tuberculosis (tb) in the kopano health district (free state)

Tuberculosis (TB) in Kopano Health District
(Free State):
A situation analysis
Ega Janse van Rensburg
Michelle Engelbrecht
Francois Steyn
Dingie van Rensburg
David McCoy
Carmen Báez
Jointly compile d by:
Centre for Health Systems Research and Development
Health Systems Trust - Initiative for Sub-District Support

TUBERCULOSIS (TB) IN THE KOPANO HEALTH DISTRICT (FREE STATE):
A SITUATION ANALYSIS
Ega Janse van Rensburg
Michelle Engelbrecht
Francois Steyn
Dingie van Rensburg
David McCoy
Carmen Báez
© 2000 Centre for Health Systems Research & Development and Initiative for Sub-district
Support
Jointly compiled by:
Centre for Health Systems Research & Development
University of the Orange Free State
P.O. Box 339
BLOEMFONTEIN 9300
SOUTH AFRICA
Health Systems Trust – Initiative for Sub-district Support
401 Maritime House
Salmon Grove
DURBAN 4001
SOUTH AFRICA
Acknowledgements
The financial support of the Initiative for Sub-district Support in the Tshepano health region is
thankfully acknowledged. Contributions by the following people during the process of the field
work are also recognised with appreciation: Ms Leonore van der Bank; Ms Monica Norman;
Mr Eric Mojake; and all respondents in the empirical survey, who include nursing personnel in
Kopano clinics and CHCs; community based volunteer DOTS supporters in Meloding and
Allanridge; TB patients; the regional pharmacist; the laboratory technician at the Goldfields
Hospital; the division of Occupational Health at the Harmony mine, as well as the general
practitioners from Welkom and Meloding.
i

EXECUTIVE SUMMARY
Background: The Kopano health district has the highest (TB) incidence rate in the Free State
(555 per 100 000). Health care managers and providers there have identified TB as one of
the priority health problem areas in the district. The Initiative for Sub-district Support (ISDS)
approached the Centre for Health Systems Research & Development to assist in conducting
a situation analysis regarding the control of TB in Kopano. The research was conducted in
November/December 1999.
Methodology: A cross-sectional once-off, assessment was conducted in the Kopano Health
District to rapidly assess the situation regarding TB control and management. Data was
obtained from primary and secondary sources. In addition to looking at district-wide data, four
primary level facilities were purposively sampled for more detailed research. Interviews were
conducted with TB managers, health care workers providing TB services, a pharmacist, a
laboratory technician, DOTS supporters and TB patients.
Key findings: A district TB coordinator oversees the provision of TB services in the district.
Each PHC facility has a TB coordinator. In some clinics this role and function is rotated from
one staff member to another. There is an indication that this happens because nurses are
reluctant to get involved with TB management. TB data appears to be lacking in complete
reliability and accuracy. Furthermore, some nurses are inadequately informed about the
correct use of the TB register. The high proportion of re-treatment patients reflects the general
failure of the TB programme to cure patients. This corresponds to the fact that a significant
number of patients are not on a DOTS system. A proportion of re-treatment cases did not
have sputum culture tests done, despite the fact that these are the patients who are at higher
than average risk of having drug resistant bacilli. There appears to be some confusion and
misunderstanding about the value and purpose of the different diagnostic procedures for TB.
Varying practices apply to active case–finding and prophylactic treatment. No clear policy
exists with regard to testing and counselling TB patients for HIV.
In search of solutions: Each clinic nurse who is committed to and interested in TB
management needs to be identified and developed to be an efficient local TB coordinator.
Basic day-to-day management of TB patients must become the shared responsibility of all
clinic staff. Health facility staff need to receive continued training and encouragement to
provide effective health promotion, TB education, use TB registers properly, and to use
correct diagnostic procedures. With regard to TB record keeping, a thorough audit of all TB
data collection needs to be done so that the system can be rationalised and simplified. The
DOTS system needs to be thoroughly assessed in terms of its strengths and weaknesses.
GPs need to come to a shared agreement with public services about a clinical policy for TB
diagnosis. Clear guidelines must be established for case-finding and prophylactic treatment. It
is important that MDR TB patients are appropriately detected and managed. The district
needs to develop an appropriate policy on voluntary testing and counselling for TB patients
with HIV.
ii

TABLE OF CONTENTS
SECTION 1: INTRODUCTION 1
1.1 The problem: TB 1
1.2 Background to the research 1
SECTION 2: AIMS, OBJECTIVES AND METHODS 2
2.1 Aim 2
2.2 Objectives 2
2.3 Methodology 2
Data sources 2
Sampling and study populations 2
SECTION 3: FINDINGS 3
3.1 Background and overall organisation of the district TB programme 3
3.2 TB incidence and general TB profile 4
3.3 TB diagnosis 6
Sputum tests 6
The use of X-rays 8
Access to clinics for diagnosis 8
General understanding of diagnostic procedures 9
Getting results back to patients 9
3.4 Case management 10
The DOTS system 10
Tracing defaulters 14
Patient counselling and health education 15
The management of very ill TB patients 15
Follow-up sputum tests 16
MDR patients 16
HIV/AIDS 16
The rural areas and mobile services 16
3.5 Active case finding and prophylactic treatment 18
3.6 Laboratory services 18
3.7 Drug supply 20
3.8 Record keeping, registration and notification of TB 20
3.9 TB management in the private sector 21
Private GPs 21
TB management at a mine 22
3.10 Treatment outcomes 22
SECTION 4: MAIN CONCLUSIONS AND RECOMMENDATIONS 24
General management and supervision 24
TB health information system 24
Treatment adherence and directly observed therapy 24
TB diagnosis 25
Case finding and prophylactic treatment 25
MDR TB 25
Link between clinics and hospitals 25
HIV 25
APPENDIX A
APPENDIX B
APPENDIX C
iii

LIST OF FIGURES
Figure 1: Age distribution of new, smear positive Pulmonary TB cases,
1998-1999 5
Figure 2: Type of TB in Kopano, 1998-1999 5
Figure 3: New and re-treatment TB cases in Kopano, 1998-1999 6
Figure 4: Bacteriological testing of PTB cases 7
LIST OF TABLES
Table 1: Clinics and Community Health Centres (CHCs) rendering
TB services in Kopano 3
Table 2: New versus re-treatment TB cases 6
Table 3: Pre-treatment bacteriological testing of PTB cases 7
Table 4: Pre-treatment bacteriological testing of re-treatment PTB cases 8
Table 5: Information from telephonic interviews with TB coordinators at clinics
in Kopano 13
Table 6: Number of TB tests done by Goldfields SAIMR for a one year period 19
Table 7: Turnaround times for the different TB tests indicated by the laboratory 19
Table 8: Turnaround times for the different TB tests encountered at clinics 19
Table 9: Treatment outcomes for patients diagnosed during 1998 23
Table 10: Comparison of treatment outcome indicators between Kopano and the
Free State (patients diagnosed in 1998) 23
iv

SECTION 1: INTRODUCTION
1.1 The problem: TB
The control of Tuberculosis (TB) remains a major challenge in South Africa, despite the fact
that effective TB drugs are available. The seriousness of the epidemic in this country was
confirmed in June 1996, when World Health Organisation (WHO) experts stated that South
Africa has one of the worst recorded TB epidemics in the world (Strides and Struggles in TB
Control, 1997-1998: 1 & Van der Linde, 1996: 897).
According to the WHO Global Tuberculosis Report (1999), South Africa was one of the 12
countries worldwide to have an estimated incidence rate of 250 TB cases per 100 000
population in 1997. The estimated incidence rate for all cases in South Africa was 392. In
2000, the South African Medical Research Council’s National Tuberculosis Research
Programme estimated 600 TB cases per 100 00 population, and 263 365 new cases, of
whom 113 945 will be infectious and 46,7% will also be HIV positive. TB is the leading
infectious killer of youths and adults in South Africa and it is estimated that it kills nearly 1 000
people every month. It is further estimated that 18% of TB patients in this country interrupt
their treatment which means that these people are exposing the communities in which they
live to the disease (South African Health Review, 1997: 197 & Strides and Struggles in TB
Control, 1997-1998: 1).
The TB problem in South Africa is largely a result of historical neglect and poor management
systems, compounded by the legacy of fragmented health services. A lack of standardised
control programme procedures and insufficient focus on crucial aspects such as case holding,
have resulted in high treatment failure and interruption rates.
A comprehensive national TB strategy, based on the Framework for Effective TB Control
proposed by the World Health Organisation was launched in 1996. Guidelines (South African
Tuberculosis Control Programme – Practical Guidelines) for the implementation of the
national strategy have since been developed (Weyer, 1997:197-200 & The South African
Tuberculosis Control Programme – Practical Guidelines, 1996: ii-iii), using the Directly
Observed Treatment Short-course (DOTS) strategy as the basis of the Programme 1 .
1.2 Background to the research
The Free State has the third highest TB incidence rate in the country (334 per 100,000), with
the Kopano health district displaying the highest TB incidence rate in the province (555 per
100,000) a . Health care management and personnel operating in the Kopano district have
identified TB as a priority, and in 1999 the Health Systems Trust approached the Centre for
Health Systems Research & Development to assist in conducting a situation analysis
regarding the control of TB in Kopano. Fieldwork was conducted during late November and
early December 1999.
1 DOTS is a patient-centred strategy to ensure the completion of treatment under direct supervision. It
uses a “DOTS supporter” to observe treatment as well as help motivate and empower patients and their
families to comply with full treatment.
1

SECTION 2: AIMS, OBJECTIVES AND METHODS
2.1 Aim
To rapidly assess the situation regarding the control and management of TB in the Kopano
health district.
2.2 Objectives
‣ Compile the basic key TB programme indicators for the health district
‣ Describe the human resources working with TB at the selected sites
‣ Describe how TB is diagnosed and treated in the public health sector
‣ Describe the case management of TB patients
‣ Describe the referral system for TB patients
‣ Describe the DOTS system in operation
‣ Describe the support systems to the TB programme: record keeping, laboratory
services and pharmaceutical supplies
‣ Describe the role played by the private sector in the management of TB patients
2.3 Methodology
This study was done to obtain a cross-sectional once-off assessment of the situation
regarding TB in the Kopano health district and is largely descriptive. It was also an attempt to
develop a methodology for rapid situation analysis that will be used in further districts of the
Free State to measure the TB situation there.
Data Sources
Data was obtained from:
‣ Secondary data from Department of Health reports, journal articles, as well as academic
and NGO publications
‣ Primary data from field observations, interviews with a range of role players and the TB
register
Interviewees included:
‣ Communicable disease coordinator of the Free State (1)
‣ Communicable disease coordinator of the Kopano district (1)
‣ Nurses based at fixed and mobile clinics who are involved in TB management (6)
‣ Community based volunteer DOTS supporters (9)
‣ Clinic TB coordinators (4 personal interviews and 23 telephone interviews)
‣ Regional pharmacist (1)
‣ Laboratory technician in charge of TB (1)
‣ Patients with TB (7)
‣ General practitioners (GP’s) (3)
Sampling and study populations
In addition to looking at district-wide data, four primary level facilities were purposively
sampled for more detailed research:
‣ Kopano Community Health Centre (CHC) in Welkom
‣ Khotaleng Clinic in Meloding, Virginia
‣ The Local Authority clinic in Allanridge
‣ A mobile team working in the rural areas around Welkom
2

