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SECOND CARNEGIE INQUIRY INTO POVERTY AND DEVELOPMENT IN SOUTHERN AFRICA

'll1e implanentation of tuberculosis pollcy in three areas

in South Africa by

Elizabeth 'Iharson & SUsan Myrdal Carnegie O:>nference Paper N;).173b

13- 19 Aprfi 1984

'!his research was furrled by. the <:SIR ProgrBlllOO for H\Jnan Needs, Iesources and the Ehvironnent.

ISBN 0 7992 0887 6

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ABSTRACT

This is the second of th~ee studies examining aspects of tuberculosis cont~ol in South Af~ica. The implementation:, of tuber.culOsis policy at hospital and clinic level is examined in three areas (Cape Town, Paar.l and the Ciskei). Methods of diagnosis, tr.eatment r.egimes and gener.al cont~ol measur.es ar.e

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investigated. I t is found that aspects such as bacteriological diagnosis, standar.dis.:d t~eatment. ~egimes, supervision of therapy and contact tracing ar.e not being cor.rectly implemented.

Compliance is a'lso found to be poo~. , I t is suggested that further. resea~ch is needed to establish ~easons for. failu~e to implement aspects of policy, and solutions to the pr.oblems.

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two clinics' thought by the health author.ities inchayge of TB in the a'l;e,a to, be r:ep r:esentative of the ar.ea, wer.estudied. The r:ecQICds of ten"clinics wer.e studied. The r.ecor:ds of f ou r.

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h,ospitals - one in Cape Town, one in ,Paar.l, one in a r.ur.al ar:ea ()

of the Cis~ei and one in an ur.ban ar.ea, wer.e also studied.

At each institution, the staff wer.e as~ed for. a l i s t of all patients on TB tr.eatment. If th~r.e wer.e less than fifty patients at a par.ticular. institution, all wer.e included in the sample. If ther:e wer.e mor.e than fifty, sequential sampling was used to select a sample of fifty. 557 r.ecor.ds were examined. Cases of non-pulmonar.y TB wer.e excluding, leaving 548 Cases. For the purposes of analysis, the hospitals in all thr.ee ar.eas wer.e grouped together. and compared with the clinics in each area.

The following aspects of TB policy were investigated: methods of diagnosis, treatment regime;s and general contr.ol measures, excluding BCG vaccination and TB health education. Information on the latter. two aspects was not available from clinic and hospital r.ecor.ds.

RESULTS

The~

'The age distr.ibution of the sample is shown in Figur.e 1. 52% of the sample wer.e !"ales and 48% females. Of the 356 adults" only 192 had r.ecor.ds of their. employment status at the time of diagnosis. Of these 91 were employed and 101 unemployed.

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'3 Methods

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^Diagnosis

Adults

Of the 35-::: adults, 306 had abnor.mal X-rays, 7 norm"l X-rays and 43 had nO record of X-ray. There were 186 (52%) bacteriol::":,Iically pr.oven (direct smear. and/or. cultu~p') cases of TB. 60 ('17%) had negative bacteriology and 110 111%) had no r.ecor.d oE 'Jny bacter.iological examination. Only l l i cases (33%) had cultt':"-(IS done. Of these, 71l had alr.eady been !llagnosed by dir.ect mi::roscoPY. Only 8 cases with negative di r.ec:t_ microscopy wer.e fou1;,::; to be positive on cultur.e.

The var.ia-:.jons in method of diagnosis by ar.ea ar.e Sh'lwn in Table I I .

Children

Both X-r.ef and Heaf testing wer.e used in the diagn""is of TS in childr.en. The r.esults ar.e show~in Table III.

Tr.eatment

a) Regime,;,.

II_~ The tr.ea::.:.,p.nt r.egimes being used for. adults and ';hildren ar.e

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^{shown in ~} "bles IV and V;

(Inser.t Table IV her.e) (Inser.t Table V her.e)

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bl DUJ:ation

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The duration of. tJ:eatment is shown in Table VI. .I

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(InseJ:t Table VI here)

c,. PJ:evious Hospital TJ:eatment

Of the patients attending clinics in the thJ:ee aJ:eas, 61% had been pJ:eviously hospitalised in the Ciskei, 26% in Paar.l and 4%

in Cape Town.

d) Supervision

The per.centage of adults r.eceiving daily supervised therapy varied according to regime and aJ:ea. (See Table VII)

(Insert Table VII here)

The percentage of children receiving daily supervised therapy varied according to regime and area. (See Table VIII)

(Insert Table VIII here)

With the exception of 17 cases, all supervision occurred at the hospital or. clinic concerned. Of the 17 cases, 16 (10 in Cape Town and 6 in Paarl) received supervised ther.apy at work. One case received sup~r.vised ther.apy at school.

