Free State pushing to get TB patients back into care
A recent study published in the journal Clinical Infectious Diseases found that there was an association between healthcare workers’ exposure to high levels of carbon dioxide (CO2) and their risk of being exposed to tuberculosis (TB). IMAGE: medicinenet.com/myhealth1st.comSince the first COVID-19 case was recorded in the Free State on 17 March 2020, the number of people visiting health facilities in the province dropped significantly. This resulted in fewer people screening and testing for conditions like tuberculosis (TB) and some people not completing their treatment courses.
Speaking at a TB workshop held by the provincial health department in November last year, Matshediso Morigihlane, Director of TB, Drug-resistant TB, and Communicable Diseases, said from 2017 to 2020 they recorded 3.8 million clinic visits in the province. Of those visiting clinics, 6 000 were placed on TB treatment over the four years – of which 500 disengaged with the healthcare system and 400 died.
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The numbers
The Free State Department of Health’s statistics show that the number of people who were placed on treatment in the first quarter of 2020 (January to March 2020) dropped from 2 611 to 1 651 in the second quarter (April– June 2020). The biggest drop was in the Mangaung Metro, where numbers dropped from 913 to 592. In other districts, the number of people who started TB treatment dropped from 648 people to 401 in the Lejweleputswa district, from 481 to 308 in Thabo Mofutsanyana, from 379 to 241in Fezile Dabi, and in Xhariep the number of people that have been identified to have TB and placed on treatment fell from 190 to 109.
Spotlight requested figures for 2021, but the Free State Department of Health has not provided any new numbers by the time of publication. The Free State does not have a publicly accessible TB dashboard like that in the Western Cape.
Apart from fewer people being diagnosed and starting TB treatment, Morigihlane pointed out that of those who did start treatment, fewer completed the treatment course (TB treatment takes at least six months). “The numbers of the first cohort (January to June) of patients who have completed their treatment in 2020 in the Free State dropped from 1 976 to 1 179,” Morigihlane said. Again, the biggest drop of those who successfully completed treatment was recorded in Mangaung (a drop from 691 to 451).
Morigihlane said the death rate among people diagnosed with TB during the COVID-19 pandemic increased to 12.5% in the second quarter of 2020, compared to 9.6% in the first quarter.
In the first quarter, most of these deaths were recorded in the Thabo Mofutsanyana district with a 12.1% death rate. She said in the second quarter TB deaths increased in all districts, with Fezile Dabi recording the most deaths at 18.7%, up from 9.9% in the first quarter.
Morigihlane also presented statistics on people living with TB who were lost to follow-up (stopped taking treatment or visiting health facilities). She says in the first quarter of 2020 there were 280 people who were lost to follow-up and 244 in the second quarter.
The recovery plan
Morigihlane says every year thousands of people living with TB are missing out on quality care and a majority of the people that are dying of TB are not on treatment. She said the provincial health department has been running a campaign to invite all those who stopped taking treatment, to come back and complete treatment. “If a person has stopped taking their treatment for two months, we have to start them afresh as a retreatment. Our plan includes sending our community health workers to do door-to-doors so that they can bring back the people that we have lost during COVID-19. We have a list of all the people that did not show up for their treatment,” she said.
“This is one programme where we want people to come to the clinic. We do not put TB patients on the Central Chronic Medicine Dispensing and Distribution Programme (CCMDD) because they are not community-based patients. A TB patient is a clinic-based patient, where we continuously have to take their sputum to see if the bacteria are dying or not,” she said. “When the bacteria is not going down, it will show that the person has not been swallowing tablets or we are treating a different type of TB, which is the Drug-resistant TB. This way we are able to test them for DR-TB and put them on the relevant treatment to align with the type of TB that is in their lungs.”
Morigihlane said the department now integrates screenings services. “We have taken the decision that each and every patient that visits our facilities will not only be screened for COVID-19 alone, they will also be screened for TB.”
Spotlight asked Bonny Sehularo, acting provincial spokesperson for health, whether there are other TB diagnostic methods the department is considering, such as mobile chest x-rays. Sehularo did not provide a response by the time of publication. Find the department’s responses Spotlight received after publication, here.