SECTION 3: FINDINGS
3.1 Background and overall organisation of the district TB programme
The Kopano health district is part of the former ‘Health Region C’ of the Free State and
includes the following major towns Welkom, Virginia, Winburg, Allanridge, Hennenman,
Odendaalsrus, Theunissen and their surrounding rural areas (see Appendix A). It has an
estimated population of 505,608 (Central Statistical Service: 1996).
TB services are rendered in the public health system through 36 clinics and two community
health centres (CHCs). Some of the clinics are run by local authorities, and others by the Free
State Department of Health (Table 1).
Table 1: Clinics and Community Health Centres (CHCs) rendering TB services in
Kopano
Town PHC facility Town PHC facility
Welkom Local Authority Clinic Allanridge Local Authority Clinic
Bophelong Clinic
Bophelong Clinic
Bronville Clinic
Leratong Clinic
Khotsong Clinic
Tshepong Clinic Hennenman Local Authority Clinic
Thabong Clinic
Phomolong Clinic
Riebeeckstad Clinic
Phomolong Mobile Clinic
Kopano CHC*
Mobile Clinic
Mobile Clinic
Odendaalsrus A. M. Kruger Clinic
Virginia Local Authority Clinic Boithusong Clinic
Meloding Clinic
Bophelong Clinic
Khotalang Clinic
Phedisanang Clinic
Saaiplaas Clinic Mobile Clinic 1
Mobile Clinic Mobile Clinic 2
Winburg Local Authority Clinic Theunissen Local Authority Clinic
Khamohelo Clinic
Masilo Clinic
Mobile Clinic
Lusaka Clinic
Mobile Clinic 1
Ventersburg Ventersburg CHC* Mobile Clinic 2
Mmamahabane Clinic
Mobile Clinic
Three district hospitals (Odendaalsrus, Virginia and Winburg), as well as the Goldfields
Regional Hospital in Welkom also render TB services. The Odendaalsrus Hospital has 17
beds available for TB patients, Virginia Hospital has ten beds and Winburg Hospital has
approximately five beds (excludes beds for children). This district used to have a TB hospital
at Allanridge but it was closed down early in 1999. TB patients who need specialised hospital
care are now referred to the SANTA TB Hospital in Thaba Nchu. The district has nine
permanent district medical officers and a larger number of private GPs, 23 of whom work on a
sessional basis in the public sector.
In terms of the key support services, nearly all the clinics use the SAIMR laboratory services
for sputum tests at the Goldfields hospital, with the exception of the Theunissen and Winburg
clinics, who use the SAIMR laboratory in Bloemfontein. Culture and sensitivity tests are done
in Bloemfontein for all the clinics. TB medication is supplied to all services by the regional
dispensary in Welkom.
The TB programme in Kopano is supervised and coordinated by a district TB coordinator, a
professional nurse who was allocated to the job. She is expected to oversee the district TB
programme as well as co-ordinate training of staff on TB. She reports to the Deputy Director:
Communicable Diseases of the province as well as the Assistant Director: Primary Health
3

Care for the Kopano district. Most clinics have identified a nurse to be responsible for TB
management and co-ordination as well as training and supporting other personnel in the
clinics. Some clinics, however, rotate the responsibility for TB management.
Key Issues: Background and overall organisation of the district TB programme
‣ The Kopano health district is large in terms of the number of clinics and CHCs. One district
TB coordinator is expected to oversee the provision of TB services in 38 primary level
facilities. The extent to which this one person is able to adequately know, monitor, supervise
and support each of those facilities needs to be reviewed, especially in light of the fact that
none of the clinics have a generic PHC supervisor.
‣ It is positive to note that each primary level facility has a person identified as the official
clinic or CHC TB co-ordinator. This should make the district TB coordinator’s job a little
easier. However, it is worrying to note that in some instances there is a reluctance amongst
nurses to work on TB, and that in some clinics, the role of clinic TB coordinator is rotated
amongst staff as this may lead to a lack of continuity.
3.2 TB Incidence and general TB profile (gender distribution / age distribution / type of
TB and ratio of new: re-treatment cases)
During 1998 and 1999 respectively, 6,164 and 3,425 TB cases were registered in the district,
including patients transferred into the area 2 . If the transferred-in patients are excluded from
these figures, the incidence of TB cases works out at 4,274 cases in 1998 and 2,368 cases in
1999. The steep decline in TB cases from 1998 to 1999 in Kopano is mainly due to the mine
hospitals not submitting their TB statistics to the Kopano District TB Coordinator during 1999.
Based on a district population of 505 608 (Central Statistical Service: 1996 census data) and
based on the 1998 figures (which includes the statistics from the mine hospitals), the TB
incidence rate can be estimated to be approximately 845.3 / 100,000.
During 1999 12,705 TB cases were registered in the Free State, and Kopano carried 26.5%
of this TB caseload. A breakdown of the district TB statistics per town and per facility
according to the official provincial statistics is given in Appendix B.
The number of new, smear positive Pulmonary TB (PTB) cases is an accurate measure of the
TB epidemic, and Figure 1 shows the age and gender distribution of new, smear positive PTB
cases in Kopano. It shows a slightly odd picture of the female incidence being two to three
times higher than the male incidence for the younger age groups, and the reverse of this for
the older age groups. One possible explanation for this is that this reflects the general
demographic composition of Kopano, although there should be no reason why there should
be twice as many females with TB in the 0-14 year age group.
2 In order to avoid double registration, patients who move from one clinic (where they are registered) to
another, are categorised as “transferred into the area”. This means that these patients will not be
included more than once in the statistics for the area.
4

Figure 1: Age distribution of new, smear positive Pulmonary TB cases, 1998-1999
1998 1999
100
80
60
40
20
0
0-14 15-19 20-39 40-59 60+
Males 26.7 35.2 75.5 86.6 65.5
Females 73.3 64.8 24.5 13.4 34.5
100
80
60
40
20
0
0-14 15-19 20-39 40-59 60+
Males 16 31.6 63.3 76.8 58.8
Females 84 68.4 36.7 41.2 41.2
In terms of the ‘type’ of TB diagnosed and registered in the district, Figure 2 shows the
relative proportion of PTB cases to primary TB and non-pulmonary TB cases, referred to as
“other TB”.
It is difficult to know if the number of extra-pulmonary cases of TB that are being diagnosed is
what should be expected. Generally speaking, one would expect to diagnose one case of
extra-pulmonary TB for every 12 cases of PTB. However, the proportion of extra-pulmonary
TB should rise as the prevalence of HIV increases in a community.
Figure 2: Type of TB in Kopano, 1998-1999
1998 1999
10,2%
6,9% 6,2%
9,7%
82,9% 84,1%
Pulmonary TB Primary TB "Other" TB
Another important general picture of the TB profile in Kopano is the relative proportion of TB
cases that are new, and those that are re-treatment cases. The official statistics for the PTB
cases are shown in Table 2. The findings show that a very high proportion of TB cases seen
in Kopano are patients who have previously defaulted on their treatment, or failed to be
previously cured.
5

Table 2: New versus re-treatment PTB cases
1998 1999
Results New cases Re-treat.
cases
Total New cases Re-treat.
cases
Total
N % N % N N % N % N
Total 2 634 74.4 908 25.6 3 542 1 427 71.6 565 28.4 1 992
Figure 3: New and re-treatment TB cases in Kopano, 1998-1999
1998 1999
25,6%
28,4%
New cases
Re-treatment cases
74,4%
71,6%
Key issues: TB Incidence and general TB profile
‣ According to the official statistics, the Kopano health district has an extraordinarily high
number of TB cases relative to the rest of the province (a quarter of the entire province’s
caseload). The incidence rate of 845.3 is also very high relative to 439.6. It may be useful
to understand the underlying reasons for this.
‣ The high proportion of re-treatment cases is cause for extreme concern as it reflects a
general failure of the TB programme to cure patients.
‣ The gender distribution of PTB cases is an odd picture which needs to be explained.
‣ The private sector statistics need to be standardised and supplied to the District TB
coordinator.
‣ PTB occurs in eight out of ten patients diagnosed with TB, while one out of ten TB patients is
diagnosed with primary TB or “other” TB.
3.3 TB diagnosis
Sputum tests
A key element of an effective district TB programme is the ability of the district to adequately
investigate all suspected cases of TB, and to then be able to accurately diagnose them. The
vast majority of TB cases are PTB cases. Most of these cases should be smear positive,
although more and more will become smear negative as the prevalence of HIV rises.
Nonetheless, all patients suspected of having PTB should have a sputum test conducted,
resulting in a bacteriological coverage rate 3 of 90%.
Generally speaking, a patient suspected of having PTB is asked to produce two sputum
samples either taken on separate consecutive days, or several days apart.
3 Bacteriological coverage is the percentage of all registered Pulmonary TB patients on whom
bacteriological investigation was conducted.
6

The pre-treatment bacteriological investigation of suspected PTB cases for both new cases
and re-treatment cases is shown in Table 3. As many as 15.6% of PTB cases in 1999 were
diagnosed without a sputum smear test having been done. The bacteriological coverage in
Kopano in 1999 (84.4%) was similar to the Free State average (84.6%) for the same time
period. Within Kopano, below average bacteriological coverage was found at the Allanridge
Hospital (20,2%), Kopano Clinic in Welkom (76,5%), Odendaalsrus (80,2%) and Winburg
(73,8%).
Table 3: Pre-treatment bacteriological testing of PTB cases
1998 1999
N % N %
Smear- 272 7,7 167 8,4
Smear+ 2 077 58,6 1 322 66,4
Smear-, culture+ 267 7,5 114 5,7
Smear-, culture- 220 6,2 79 4,0
No bact. 706 19,9 310 15,6
Total 3 542 100 1 992 100
In addition to the PTB cases with no bacteriological examination, there were a number of
cases who were diagnosed with PTB despite being smear negative, and even despite being
smear negative and culture negative. Altogether therefore, 28% of PTB cases registered in
1999 were diagnosed without a positive smear or a positive culture.
Figure 4: Bacteriological coverage in Kopano and the Free State, 1998-1999
100
80
60
40
20
0
Bacteriological tests conducted 80.1 77.5 84.4 84.6
Bacteriologocal tests not
conducted
Kopano
(1998)
Free State
(1998)
Kopano
(1999)
Free State
(1999)
19.9 22.5 15.6 15.4
Table 4 shows the bacteriological testing that was done only on the re-treatment cases. What
this shows is that slightly more than 15% (1998=17,5%, 1999=15,9%) of re-treatment cases
were not tested bacteriologically.
7

Table 4: Pre-treatment bacteriological testing of re-treatment PTB cases
1998 1999
N % N %
Smear- 72 7,9 48 8,5
Smear+ 508 55,9 329 58,2
Smear-, culture+ 115 12,7 75 13,3
Smear-, culture- 54 5,9 23 4,1
No bact. 159 17,5 90 15,9
Total 908 100 565 100
There does not appear to be any problems for the clinics to get access to culture tests, or for
getting the results back.
When asked to list the indications for doing a culture test, there was broad agreement that the
indications are:
- in re-treatment cases (Clinics A, B, and C)
- if one of the sputum tests is negative and the other is positive
- when a high index of suspicion remains despite both sputum tests being negative
- when the patient is still positive after two or three months of treatment
However, as can be seen from Table 4, a high proportion of patients officially categorised as
re-treatment cases do not have culture tests done.
The use of X-rays
According to policy, X-rays should be seldom used for the diagnosis of PTB, due to the fact
that many other lung diseases can present like TB. However, as mentioned earlier, a high
proportion of PTB cases have neither had a positive sputum smear test nor a positive sputum
culture test. This is partly due to a sizeable number of TB patients being diagnosed through
X-rays only.
The Clinic A TB coordinator indicated that about 10% of all TB patients were diagnosed by
means of X-rays only. A large proportion of these are patients who had X-rays taken or
ordered by the local GPs, either in their private capacity or when they are contracted to
provide sessions at public facilities.
When GPs diagnose TB by means of an X-ray and then send the patient to the clinic for
treatment, clinic nurses are unsure if they should confirm the GP’s diagnosis microbiologically,
whether they should simply start treatment, or whether they should do both.
In Clinics A and B, the professional nurses have the authority to request X-rays when sputum
cannot be obtained, but a medical practitioner still interprets the X-rays and makes the final
diagnosis.
Access to clinics for diagnosis
In some of the sampled clinics, it was apparent that access for TB diagnosis was not
optimised. For example, although Clinic A offers a 24 hour health service, TB diagnoses are
not done after hours. If a professional nurse, other than the TB coordinator, suspects a patient
of having TB in the evening, the patient is asked to come back the following day.
8