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e) Camp Hance

Compliance rateswer.e divided into four categories~ 25% or. less, 26 - 49%,

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50 - 74%, and 75\ or. more of the total number. of Possible doses. The results according to area ar.e shown in Table

IX.

(Inser.t Table IX here)

General Contr.ol Methods

al Case Finding

The manner in which patients were referred to the clinic or.

hospital concer.ned is shown in Table X. The sample also included

I' 64 cases on prophylactic trea'tment as a r.esult of contact

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^tracing. Of the r.emaining 4B4 cases, 114 (24\) did not have I·, I ~

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records of method of referral. 29 (8%) of those with records were refer.red as a result of active case finding (that is, the health services seek out the cases), and 339 (92%) as a r.esult of passive case finding (that is, the patient himself seeks

treatment).

(lnser.t Table X here)

b) Contact Tr.:acing

In order for contacts to be followed up', it i.s necessar.:y fir:st to record their names and then to tr.:ace and, scr.:een them. Recor:ds were not available for. two of the hospitals. Results differ.:ed markedly from clinic to clinic and thus are given for.: each TB health service in Table Xl.

(Insert Table XI here)

c) Notification

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63%(346.1

of'

cases had' t:ecord of notification'.

DISCOSSION

Diagnosis

The importance of bactetiological as well as tadiological diagnosis has been emphasised by the WHO (4) and the American Lung Ass ⁰ cia t i on ( 5 ) • Studies on the unr.eliability of chest radiography in the diagnosis of TB have been summar.ised by Toman (6). In the TB health services 'studied, radiogr.aphy is widely used, with 306 out of 356 adults having abnormal X-r.ays. Only 183 of these 306 patients had records of bacter.ioiogical proof of diagnosis. The percentage of patients with bacteriologically

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pr.oven TB vaned from 74% of those hospitalised to 22% of those attending clinics in the Ciskei (see Table II). In a previous study of TB policy, the health authodties in charge of TB services reported pr.oblemsin getting specimens to and results back fr.om central laboratories as. a result of long .delays, transport and staff p r.oblems. Possibly the use of periphe.ral laboratories manned by people with limited training might provide a mote accessible, convenient service. This has been found in India (6). Res"earch would have to be done in the South African

situation. .

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Cultur.e is only used to a ver.y limited extent. Diagnosis of TB in childr.en is done by a combination of X-r.ay and tubetculin testing. Heaf ~nd not Mantoux tests are ^C gen~r.allyu5ed. The latter. is regarded as a more reliable diagnostic tool (7). For 36% of the children attending the clinics studied in the Ciskei ther.e was no recor.d of how diagnosis was made. ,This makes the monitoring of pr.ogr.ess difficult.

Tr.eatmen't

a) Regimes

Rifampicin-containing r.egimes ar.e extensively used in hospitals and in the Cape Town clinics. The only other. State Health- recommended r.egime that is used is Schedule 3 (INH, PZA, Str.eptomycin, Ethambutol daily).' This is used to a ver:y limited degree in the Ciskei. Other. regimes, i.e. those not recommended by State Health, are used fairly extensively in the Paarl clinics (33% of patients) and in the Ciskei clinics (74\ of patients).

HOw effective these other regimes are is uncer.tain.

The major.ity of the children in the sample (63\) were on full TB tr.eatment, I.e. shor.t course regimes. containing rifampicin. 23' wer.e being treated for str.ongly positive 'tuberculin r.eactions· (e ,I - 5 year.s) and uncomplicated pr.imar:y TB with two d·t'Ugs. In Pa'arl (21\) and the Ciskei I l l ' ) t'egimes other than those recommended by State Health ar.e being used.

8 b) Dur.ation

When shor.t cour.se regimes containing rifampicin are used the majority of patients s~o~ld not be on treatment for longer than 6 months. In both Paarl and the Ciskei where other regimes are used to a Significant extent, the majority of patients have been on treatment for longer than 6 months.

c) Previous Hospital Tr.eatment

The aim of modern TB chemotherapy is that the majority of patients should be tr.eated on an ambulatory domiciliary basis.