Experiences from the frontline
“Daily I go into the community to look for patients that do not go back to collect their TB and HIV treatment,” says Mpho Morolong * a community health worker at the Thusong Clinic in Mangaung.
“Sometimes the patients are too sick to go to the clinic, especially those patients who have both TB and HIV at the same time. Sometimes they do not have transport that can take them to the clinic during the time when they are too sick,” says Morolong. “Some of the patients say that they do not want to go back to the clinic because of the long waiting periods [and] long queues. What the department also does not understand is that once patients are placed on TB medication, they need a nutritious diet. Unfortunately, many of the patients are poor and do not get better because they cannot afford to buy the right food. I do my best as a community health worker to explain to the patients the importance of going back to complete their treatment, and some listen but others do not listen.”
Twana Ngconco, 56, from Phahameng is a patient at Mmabana clinic in Mangaung. He recently restarted TB treatment after having stopped.
“I stopped going to the clinic last year when I was feeling better. I did not see the need to go back because I felt better,” says Ngconco. “But I went back again when I started coughing in November last year. The nurses welcomed me and encouraged me to complete my medication. What I have learned from my experience is that it is important for me to complete my TB treatment,” says Ngconco.
TB plans falling short, activists say
Mpho Matobako, Provincial Manager of the Treatment Action Campaign (TAC), says they are not happy with the overall management of TB services in the province and that sending out community health workers is not enough.
“Things went from bad to worse now during COVID-19 as services of TB came to a halt and the whole department was focused on COVID-19. We are saying whatever you are doing for COVID-19, please do it for TB,” says Matobako.
“A multi-drug resistant TB unit at Kopano Old Provincial Hospital in Welkom, Lejweleputswa District has been closed since 2019, and all patients were transferred to Moroka Hospital in Thaba Nchu, which has placed a burden on the facility. The hospital was closed down because the unit was in a bad condition, but the problem is it has been closed since 2019,” he says.
Spotlight asked the department about a new MDR-TB unit that was set to replace the one closed in Welkom, but Sehularo could not immediately provide a response. MEC for Health in the Free State, Montsheng Tsiu in her budget speech last year did, however, say that the department completed a 30-bed MDR-TB specialised hospital at the old Mantsopa Hospital in Ladybrand.
According to the department, funding is not a problem. Morigihlane said the department has a budget of R84 million for TB programmes in the province. “The money is used to pay the personnel [providing] TB [services], to buy the sputum tests and machinery as well as the DR-TB tests. With that said, we can say that we do have enough money. What we need is for the missing people to come and those that are showing signs and symptoms to go to their nearest clinics.”
‘Facilities are in terrible conditions’
Another organisation advocating for the rights of TB and HIV Patients in the province, Positive Action Campaign’s general secretary Sello Mokhalipi says the department’s plan does not speak to the realities on the ground.
“Facilities are in terrible conditions, patients are treated badly by nurses, and facilities have small waiting rooms which are bad for TB patients. One of the biggest problem clinics has to be the Bloemspruit Clinic in Mangaung and I continuously get daily complaints from patients about the service they get at facilities. We would really like the department to take these matters seriously because this is the health of our people.”
A report by community healthcare monitoring group Ritshidze’s published in September last year also flagged Bloemspruit Clinic as one of the clinics that were found not to comply with the World Health Organization’s Guidelines on Tuberculosis Infection Prevention and Control. These guidelines, among others, state that everyone at the clinic should be screened for TB. It also states that there should be enough room and space for patients to wait without overcrowding and that the waiting time must be less than an hour and 15 minutes, and patients who are coughing on arrival at the clinic must be separated from others. Ritshidze found that Bloemspruit clinic fell short since there was not enough room in the waiting area, patients can spend up to six hours in the facility, only 28% of patients are screened for TB symptoms, and only 17% of coughing people are put in a separate room.
Asked about these challenges, the implications for the province’s TB response, and what plans there are to address these infrastructural challenges, Sehularo failed to provide an answer by the time of publication.
Note: Someone from the TAC is quoted 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.
*Not her real name
This article was updated on 21 January 2022.