Drop in DR-TB detection points to “crisis” in SA’s TB response
Since the beginning of South Africa’s COVID-19 pandemic and lockdown, non COVID-related healthcare services have taken a hit. This ranges from delays in various types of surgery, to delays in diagnosis and treatment of conditions such as tuberculosis (TB).
Modelling published by the Stop TB Partnership earlier this year, suggests that an extended lockdown period may result in more TB-related deaths in the future. Similarly, modelling published in the Lancet Global Health medical journal suggests that lower and middle-income countries could see a dramatic increase in HIV, TB and malaria-related deaths as a result of the lockdown’s impact on care and prevention services.
Three months ago Spotlight reported on the effect of lockdown on TB services. Now new information from the National Department of Health confirms a severe drop in the number of people diagnosed with Drug-Resistant TB (DR-TB), something experts suggest is due to reduced testing rather than an actual decline in people getting sick with DR-TB.
“The TB situation has continued to be exceptionally worrisome,” says Jennifer Furin, a Multi-Drug resistant TB (MDR-TB) doctor working with Doctors without Borders (MSF).
She says that the number of people presenting at clinics continues to be low, partly due to people being told to avoid healthcare facilities during the pandemic, but also as a result of clinic closures or under-staffing at facilities. Adding to this, she says that TB testing is not routinely offered.
“It is no exaggeration to say there is a TB crisis in the country, and the impact of this crisis could be even more devastating than COVID-19,” says Furin. “The problems with TB testing and treatment have been known for a number of weeks now, and they are being discussed at high levels. However, there is little actual movement on the ground to ensure access to TB testing and treatment, even though simple interventions could help.”
Treatment Action Campaign (TAC) National Chairperson, Sibongile Tshabalala, shares similar concerns. “What we have been experiencing lately is that since facilities keep on being closed because of staff members testing positive for COVID-19, patients are left stranded without any medication, referral, support or any communication,” she says.
“Most of the patients we are talking about were telling us about their frustrations and they feel like they are being dehumanised because they can’t afford to buy healthcare.” Tshabalala says many patients who cannot afford to make it to private hospitals, feels like they are not respected as patients. They spend hours in facilities, not just feeling disrespected but like they are begging for healthcare services instead of being given their right, she says.
Co-screening for TB and COVID-19 a work in progress
In May, Dr Norbert Ndjeka, Director of HIV, TB and DR-TB at the National Department of Health told Spotlight that a co-screening process for COVID-19 and TB was underway. Following up this week, he says that the principle of integrating both screening processes is accepted and that some provinces, like Gauteng, have started this process.
“I know that other provinces started before without making noise, the rest of the provinces are still planning implementation. Hopefully next month, we shall get a full report province by province. For now, our report is still incomplete regarding this matter,” he says.
According to Tshabalala, co-screening does not appear to be happening in communities. “There is nothing like that where people are going to test for COVID-19 and they are also tested for TB. When people go to test for COVID-19, they are only tested for [that] and you will only be tested for TB if you have TB symptoms. In most cases, people are not being tested for TB because the only thing that they are focussing on is COVID-19,” she says.
Furin says that there is a form for combined screening, but it’s confusing and does not address the logistical bottlenecks at healthcare facilities.
“There is also some confusion with the form, which states people should only be tested for TB if they have had a cough for two or more weeks. But really anyone with a cough should be tested for TB, and South Africa has great capacity for doing TB testing,” she says.
“There needs to be more work done to get sputum samples from people, to offer TB testing, or at least sputum collection outside of clinic facilities, and to make sure all South Africans know the symptoms of TB and COVID-19 are very similar and if you are tested for one of them, you should be tested for the other,” says Furin.
She adds that government should use paid networks of community healthcare workers (CHWs) to allow for more people to self-screen for both TB and COVID-19.
Furin says when patients present at health facilities with a cough, the individuals working in the triage areas often ask the TB staff/nurses to assist with TB screening and testing, and this can lead to significant bottlenecks. “So while the idea of co-screening is there on paper, and the paper form exists, the process is too complicated and it is still too situated within the health care facility.” Furin says all people with a cough need to be tested for both TB and COVID-19, and this is not happening.