General understanding of diagnostic procedures
Although a structured assessment of the nurses’ understanding of diagnostic procedures was
not conducted, it was apparent there is some confusion about how and when a patient should
be diagnosed with TB. One area of confusion appears to be what the nurse should do when
one test comes back negative and the other is positive. Although in theory, both sputum tests
have to be positive to make a diagnosis of TB, and a culture test is supposed to be done if
one of the tests is negative. Nurses, however, queried the appropriateness of this when the
patient has all the clinical signs and symptoms of PTB. In some cases clinic staff indicated
that treatment is started before any results are received back if the person has obvious
clinical symptoms and is very ill.
Some nurses also indicated that they thought that culture tests and sputum tests were
alternative diagnostic procedures, rather than diagnostic procedures that complemented each
other. Another nurse indicated that she preferred culture tests because they are more
accurate than sputum tests.
Getting results back to patients
TB is a diagnosis that often cannot be made immediately on the spot, unless there is
somebody on the spot who can do sputum microscopy. Therefore it is up to the patient to
return to the clinic to get his/her sputum test result back. It can therefore be expected that
some patients will not return for their results.
In some places it may be possible for the clinic to notify the patient by telephone about his/her
result, but this would be in rare circumstances. At Clinic A, if the results are positive, the TB
nurse visits the patient at his/her home and, if the patient is not very ill, he/she is asked to visit
the clinic for treatment.
Key issues: TB diagnosis
‣ 15.6% of PTB cases were diagnosed without a sputum smear test having been done.
This equates to a bacteriological coverage rate of 86.4%, short of the desired 90%.
‣ 28% of PTB cases registered in 1999 were diagnosed without a positive smear or a
positive culture – this corresponds to the finding that are large number of patients are
diagnosed on the basis of chest X-rays. It may be that many of these patients did in
fact have PTB, but it is possible that some of them had an acute chest infection on top of
chronically damaged lungs which can look like PTB on a chest X-ray.
‣ The GPs in the Kopano area need to be brought into a shared agreement with the
public services about a clinical policy for TB diagnosis, so that nurses are not caught
between what a GP has said and done on the one hand, and the provincial TB guidelines
on the other hand.
‣ There is an unacceptably large proportion of re-treatment cases, reflecting a generally
poor TB control programme.
‣ A proportion of re-treatment cases did not have sputum culture tests, despite the
fact that these are patients who are at a higher than average risk of having drug resistant
bacilli.
‣ In Clinic A, despite being open 24 hours a day, patients are sometimes told to come back
the following day to have their sputum samples taken. Such a patient may not return to a
clinic for weeks, and this constitutes a missed opportunity for the diagnosis of TB.
Patients suspected of having PTB should have maximum access to sputum smear
tests, and the district needs to conduct a thorough assessment of the practices in each
clinic.
9

Key issues: TB diagnosis
‣ There appears to be some confusion and misunderstanding about the value and
purpose of the different diagnostic procedures for TB – sputum microscopy, sputum
cultures, clinical signs and symptoms and X-rays. Nurses need to be given further inservice
training about this, and there may be a need for the province and district to draw
their own locally appropriate policies, based on the national guidelines.
‣ This rapid situation analysis did not find out the proportion of smear positive patients who
did not return to the clinic for their results, nor did it find out the success of clinics in proactively
tracing patients with smear positive results. This is an area of action research that
the district TB coordinator may want to instigate in the future.
3.4 Case management
The DOTS system
The district communicable disease coordinator (CDC) explained that in general, it is
impossible for clinic nurses to go out into the community every day to directly observe
patients taking their TB medication. This is due to the workload in the clinics, as well as a lack
of subsidised transport. At the same time, for a number of TB patients, it is impossible for
them to attend a clinic every day to take treatment under direct supervision. Reasons for this
could include that they are too ill, they may be at work during clinic hours or because they
cannot afford daily transport to the clinic. Having TB patients come to a clinic ever day may
also be undesirable because of the congestion that such patients can add to a clinic.
Therefore there is no option but to have a community-based DOTS system.
Clinic-based observation of therapy is, however, encouraged in certain circumstances:
- Patients who work or live close to the clinic
- Re-treatment patients who require thrice-a-week injections
However, because of the lack of a community-based system of TB supporters, most PHC
facilities continue to operate a clinic-based system for many other patients (see case studies
below).
A formal community-based DOTS programme is limited in Kopano district. At the end of 1999,
the number of active ‘formally trained’ community-based DOTS supporters was 36: ten in the
three clinics in Virginia, ten in Kotlahong/Odendaalsrus, and sixteen in Allanridge.
Although major successes are being reported in all three of these communities, several
interviewees complained that the establishment of community based DOTS is hampered by
the communities’ lack of interest and participation in TB management, due to the absence of
any remuneration and because some DOTS supporters find it difficult to travel to clinics to
obtain drug supplies. These and other considerations cause health care facilities to establish
clinic instead of community based DOTS.
In these three areas, the community-based DOTS supporters are supplied with TB medication
on a weekly basis by the clinics, and then do home visits every day, taking medication to TB
patients and directly observing that the medication is consumed. They are also trained to
provide health education on TB. They generally report back every week to a clinic nurse who
supervises and monitors them, and who also inspects the patient cards. If there is a problem
with one of the patients, the supporter refers the patient back to the clinic.
The volunteers are all from the local communities, and have been trained collaboratively by
SANTA and the Department of Health, with some support from the Rotary Club. As an
incentive and a token of appreciation for their work and status, some of the DOTS supporters
are given bags in which to carry their supplies, as well as an identity badge.
The quality of support and supervision provided by these community-based volunteers was
not thoroughly assessed. However, it was possible to ascertain that although they did not
10

know the names of the different pills, they are able to go on the colour of the tablets and the
number to be administered as indicated on the container. One community volunteer DOTS
supporter also indicated that, after the patient has taken the TB medication, she makes
conversation while observing the movement of the patient's mouth and determines in this way
whether the tablets have actually been swallowed.
Finally, it was mentioned that the policy of rotating staff to be in charge of TB control at some
clinics for periods of time is detrimental to ensuring continuity of the DOTS programme. Part
of the reason for this is that in some clinics there is a general unwillingness for anyone to
volunteer as the TB coordinator, because of a perception and feeling that this is a difficult and
burdensome programme for which to be responsible.
Clinic A
The clinic-based DOTS programme is managed by a professional nurse and a staff nurse.
Patients on Regimen 1 attend every day for the first two months, and thereafter once a week
to collect their medication. Patients on Regimen 2 attend on Mondays, Wednesdays and
Fridays to receive their pills and injections for the first three months, after which they attend
once a week to collect their pills. At any one time, the CHC has about 100 patients attending
the clinic to receive their TB treatment.
Although the TB coordinator indicated that they prefer TB patients to attend the clinic every
day, if a patient is unable to do so, patients are asked to identify someone close to their home
or workplace who might support them during their treatment. It was, however, noted that
community members in the area are generally reluctant to become involved as community
based DOTS supporters.
After such a person is identified and has consented to the responsibility, the patient is asked
to bring that person to the clinic in order to receive DOTS-supporter orientation. These
supporters are then usually supplied with TB medication every week, in most cases via the
patient who obtains it from the clinic weekly. Some of those DOTS supporters, who fetch the
medication themselves, complain that the clinic is too far to travel to every week.
When an employer is identified as a potential DOTS supporter, the Clinic A TB coordinator
contacts the employer by telephone or letter and informs him/her about the situation. Although
high success rates have been recorded in cases where employers act as DOTS supporters, it
has happened in the past that TB patients have lost their jobs as a result of their TB positive
status having been revealed.
More than half the TB patients at Clinic A are supported by these community-based DOTS
supporters. Approximately 20-30% of patients fetch the medication at the clinic themselves,
and it is expected that a proportion of them end up treating themselves without supervision or
direct observation. On average, a week’s supply is provided to patients, but in some cases
monthly supplies are provided.
11

Clinic B
The majority of patients attend the clinic daily for their treatment under the supervision of a
nurse. Re-treatment patients attend the clinic on Mondays, Wednesdays and Fridays. Those
who are unable to attend the clinic daily, take their drug supply home or to an employer who
acts as a DOTS supporter. Unlike Clinic A, there is a formal community-based volunteer
DOTS programme for TB patients who are too ill or old to travel to the clinic every day.
Clinic C
Clinic-based DOTS was introduced in March 1999. Before that, a mobile TB team went to all
the TB patients’ houses to deliver medication on a two-weekly basis. The PHC services in this
area also have a mobile clinic vehicle with two nurses who work full time on TB management.
The clinic-based DOTS system was implemented for school-based learners, patients who live
near the clinic and for re-treatment cases who need injections.
Patients who go away for a period of time are requested to take their TB treatment cards with
them. If they go to a place near a clinic, they have to visit that clinic for their medication. If
they go somewhere where there is no clinic, e.g. a farm, they are given their medication for
the time they will be gone.
Learners attend the clinic after school for their medication as the nurses found that most of
them are embarrassed about their TB positive status and do not want other learners to know.
For this reason, teachers are generally not assigned as community based DOTS supporters.
In addition to the mobile TB service and the clinic-based DOTS system, there are 16 formally
trained community volunteer DOTS supporters who work with all the clinics in the area. They
were recruited by SANCO in collaboration with the TB coordinator, and then trained by
SANTA over two days. New TB patients requiring home DOTS support are assigned to
volunteer supporters during clinic meetings every Monday. The volunteers work in teams of
two, to render them safer while working in the community, and each team is assigned
between one and seven patients at a time.
Clinic D
This area has another formal community-based DOTS supporter programme supported by
SANTA. Here, the catchment area is divided into ten parts, each of which is covered by a
DOTS supporter who operates Mondays to Friday. The coordinator of the programme
matches the DOTS supporter to a patient according to geographic proximity, but no more
than five patients are assigned to one DOTS supporter at any one time. Monthly meetings are
held between the DOTS supporters, the TB nurse and SANTA officials during which problems
are discussed. Generally speaking, no problems with the community volunteer DOTS system
have been experienced this far.
Table 5 (based on data from short telephonic interviews with clinic personnel) shows a
summary of how DOTS is managed in each clinic.
12

Table 5: Information from telephonic interviews with TB coordinators at clinics in
Kopano
Town
Virginia
Local Authority
Clinic
Meloding Clinic
Saaiplaas
Clinic
Welkom
Local Authority
Clinic
Bophelong
Clinic
Bronville Clinic
Khotsong
Clinic
Thabong Clinic
Riebeeckstad
Clinic
Winburg
Local Authority
Clinic
Khamohelo
Clinic
Mobile Clinic
Allanridge
Local Authority
Clinics x 3
Hennenman
Phomolong
clinic
DOTS system
Traditional “white” clinic where patients are generally “better off”, so that there are few TB
cases.
Patients generally come to the clinic on a daily basis, and receive treatment from an
assistant nurse. Three volunteers trained by SANTA. Visit some of the patients who
cannot come to the clinic at home. Family members are not used for giving TB medication,
but are given information about TB and the importance of taking TB medication regularly.
Clinic nurse (TB coordinator) is responsible for DOTS. Very few TB patients (± 9 patients).
All come to the clinic on a daily basis.
Clinic nurse (TB coordinator) is responsible for DOTS. Patients come to the clinic every
day. Alternative arrangements can be made, e.g. they can come in every second day.
Family members given information and may then be responsible for giving the patient
his/her medication on a weekly basis. Employers also used for DOTS.
Two staff members are responsible for DOTS, but only do home visits in critical cases.
Family members given information and may then be responsible for giving the patient
his/her medication on a weekly basis.
Patients generally come to the clinic on a daily basis. Family members given information
and may then be responsible for giving the patient his/her medication on a weekly basis.
Patients evaluated on a two weekly basis.
Patients generally come to the clinic on a daily basis. Family members given information
and may then be responsible for giving the patient his/her medication on a weekly basis.
Patients evaluated on a two weekly basis. Employer can be contacted if the patient trusts
him/her.
Patients come in to a clinic on a daily basis. Staff assisted by a health educator employed
by SANTA, who visits TB patients and encourages them to come to the clinic on a daily
basis for their TB medication. Family member can be given information and is then
responsible for giving the patient his/her medication. This is done for very ill patients.
Employer can be given information and is then responsible for giving the patient his/her
medication
Patients come in to the clinic on a daily basis. Follow-up of patients who default via the
telephone and by sending messages.
All patients come in to the clinic on a daily basis. Follow-up of patients who default via the
telephone and by sending messages.
All staff at the clinic work with TB patients. Patients come on a daily basis. Home visits are
done if necessary. Family member can be given information and be responsible for giving
the patient his/her medication.
Mobile clinic nurse dispenses medication during visits to a farm approximately every seven
weeks. A family member with a strong bond with the patient is identified. This family
member is given information and is then responsible for giving the patient his/her
medication.
A few patients are on a clinic-based system. Community based DOTS in operation for
three quarters of TB patients. This system is coordinated between all three clinics. DOTS
supporters visit the clinic weekly to collect medication and report back to the nurse in
charge of them. Mobile clinics do home visits, if patients are not able to come into the fixed
clinic.
All TB patients must come to the clinic on a daily basis. They are supervised by a
professional nurse. If a patient is not able to come to the clinic, the mobile clinic nurse
does home visits before going out on her rounds, and observes them taking their
medication. Mobile clinic nurse also traces defaulters.
If a patient is unable to come to the clinic on a daily basis, a community member close to
him/her (i.e. family member or friend) is identified to administers the TB drugs to the
patient daily – he then has to come to the clinic with the patient on a regular basis. Family
members are also used on the farms.
13