(Glatthaar) The Ciskei has a policy to hospitalise as many TB patients as possible. 61% of patients attending clinics in the Ciskei have previously been in hospital.

d) Super.vision

The majority of patients receiving r.ifampicin-containing regimes receive supervised treatment, whereas very few of those on other reg imes do. If the aims of supervision are of improving patient compliance and not merely ensuring that expensive dr.ugs like rifampicin are not wasted, then this situation is unsatisfactory.

One of the great advantages of modern chemotherapy is that i t allows TB patients to be treated in the community and to continue to be economically active. In th~ sample under consideration, 91 patients were employed at the time of diagnosis. 44 of these

were hospitalised. Of the remaining 47, only 176 were receiving.

supervised therapy at work. Ideally, as many patients as

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possible should receive treatment at work in or.der. to e~sul:e that their disease'causes as l i t t l e disr.uption as possible to their.

nOl:ipal lives. All other. super.vised ther.apy was administer.ed at hospitals or. clinics,

~ndicating

that as yet ther.e is yer.y l i t t i e par.ticipation of the community in super.vised therapy, one of the aims of the national tuber.culosis control pr.ogr.amme.

e) Comp liance

Compliance, outside of hospitals, is gener.ally poqr., with' only 50% of patients r.eceiving 75% or. mor.e of their treatment in the Cape Town clinics, 44% in Paar.l and 25% in the Ciskei. This is obviously a major. block to effective TB control.

Gener.al Control Methods

a) Case Finding

Passive case finding plays by far. the greatest r.ole in the detection of TB cases. The majority of patients are"detected after. they have presented themselves at ordinary State Health services.

b) Contact Tracing

Contact tracing which has been shown to be an effective method of case finding, plays a I':elatively small r.ole, contributing only 5\

to the total number. of cases. The reason for. this becomes clear when one r.ealises that only 21% of known cases of TB in the study had more than 2/3 of thei r. contacts screened. This vill':ied.,

greatly from clinic to clinic.

c) Notification

Not i fie a t ion i s a l s 0 a n i mp 0 r tan t f eat u r. e 0 f T B con t r. 0 1, as i t

allows the iuthor.ities to monitor. the number. of cases in each ' J

a r.ea. Only 63% of the cases in the study had clear. r.ecords of notification having been done.

CONCLUSIONS

The air.' '2'f this study was to see how TD policy was being impler,-,ented in differ.ent areas

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south,l,frica. r t was found tllat certain as?~cts were not being correctly implemented. These a TO:

1) bacter.iological diagnosis

2) use of standardised treatment r.egimes

j ) community-based supervisio-:l of all TH t.hc:ra;JY

4) contact tracing.

It was a}~.o founJ that co~plian-::e y:as poor.

No obJective r.easons for t!":r:st:' fincl:J!?S were t2s~21bllsI1ed.

However, in a previous study, r.f:a:th al.l~~oTities, in each area

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w,~>re asked t h e i r subjective opInions on thE' problems of

im?lpmenti~g ~R p01icy.

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1) problems of medical infr.ast~ucture such as lack of staff and funds and problems of access to laboratory facilities;

2) problems

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g'eneral infrastructure such as transport, unem- ployment and povefyty. These were particularly important in

theCiskei;

3) patient-associated problems such as non-compliance.

It would seem important if TB is to be controlled in South Africa that further research be conducted to establish the reasons for and solutions to the failure to implement certain ab-pects of TB policy. Local evaluative research undertaken at clinics is also

important since standards vary greatly from clinic to clinic.

To facilitate such research, better standar:ds of recor:d keeping ar:e requi rec. The development of a national standar:dised TB record to be used by all clinics would be a f i r s t step in this direction. During field work for this study, i t was found that

re~ord5 varied from blank sheets of paper to well-str:uctured

r:e~ 0 rt cn. res.

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REFEREN~ES

1,. Gla,tthaar. E. Tuber.~ulosis Contr.ol in South Afr.ica: 'Wher.e have we gone wr.ong?' and 'A look at the futur.e'. ~ A Med J 1982; Special Issue, p.36.