Drop in case finding
In May Ndjeka told Spotlight that the Department had noted a severe drop in TB case finding in April. New numbers released last week indicate that in the months since then case detection numbers has fallen yet further. The number of new cases detected in June this year was only 284 compared to 753 in June last year (a decrease of over 60%).
DR-TB cases detected in SA by month
Ndjeka said that the department was engaging with provinces every second week, and that each province had developed a catch-up plan for TB, DR-TB and HIV. “The provinces have implemented catch-up plans. We have also involved our partners who are supporting the implementation of [these] plans,” he says.
“We are hoping that our catch-up plans will help address challenges described in the Stop TB Partnership report. If we do nothing, we shall reverse the gains made so far. That is why we are working very hard to keep the gains made so far and improve from where we are.”
Not diagnosing people with TB or DR-TB early enough was widely recognised to be a problem even before the COVID-19 pandemic. The World Health Organisation (WHO) estimates that of the roughly 301 000 people who developed TB in South Africa in 2018, only around 228 000 were diagnosed. The 301 000 estimate is however highly uncertain and the real number may be substantially higher or lower.
South Africa’s National TB Prevalence Survey, which is expected to give more insight into the real numbers, was set to be published earlier this year near World TB Day in March. However, in May, Ndjeka said that as a result of the pandemic, it was unclear when it would be released. Spotlight has since requested access to the survey’s findings in terms of the Protection of Access to Information Act.
How to improve case finding
To increase case finding, Furin urges that anyone with a cough or other TB symptoms needs to be tested for TB, and that this should happen both outside and inside of healthcare facilities.
“Some populations, especially household members of individuals who are newly diagnosed with TB, need special screening and ready access to preventive therapy for all forms of TB, including DR-TB. This is especially important given that household transmission of TB may have increased when people had to shelter in [one] place during the lockdown,” she says.
“The country needs to also rapidly implement other means of looking for TB, including chest X-ray screening and urine LAM testing [a urine test for an antigen specific to people with active TB disease],” she says.
Tshabalala says that screening for TB needed a fresh start, and that all stakeholders needed to re-do the ground work to ensure screening and testing increased.
“The challenge now is that we are not sure how many people are dying of TB because everybody is focussing on COVID-19.” Tshabalala says this is understandable because it is a pandemic, but we cannot ignore the challenges we have. Since more people will go back to health facilities as lockdown eases, Tshabalala says the government has to come up with a plan to make sure that people use these facilities as before the pandemic.
Lost to follow-up
Both Furin and Tshabalala raised concerns over TB patients who may have been lost to follow-up.
“All support pathways in the clinics have been disrupted, since many clinics have been closed, staff have been sick with COVID-19, and health care workers have been traumatised. This has meant people with TB diagnoses are not started on treatment, there have been stock-outs of essential TB medications, patients go to clinics to be seen and find there are no staff there,” says Furin.
Adding to this, she says that many people with TB have had to look for work to survive financially, and as a result could not continue with treatment or attend clinics. “We also need to address the socio-economic needs of people living with TB since the COVID-19 situation put people already in poverty, in even more precarious positions. Many people were cut off from SASSA grants or could not apply, and they are really on the edge.”
Furin notes the system is not functioning well and needs to be reinvigorated.
COVID-19 interventions could be used for TB, HIV
An article penned by Furin and some colleagues and published in the Lancet – Respiratory Medicine in August, notes that mechanisms put in place to address COVID-19 in South Africa could be well-used for HIV and TB.
“Interventions developed specifically for COVID-19 could also enhance [TB] and HIV services. For example, community networks developed for COVID-19 screening could be repurposed to support [TB] and HIV, to expand [TB] screening and HIV self-testing, identify individuals who need additional support (social grants), and link new cases or patients lost to follow-up to care. Stigma reduction campaigns for COVID-19 could also embrace positive messages about HIV and [TB],” the authors wrote.
Ndjeka says that the department hopes to use the COVID-19 contact tracing capacity for TB contact tracing. However, he could not guarantee this will happen. “For now, we cannot tell with certainty,” he says. “It is still speculations.”
Note: The TAC is mentioned in this article. Spotlight is published by SECTION27 and the TAC, but is editorially independent, an independence that the editors guard jealously. Spotlight is a member of the South African Press Council.