Decentralized management of MDR TB at Themba hospital (working document) (DRAFT)(7) (edited)

The recent past has seen a rise in the patients with DR-TB in areas around Mbombela.
Themba hospital and its surrounding clinics have diagnosed an increased number of
patients. This has necessitated the need for Themba hospital to address the challenge
through the implementation of strategies that seek to curb the scourge before it is blown
out of proportion. This required a decentralized approach for the management of these
patients, as required by the MDR-TB policy. The policy framework provides for health
facilities to manage DR-TB closer to their homes in order to foster treatment adherence
and improve TB outcomes. Decentralized management of DR-TB refers to the transfer
of responsibility for treating DR-TB patients to other levels of care than central and/or
decentralized sites. The policy also provides for the establishment of satellites sites to
manage all patients that fit a specific criterion. This will see patients treated/managed in
their local areas and thereby fostering adherence to their anti TB treatment and
ensuring improvement of outcomes. The concept of DR-TB treatment decentralization
also involves the management of DR-TB in decentralized DR-TB sites, satellite sites,
and/or in the community using mobile teams and community caregivers and
households. The policy framework provides guidance for management of MDR-TB
patients closer to their homes, both in health facilities and in community. Given rise of
patients with MDR-TB, Themba hospital has taken a position to be established as a
MDR-TB site which will see to the shortening of the number of days between DR-TB
diagnosis and treatment initiation. This initiative will ensure an increase in treatment
coverage and decrease the risk of DR-TB infection rate (especially Primary MDR-TB)
and consequently increase the social responsibility of DR-TB treatment. The initiative
will ensure that patients are initiated as soon as possible leading to less infections as
proven by a number of studies.
Rationale and DR-TB situational analysis in Mbombela (current status)
The current approach for the management of DR-TB patients has been confronted with a
number of challenges for both the patients and the TB program. The following are but a few
experiences that contribute to the initiative and the position taken by Themba hospital:
 The death rate of DR-TB patients has increased in the recent years (above 32% in the 2015
 Patients who have been lost to follow up have also increased in the recent years (above
25% in the 2015 cohort).
 The transmission rate of DR-TB, (especially Primary MDR-TB), has also increased in the
recent years.
 There has been significant delays in DR-TB treatment initiation rate due to a long and
cumbersome process leading to treatment initiation.
 Nearly half of the diagnosed patients are not started on treatment within the prescribed
period of five (5) days.
 Nearly all patients who are admitted at Themba hospital for other ailments but also infected
with DR-TB are not initiated on treatment.
 The lengthy hospitalization of MDR-TB patients has seen an increased number of patients
absconding from the decentralized site.
 The lengthy monthly follow-up visits to the decentralized site has taken a serious toll for the
patients’ socio-economics and has become arduous and costly.
The establishment of Themba hospital as MDR-TB satellite site seeks to address all the
challenges indicated above and envisages to achieve the following five objectives:
 To promote access to care by shortening the number of days between DR-TB diagnosis and
treatment initiation.
 To ensure increase of treatment coverage by prompt treatment initiation.
 To facilitate treatment adherence by ensuring that follow-ups are conducted locally.
 To reduce the rate of infection for Primary MDR-TB through treatment initiation (ensuring
that treatment becomes part of prevention).
 To increase the social acceptability of treatment and care.
The Process
It is envisaged that the process will start on a small scale to ensure that both Themba hospital
and Bongani TB specialized hospital staff and management are comfortable with the necessary
skills and abilities to fully participate in the initiative. Bongani TB specialized hospital, as a
decentralized site, will ensure full support for Themba hospital staff members to foster success
for the initiative. The support of the decentralized site will range from capacity building, through
adequate training and mentoring to medication distribution as well as monitoring of the
processes and activities involved in satellite functions. All stakeholders will be involved in
making this initiative a success.
Required structures
Envisaged activities
Prompt and accurate
DRTB diagnosis
multidisciplinary team
with adequate and
effective mentorship
and supervision
Integration with local
TB program activities
and HIV and PHC
Onsite NHLS for GXP and microscopy and the TAT is 24/48
Culture, LPA and DST are accessible in Ermelo and the
TAT is between 7 day and 14 days.
Results for GXP and microscopy should be reported within
24 hours (TAT)
Training of personnel on MDR-TB:
 1 doctor
 1 Professional nurse
Conduct in-service training on DR-TB for all other
personnel involved in the care of DR-TB patients
Tracer teams need to be established to conduct home
visits, identify contacts and trace defaulters.
Provide regular support from a doctor familiar with the DRTB and ART guidelines.
Conduct HIV tests as soon as possible in patients
diagnosed with DR-TB
Initiate ART within two weeks in HIV-positive patients who
are not already on ART
Review latest HIVVL result and address virological failure in
patients who are already on ART
Selection of patients
who will benefit from
completing MDR-TB
treatment at
decentralized site,
satellite and/or
community level.
Close monitoring of
daily treatment,
including providing
injections and
supervising adverse
between all levels of
Monitoring and
Treatment follow-up
Establish criteria for:
 Selection of patients who can be initiated and / or
followed up at the satellite;
 Selection of patients eligible for initiation and / or followup at the decentralized hospital.