2. Thomson E M, Myrdal S. Regional var.iations in Tuber.culosis Policy in South Afr.ica. ~ ~ Med ';!. (in pr.ess), 1983.

3. Glatthaar. E Tuberculosis: Basic Perspectives. Mer.-National, 1982.

4. WHO Expert Committee on Tuberculosis - 9th Repor.t WHO Technical Report Series. Geneva, 1974, p.5.52.

5. American Thor.ac'ic"Society; Diagnostic Stan'dards and Classification of TB and other Mycoba~te~ial Diseases. (14th Edition) New Yor.k, American Lung Association, 1974.

6 .To m an K. !E.~~!:~~.!.£~.i~.:.. C

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,Questions and Answers. Geneva,' WHO, 1979 p.28.

7,. Rosen E U. The problems of d~agnosis and tr.eatment of childhood pulmonar.y tuber.culosis in developing countr.ies. ~ A Med

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1982; Special Issue, p.26.

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TABLE I. NATIONAL TB CONTROL PROGRAKKE(3)

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The contr.ol measur.es of the Depar.tment of Health and Welfar.e, in or.der. of prior.ity, ar.e:

l.Tuber.culosis Health Education.

This is aimed at involving the community in a) supervised ambulator.y tr.eatment.

b) case finding.

c) impr.ovement of socio-economic conditions.

2.Super.vised Ther.apy.

i.e.supervised, short cour.se, ambulatory tr.eatment with full community involvement and par.ticipation.

3.Case finding.

a) active (i.e. author.ities seek out cases)

Mass minatur.e X-r.ay and tuberculin campaigns ar.e recommended only in selected cases. Bacter.iological scr.eening is

recommended in r.emote ar.eas.

b) passive (i.e. the patient seeks tr.eatment)

This is consider.ed the most impor.tant method of case finding.

4.BCG vaccination.

All children must be immunized before 6 months of age.

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Table II.

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Method of Diagnosis by area

% age of adult patients given

AREA Cape

Method of Town Paarl Ciskei

diagnosis Hospitals Clinics Clinics Clinics TOTAL Bacteriologically

co~firmed 74 43 68 22 53

X-ray

only 25 56 32 44 37

No record

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0 34 10

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Table III

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Method. of diagnosis by area

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, age of child patients given

Method of

diagnosis Hospitals X-ray and

Tuberculin test

Grade 3-4 39

X-ray and Tuberculin test

Grade 1-2 11

X-ray and Tuberculin test

Grade 0 13

X-ray only 31

Tuberculin test

only 0

No record 4

Cape

Town Paarl Clinics Clinics

18 54

30 23

18 0

27 15

0 B

3 0

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Ciskei

Clinics TOTAL

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29 33

0 1S

0 10

18 26

14 4

36 10

Table IV

Adult Treatment Regimes Being Used by Area

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, age of adult patients given

AREA"

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Cape

Town Paa~l

Regime Hospitals Clinics Clinics Rifampicin-

containing 99 93 67

Schedule 3 (INH, PZA, Strep and

Ethambutol) 0 0 0

Other 1 7 33

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Ciskei ALL Clinics AREAS

13 70

12 3

74 27

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Table V ^I

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Treatmeht Regimes being used for Children by Area

% of child patients given

AREA Cape

Town Paarl Ciskei

Hospitals Clinics Clinics Clinics TOTAL 2-drug therapy

(1° complex) 9 12 36 56 23

4-drug therapy

(full TB Rx) 83 78 43 11 63

Other 7 9 21 33 15

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Table VI

Duration of Treat~ent by Area

\ of all patients given

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Cape

Town Paarl Ciskei

Duration Hospital Clinics Clinics Clinics TOTAL

6 months

or less 94% 64% 47% 37% 67%

more than

6 months 6% 36% 53% 63% 33%

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Table VII

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Percentage of adult patients receiving daily supervised th.erapy for each regime b{ area

Total number of patients receiving each regime shown in brackets

AREA Cape

Town Paarl Ciskei

Regim~ Hospital Clinics Clinics Clinics TOTAL

Rifampicin- 100 95 70 85 95

containing (144 ) (62) (26) (13 ) (245)

Schedule 3 0 0 0 5 50

(0) (0) (0) (12 ) ( 12)

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Other 100 50 0 3 5

(4 ) (13 ) (74) (92)

TOTAL 100 92 46 18 -67-

(145 ) (66) (39)

