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DTBE in South Africa

map of South Africa

Capital City: Pretoria
Area*:1.2 million sq. km. (470,462 sq. mi.).
Population (est.), 2011*: 50.59 million
Estimated TB Incidence, 2010**: 981/100,000
Estimated TB Prevalence, 2010**: 795/100,000
Adult HIV Prevalence Rate, 2009***: 17.8%
Number of people living with HIV (PLHIV), 2009***:5,600,000
Percent of tested TB patients who were HIV+, 2010**: 60%

*Source: www.state.gov
**Source: WHO Global TB Control Report 2011
***Source: UNAIDS, Report on the Global AIDS Epidemic, 2010

Background

South Africa has the second highest rate of new tuberculosis (TB) cases in the world, the highest rate of drug-resistant TB in Africa, and the fourth highest prevalence of HIV/AIDS.  Since 1996, when South Africa established a National TB Control Program (NTP) and adopted Directly Observed Therapy Short-course (DOTS) as its TB control strategy, the Centers for Disease Control and Prevention’s Division of Tuberculosis Elimination (CDC/DTBE) has provided technical assistance to the program.  CDC/DTBE has worked with the South African Medical Research Council (SA MRC), the South African National Department of Health (SA NDOH) and provincial multidrug-resistant TB (MDR TB) treatment centers to address the challenges of MDR TB and co-infection with HIV and TB or MDR TB in South Africa.  The U.S. and South African governments are focused on strengthening the NTP’s technical and information management capacity while improving service delivery.  In 1995, the World Health Organization (WHO) accredited the SA MRC TB laboratory as the supranational reference laboratory for the region.  South Africa continues to share their experience and knowledge about TB and HIV with other African countries.

Recent Accomplishments & Ongoing Collaborations

Program Strengthening and Epidemiology

Evaluation of the TB Surveillance System:  CDC/DTBE and the SA MRC conducted a systematic evaluation of the TB Surveillance System and the Electronic Tuberculosis Register (ETR) in South Africa from 2011-2012.  A standardized audit of patient-level information from multiple data sources from different levels of the public health system was used to assess the validity, reliability, efficiency, and utility of the TB surveillance system in South Africa.  The study also included interviews with health care workers responsible for recording and reporting to determine knowledge and practices related to their duties.  Analysis is underway to provide findings and recommendations to the TB program to strengthen their recording and reporting systems at all levels.

TB Tracer Project Evaluation:  CDC/DTBE, the SA NDOH, and the SA MRC conducted an evaluation of the NDOH’s TB Tracer Project, which employed 72 tracer teams across the country to help identify patients who had defaulted from TB treatment and encourage them to return to therapy.  The goal of this project was to reduce rates of default and improve TB treatment outcomes among TB patients.  The evaluation concluded in early 2012 and analysis and dissemination of the findings are ongoing.

TB Infection Control Assessments and Training: The SA MRC and CDC/DTBE have partnered to conduct environmental infection control (IC) assessments and implement and evaluate infection control (IC) interventions in health facilities caring for TB patients.  These assessments helped develop cost-benefit strategies for institutional infection control in hospitals in resource-limited countries where TB and MDR TB patients are treated.  As part of the International Tuberculosis Research Center (ITRC), MRC and CDC/DTBE established joint faculty and developed a curriculum for training environmental specialists, clinicians, and health care workers on IC in public health facilities to identify IC risk areas and to develop cost-effective strategies.  This curriculum has undergone continual improvement since its inception in 2006 and has been taught throughout the South African Development Community (SADC). 

Multidrug-Resistant TB (MDR TB), TB/HIV, and Other At-Risk Populations

Epidemiology of Drug-Resistant TB (DR TB) among Children: Very little is known about the burden of DR TB in children. CDC/DTBE has been working with the SA MRC, NDOH, and the National Research Laboratory (NRL) to better understand this burden in South Africa.  A study is underway to review all recording and reporting systems’ data in addition to medical records of children with DR TB to help describe the burden of disease, clinical and patient characteristics, and risk factors for poor treatment outcomes. In addition, the study aims to assess the ability of current national recording and reporting systems to capture data on children with DR TB.  Data collection is ongoing in 2012.

TB and HIV Treatment Adherence: For patients with both HIV infection and TB disease, adherence to both treatment regimens can be difficult for many reasons.  The level of adherence and the difficulties associated with non-adherence are not well understood in South Africa.  CDC/DTBE and the SA MRC are collaborating to evaluate adherence to concurrent TB treatment and HIV Antiretroviral Treatment (ART) regimens in South Africa.   In addition, HIV medical record systems will be evaluated to document flow of information and assess the knowledge and practices of those using the systems. Data collection was completed in early 2012, with analysis and dissemination of findings ongoing throughout 2012.

Preserving Effective TB Treatment Study (PETTS):  In collaboration with the MOH and local partners in nine countries (including the Republic of South Africa), CDC/DTBE spearheaded the Preserving Effective TB Treatment Study (PETTS). PETTS, a large multi-year, multi-country study compared programs approved by the Green Light Committee (GLC) to programs that were not GLC approved; this was done to determine the incidence and consequences of acquired resistance to second-line drugs (SLD) among MDR TB patients. Preliminary results suggest that acquired resistance to these drugs was lower in GLC approved programs. GLC approved projects also demonstrated higher cure rates, lower mortality, and lower treatment failure rates when compared with non-GLC approved projects. PETTS has informed the new framework for WHO and international partners that support countries in achieving universal access to the diagnosis, treatment, and care of MDR TB.

MDR TB and HIV Partnership: The International Training and Research Center (ITRC) is a partnership between the government of South Africa and the U.S. Government. The purpose of the ITRC is to address MDR TB and the HIV epidemic. ITRC provides medical staff from several collaborating African countries to implement the treatment of MDR TB and HIV. Additionally, the ITRC equips public health professionals with scientific research, surveillance data, and knowledge to better control TB and HIV. The ITRC has developed curricula and conducts training for clinicians on the programmatic management of MDR TB and XDR TB. As of early 2012, more than 65 clinicians have been trained across nine provinces in South Africa.

 
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