USAID Tuberculosis South Africa Project
Contract Number: AID-OAA-I-14-00035 Order Number: AID-674-TO-16-00002
Project Quarterly Report
January 2020 to March 2020
Submitted April 30, 2020
Submitted by: University Research Co., LLC (URC) To: USAID Southern Africa
USAID Tuberculosis South Africa Project - Project Quarterly Report: January 2020 to March 2020 i
USAID Tuberculosis South Africa Project Contract information: This project is made possible by the generous support of the American people through the United States Agency for International Development (USAID) under the terms of its Contract Agreement Number: Contract Number: AID-OAA-I-14-00035; Order Number: AID-674- TO-16-00002 (USAID Tuberculosis South Africa Project held by prime recipient University Research Company, LLC. and implemented by sub-recipients BEA Enterprises, Brigham and Women’s Hospital/Harvard/Partners in Health (BWH/PIH), Centre for Communications Impact (CCI) formerly JHHESA, NEXT, World Health Organization (WHO), and University of Pretoria. The USAID TB South Africa Project is funded and managed by the USAID Southern Africa mission.
Prepared by: University Research Co., LLC
Submitted by: Dr Gregory Jagwer Chief of Party USAID Tuberculosis South Africa Project Tel: +27 12 484 9300 Email: [email protected] Web: https://tbsouthafrica.org.za
Submitted to: Ms Cindy Dlamini Project Development Specialist-TB USAID Southern Africa, Health Office Tel: +27 12 452 2330 Email: [email protected] Web: http://www.usaid.gov/southern-africa-regional
For more information: Dr Refiloe Matji Vice President University Research Co., LLC USAID Tuberculosis South Africa Project Tel: +27 -12-342-1419 Email: [email protected] Web: www.urc-chs.com
USAID Tuberculosis South Africa Project - Project Quarterly Report: January 2020 to March 2020 ii CONTENTS Acronyms...... iv List of Tables ...... vi List of Figures ...... vii INTRODUCTION ...... 1 ACCOMPLISHMENTS BY INTERMEDIATE RESULTS (IRs) ...... 2 IR 1: TB Infections Reduced ...... 2 IR 1.1: Increased public awareness of the TB epidemic ...... 2 IR 1.2: Effective implementation of Infection Prevention and Control (IPC) ...... 8 IR 1.3: Expand strategies to reach, screen and evaluate individuals with high TB risk... 14 IR 2: Sustainability of Effective TB Response Systems Increased ...... 16 IR 2.1: Strengthened management capacity at all levels ...... 16 IR 2.2: Strengthened service delivery capacity at all levels ...... 22 IR 2.3: Improved data reporting and recording at all levels ...... 27 IR 3: Care and Treatment of Vulnerable Populations improved ...... 35 IR 3.1: Increased contact tracing of key populations ...... 37 IR 3.2: Improved TB case management among key populations ...... 40 IR 3.3: Strengthened comprehensive systems and partnerships for care...... 43 FINANCIAL MANAGEMENT ...... 48 Annexures ...... 49 Annex I: 90 90 90 Cascade Performance ...... 49 Annex III: Finding Missing TB Patients ...... 65
USAID Tuberculosis South Africa Project - Project Quarterly Report: January 2020 to March 2020 iii Acronyms
ACSM Advocacy, Communication and Social Mobilization AFB Acid Fast Bacilli AIDS Acquired Immune Deficiency Syndrome ART Antiretroviral Therapy BC Bacteriological Coverage CHW Community Health Worker CO2 Carbon Dioxide CPT Cotrimoxazole Preventative Therapy CQI Continuous Quality Improvement DM Diabetes Mellitus DOT Directly Observed Treatment DOTS Directly Observed Treatment, Short Course DR-TB Drug-Resistant Tuberculosis DSPs District Support Partners DS-TB Drug-Susceptible Tuberculosis DVE Data Verification Exercise ETR Electronic Tuberculosis Register FAST Finding TB Actively, Separating safely, Treating effectively PY03 Financial PY03 GXP GeneXpert® MTB/RIF (Xpert) HCT HIV Counseling and Testing HIV Human Immunodeficiency Virus ICSM Integrated Clinical Services Management IC Infection Control IEC Information, Education and Communication IPC Infection Prevention and Control IPCC Interpersonal Communication and Counselling IPT Isoniazid Preventive Therapy LDHF Low-Dose High-Frequency M&E Monitoring and Evaluation MDR-TB Multi-Drug Resistant Tuberculosis NDOH National Department of Health NGO Non-Governmental Organization NTP National Tuberculosis Control Program