 Admission of patients at the decentralized site.
All complicated cases and patients with a smear positive will
referred to the decentralized site (Bongani TB specialized
hospital) for initiation and admission.
All patients will be given an option to choose their preferred
treatment alternatives.
Ensure close supervision of PHC facilities and CommunityBased Organizations (CBOs)
Ensure clear pathways for feedback to the satellite from
PHC facilities and the CBOs
Keep track of patients in order to detect missed
appointments and trace those, before they become lost to
follow up
Establish communication channels between the
decentralized site and the satellite site.
Develop clear referral guidelines and pathways from
community, satellite as well as decentralized site.
Conduct regular/monthly meetings for monitoring and
The decentralized site will be responsible for data
Reporting and Updates on EDR WEB will be the
responsibility of the decentralized site.
Patient registration numbers will be sourced from the
decentralized site.
Ensure information technology support and database
DR-TB treatment should be monitored closely through daily
Sputum for smear microscopy and culture should be
collected every month for the duration of treatment at the
satellite site
Adverse drug reactions should be monitored continuously
by the facility where the patient is receiving treatment or the
mobile team and DOTS supporters.
Ensure involvement of CBOs and WBOTs for tracking of
patients who have defaulted and became lost to follow up.
Key success factors for the satellite
Below are key success factors to which all interested stakeholders will commit to facilitate the
process of DR-TB treatment initiation and follow-ups for DR-TB patients at Themba hospital.
Means and responsibilities
Support structures
Sub-district TB coordinator
Decentralized hospital (Bongani)
Developmental partners (Right to Care, JPS Africa)
Themba management
To give full support to the established satellite
Support role from the
Sub-district and
Conduct facility readiness assessment
The sub-district has administrative and management
responsibilities in ensuring effective DR-TB services in the
The site will be regularly monitored and supported during
initiation process
Assist in the development of clear SOPs/algorithms for
treatment initiation and referral pathway.
Ensure the availability of Audio-apparatus such
KUDUwave™ for continuous monitoring of DR-TB
Collaborate with ART program to ensure provision of ART
for MDR-TB patients.
To ensure infection control on site;
Readiness assessment already conducted in Themba
hospital on the 12th of May 2017.
The sub-district and the Province will monitor and evaluate
DR-TB management according to the National guidelines
Support role from the
decentralized hospital
Conduct readiness assessment
Provision of DR-TB drugs
Ensure necessary trainings
Provide mentorship and coaching
Support during initiation and follow-up
Ensure data management (M&E)
partners (JPS Africa
and Right to Care)
Themba hospital
management support
Conduct monthly meetings with the satellite site to monitor
progress and address emerging challenges.
Admit all DR-TB complicated cases and patient requiring
such in accordance with MDR policy framework.
Participate in the readiness assessment
Conduct trainings (NIMDR, KUDUwave™ training, IPC and
fitness test)
Conduct mentorship and coaching
Conduct site visits to the satellite
Infrastructural readiness
Provide necessary personnel such as Doctors, Nurses,
Pharmacist, Audiologist, Social worker, Dietician, Clinical
Psychologist, Data capturer, lay counsellors etc.)
Install IPC amenities such extractor fans to promote and
improve infection control in all operating cubicles (the wards
and at Bambanani).
Ensure availability of space for DR-TB drugs.
Provide IPC related services for the initiating site.
Liaise with the decentralized hospital (Bongani TB specialized
hospital) for treatment availability.
Monitor the conduction of follow-ups in the initiating site.
Create an interactive clinical engagement platforms for
relevant stakeholders.
Down-refer and liaise with, as may be necessary and/or when
the need arises, all patients to relevant PHC facilities.
Audiology: Ototoxicity Monitoring
 Well ventilated with TB protection package working
environment in Bambanani
 Video and manual otoscope: outer ear assessment
 Diagnostic Tymp/Reflex machine: middle ear
 Kuduwave: hearing assessment
 Hearing aids and hearing aid consumables: will be
provided by Bongani
 Cerumen management kit
 Decentralized management of MDR-TB increases access to care
 It reduces time to MDR-TB treatment initiation which may reduce community
transmission of MDR-TB
 Decentralized management of MDR-TB produces outcomes similar to
hospitalization generally; and sometimes even better outcome than
Based on the above, Themba Hospital should be supported and assisted for
readiness to initiate DR-TB treatment starting from 1 October 2017
Concept document compiled by:
 Dr FM Edonmi (project leader)
 Mr VS. Khoza (NSM: Bongani hospital)
 Ms Mashile (Area manager: medical wards)
 Mr JS. Mahlangu (Pharmacist)
 Ms RJ. Sono (Acting TB focal: Bambanani)
 Ms SP. Ngwenya (Audiologist)
Themba hospital and Bongani TB specialized hospital hereby commit to the
above and the management bind themselves to supporting the initiative for the
establishment of the satellite site at Themba hospital.
Approved/ Not Approved
Mr MJ. Shabangu
CEO:Themba hospital
Mr SD Khumalo
CEO: Bongani TB specialized Hospital