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Ta'ble 'VIII

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Percentage of chitdrenreceiving supervi~ed therapy for each re9ime by a~ea"

Total number of patients receiving each regime shown in brackets

AREA Cape

Town Paarl Ciskei

Regime Hospitals Clinics Clinics Clinics TOTAL

2~drug therapy 100 25 0 0 21

(1⁰ complex) (5) (4) (5) (15) (29)

3-drug therapy 100 93 100 33 94

(full TB Rx) (35) ⁽²⁸⁾ (6) (3) (72)

Other 100 0 0 0 21

( 4) (3) (3) (9) (19)

TOTAL 100 77 43 4 65

(44) (35) (14)

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Table IX

Compli~nce rates

Py

area for all patients

(percentages given)

AREA Cape-

Town Paarl Ciskei

Compliance Hospitals Clinics Clinics Clinics TOTAL 25% or

less 0 4 7 20 8

26-49% -0 8 14 18 9

50-74% '0 11 21 28 13

75% or

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more 100 50 44 25 60

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no record 0 27 14 10 10

Table X

Method of referr~l of cases by area per hospital or clinic given o

Percentages of patients

AREA Cape

Hethod of Town Paarl Ciskei

Referral Hospitals' Clinics Clinics Clinics TOTAL

Contact 1 12 15 2 5

X-ray

screening 2 0 12 0 2

Tuberculin

screening 0 0 6 0 1

General

Practitioner 2 12 13 5 6

Non-TB

hospital 73 53 40 23 55

TB

hospital 1 8 2 65 16

TB clinic 22 12 10 4 15

Table XI

" of cases in wh~h contacts were both recorded and screened by TB health service

TB Health Service

Cape Town Hospital Clinic 1 Clinic 2

Paarl Hospital Clinic 1 Clinic 2

Ciskei

Peddie District ..

Hospital Clinic 1 Clinic 2

Mdantsane District Hospital

Clinic 1 Clinic 2

Hewu District Cl inic 1 Clinic 2

TOTAL

, of patients with 213 or more contacts recorded and screened

Records not available 22

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19 79 44

40 44

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Records not available

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29 17

21

HOSP. ^r _CAPE TOWN

CLINICS ,.. ,

PAARL CISKEI

100 .~' •• ;o ••••••• 1o~.·.30/0.·. ~~%~

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. :.:.:8:.:.:. :.: ... ::. 0/.-:-.-:.:;:.:;

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•••••••••••• ~: .:.:.:.:.:.:.:.:. i-:.:.:.:.:.:.:.:.: ••••••••••••••

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... ~ :::: :::::::::::::::::: : .: .. ^:. . ... . ^{:.:.: .:.:.: .:.:}

•••••••• ••••••••• • :.:.:.:.:. :.:. :.1-: •. :. :.:.:. :.:.:.: :.:.:.:. :.:.:.:.:.

...•... ... . ... .

· . . . . . . ^.. ... . ... .

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:: 56% ::: :~:~:~:~:f~:~: mmmfmm\t~ ~:~ ~~:a}

PERC ENTA G E ~tftf ~:~:~:~:~:~:~:~:~ :fmm~rmmm@ :~:~:~:~:~:~:~:~::

~ ~~ ~ ~~~ ~~~~~~~~~ ~~ ~~~~ ~~~~~~~~m~~ ~j~jjlljljjjlljjjjljlljjll~j~ ~~~~~~~~~~~~ ~~~~~:

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::::.:::.:::::.: . . :0:.::.:.::.:::: ... ::.::.:.:=::::.::: .. :.:::::::: .. ': .. :

· ... . ...

· ... . > 65 YEARS

16-65 YEARS

0-15 YEARS

'---_--.lNO RECORD OF AGE

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These papers constitute the preliminary findings of the Second Carnegie Inquiry into Poverty and Develop- ment in Southern Africa, and were prepared for presen- tation at a Conference at the University of Cape Town from 13-19 Apri I, 1984.

The Second Carnegie Inquiry into Poverty and Develop- ment in Southern Africa was launched in April 1982, and is scheduled to run until June 1985.

Quoting (in context) from these preliminary papers with due acknowledgement is of course allowed, but for permission to reprint any material, or for further infor- mation about the Inquiry, please write to:

SALDRU

School of Economics

Robert Leslie Building

University of Cape Town

Rondebosch 7700