USAID Tuberculosis South Africa Project - Project Quarterly Report: January 2020 to March 2020 iv PEPFAR United States President’s Emergency Plan for AIDS Relief PMDT Programmatic Management of Drug-Resistant Tuberculosis PPP Public-Private Partnership PTB Pulmonary Tuberculosis QI Quality Improvement QIP Quality Improvement Plan RTCs Regional Training Centers RR Rifampicin Resistant SCR Smear Conversion Rate SOP Standard Operating Procedure STI Sexually Transmitted Infection TAT Turnaround Time TB Tuberculosis TOT Training of Trainers URC University Research Co. LLC USAID United States Agency for International Development WBOT Ward-Based Outreach Teams WC PDC Western Cape People Development Centre WHO World Health Organization XDR-TB Extensively Drug-Resistant Tuberculosis
USAID Tuberculosis South Africa Project - Project Quarterly Report: January 2020 to March 2020 v List of Tables
Table 1: ACSM Inicators ...... 2 Table 2: Numbers of healthcare workers, facilities and patients reached through interpersonal communications and councelling ...... 3 Table 3: Numbers of people reached through build up activities towards world TB day for the period Jan-March 2020 ...... 5 Table 4: Abstracts developed for presentation at various conferences to highlight work done by the project ... 5 Table 5: Districts distribution and reach through facility-based television ...... 7 Table 6: Overall FAST Implementation for the first six months of FY4 (October 2019 – March 2020)...... 12 Table 7: LAM performance report for the first six months of FY4 (October 2019 – March 2020) ...... 13 Table 8: Lessons Learned and Corrective Actions ...... 14 Table 9: NMBHD TB Care Cascade, Q4 2019 to Q1 2020 ...... 18 Table 10: Analysis of facility gaps and recommended actions to be implemented in Nelson Mandela Bay Metro ...... 18 Table 11: TB care cascade for West Coast ...... 20 Table 12: Missing TB patients diagnosed by strategy ...... 22 Table 13: Didactic Trainings ...... 23 Table 14: Capacity Building for Managers ...... 23 Table 15: Capacity Building using Low-Dose High Frequency ...... 24 Table 16: Outcomes of the clinical questionnaire tool ...... 26 Table 17: Number of interviews and adverse event report forms audited in 10 study sites ...... 27 Table 18: NMBHD Data Capturer Support ...... 28 Table 19: Engagement of DOH and District Support Partner personnel to build capacity for recordning and reporting ...... 28 Table 20: KZN DR-TB quarterly review challenges and remedial actions ...... 29 Table 21: uMkhanyakude HAST quarterly review challenges and remedial actions ...... 30 Table 22: Sekhukhune Data Clean up findings ...... 31 Table 23: Free State before and after results of data validation for 2018 outcomes ...... 32 Table 24: Fezile Dabi before and after results of data validation for 2018 outcomes ...... 32 Table 25: Outcomes of data validations in the Free State ...... 33 Table 26: NGOs campaigns data ...... 37 Table 27: Adult contact management data ...... 38 Table 28: Summary of Grants Technical Team financial and technical capacity building ...... 40 Table 29: Child contact management ...... 40 Table 30: Consolidated facility level key populations TB case finding data for Q2/FY4: January – March 2020 .. 41 Table 31: Consolidated TB in Farms data for Q2/FY4 ...... 42 Table 32: Summary table of DSPs in project supported district...... 43 Table 33: TB/HIV Integrated services progress update ...... 46 Table 34: Accrual Expenditure Report Q2 FY2020 ...... 48 Table 35: USAID TB SA Project supported districts cascade data 2016 to 2020...... 49 Table 36: South Africa DR-TB initiation rates Oct 2018 to Sept 2019 by quarter ...... 56 Table 37: Q4 (Oct-Dec 2019) DR TB intitian rates by distrcits ...... 56 Table 38: Missing TB patients diagnosed by strategy ...... 65