Town
Hennenman
Local Authority
Clinic
Odendaalsrus
AM Kruger –
Local Authority
Clinic
Boitusong,
Bophelong and
Phedisaang
Clinics
Mobile Clinics
Theunissen
Lusaka Clinic
Mobile Clinics
Community
Health Centre
Mmamahabane
Clinic
Ventersburg
Mobile clinic
DOTS system
Only one TB patient who comes to the clinic on a daily basis.
Most persons live too far away to attend the clinic every day, therefore the health care
workers together with the TB patient identify a family member to serve as a TB supporter.
The supporter receives the TB medication at least every two weeks. The patient and
supporter report to the clinic for supervision. A mobile clinic does go to the farms each
Wednesday to search for defaulters.
Patients who can, attend the clinic daily for their medication and are observed by the
professional nurses. These clinics also work with community supporters trained by SANTA
and the Department of Health who only support patients who have problems attending the
clinics (e.g. HIV patients who do not want to be seen at the clinic, old people or people
who are very ill). These supporters are co-ordinated and supervised by the clinic
personnel. In some cases these supporters are given a weekly supply of medication. If
employers are willing, they observe the patient taking his/her medication. Supporters also
look for defaulters and motivate them to come to the clinic.
Farmers and their wives usually act as DOTS supporters. Family members are not
generally used as this causes conflict in the families. These supporters are given the
patient cards and are trained to observe the patient every day.
Patients attend the clinic every day for DOTS. In cases where it is impossible for patients
to come to the clinic, a general assistant from the clinic takes the medication to the
patients and/or family supporter on a weekly basis. General assistants also trace
defaulters. If a family supporter can come to the clinic, he/she is encouraged to do so in
order to collect the medication. In some cases employers support the patients, but often
the patients do not want their employers to know that they have TB.
Family members act as DOTS supporters for learners during the school holidays. Family
members act as DOTS supporters for adults with TB. Teachers act as DOTS supporters
for learners during the school terms.
Patients are supervised by clinic staff and most patients do not have a problem coming to
the clinic each day as the township is situated within close range of the clinic.
Patients are supervised by the clinic personnel. If a patient is unable to come to the clinic
daily, he/she is given a weeks supply of medication to take home but are asked to identify
a family member who can directly observe them taking their medication. This supporter is
not asked to come to the clinic for the professional nurse to explain to him/her the
importance of DOTS.
In cases where there is no school on the farm, a family member or neighbour is identified
to act as a DOTS supporter, otherwise teachers are used. This system works well as most
farms have a farm school.
Tracing defaulters
The tracing of defaulters is linked to the DOTS system in that one of the responsibilities of the
DOTS supporter is to supervise the patient’s adherence to treatment. A good DOTS system
should therefore keep the default rate down. However, the high proportion of re-treatment
cases indicates that the defaulter rate is high and adherence to treatment rate is low.
The main reasons for defaulting in this area were indicated to be, firstly, that migrant workers
often do not stay in one place long enough to complete their treatment and secondly that
patients have transport difficulties. According to one professional nurse, the side effects of TB
drugs are not common and not a reason for defaulting. However, other nurses indicated that
side effects were encountered on a reasonably regular basis, although they agreed that side
effects do not significantly contribute to patients defaulting.
According to the TB coordinator at the Clinic A, it is generally not possible for staff to trace
defaulters because they do not have time or transport to physically go and search for a
person who has defaulted. Health care providers therefore aim to prevent defaulting by
building a trusting relationship with their TB patients and informing them about the necessity
14

of completing treatment, as well as by trying to find them a community-based DOTS
supporter.
At some clinics, nursing personnel do trace defaulters, sometimes with the assistance of the
volunteer DOTS supporters and SANTA. At Clinic C, the mobile TB team traces defaulters
with their mobile unit. In some areas, there were said to be no problems with tracing of
defaulters, since the community is small.
Patient counselling and health education
The district communicable disease coordinator indicated that she devotes special attention to
ensure that all nurses know how to counsel a TB patient and that they invest enough time in
this counselling to adequately prepare the patient for the treatment period. Patients are
supposed to receive health education on matters relating to TB, including issues related to
hygiene and having a balanced diet.
However, it was also noted that some health care providers prefer not to work with TB
patients, and that the presence of HIV and AIDS contributes to lack of staff motivation to
provide TB services. The fear of HIV/AIDS being associated with TB was also reported to be
an issue affecting communities.
Six of the seven patients interviewed confirmed that they received health education, including
being told they had TB, being given an explanation of what TB entails, the importance of
taking medication regularly and that TB can be spread by breathing, spitting and coughing.
Four of the interviewed patients did, however, appear to be slightly less informed than the
other three patients. This was evident as some of the patients did not even know when their
treatment would be completed.
The management of very ill TB patients
According to the Assistant Director: Communicable Disease Coordinator, serious TB cases
should be referred to district hospitals (Odendaalsrus, Virginia and Winburg) for a period of up
to 2 weeks for stabilisation, after which the patient is referred back to the clinic for further
management. If a patient is too ill to be treated by a district hospital, he/she should be
transferred to the provincial TB Hospital in Santoord or the Goldfields Regional Hospital in
Welkom. The closure of the Allanridge TB Hospital in the region was also said to have
created numerous problems with the referral of TB patients for hospital care.
However, some personnel seem to be confused as to where exactly TB patients should be
referred. A clear referral policy with criteria for admission seems to be lacking. This is
compounded by the fact that the TB bed capacity of the district hospitals seemed to be
inadequate to deal with the need in the district. Some TB patients were reportedly sent home
after only two days of in-patient care, and in some cases clinics were unable to get their
patients admitted to their referral district hospital. For example, one TB patient had recently
been referred to a halfway house in Welkom (meant for HIV/AIDS patients) because there
were no TB beds available at the referral hospital.
It was also said that the preparedness of the District hospitals to receive TB patients is still
poor, as they are unused to managing TB patients. There were complaints about poor backreferral
letters from district hospitals and a general lack of communication between different
levels of TB care from some clinics. Finally, transporting patients from the clinic to the district
hospital was said to sometimes be a problem.
On the other hand there are clinics, such as Clinic B, that indicated that they experienced no
problems with referring TB patients to Virginia Hospital, or with getting back-referrals from the
hospital.
Follow-up sputum tests
15

All new smear positive TB patients are supposed to have a sputum check at two months, and
at three months for re-treatment cases. Sputa are also supposed to be taken on completion of
treatment. Anyone who remains sputum positive at any of these times are expected to have a
sputum culture and drug-resistance done. This study did not thoroughly assess the sputum
follow-up success rates.
MDR patients
The Free State policy is that MDR TB cases are to be referred only to Santoord, and in future,
to the MDR TB Unit at Moroka Hospital. However, respondents indicated that MDR patients
are referred to the isolation unit at Pelonomi Hospital in Bloemfontein or to Santoord Hospital
in Thaba Nchu. After the intensive phase of MDR treatment is completed, cases are further
managed by clinics.
The number of MDR cases detected in the Kopano district in 1999 was 69. Given the number
of re-treatment cases that did not have culture tests done, it is possible that the true number
of MDR cases could be higher.
HIV/AIDS
The relationship between TB and HIV means that a large proportion of TB cases will be coinfected
with HIV. The policy for testing TB patients with HIV in the district is to ask patients
who are not responding to treatment, but who are not MDR TB patients, to consent to be
tested for HIV. These patients receive counselling and are then tested for HIV. Postcounselling
is also given. However, in Clinic B only consenting re-treatment patients are
tested.
Those TB patients who are known to be HIV positive do not appear to be treated any
differently, except that at Clinics A and B they are given additional vitamins. One area of
confusion appears to be about giving streptomycin to re-treatment patients known to be HIV
positive. In some clinics they do not give streptomycin because it is believed to be detrimental
to the health of the patient, while in others, streptomycin is given. According to the
communicable disease coordinator of the Free State, all TB patients, whether they have
HIV/AIDS or not, should receive the same treatment. Therefore, there is no reason why TB
patients with HIV/AIDS should not be given streptomycin.
The rural areas and the mobile services
The rural areas in Kopano have traditionally been poorly served by the health services. It is
for this reason that there is separate but brief section on the rural areas in this report.
From the health information data available, the number of TB patients seen by the mobile
clinics is very low. Of the 54 mobile service points in the district, only two currently had
patients receiving TB treatment. The main explanation for the apparent low incidence of TB in
the rural areas is that many rural dwellers probably make use of health facilities in the nearby
towns. This is especially the case as mobile clinics visit farms during working hours, making it
difficult for farm workers to attend them. There was also a suggestion that TB may be underdiagnosed
on the farms because of a perception among some mobile clinic staff that people
on farms normally suffer from chronic cough because they make fires inside their homes,
especially during the winter.
Those few TB patients who are managed by the mobile clinics generally use a local DOTS
supporter. In one case, a child with TB had her grandmother act as the DOTS supporter
(though problems were experienced as the child was given the wrong amount of drugs by the
grandmother), and in the other, a farmer's wife acted as the DOTS supporter.
Other factors that negatively impact on the management of TB in the rural areas were said to
be that some farm workers are migrant workers, who are difficult to keep track of and
frequently do not complete their treatment. Furthermore, some farmers are reluctant to
16

employ TB patients or to keep them in employment. Finally, some rural areas cannot even be
visited due to safety and security problems.
Key issues: Case management
‣ Some patients in Kopano district are not on a DOTS system at all, basically being in
charge of their own medication. A more thorough assessment of the strengths and
weaknesses of directly observed therapy in each clinic is required. The fact that not all
facilities are tracing their defaulters also needs attention. Of importance will be the
extension of the formal community-based DOTS programme that was only established
in three areas of the district. SANTA has indicated their willingness to assist in the further
development of this programme, and the Rotary Club has also indicated a possibility of
sponsoring more training in the future. There is therefore good reason to be optimistic about
the strengthening of the TB programme, and the district needs to develop a clear strategy
and operational plan for increasing formal DOTS coverage.
‣ An effective clinic-based DOTS programme is dependent on a very dedicated and thorough
district TB co-ordinator who will ensure that everything is running smoothly. However, in
some clinics the policy of rotating staff to be the TB co-ordinator for short periods of
time is making this difficult. This is partly due to a perception and feeling that this role is
excessively difficult and burdensome.
‣ The ability of clinics to trace defaulters appears to vary from clinic to clinic, depending on the
availability of health personnel to look for patients in the community, and on the availability
of formal community-based DOTS supporters.
‣ Health education and information provided to patients appears to be poor in some of
the clinics. While there is a need to strengthen the community-based DOTS programme,
health facility staff need to receive continued training and encouragement to provide
effective health promotion and education on TB.
‣ It is also important that awareness and understanding about TB is increased at a public
level. Although it was said that TB awareness campaigns have increased awareness, this
study did not assess the quality or quantity of district information, education and
communication (IEC) strategies (including community radio and school health promotion).
This is something that the district’s community liaison officers could do as a follow-up to this
study.
‣ Communication between clinics and hospitals concerning TB patients is lacking, and
a clear referral policy with criteria for hospital admission needs to be developed jointly with
district and hospital personnel, taking into consideration the total bed capacity. Due to a
rising incidence of TB and to the fact that TB patients can expect to become sicker and
sicker, a study on future bed capacity should be instituted.
‣ The quality of in-patient TB care as well as their discharge procedures was not properly
assessed in this rapid situation analysis. However, some of the findings indicated that are
problems in this regard, and should be further investigated.
Key issues: Case management
‣ The follow-up sputum tests were not formally assessed in this rapid situation analysis. This
is however, something that needs to be looked at in the future.
‣ A clearer picture about MDR cases in the district is required.
‣ The district needs to develop an appropriate and clearer policy on voluntary testing and
counselling for HIV in all TB patients.
‣ Any misunderstandings about the correct management of TB patients with HIV co-infection
needs to be addressed.
17

