WINS identifies positive activities and easily
achievable targets to improve performance with minimal effort. Previously
the focus was solely on closing the gap between treatment completion and
cure rates. With the introduction of the ETBR two new quick-wins have been
added: ensuring that each patient has an outcome evaluated and followingup outcomes of all patients transferred-out. Exploring synergies between the
different programmes is showing us more areas for ‘quick-wins’.
RECOGNITION, the simple applause of peers, certificates of achievement,
small incentives, and public acknowledgement from supervisors — all play
an important role in improving performance and instilling pride in one’s
work. A bi-annual TB certification ceremony is held to acknowledge the
efforts and achievements of all role-players in TB control.
COMMUNITY BASED TREATMENT remains an important strategy for
improving TB management. There are benefits to the health system
(reduced patient volumes), to the patient (the convenience of more
accessible treatment) and the community (taking ownership of local
problems, financial and other incentives). To be successful, it requires
an investment in partnership building. The effective management and
funding of community DOT remains a challenge.
23