The first ever South African National TB Prevalence survey, which commenced in 2017 and was recently launched, has left us reconsidering our approach to eliminating TB in South Africa. It was undertaken by the Tuberculosis Platform of the South African Medical Research Council (SAMRC) in collaboration with the Human Sciences Research Council (HSRC) and the National Institute for Communicable Diseases (NICD).
The survey showed that:
A staggering 57.8% of the participants that had bacteriological confirmation of TB, did not report any TB symptoms.
Pulmonary TB was most prevalent in age groups: 35 to 45 years and 65 years and older.
TB prevalence was 1.6 times greater in males, than females.
More males (71.3%) than females (63.4%) did not seek care for their TB symptom/s.
66.6% of participants who reported at least one TB symptom did not report seeking care for their symptom/s.
Among people with TB who did not report symptoms, the majority (78%) were HIV negative, showing that HIV positive people with TB were more likely to be symptomatic.
This study highlighted that innovative approaches are needed to address the high rates of TB seen in South Africa and to decrease drop-offs in the TB cascade of care. The high prevalence of asymptomatic or minimally symptomatic people with TB highlights that TB symptom screening, alone, to identify people with TB, will continue to miss people with TB. Furthermore, perceptions regarding TB symptoms and care seeking behaviour need to change.
The National TB Prevalence survey was conducted before the start of the COVID-19 pandemic. Data from the South African National Institute for Communicable Diseases demonstrate a catastrophic 48% drop in the number of TB tests conducted in South Africa (seen over a period of three months, from February 2020 to May 2020), meaning that people with TB were missed or experienced delays in diagnosis. (NICD, 2020).
Community health workers (CHWs) play a vital role in filling these gaps considering that care seeking behaviour was very low and additional barriers may prevent people from accessing health care facilities. CHWs can offer many essential services such as: creating awareness about TB in their communities; assisting with TB testing for asymptomatic high-risk groups; conducting TB screening and linking symptomatic patients to healthcare facilities; and by supporting patients throughout their TB journey. CHWs support health system preparedness to respond to health emergencies such as COVID-19 and TB. Yet, they remain unsupported in this critical role.
It is essential that South Africa (and other high TB incidence countries) respond by strengthening TB services, including the services of CHWs, and exploring ways to integrate testing and tracing, and other infection control measures for TB and COVID-19 such as the wearing of masks. TB Proof advocates for high quality, person-centred TB care for all, free from stigma and discrimination. This should include the advancement of CHW priorities, including high quality standardised training, sufficient infection prevention equipment and adequate remuneration.
5 Questions for the Twitter Chat:
What were the most important finding/s from the National TB Prevalence survey?
Based on the National TB Prevalence findings, what efforts are needed at a national and at a local level to reduce the burden of TB?
How has the COVID-19 pandemic further complicated the TB burden in South Africa?
How can CHWs support these efforts to reduce the TB burden?
What support do you think should be given to CHWs to improve the quality of care that they provide to community members?