USAID Tuberculosis South Africa Project - Project Quarterly Report: January 2020 to March 2020 vi List of Figures
Figure 1: FAST Screening, Case Detection & Treatment Initiation...... 13 Figure 2: NMBHD HIV positive new initiated on TPT ...... 15 Figure 3: NMBHD Subdistrict A HIV positive new initiated on TPT ...... 15 Figure 4: Screening rates in Sekhukhune district from Q4 2016 to Q1 2020...... 17 Figure 5: TB screening in OR Tambo District ...... 19 Figure 6: TB Sputum testing rate in OR Tambo ...... 19 Figure 7: Swartland Case Fining 2017-2019 ...... 20 Figure 8: Staff TB Screening, Limpopo Province ...... 24 Figure 9: Zola CHC Facility level data before and after clean-up...... 34 Figure 10: Chiawelo CHC Facility level data before and after clean-up ...... 34 Figure 11: Data verification done between NICD alerts, facility TB register and facility level Web EDR for Q3 2017 DR-TB long regimen treatment started patients ...... 35 Figure 12: Distribution of patients by district ...... 35 Figure 13: Contact Management in two quarters (Oct-Dec 19) and (Jan-Mar 20)...... 38 Figure 14: TB in farms data for FY4: Q1 and Q2...... 42 Figure 15: Screening rates for TBSAP districts Oct 16-Jan 20 ...... 50 Figure 16: Testing rates for TBSAP districts Oct 16-Jan 20 ...... 50 Figure 17: Tx initiation rates for TBSAP districts Oct 16-Jan 20 ...... 50 Figure 20: Treatment success rate for all TB cases in project supported districts ...... 52 Figure 21: LTFU in project supported districts: Jul 2017 to Dec 2018 by quarter...... 53 Figure 22: Mortality rate for all TB cases project supported districts ...... 54 Figure 23: ART Uptake in project supported districts ...... 55 Figure 24: Treatment success rate by district for DR-TB short regimen: Q3 and Q4 2018 ...... 59 Figure 25: Loss to follow up rate by district for DR-TB short regimen: Q3 and Q4 2018 ...... 60 Figure 26: Mortality rate by district Q3 and Q4 DR-TB short regimen ...... 61 Figure 27: Treatment success rate by district Q3 (Jul-Sep 2017) and Q4 (Oct-Dec 2017) DR-TB long regimen ...... 62 Figure 28: Loss to follow up rate by district Q3 (Jul-Sep 2017) and Q4 (Oct-Dec 2017) DR-TB long regimen. 63 Figure 29: Loss to follow up rate by district for DR-TB long regimen: Q3 (Jul-Sep 2017) and Q4 (Oct-Dec 2017) ...... 64
USAID Tuberculosis South Africa Project - Project Quarterly Report: January 2020 to March 2020 vii EXECUTIVE SUMMARY
The TB programmatic response in South Africa is broadly guided by the National Strategic Plan for HIV, TB and STIs, and aims to achieve the National TB 90-90-90 targets as outlined in the ‘Stop TB Partnerships’ Global TB Plan. The TB South Africa Project in partnership with the Government of South Africa aims at achieving these ambitious targets through strategies that will reduce TB infections; increase the sustainability of effective TB response systems; and improve care and treatment of vulnerable populations. Building on progress made from quarter one, the project continues to accelerate efforts in the implementation of effective interventions to ensure population wide impact in the 14 supported districts.
st 100% TB Screening (1 90): There has been a 20% 85% 89% increase in the screening rate in the project’s 80% 60% 14 supported districts from 69% (2016) to 40% 89% (2020). The success is largely attributed 20% to targeted and intensified efforts to find the 0% missing TB patients, demand generation interventions, commemoration of key health days, involvement of the private sector and Screening Screening target line other government institutions, intensified Infection Prevention and Control, focusing interventions at TB hot spots and high burden facilities, contact management for index case and continuous quality improvement to close the gaps in the TB care cascade.