‣ The situation of TB and TB case management on the farms and rural areas needs further
investigation. Although the numbers of TB cases reported by the mobile clinics are low, this
is probably the consequence of the low level of rural health care delivery, rather than the
true incidence of TB amongst rural dwellers. Reports that farmers are discriminating
against workers who contract TB need also be investigated and addressed.
3.5 Active case finding and prophylactic treatment
Active case finding happens to varying degrees in the district. For example, at Clinic B all
children living with TB patients are supposed to be brought in by the patient to be screened
for TB. At Clinic C, if a patient is diagnosed with TB, a home visit is done by a professional
nurse to investigate the patient’s contacts. At Clinic B, if a child has been diagnosed with TB,
his/her parents, or those living with him/her, are also brought in for investigation.
There also appears to be varying practices when it comes to giving prophylactic treatment. At
Clinics A and B, all contact children younger than two years receive prophylaxis. However, in
Clinic C, all children under five years receive prophylactic treatment.
However, when patients were asked if staff had requested them to bring their contacts to the
clinic, none of the Clinic A (n=2) and Clinic C (n=1) patients said that they had been asked to
do this. However, all four patients interviewed at Clinic B said that staff had asked them to
bring their household contacts to the clinic for screening.
Key issues: Active case finding and prophylactic treatment
‣ There seems to be varying practices when it comes to active case-finding and prophylactic
treatment. Clear guidelines need to be established for when a clinic should do any active
case-finding at all, as well as for prophylactic treatment.
3.6 Laboratory services
Kopano is served by two laboratories - the South African Institute for Medical Research
(SAIMR) laboratories at Goldfields Hospital and in Bloemfontein.
Table 6 shows the number of TB tests that were conducted in a recent 12 month period, for
public facilities. It is unclear why there is a discrepancy between culture tests and sensitivity
tests, and what criteria are used to conduct sensitivity tests. A laboratory technician
interviewed indicated that they take this work very seriously and work until 21h00 at night on
weekdays and on Saturdays.
18

Table 6: Number of TB tests done by Goldfields SAIMR for a one year period
Test
Number
Sputum microscopy 20 592
TB cultures 2 636
TB sensitivities 228
Sputum samples are sent to the laboratories using a daily courier service (hired by the
laboratory). The same courier service is supposed to bring back the test results when
collecting new samples the following day, and urgent results can also be obtained directly
from the laboratory by phone or fax. The expected standards for the turn-around times of
tests at the Goldfields laboratory are shown in Table 7. However, according to the nurses
interviewed, the sputum turn-around times typically vary from between two to seven days
(Table 8). The laboratory respondent did, however, indicate that in case of any deviations
from their standard times, clinics should contact the laboratory so that deviations can be
investigated.
Table 7: Turnaround times for the different TB tests indicated by the Laboratory
Test
TB Microscopy
TB Culture
Turnaround time (including transportation time)
Nearby clinics: 24 – 48 hours
Rural clinics: less than 72 hours
Mean: 12 days (5 – 28 days)
(TB culture negative if no growth reported after 32 days)
Table 8: Turnaround times for the different TB tests encountered at clinics
Facility
Turnaround time:
TB Microscopy test
Turnaround time:
TB Culture test
Clinic A 2 days 6 weeks
Clinic B 2–7 days 4-6 weeks
Clinic C 3-7 days 4 weeks
The laboratory also indicated experiencing some problems with the sputum samples they
receive. For example, on occasions they receive containers that are not closed or labelled
properly. On the whole, however, the laboratory respondent indicated that the relationship
between the clinics and the laboratory was healthy and that communication had improved as
a result of efforts by the district communicable disease coordinator and the laboratory.
Key issues: Laboratory services
‣ There seems to be a good laboratory service available to the clinics in Kopano district.
Clinics should, however, be encouraged to communicate more directly with the laboratories
in instances when turn-around times fall below the expected standard.
‣ Spillage of sputum on the way to the laboratory is reported to occur quite often as a
result of containers not being closed properly. Some attention should be devoted to this.
‣ The laboratory service is dependent on a private courier service for the transportation of
sputum samples. This study did not discover the cost of the service, and it is suggested that
this be an activity which the district follows-up on.
19

3.7 Drug supply
TB drugs for the Kopano clinics are supplied through the regional pharmacy in Welkom, which
compiles the separate clinic orders, and orders drugs on a monthly basis from the provincial
depot in Bloemfontein. TB drugs are now ordered through a special order form separate from
the normal bulk order of drugs. According to the regional pharmacist, no problems were
experienced with the supply of TB drugs, especially since a new supply of combination drugs
had been made available. The previous single non-combination drugs were sometimes out of
stock and it was more difficult to keep the clinics adequately stocked.
However, according to the pharmacist there were still some clinics that ordered either too
many or too few drugs by not calculating their stock requirements on the basis of their patient
load. However, the pharmacist indicated that he was training nurses to rectify this situation.
A delivery truck is used to deliver the drugs to each clinic every month, and there were no
problems reported with this.
At Clinic B, nurses indicated that ordered medication is usually received within a week, and
the clinic currently had a TB drug supply for two months. Clinic C staff also confirmed that
since the introduction of combination drugs, fewer problems are experienced with drug supply
and that for them, it only took one day to receive the drugs they ordered.
Despite the introduction of combination tablets, patients still have to take 14 tablets per day
(12 Ethambutol and 2 Pefampaan), and nurses feel that it would be an advance if
combination drugs could be designed so that even fewer tablets have to be taken.
Key issues: Drug supply
‣ There were no complaints about the supply of TB drugs to the clinics, especially since
the introduction of combination tablets, and the district and regional pharmacy should be
highly commended.
‣ Even so, the state of all drug stocks at each clinic should be measured and monitored on a
monthly basis, and a routine monitoring system should be put in place if one doesn’t already
exist.
‣ Pharmaceutical companies are in a constant process of trying to improve the quality of
combination tablets, and given the concerns raised by nurses about the high number of
tablets that patients have to consume each day, it is hoped that the national TB authorities
will keep a close eye on the availability of acceptable and affordable tablets as they emerge
on the market.
3.8 Record keeping, registration and notification of TB
According to the district communicable disease coordinator, numerous problems are
experienced with the record keeping of TB cases. Some of the TB statistics sent from
different service points in the district are incomplete or sent late, causing delays in the
compilation of TB data for analysis by the Provincial Department of Health. The TB statistics
received from rural clinics were even more problematic even though the TB coordinator
devotes substantial time to training nurses in rural clinics to keep accurate records. There are
also discrepancies between the TB data sent to the provincial DoH and the same data
received back from them, which means that compilation errors occur at the provincial level.
It is therefore clear that some clinic personnel do not know how to correctly keep TB records
despite the fact that every clinic has a TB coordinator who is supposed to train all nurses to
maintain the TB register. Contributing to this situation is the policy of staff rotation within the
clinics leading to a constant need for further training.
From the clinic side, staff note that the completion of the TB patient cards, the TB register and
case notification are all very time consuming with a lot of unnecessary duplication of data
20

capture. Nurses at Clinic B described how the information on the TB treatment card has to be
copied into the District TB Register, and that it was time consuming having to complete the
other TB cards and forms. The value of some of this information collection is also questioned
– for example, although case notification forms are sent to the local authority, it is unclear
what this serves to achieve.
At the provincial level, TB statistics are collated and managed by the TB Statistical Advisor of
the Research and Information Division of the Department of Health, with a data analysis
program that has recently been updated to include all the correct towns in each district. The
division strives to ensure that all TB statistics are received from the various towns in the Free
State, but state that the accuracy of the data presented is ultimately dependent on the
completeness and accuracy of the quarterly reports received from the various district TB
coordinators. It was their opinion that the TB data provides a fairly accurate picture of the
situation in the Free State.
Key issues: Record keeping, registration and notification of TB
‣ The data capture system appears to be irrational and over bureaucratised, with a
significant amount of duplication and un-used data capture. This is a source of frustration
to clinic staff as well as a waste of their time. A thorough audit of all TB data collection
needs to be conducted with the provincial DoH so that the entire system can be rationalised
and simplified.
‣ The national TB register is undoubtedly a difficult register to maintain and keep
accurate. Nurses need to be constantly in-serviced on the proper use of these registers, as
well as on an understanding of the different TB definitions used and the value and purpose
of all the information collected. The practice of staff rotation within the clinics is contributing
to the need for continued training, and this is a policy that the district and region may want to
examine and modify.
‣ The accuracy of the official data provided through the quarterly returns is thought to be ‘fairly
accurate’. However, the discrepancy between TB statistics at the district office and at
the provincial office indicates that there are problems. The alleged inability of some
clinic nurses to use the TB register also needs to be investigated. A formal audit of the TB
information system could be useful.
3.9 TB management in the private sector
Private GPs
Although the arrival of Cuban and community service doctors has reduced the traditional
reliance on private sector doctors to provide medical care, GPs are still quite prominent.
Several, for example, are contracted to do sessions in district hospitals and clinics. One
influence of these doctors on the TB programme has already been mentioned earlier – many
GPs use X-rays to make a diagnosis of TB which comes into conflict with the national TB
guidelines, and which can put clinic staff in a difficult position. The Assistant Director:
Communicable Disease Coordinator indicated that very few private practitioners are aware of
the national guidelines and therefore do not diagnose TB by means of sputum tests.
This was confirmed by three private practitioners from Virginia and Welkom who all indicated
that they sometimes send patients to the public sector clinics after they have diagnosed TB.
On occasion they also send patients suspected of having TB for further investigation.
TB management at a mine
The other major private sector health provider in the district are the private mining companies
who provide a health service for their employees. TB patients at the Harmony mine, for
example, are managed by an internal occupational health service. Patients who are very ill
are also hospitalised at the Harmony Hospital, where even a small number of MDR cases in
an isolation hall are managed. The Department of Health subsidises the treatment of TB
21

