What should the TB priorities be in the new NSP?The World Health Organization (WHO) estimates that South Africa has approximately 27 000 children (under the age of 15) living with TB. IMAGE: Health24

What should the TB priorities be in the new NSP?

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The period covered by South Africa’s National Strategic Plan (NSP) for HIV, TB, and STIs 2017 – 2022 will soon come to an end and a new NSP will have to be developed for the next five years. Against the backdrop of World TB Day (24 March), Spotlight asked several local TB experts what they think should be the tuberculosis (TB) priorities in the new plan.

The plan is being developed in the context of a COVID-19 pandemic that has severely impacted the TB response in South Africa and elsewhere. In South Africa, the impact was particularly clear in a reduction in TB diagnoses in the early months of the COVID-19 pandemic. While TB catch-up plans are in place, it is unclear to what extent those plans are currently being implemented and succeeding.

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Better TB data and monitoring

Dr Fareed Abdullah, Director of the Office of AIDS and TB Research at the South African Medical Research Council (SAMRC) says for him the most important thing to get right in the TB Programme is the proper recording of data and monitoring of the TB programme.

“At the moment the data is not very reliable and without accurately being able to record the number of cases, the number on treatment and treatment outcomes, we will not be able to identify the problem areas and to improve the management of the national TB programme,” he says. He adds that a second priority is to ensure that there is capacity, skills and expertise at the provincial, district, and clinic level to implement the TB programme effectively.

Changing diagnostic tactics

Professor Keertan Dheda, pulmonologist and critical care specialist who heads up the Division of Pulmonology at Groote Schuur Hospital and the University of Cape Town, says enhanced finding of the ‘missing persons’ with TB is important. “These are undetected or undiagnosed individuals with TB, about a third of whom are infectious and who reside mainly in peri-urban informal housing. We also need to find these cases to mitigate the negative impact of COVID‑19 on TB. We need to change our diagnostic tactics in terms of the public health strategy by going out into the community to actively look for persons with TB (rather than waiting for them to self-report to our healthcare facilities),” says Dheda.

Professor and pulmonologist, Keertan Dheda at Groote Schuur Hospital. PHOTO: Supplied
Professor and pulmonologist, Keertan Dheda at Groote Schuur Hospital. PHOTO: Supplied

According to him, we could look for these cases in TB hotspots and in peri-urban communities, in contacts of those with active TB, in HIV-infected persons, in prisoners, and also in our own healthcare facilities where people might be attending due to reasons unrelated to TB symptoms. Dheda says that there are different models through which this could be affected including door-to-door screening or the use of scalable mini mobile clinics.

He says part of the priorities should be addressing the risk factors and key drivers of TB.

“As the old adage goes, prevention is better than cure. Thus, a major focus must be the prevention of TB. At the heart of this must be cross integration and working across different departments for poverty alleviation. The biggest driver of TB in South Africa is poverty and overcrowding, and if this is not addressed through poverty alleviation interventions, then TB will never be controlled or eradicated,” he says.

Customised and targeted interventions

Ingrid Schoeman, Director of Advocacy and Strategy at TB Proof (an NGO), says TB-affected communities, civil society organisations and key partners have called on the National Department of Health to implement national TB Recovery Plan interventions to achieve the NSP goal to reach all key and vulnerable populations with customised and targeted interventions.

Healthcare workers manning a mobile X-ray Clinic in KwaZulu-Natal. PHOTO: KZN Health

For Schoeman, priorities include “implement[ing] systematic screening guidelines to evaluate people with a cough of any duration (not only people with a cough duration >2 weeks) for both TB and COVID-19, and to test high-risk groups with Xpert Ultra (irrespective of symptoms). [This includes] people living with HIV, TB contacts, and people with a history of TB within the past two years (in keeping with findings on the targeted universal testing strategy),” she says, adding that there should be more endeavours to test and treat all close TB contacts and other high-risk groups such as people living with HIV with TB Preventive Therapy. (Xpert Ultra is a molecular test used for TB diagnosis.)

Integrate COVID-19 innovations

Professor Martie van der Walt, Director of the Tuberculosis Platform at the SAMRC, stresses that data from South Africa’s first national TB prevalence survey showed a large gap between case notifications and incidence.

“In the period of the previous NSP, a lot of effort went into finding the missing cases. However, due to COVID, many of the gains made in case finding and bringing incidence down has been largely lost. Going forward, we have to make up the gains lost due to COVID-19 and also do better than we had done prior to COVID-19,” says van der Walt. “We also need to move beyond demonstrating in certain selected sites the mobile chest X-ray vans and computer-aided reading to find asymptomatic cases. Instead of just demonstrating, we need to implement mobile chest x-ray vans and other tools as wide as possible. We know these new tools work so we must make it a standard tool in the case-finding approach,” says van der Walt.

She argues that the focus should be to ensure that much of the innovations developed during COVID-19 be fully integrated into TB care. “These are, for example, using mobile apps that people can screen themselves and [using] mobile phones to communicate with patients. The TB programme should change how we interact with patients, issue them with multi-month treatment so that they do not have to come on a monthly basis to clinics for collection of treatment,” she says.

sign in groote schuur hospital reading lung Function
PHOTO: Nasief Manie/Spotlight

Professor Harry Hausler, Chief Executive Officer of TB/HIV Care, also weighed in. He says improved case finding using evidence-based strategies and the rapid implementation of innovations is key.

“Given that 42% of people with TB are not diagnosed or treated in South Africa, evidence-based strategies which help to find more people living with TB and the rapid implementation of innovations are required to improve case-finding. These include targeted universal TB testing (TUTT) which focuses on people living with HIV, household contacts of people with TB, and people who have had TB in the last two years,” he says.

“New innovations such as urine lipoarabinomannan (U-LAM) tests make it possible to diagnose TB in people living with HIV with low CD4 counts—a group that is often difficult to diagnose using sputum samples but who are likely to be severely affected if they have TB and it is not diagnosed.” Digital chest X-rays, he says, have been found to be 12 times more effective at identifying asymptomatic TB than screening alone and, therefore, is another important tool to use to find the ‘missing people with TB’.

Hausler says innovations such as 3HP, which makes it easier to prevent TB among household contacts, including those under five years old who are at particular risk of being infected, need to be prioritised and rolled out.