100% TB Testing: During Q2, the testing rate 80% increased by eight percent in the supported 60% districts from the baseline of 84% in 2016 to 40% 92% in the quarter two of PY04. 20%
0% TB Treatment Initiation: In this quarter, the DS TB initiation rate was 96%; some districts have rates above 100% because the number Tested Testing target line initiated on treatment includes patients
USAID Tuberculosis South Africa Project - Project Quarterly Report: January 2020 to March 2020 viii diagnosed by other diagnostic methods while the denominator includes only bacteriological diagnosed cases. Nevertheless, with the project’s priority being to ensure that all TB identified patients are initiated on treatment, the treatment initiation rate has been maintained above the 90% target since project inception.
The DRTB initiation has also progressively increased from a baseline of 59% at project inception in 2016 to 96% in 2019. In Q2 (January – March 2020) an additional 899 patients were initiated on treatment.
100% The improvement in treatment initiation rates is 80% attributed to capacity building 60% initiatives and mentorship on DRTB management for health 40% care workers, implementation 20% of the DR TB Management
0% protocols and tools as well as adoption of clustered supervisory structures for quality improvement. Clinical Tx Initiation Tx initiation target line systems mentorship focused on the 475 high burden facilities that report 80% of all TB cases in the 14 supported districts. For DRTB the project has also been in the forefront supporting the DoH in the scale up of the new treatment regimens, including management of serious adverse events and adverse events. This is further augmented by the adaptation and scale up of the DR TB service package in the 202 decentralized sites.
Treatment Success Rate: The Government has set the ambitious target of increasing the TSR for DRTB to 75% and for DSTB to 90% by 2020. Of the 22,240 DSTB cases reported in Q4 (Oct-Dec 2018) in the supported districts, 75% patients were successfully treated. Out of the 554 DRTB patients who completed the short regimen treatment in Q4 (Oct-Dec 2018), a total of 371 (67%) were successfully treated. Among the 358 DRTB patients on long regimen, who completed treatment in Q4 (Oct-Dec 2017), 180 (50%) were successfully treated.
Loss to follow up: Of the 2,2240 DSTB cases reported in Q4 (Oct-Dec 2018), 11% were lost to follow up. The districts with high LTFU are Sarah Baartman with eighteen percent (18.0%), Cape Winelands, City of Cape Town SWSS and Tshwane Metro all with 13.0% in the reporting quarter. Of the 554 DR-TB patients who completed the short regimen treatment Oct-Dec 2018, like the DSTB, 11% were lost to follow. Among the 358 DR-TB patients who completed the long regimen treatment Oct-Dec 2018 quarter, 17% were LTFU
Mortality Rates: Of the 22,240 DSTB cases notified in Q4 (Oct-Dec 2018) in the 14 supported project districts 6% died. The districts of eThekwini (4,6%), West Coast (2,7%), Cape
USAID Tuberculosis South Africa Project - Project Quarterly Report: January 2020 to March 2020 ix Winelands (4,1%) and City of Cape Town - Southern Sub-district (3,9%) have mortality rates below the 5% national target. The districts contributing the highest mortality above 10% are Waterberg, Sekhukhune, and Tshwane Health Metro. Among the 554 DRTB patients who were initiated on the short course regimen 13% died while on treatment. Among the 358 DRTB patients on long regimen 19% died.
TB/HIV co-infected on ART: The total number of notified TB cases in TIER in the 14 supported districts is 25,763 of which 84% have a known HIV status. Among the 11,344 people co- infected with TB and HIV, 91% were on ART. The incomplete data entry for TB contributes to some of the poor outcomes reported due to the 2017 transition in the reporting system from ETR.net to the “TB module in TIER.net”. Currently the TIER.Net data is incomplete particularly with parameters that define TB outcomes. There is also a reluctance from the data clerks to enter TB data into the new system because of prioritization of the HIV data by the government. The reluctance is further accentuated by the backlog of HIV data entry at most sites, thus the apparent lower and unanticipated outcomes from the supported districts.