patients at the mine by about R2 per outpatient per day and R6 per hospital in-patient day 4 .
The mine has a TB committee which meets every month and which the district communicable
disease coordinator keeps contact with.
A strict DOTS system is applied with all patients required to go to ‘dressing stations’ every
day for their medication. Each patient has a booklet at the dressing station, in which he signs
after receiving treatment. Failure to take their TB medication every day is in contravention of
the Mine Health Act and can lead to prosecution.
According to the mine health workers, case management follows the national guidelines in
terms of the treatment regimens, but they adopt slightly different diagnostic procedures. For
example, they can take up to 6 sputum samples if TB is suspected but microscopy tests keep
on coming back negative, and X-rays are generally used more frequently than in public
services.
TB statistics are sent to the regional office in Welkom every quarter, and are notified in the
same way as the public sector. While they no longer use the national TB register for record
keeping, they have developed a data base to keep record of TB patients. However, in 1999
there was problem with not all of the mine hospitals submitting their TB statistics to the
Kopano District TB Coordinator, resulting in a steep decline on the overall Kopano TB
incidence rate compared to 1998. The TB Statistical Advisor at the Research and Information
Division of the Department of Health has undertaken to contact the mines and follow-up why
TB statistics were no longer being submitted to the district TB Coordinator.
Key issues: Private Sector
‣ There is no standardisation of diagnostic procedures and policies across the public
and private sector. GPs are generally unaware of the national guidelines with regard TB.
The private GPs in Kopano need to be engaged with in order to develop a common
approach to case detection and case management, particularly around the use of sputum
tests and X-rays.
‣ The failure of the Harmony mine to submit their statistics to the district TB co-ordinator has
distorted the TB profile in the district, and needs to be rectified as soon as possible.
3.10 Treatment outcomes
The official treatment outcome indicators 5 are based on PTB patients (those diagnosed in the
area as well as those transferred into the area). Treatment outcomes exclude the patients
who were transferred out of the area during their treatment period.
The outcomes are generally calculated in the year following the patient’s diagnosis as
treatment lasts for a minimum period of six months. Outcomes are focused on PTB patients
due to the infectious nature of this type of TB, although it is important for staff to be fully
aware of the treatment progress and outcomes of patients with extra-pulmonary TB.
4 According to the Communicable Disease Coordinator in the Free State, the Department of Health
subsidises the treatment of TB patients by the min at R2-50 per outpatient per day and R26-00 per
hospital patient per day.
5 According to the national TB programme there are five main treatment outcomes:
‣ Cured – patients who have completed a course of tuberculosis treatment and have a negative
sputum smear or culture at the end of their treatment, or who has a negative sputum smear or
culture at two months and documented proof of adherence, but was not able to produce a sputum
smear at the end of his/her treatment.
‣ Successful completed treatment – patients who have adhered to a full course of treatment with
direct observation, even if no sputum investigation are done at the end of treatment.
‣ Failed - patients who remain smear or culture positive after six months (new cases) or eight months
(re-treatment cases) of treatment.
‣ Interrupted – patients who are non-adherent with treatment for two months or longer over the
treatment period.
‣ Died – patients who have either died from TB or from other causes
22

During 1998, 3 482 TB cases were registered in Kopano, including transfers into the area. Of
the PTB patients, a total of 744 cases were transferred out of Kopano during 1998 and
therefore have no final outcome in this area. Thirty nine cases initially registered as TB,
proved not to be TB and were excluded. This leaves 2 612 PTB cases with a known treatment
outcome. There were also 440 cases of primary TB and 186 patients with “other” forms of TB.
Table 9: Treatment outcomes for patients diagnosed during 1998
Category of
patient
Cured Treatment
completed
Treatment
failed
Treatment
Interrupted
Died of TB Died (other
causes)
Total
N % N % N % N % N % N % N %
New 774 39,5 668 34,1 25 1,3 351 17,9 118 6,0 24 1,2 1 960 100
patient
Re-treat. 230 35,3 174 26,7 25 3,8 149 22,8 48 7,4 26 4,0 652 100
Patient
Total 1 004 38,4 842 32,2 50 1,9 500 19,1 166 6,3 50 1,9 2 612 100
With regard to new PTB cases, 39,5% were cured and a further 34,1% completed treatment,
leading to an overall treatment success rate of 73,6%. Treatment was interrupted by 17,9% of
new patients and 6% died from TB. It is encouraging to note that slightly more than a third of
the re-treatment patients (35,3%) were cured, and a further 26,7% had completed their
treatment. On a more discouraging note, a quarter of the re-treatment patients (22,8%)
interrupted their treatment, and this is a definite area for concern as these patients are
candidates for MDR TB.
Table 10: Comparison of treatment outcome indicators between Kopano and the Free
State (patients diagnosed in 1998)
Indicators Kopano (%) Free State (%)
Overall cure rate 38,4 40,5
Successful treatment rate 70,7 72,0
Overall treatment failure rate 1,9 2,4
Overall treatment interruption rate 19,1 16,6
New smear positive cure rate 64,9 61,9
Re-treatment smear positive cure rate 51,4 50,5
Died from TB 6,4 7,0
Died from another cause 1,9 2,0
The overall cure rate in Kopano (38,4%) was slightly lower than that for the Free State
(40,5%), although the new smear positive cure rate was higher in Kopano (64,9%) than the
Free State (61,9%). On a negative note, Kopano had a higher overall treatment interruption
rate (19,1%) than the Free State (16,6%).
23

Key issues:
‣ The official figures for 1998 needed to be treated with caution:
- overall cure rate of 38,4%
- successful treatment rate of 70,7%
- treatment failure rate of 1,9%
- treatment interruption rate of 19,1%
SECTION 4: MAIN CONCLUSIONS AND RECOMMENDATIONS
This section has taken the key issues listed in the previous section and has highlighted the
issues considered to be most important.
General management and supervision
A successful TB programme needs intensive management and close supervision. In the
Kopano health district one district TB coordinator is expected to oversee the provision of
TB services in 38 primary level facilities, and the extent to which this one person is able to
adequately know, monitor, supervise and support each of those facilities needs to be
reviewed, especially in light of the fact that none of the clinics have a generic PHC supervisor.
The practice of having an identifiable TB coordinator for each clinic appears to be sound.
However in some clinics this role and function is rotated from one staff member to
another, leading to a lack of continuity and to difficulty in building up the technical and
managerial expertise that is required of a TB co-ordinator. What is particularly worrying is
the indication that this happens because nurses are reluctant to get involved with TB
management due to an apprehension of the complexity of the programme and the hard work
involved, as well as a fear and stigmatisation of TB and HIV.
It is critical that in each clinic a nurse who is committed to and interested in TB management
is identified and developed to be an effective local TB co-ordinator. At the same time, the
impression that all TB responsibilities will then pass onto the shoulders of this one staff
member must be dispelled, so that the basic day-to-day management of TB patients is
accepted as the shared responsibility of all clinic staff. Health facility staff also need to receive
continued training and encouragement to provide effective health promotion and education on
TB.
TB health information system
The lack of complete reliability and accuracy of the TB data is worrying, as are the
findings that some nurses are inadequately informed about the correct use of the TB
register and that the data capture system at facilities is irrational and has a significant
amount of duplication and un-used data capture. A thorough audit of all TB data collection
needs to be conducted so that the system can be more rationalised and simplified. At the
same time, nurses need to be constantly in-serviced on the proper use of the TB registers.
Treatment adherence and directly observed therapy
The high proportion of re-treatment cases reflects a general failure of the TB programme
to cure patients. This corresponds to the finding that a significant number of patients are
not on a DOTS system at all, basically being in charge of their own medication, and that not
all facilities are able to actively trace defaulters in the community. A thorough assessment
of the strengths and weaknesses of directly observed therapy in each clinic is required. The
extension of the formal community-based DOTS programme that was established in
three areas of the district needs to be expedited, using the assistance of SANTA and the
Rotary Club.
24

TB diagnosis
There appears to be some confusion and misunderstanding about the value and purpose
of the different diagnostic procedures for TB – sputum microscopy, sputum cultures,
clinical signs and symptoms and X-rays. Nurses need to be given further in-service training
about this, and there may be a need for the province and district to draw their own locally
appropriate policies, based on the national guidelines. The GPs in particular need to be
brought into a shared agreement with the public services about a clinical policy for TB
diagnosis, so that nurses are not caught between what a GP has said and done on the one
hand, and the provincial TB guidelines on the other hand.
Case-finding and prophylactic treatment
There seems to be varying practices when it comes to active case-finding and prophylactic
treatment. Clear guidelines need to be established for when a clinic should do any active
case-finding at all, as well as for prophylactic treatment.
MDR TB
It is critical that detected cases of MDR TB are appropriately detected and managed. A
proportion of re-treatment cases did not have sputum culture tests, despite the fact that
these are patients who are at a higher than average risk of having drug resistant bacilli. This
needs to be addressed.
Link between clinics and hospitals
A clearer referral policy with criteria for hospital admission needs to be developed jointly
with district and hospital personnel, taking into consideration the available bed capacity. The
quality of in-patient TB care as well as their discharge procedures needs to be further
investigated.
HIV
The district needs to develop an appropriate and clearer policy on the voluntary testing
and counselling for HIV in all TB patients. Any misunderstandings about the correct
management of TB patients with HIV co-infection also needs to be addressed.
25

APPENDIX A
Is attached as a CorelDRAW 7 file.
APPENDIX B
Table 11 : TB statistics for Kopano, 1998-1999
Towns/facilities 1998 1999
Allanridge 82 114
Allanridge Hospital 371 107
Harmony Hospital, Virginia 582 94
Lorraine Mine Hospital 22 0
Fort St. Helena Hospital, Welkom 202 48
Ernest Oppernheimer Hospital, Welkom 674 0
Kopano, Welkom 88 146
Winburg 89 47
Venterburg 48 51
Theunissen 95 71
Viginia 482 304
Welkom 1 031 867
Henneman 80 109
Odendaalsrus 428 410
Total 4 274 2 368
APPENDIX C
TSHEPO AND KOPANO DISTRICTS: TB SITUATION ANALYSIS FEEDBACK
WORKSHOP
BACKGROUND
During the second semester of 1999, the ISDS facilitated the start of a process of integration
of PHC programmes in the Free State. The chief objectives of the process were to develop a
joint integrated framework for PHC delivery as a whole, and to try to change the type of
relationship between the provincial programme managers and their counterparts at district
level.
The district identified was Kopano, and the programmes or health problems to be integrated
were STDs/HIV/AIDS and TB. The ISDS was mandated to support the district in the
development of separate situation analyses of the programmes that were to be integrated.
The purpose of the exercise was to identify common problems in terms of strengths and
weaknesses and to facilitate the integration process in a smooth and practical way.
With regard to STDs, the DISCA tool, that provided the required information, had already
been implemented in Kopano. Furthermore, a quick HIV/AIDS situation analysis was carried
out by the town managers in Kopano, towards the end of November 1999. With regard to TB,
the ISDS requested the CHSR&D to conduct a rapid TB situation analysis, which was done in
a short period of time. Unfortunately, the whole integration process came to a standstill due
to re-structuring in the FS DoH, and no further progress has been in this regard until now.
The results of the TB situation analysis in Kopano highlighted the need to investigate certain
aspects of the programme in more depth. In February this year, an intensive new process
started in which the CHSR&D, in conjunction with the ISDS and the DoH, developed a
comprehensive set of tools to investigate certain aspects of the TB programme in greater
depth. The DoH showed an interest in conducting such investigations in all districts of the
Free State and a plan for achieving this was developed. From the beginning, this was a joint
26

venture between the ISDS, the DoH and the CHSR&D, involving the field- work, compilation
of data and reporting of the situation analysis of Kopano and Tshepo Districts.
A workshop was planned as part of the situation analysis to present the findings and
preliminary recommendations. The aim was to involve the implementors right from the
beginning of the process in order to develop ownership of the findings and recommendations.
This report is a reflection of the above-mentioned workshop, from which additional
recommendations have emanated and will be included in the final situation analysis
document. The workshop was amazingly well attended by a broad representation of
stakeholders and therefore a broad range of local ideas and solutions will contribute to the
improvement of the TB control programme in the district.
INTRODUCTION
Prof Dingie van Rensburg, the Director of the Center for Health Systems Research &
Development (CHSR&D) welcomed the participants and explained the background of the TB
situation analysis. He also explained that this is only the start of a long exercise that will be
repeated in other districts in the Free State.
FEEDBACK ON TB SITUATION ANALYSIS
The two districts Kopano and Tshepo were presented separately by the following researchers
from the (CHSR&D):
• Ega Janse van Rensburg
• Michelle Engelbrecht
• Christo Heunis
• Zacheus Matebesi
The research was conducted in November 1999 in Kopano and in March 2000 in Tshepo.
The aim of the study was to rapidly assess the situation regarding the control and
management of TB in the Kopano and Tshepo health districts.
The methodology used was a cross-sectional, once-off assessment for rapidly assessing the situation
regarding TB control and management. The data was obtained from primary and secondary sources.
The team looked at district-wide data, as well as purposively sampling three fixed primary health care
clinics and two mobile clinics in each district for more detailed research. In Kopano private doctors as
well as the mining sector were included, while in Tshepo two hospitals were included in the situation
analysis.
The data was obtained from: Department of Health reports, journal articles, as well as
academic and NGO publications (secondary data), and from field observations, interviews
with a range of role players and the TB register (primary data).
Interviewees were carried out with a broad range of people as follows:
‣ Communicable disease coordinator of the Free State
‣ Communicable disease coordinator of the Kopano and Tshepo districts
‣ Nurses based at fixed and mobile clinics who are involved in TB management
‣ Community based volunteer DOTS supporters
‣ Clinic TB coordinators
‣ Hospital TB coordinators in Tshepo
‣ Regional pharmacist
‣ Lab technicians in charge of TB
‣ Private doctors in Kopano
‣ TB nurse at a mine in Welkom
‣ Patients with TB
27

KOPANO MAIN CONCLUSIONS AND RECOMMENDATIONS
This section has taken the key issues and highlighted those considered to be most important.
General management and supervision
A successful TB programme needs intensive management and close supervision. In the
Kopano health district one district TB coordinator is expected to oversee the provision of TB
services in 38 primary level facilities, and the extent to which this one person is able to
adequately know, monitor, supervise and support each of those facilities needs to be
reviewed, especially in light of the fact that none of the clinics have a generic PHC supervisor.
The practice of having an identifiable TB coordinator for each clinic appears to be sound.
However in some clinics this role and function is rotated from one staff member to another,
leading to a lack of continuity and to a difficulty in building up the technical and managerial
expertise that is required of a TB coordinator. What is particularly worrying is the indication
that this happens because nurses are reluctant to get involved with TB management due to
an apprehension of the complexity of the programme and the hard work involved, as well as a
fear and stigmatisation of TB and HIV.
It is critical that in each clinic a nurse who is committed to and interested in TB management
is identified and developed to be an effective local TB coordinator. At the same time, the
impression that all TB responsibilities will then pass onto the shoulders of this one staff
member must be dispelled, so that the basic day-to-day management of TB patients is
accepted as the shared responsibility of all clinic staff. Health facility staff also need to receive
continued training and encouragement to provide effective health promotion and education on
TB.
TB health information system
The lack of complete reliability and accuracy of the TB data is worrying, as are the findings
that some nurses are inadequately informed about the correct use of the TB register and that
the data capture system is irrational and has a significant amount of duplication and un-used
data capture. A thorough audit of all TB data collection needs to be conducted so that the
system can be rationalised and simplified. At the same time, nurses need to be constantly inserviced
on the proper use of the TB registers.
Treatment adherence and directly observed therapy
The high proportion of re-treatment cases reflects a general failure of the TB programme to
cure patients. This corresponds to the finding that a significant number of patients are not on
a DOTS system at all, basically being in charge of their own medication, and that not all
facilities are able to actively trace defaulters in the community. A thorough assessment of the
strengths and weaknesses of directly observed therapy in each clinic is required. The
extension of the formal community-based DOTS programme that was established in three
areas of the district needs to be expedited, using the assistance of SANTA and the Rotary
Club.
TB diagnosis
There appears to be some confusion and misunderstanding about the value and purpose of
the different diagnostic procedures for TB – sputum microscopy, sputum cultures, clinical
signs and symptoms and X-rays. Nurses need to be given further in-service training about
this, and there may be a need for the province and districts to draw their own locally
appropriate policies, based on the national guidelines. The GPs in particular need to be
brought into a shared agreement with the public services about a clinical policy for TB
diagnosis, so that nurses are not caught between what a GP has said and done on the one
hand, and the provincial TB guidelines on the other hand.
28

Case-finding and prophylactic treatment
There seems to be varying practices when it comes to active case-finding and prophylactic
treatment. Clear guidelines need to be established for when a clinic should do any active
case-finding at all, as well as for prophylactic treatment.
MDR TB
It is critical that cases of MDR TB are appropriately detected and managed. A proportion of
re-treatment cases did not have sputum culture tests, despite the fact that these are patients
who are at a higher than average risk of having drug resistant bacilli. This needs to be
addressed.
Link between clinics and hospitals
A clearer referral policy with criteria for hospital admission needs to be developed jointly with
district and hospital personnel, taking into consideration the available bed capacity. The
quality of in-patient TB care as well as their discharge procedures needs to be further
investigated.
29

HIV
The district needs to develop an appropriate and clearer policy on the voluntary testing and
counselling for HIV on all TB patients. Any misunderstandings about the correct management
of TB patients with HIV co-infection also needs to be addressed.
TSHEPO MAIN CONCLUSIONS AND RECOMMENDATIONS
Management and human resources
The district appears to be relatively well resourced in terms of medical, nursing and auxiliary
staff/ services. However there is a perception about a shortage of staff, which needs further
investigation.
One district TB coordinator oversees the provision of TB services in 24 primary level facilities.
The extent to which this one person is able to adequately know, monitor, supervise and
support each of those facilities needs to be reviewed, especially given reported transport
problems.
It is positive to note that each primary level facility has a person identified as the official clinic
TB coordinator. This should make the district TB coordinator’s job a little easier.
Accurate diagnosis and appropriate use of tests
Despite improvements in diagnosis since 1998, and although most patients were diagnosed
bacteriologically, there was evidence of improper clinical diagnostic practice in a number of instances:
‣ Some nurses indicated that they did not know when a culture test was indicated.
‣ Some doctors continued to base diagnosis on X-rays without conducting complementary
sputum tests.
‣ Although only sputum tests should be taken when first testing for TB, some clinic sisters
order both sputum and culture tests immediately.
‣ The interpretation of X-rays can be difficult and prone to error, and the accurate and
appropriate interpretation of X-rays by inexperienced community doctors does not seem
to be adequately monitored.
‣ One nurse reported that children with TB could be missed if the score sheet is used,
which indicates a misunderstanding of the score sheet, which is designed specifically to
reduce under-diagnosis.
‣ At least one child over the age of five years was diagnosed partly on the basis of a
reactive tuberculin test.
Of greater concern was the reporting on sensitivity tests, especially in those patients who
have previously defaulted, or who remain sputum positive after treatment. These are patients
who may be MDR positive and need to have accurate sensitivity tests done. One patient, who
was consistently sputum and culture positive at six months, had no indication of the sensitivity
results.
It appears from the most recent data that the overall number of culture tests being ordered
has reduced.
Laboratory tests for diagnosis are a particular problem with the mobiles that only visit points
on an infrequent basis.
Possible under-diagnosis of children and extra-pulmonary TB
A rough analysis of the age distribution indicates a relative under-diagnosis of TB amongst
children. It was particularly worrying that there were no cases of TB in children younger than
five years amongst fifty consecutive TB patients at one clinic.
30

All the clinics indicated that the contacts of TB patients are investigated and children under
five years of age are put on prophylactic treatment. However, this did not appear to be
followed through, nor is there any monitoring of prophylactic treatment.
There seems to be varying practices when it comes to active case-finding and prophylactic
treatment. Clear guidelines need to be established for when a clinic should do any active
case-finding at all, as well as for prophylactic treatment.
Correct use of the register and un-used data capture
The lack of complete reliability and accuracy of the TB data is worrying, as are the findings
that some nurses are inadequately informed about the correct use of the TB register and that
the data capture system is irrational and has a significant amount of duplication and un-used
data capture.
A thorough audit of all TB data collection needs to be conducted so that the system can be
rationalised and simplified. At the same time, nurses need to be constantly in-serviced on the
proper use of the TB registers.
Health workers’ knowledge of TB
A formal and structured assessment of the knowledge of health workers in TB was not conducted.
However, gaps in understanding were identified in the process of the research, including the following
areas:
‣ The appropriate use of X-rays for diagnosis
‣ The ability to interpret X-rays
‣ The appropriate indications for conducting a culture test
‣ The proper use of the TB register
‣ Management of TB medication side-effects
‣ The treatment of TB patients with HIV/AIDS
‣ Contra-indications to streptomycin injections
‣ Official TB policy and guidelines.
The variety of short TB training workshops appears to only be attended by one or two health
care workers from each facility. There is a need for more health care workers to attend such
workshops and training. Auxiliary staff also plays a role in TB management and should be
targeted for relevant training.
Confusion about clinical issues such as the management of HIV and MDR cases
The district needs to develop an appropriate and clearer policy on the voluntary testing and
counselling for HIV in all TB patients. Any misunderstandings about the correct management
of TB patients with HIV co-infection also need to be addressed.
The hospital management of TB cases and MDR cases seems to be hampered by the
following main problems:
‣ A lack of district hospital beds for the admission of very sick TB patients
‣ Problems with the physical transportation of MDR patients to Santoord
‣ Inaccessibility of Santoord to the communities of Tshepo
‣ Absconding of MDR TB patients from Santoord
The possibility that MDR patients are not being treated according to policy needs to be
investigated
31

The particular difficulties and constraints of mobile clinics
Laboratory test for diagnosis is a particular problem with the mobiles that visit points
infrequently. It is also difficult to follow-up problems as they arise.
The need to strengthen and expand community-based DOTS
The procedures of the DOTS system appear to be effective and logical. The volunteer DOTS
supporters have been trained and are supported by SANTA, and this arrangement seems to
be an example of a good partnership with the DoH. Their knowledge of TB is fairly good, and
they appear to be both competent and confident in their work.
Supervision and support of the volunteer supporters was found to be important, and the
DOTS supporters themselves are satisfied with the support and supervision they receive. The
volunteers do not receive any remuneration for their work, or even to cover costs and there
seems to be a hope that it may lead to some kind of paid employment in the future.
Health promotion at community level
The need for health promotion at the community level is important given the factors that
contribute to poor health care seeking behavior and non-adherence to treatment. The main
issues to be tackled seem to include:
‣ The stigmatisation of TB
‣ The perception that all TB patients have HIV
‣ The fact some patients stop coming for treatment if they feel better
DISCUSSION OF THE SITUATION ANALYSES
Dr Báez explained to the participants that the development of a situation analysis is always
important to identify the weaknesses and the gaps in services, such as the TB programme,
and to be able to tackle them in a systematic way. She also asked the participants not to take
the results personally, for example when a particular clinic is mentioned.
Dr Chapman made a similar input, reinforcing the issue of viewing the exercise in a positive
light, so that the programme could be strengthened.
Dr Lesley Bamford from the ISDS facilitated the discussion session after the presentations
and the researchers were asked to clarify some points made. The issues were discussed later
in groups.
LABORATORY SERVICES
Mr Botes from SAIMR at GHR in Welkom made a request for improving communication
between his staff and the clinics. He also made an appeal for good practices and for the
correct implementation of the sputum collection technique, which basically means that the
container should be closed properly. The number of leaking containers appears to be a
frequent problem in both districts. (See procedures and Mr Botes’ notes in annexure)
GROUP DISCUSSIONS
In order to receive more explicit inputs from the participants, the group was broken into
smaller groups to discuss the most relevant issues as follows:
• Group 1: DOTS
• Group 2: Hospitals
• Group 3: The role of mobiles
• Group 4: Diagnostic tests
• Group 5: Clinical diagnosis and contact tracing
• Group 6: The register
FEED BACK FROM THE GROUPS:
32