Missing TB Patients: Of the 80,000 missing TB patients targeted to be found in the 2019/2020 financial year, 37,665 (47%) are estimated to be in the 14 districts supported by the project. The project has targeted to find at least 50% of the missing 37,665 patients during PY04. Between October 2019 and March 2020, the project using various strategies has found a total of 6593 TB patients, representing 35% of the target. These results are largely due to the FAST intervention, which contributed 57% of all TB cases diagnosed, as well as the data cleaning exercise conducted in the reporting quarter. The community level interventions have limited results due to the reduction in the number of operational community-based organizations supported by the project.
Table: Cumulative number of Missing TB Patients found and linked to treatment, October 2019 – March 2020 in the 14 Project Support Districts Strategy Project Totals Strategy Oct-Dec Jan-Mar Cumulative contribution 2019 2020 (Oct 19 - March 20) FAST Approach 2505 1243 3748 57% Community focused interventions 559 68 627 10% Contact management 59 59 118 2% Key population interventions 77 58 135 2% Diagnostics tests (Urine-LAM) 277 101 378 6% Linkage to care –ILTFU 55 76 131 2% Updating of records and data clean-up 312 1144 1456 22% Total 3844 2749 6593 Overall achievements described above are attributed to key project activities. At the end of quarter two, the total project budget spent to date was $41,231,434.08 which is approximately 63.6% of the overall budget of $64,801,397.00. The project continued to increase public awareness of the TB epidemic through inter- personal communications and counselling, building the capacity of DOH program managers to generate demand for TB services, development of new creative messages to raise
USAID Tuberculosis South Africa Project - Project Quarterly Report: January 2020 to March 2020 x awareness on district specific TB epidemics , as well as collaboration with NDOH on national campaigns which are aimed at raising the profile of TB in South Africa . To improve IPC practices at facility level, the project supported 252 facilities on IPC related activities including implementation of the FAST Strategy, IPC training, IPC risk assessment at facility level and home risk assessments to identify risks and improve infection control measures. Within the FAST sites, the project institutionalized the implementation of a package of support which includes TB quality improvement and Lateral Flow Assay Lipoarabinomannan Assay (LF-LAM) for diagnosing TB among severely immunocompromised patients. During the reporting quarter, the project also retained its focus on reaching marginalized and TB vulnerable populations considered to be most at-risk and hardest hit by the TB epidemic. The project facilitated door-to-door and awareness campaigns, contact tracing, treatment adherence support, household infection prevention and control as well as establishing partnerships with other community-based organizations critical to the comprehensive management of TB. In the reporting quarter, the project funded 10 grantees in 9 out of the 14 supported districts. A total of 2,690 active patients, comprised of 2,006 (75%) DS-TB and 684 (25%) DR-TB were offered DOT support by the grantees. In quarter 1 and 2, a total of 5,855 contacts were reached, which is only 22% of the anticipated target of 27,037, largely due to the limited coverage by the 10 currently contracted NGOs.
USAID Tuberculosis South Africa Project - Project Quarterly Report: January 2020 to March 2020 xi INTRODUCTION
The USAID Tuberculosis South Africa Project (2016-2021) has the primary objective of providing technical assistance to the Government of South Africa (GoSA) to reduce the burden of TB in the country. The specific objective of the project is to reduce TB infections, increase sustainability of effective TB response systems, and improve care and treatment of vulnerable populations. To achieve these objectives, the project is guided by the Government of South Africa’s National Strategic Plan for HIV, TB and STIs (2017-2022) which aims to find 90% of all TB patients and place them on appropriate treatment; to find at least 90% of the TB patients in key populations and place them on appropriate treatment; and to achieve 90% treatment success for DS-TB, and 75% for DR-TB. Thus, the project’s activities and interventions are aligned to the 90-90-90 strategy to ensure that South Africa’s National TB program can achieve these ambitious targets. In addition, the project has prioritized finding 50% of all missing TB patients (34,523) estimated to be in the project’s 14 supported districts. Geographical Coverage The project is strategically positioned to provide support to the highest TB burden facilities and districts in South Africa. During the reporting period, support was provided to 14 districts which accounts for 48% (113,997) of all notified TB patients in 2018 in South Africa. Furthermore, the project supports eight (OR Tambo, Nelson Mandela Bay, eThekwini, City of Tshwane, City of Cape Town, Mangaung and Sekhukhune) of the 21 priority districts identified by the government of South Africa for finding missing TB patients. Within the supported districts there are a total of 1,237 facilities, of which 475 are high TB burden facilities, which contribute 80% of the TB burden in the respective districts in which they are located.
Figure 1: Map of South Africa showing the geographical coverage of the USAID TB South Africa Project
USAID Tuberculosis South Africa Project - Project Quarterly Report: January 2020 to March 2020 1 ACCOMPLISHMENTS BY INTERMEDIATE RESULTS (IRs)
IR 1: TB Infections Reduced
IR 1.1: Increased public awareness of the TB epidemic
Overall Summary of Achievements
Despite the high prevalence of TB in South Africa, experience from the ground suggests that the level of patient People reached since knowledge and education about TB infection, transmission October 2019 and treatment is still sub-optimal, demonstrating a clear need to improve patient education and counselling 20,059 particularly at facility and community levels. To increase Patients counselled public awareness of the TB epidemic , several approaches 4,949 are used including (i) inter-personal communications and Number of Healthcare counselling (IPC/C), (ii) building the capacity of DOH workers trained in IPCC program managers to generate demand for TB services, (iii) development of new creative messages to raise awareness 413 on district specific TB epidemics , as well as (iv) collaboration with NDOH on national campaigns (Phutuma, Cheka Impilo and other related campaigns) which are aimed at raising the profile of TB in South Africa . Through these strategies, a total of 20,059 people have been reached with awareness activities since the start of the new financial year of which 40 % (7,722) were reached this quarter. (see Table 1, below). Additionally, 413 department of health staff were trained on interpersonal communications and counselling, resulting in counselling support being provided to 4,949 patients across the 14 supported districts.
Table 1: ACSM Inicators (Source: project monthly quarterly reports)
Oct- Jan- ACSM indicators Total Dec Mar Number reached through community outreach activities 12,337 7,722 20,059 Number of radio interviews 8 45 53 Number of Newspaper inserts/ interviews 6 5 11 Number health days commemorated 2 2 4 Number of IEC materials distributed 0 Number of people trained in interpersonal communication and counselling 210 203 413 Number of TB patients supported by health staff trained in IPC/C 1,510 3,439 4,949 Number of HCWs trained on ACSM guidelines 0 30 30
1.1.1 Implement patient-centered inter-personal communications and counselling (Inter-PC/C) package
Between January – March 2020, a total of 3,439 TB patients were counselled through the patient centered interpersonal communication and counselling package (IPCC/C), to specifically improve treatment adherence and treatment outcomes for TB patients. The counselling package highlights important aspects of TB prevention and control including
USAID Tuberculosis South Africa Project - Project Quarterly Report: January 2020 to March 2020 2 infection, prevention and control, stigma and discrimination, People counselled treatment adherence as well as side effects management. The through IPC/C counselling was conducted in nine of the project’s 14 supported 3,439 districts (with the exception of districts in the Gauteng and Western Cape Provinces where there are no currently funded NGOs).Whilst DOH implementing the package is primarily implemented through the project’s health facilities funded NGOs, a total of 203 department of health healthcare 156 workers were trained on implementation of the package, Number of Healthcare resulting in 156 health facilities counselling their patients using workers trained the package. Building capacity of DoH staff for patient counselling on TB is important for continuity and sustainability 203 of the project.