GROUP 1: DOTS
1. Recruitment of DOTS supporters
Members of the community should come to the clinic out of their own if they wish to act as
DOTS supporters. Persons who volunteer to act as DOTS supporters must be familiar with
the community that they wish to serve. It must be emphasised to them that their work is
voluntary and that there is no remuneration.
2. Training of DOTS supporters
Volunteers should not only be trained on how to act as DOTS supporters, but also on
HIV/AIDS and home-based care. This will counter duplication of training. All clinics must be
made aware of the fact that SANTA is willing to train DOTS supporters. Family members who
act as DOTS supporters need to receive more training. All training must follow the TB Control
Programme Guidelines 2000.
3. Supervision of DOTS supporters
Health care workers should have weekly meetings with DOTS supporters. The TB
coordinators should visit employers who act as DOTS supporters. Furthermore, the TB
coordinator should ensure that all patients attending the clinic are educated on TB.
There was a feeling among the group that DOTS supporters should not be overloaded with
training and information on HIV and home-based care, especially in light of the fact that some
DOTS supporters were of the opinion that they were already doing the nurse’s job. One way
to deal with this problem is to carefully define what would be expected of the volunteer with
regard to HIV and home-based care. TB is an entry point for the volunteer and additional
tasks such as home-based care may follow quite easily.
Passive recruitment of DOTS supporters may also not work. Instead it was felt that it might be
necessary to actively recruit DOTS supporters. DOTS supporters must be trained and linked
to a specific clinic. They should receive at least one month of practical training at the clinic.
This would allow the sister to supervise the DOTS supporters and slowly begin to assign
patients to him/her. DOTS supporters must report on a weekly basis to the clinic sister and
then also collect the patient(s) medication. Any problems should be reported immediately.
DOTS supporters should be given name tags that clearly indicate that they are community
health workers.
Finally, supporters should be recruited and trained according to the number of TB patients. If
too many supporters are trained, they will not have any patients to support.
GROUP 2: HOSPITALS
There are not enough hospital beds to accommodate TB patients who need to be
hospitalised. Furthermore, Welkom does not have a district hospital. A question was raised
with regard to the closure of Allanridge Hospital and whether or not this resulted in saving
money. It was indicated that if any money had been saved, this money should be used to
introduce an alternative plan, for example opening a ward exclusively for TB patients.
Hospital personnel should be trained with regard to TB management. Hospitals must be given
“pink forms” and should take care of notification of TB patients. Clear policies on the
admission and discharge of patients should be drawn up and circulated.
A clear policy for the handling of the TB registers needs to be formalised and all staff need to
be made aware of this. There is especially a problem with patients diagnosed at hospital or in
prison.
With regard to medical officers, the regional medical officer needs to properly inform his
doctors about protocols, diagnosis and regimens. Circulating policy documents to doctors
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does not help, as they ignore it. Doctors need to be given training. They can be encouraged
to attend training by providing them with CBD points if they do.
Someone at each clinic should co-ordinate the transportation of TB patients, especially with regard to
Santoord. A waiting house for patients, who have been referred to Santoord, would make the referral
system more effective.
The mining hospitals complained that the R26 they are subsidised per patient per day is too
little.
GROUP 3: THE ROLE OF MOBILES
Why are there so few TB patients who attend the mobiles?
1. Male workers do not come to mobile clinics
Empower women and farmers or their wives, so that they can recognise the signs and
symptoms of TB. Liaison officers would prove to be valuable in giving health education and
promotion and some of the pressure would also be taken off the mobile clinic sister.
2. Migration of farm people to locations
Patents who move from a farm to a township should be properly referred from the mobile
clinic to a town clinic.
3. Irregular visits of mobiles to farms
DOTS supporters must know where they can collect TB medication/supplies from if the
mobile does not arrive due to bad weather or a broken vehicle. Mobile staff must provide
DOTS supporters with the necessary documentation that will allow them to collect TB
medication in instances when the mobile clinic does not arrive.
4. Shortage of mobiles
The shortage of mobiles can be addressed by:
‣ introducing a point system;
‣ distributing mobiles according to the population of the area; and
‣ negotiation with the LA (urgent task for management).
5. Passive tracing of TB patients
Staff who are committed are likely to actively trace TB patients. History taking and follow-up
allows the clinic sister to trace contacts of patients as well as to determine whether the patient
is a re-treatment or new case. A change of attitude and approach will also promote the tracing
of TB patients and contacts. Very important – clear guidelines for dealing with TB at mobile
clinics, should be developed!
6. Patients consult a GP instead of coming to the clinic
In order to address this problem, health promotion workshops could be held.
7. Attitude of the farmers
There is a need to establish good communication with the farmers. Change the farmer’s
attitudes about TB by providing them with knowledge about the disease. Farmers also need
to receive health education and information about DOTS.
8. Literacy
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Workshops can be held with community members in order to promote literacy.
9. Mishandling of specimens
Proper supervision of specimen collection and transportation.
GROUP 4: DIAGNOSTIC TESTS
1. First contact
Two sputa samples are taken, if both are positive the patient is started on TB treatment. If
only one smear is positive, a chest X-ray is taken to confirm the diagnosis.
2. Re-treatment
Two sputum smears are done (change in policy from one to two), as well as culture and
sensitivity tests. TB culture and sensitivity tests are done to make sure of the patients’
sensitivity to TB drugs and therefore rule out MDR TB. A problem is, however, experienced
when not all sensitivity test results are received back from the lab.
Management must discuss the viability of taking three sputa samples from patients living on
farms, as these patients cannot easily be referred for X-rays.
3. Chest X-ray
Private practitioners refer patients to the public sector. These patients are usually diagnosed
solely on the basis of chest X-rays in the private sector. Nurses who receive the patient are to
follow-up policy.
4. In children
Children are diagnosed by using:
‣ Score sheet
‣ Tine test/tuberculin
‣ Sputum (at what age should children be able to cough up sputum?)
‣ CSF (lumbar puncture for meningitis)
‣ Chest X-rays
5. In adults
Adults are diagnosed in the following manner:
‣ two sputum results in new cases - if one is positive and one is negative, take a chest X-
ray
‣ re-treatment cases, two smears, one culture and one sensitivity
GROUP 5: CLINICAL DIAGNOSIS AND CONTACT TRACING
1. Clinical diagnosis
The group identified the following symptoms as the most frequent in adults:
‣ Coughing for more than three weeks
‣ Weight loss
‣ Appetite
‣ Fatigue, weakness, loss of energy
‣ Chest pains
‣ Shortness of breath and dyspnoea
‣ Night sweets – early hours of the morning, climate, blankets, leading questions
‣ Swollen glands
‣ Infertility
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‣ Severe headaches – meningitis
‣ Deformities of the vertebra
‣ Swollen, painful and deformities of joints
‣ Recurrent UTI (urine tract infection)
‣ Abnormal skin pigmentation
‣ Abdominal masses or ascites
The under-diagnosis of children may be due to problems related to the implementation of:
‣ Score sheet
‣ Monotest – rural areas (can staff return to check the next day?), HIV/malnutrition, correct
measuring of monotest
2. Contact tracing
Contact tracing, if the patient has a positive smear –
‣ History taking, includes asking about family members and their ages; social and
economic status and environmental status
‣ Home visits by nursing personnel or DOTS supporters
‣ Mine workers – contacts at home (outside the district) are difficult to trace
3. Recommendations of the group:
Road to health card must be clearly plotted. Health care workers as well as mothers must be
educated on the use of the road to health card.
The Score sheet must be used to diagnose TB in children. Personnel must be trained on how
to use the score sheet. Personnel also need to receive proper training on how to interpret the
Monotest/Montaux.
Further training for health care workers should include the diagnosis and treatment of extrapulmonary
TB; and in-service training on Pulmonary TB at the clinics. The community must
also be educated about TB.
GROUP 6: TB REGISTER
The group agreed that the register and forms are quite straightforward and easy to complete.
Duplication is no longer a problem. It was recommended that hospitals complete the correct
forms. Mine statistics need to be included. The Department of Health and the mines should
work together. Clinics should keep a record of their statistics in order to have a picture of the
TB incidence in their area.
WRAP-UP AND WAY FORWARD
Dr Báes summarised the discussions of the day. Three main areas were identified, namely
Training, Policy and DOTS.
With regard to training, it must be determined what the most appropriate form of training will
be. Should it be only for TB clinic coordinators or for all nurses at the clinic? If it is only
offered for the TB coordinators, training must be cascaded down to all staff at the clinics. The
content of the training needs to emphasise the importance of good history taking, which will
allow the nurse to make a correct diagnosis, to classify the patient appropriately and to
investigate the contacts in the family. In addition, children and the score sheet, EPI, HIV, and
signs and symptoms of extra pulmonary TB need more attention.
The regional medical officer needs to train the medical officers, especially about the diagnosis
of TB patients (sputum not X-rays).
A broad managerial approach should be encouraged at all facilities. This should promote the
accurate completion and analysis of statistics and the compilation of graphs. Furthermore, the
completion of the TB register needs to receive attention.
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With regard to the DOTS system, Dr Báes emphasised the concept that a good DOTS
system will improve the TB indicators (e.g. cure rate) and prevent re-treatments and MDR TB
cases. This means that active recruitment will have to take place and the voluntary character
of the supporters needs to be emphasised. Facilities must place targets for themselves and
then strive to meet these targets. DOTS supporters can be trained by SANTA and supervised
by the clinic nurse. They can be encouraged and motivated by introducing competitions and
prizes for the best DOT supporter. The private sector has a role to play as well. Mothers and
the community at large can be empowered to recognise signs and symptoms of TB. This can
be achieved through health promotion and education.
The DOTS supporters’ activities that link closely with HIV/AIDS need to be expanded upon.
DOTS supporters will be given more credibility if they are provided with name-tags, clearly
identifying them as DOTS supporters.
With regard to policy, hospitals need to have clear guidelines concerning: the number of
beds for TB patients at district hospitals and referral hospitals; entry and exit criteria; the
transportation of TB patients and MDR TB patients. This also applies to the prisons. There
are no clear guidelines, at least not known by the staff, on case management, registering of
TB cases and patients with TB and HIV/AIDS.
Another important issue concerning policy is the diagnosis of TB in rural areas. Mobile clinics
should be allowed to take three sputa samples, as this will be more cost effective and simpler
for the patients. There is a need for specific TB guidelines for mobiles services.
Although policy advocates passive case finding, this needs to be interpreted with caution. A
really good clinic sister will probe and ask questions that will assist her to identify whether any
of the patients as well as their relatives, in particular children, have signs and symptoms of
TB. Once this has been determined, active case finding (going to people’s houses) can be
done, when possible.
Taking into consideration the age of the new programme, it can be said that in general the
programme is working quite well in Tshepano. This study provided concrete data for the
district to work with. The TB Task Team needs to tackle the local resolvable tasks, and the
DoH needs to accept the proposals and suggestions and look at the policy issues in a
constructive way.
The workshop was adjourned at 16:00 p.m.
a SOURCES : Fourie, B & Weyer, K. 2000. World TB Day, 24 March 2000: A noxious synergy:
Tuberculosis and HIV in South Africa. Press Release. Medical Research Council. National Tuberculosis
Research Programme. Free State Department of Health 1999 TB statistics for the Kopano health
district; Health Systems Trust. 1997 South African Health Review 1997. Durban: HST; National
Department of Health 1996 The South African Tuberculosis control programme: Practical guidelines.
Pretoria: Department of Health; National Department of Health 1998 Strides and struggles in TB control:
Annual TB advocacy report: 1997 – 1998. Pretoria: Department of Health; National Department of
Health 1999 Faces of TB: Annual TB advocacy report: 1998 - 1999. Pretoria: Department of Health.
Regional Department of Health: Kopano district offices 1999 TB statistics for the Kopano health district;
Van der Linde I 1996 Stop the TB scourge. South African Medical Journal. pp 897 – 898; Weyer K 1997
Tuberculosis. In: South African Health Review 1997. pp 197 – 202. WHO Global Tuberculosis Report,
1999.
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