Table 2: Numbers of healthcare workers, facilities and patients reached through interpersonal communications and councelling (Source: project monthly/ quarterly reports) District No. HCWs trained No. of Facilities No. of patients eThekwini 0 7 125 Fezile Dabi 0 1 539 NMBM 18 31 860 Mangaung 30 47 1,400 uMkhanyakude 37 27 38 OR Tambo 112 8 463 Sekhukhune 0 8 8 Sarah Baartman 6 25 0 Waterberg 0 2 6 Total 203 156 3,439
1.1.2 Capacity building of DOH program managers (TB/HIV, PMTCT, NCDs, etc.) and manager of funded NGO on ACSM in supported districts to generate demand for services
To support government efforts to improve awareness creation and demand generation for TB services, the project in collaboration with the national department of health, hosted a provincial capacity building session on advocacy, communication and social mobilization (ACSM) in January 2020 in the Free State province. The project facilitated the capacity building session which was attended by over 30 TB coordinators, health promoters and managers from the Free State provincial department of health and its five districts (Xhariep, Lejweleputswa, Mangaung, Fezile Dabi and Thabo Mofutsanyane). The training session achieved the key objective of ensuring that TB program managers are able to generate demand for TB services within their districts and that they have the requisite skills to communicate with both patients and communities about TB prevention and control. A key deliverable of the workshop was the development of ACSM plans for each of the districts within the Free State province. The next step will be to provide ongoing support for the implementation of the ACSM plans and track anticipated improvements in numbers of people reached and presenting at facilities for screening, testing and TB treatment.
USAID Tuberculosis South Africa Project - Project Quarterly Report: January 2020 to March 2020 3 Within the current workplan, the target is to provide capacity building to each of the 14 supported districts and to assist them to develop ACSM plans which will outline clear steps on how demand for TB services will be generated in the supported districts. To date, a total of 12 districts (Fezile Dabi, Mangaung, Xhariep, Lejweleputswa, Thabo Mofutsanyane Sarah Baartman, OR Tambo, Nelson Mandela Bay, Alfred Nzo, Amathole, Chris Hani and Joe Gqabi), have developed ACSM plans as a direct result of the technical assistance provided by the project. Three districts (uMkhanyakude, Waterberg and Tshwane) had already planned capacity building sessions for the month of March, however, these had to be postponed indefinitely due to the outbreak of the COVID-19 epidemic in South Africa.
Figure 2: ACSM capacity building workshop in the Free State Province
1.1.3 Increase TB awareness through participation of DOH activities on key national health days
The reporting period coincided with the commemoration of World TB Month; however, the main commemorative events were cancelled due to the COVID-19 pandemic. Despite this, the People reached project continued to participate in the national planning 7,722 committee for South Africa’s World TB day commemorations People presumptive activities. Nine (9) build up activities were conducted in eight (8) of the project’s 14 supported districts including community 1,933 dialogues, door to door campaigns, screening of farm workers and People diagnosed other key populations as well facility-based awareness creation. with TB Through these activities, a total of 7,722 people were reached with 38 TB messages and 7,540 were screened for TB. There were 1,933 presumptive clients with 1,827 tested. A total of 38 tested positive for TB and started on treatment.
Figure 3: A community dialogue at the Metsimaholo Community Hall in Fezile Dabi
USAID Tuberculosis South Africa Project - Project Quarterly Report: January 2020 to March 2020 4 1.1.4 Increase the project’s contribution to TB research and knowledge through write- ups, content for e-learning platforms, presentations at local and international conferences, and material dissemination at strategic events
Table 3: Numbers of people reached through build up activities towards world TB day for the period Jan-March 2020 (Source: Project monthly/quarterly reports)
#Health Presumpti Tested District Reached Screened Tested Days ve positive OR Tambo 2 625 565 266 266 20 NMBM 1 898 898 278 278 9 Sarah 1 569 569 59 3 3 Baartman Mangaung 1 549 544 46 46 0 Fezile Dabi 1 194 194 13 13 0 Waterberg 1 637 637 95 95 2 City of 1 179 179 50 0 0 Johannesburg Cape 1 3,954 3,954 378 378 4 Winelands City of Cape 1 117 0 0 0 0 Town Total 7,722 7,540 1,185 1,079 38
To increase the project’s contribution to TB research and knowledge, nine abstracts were drafted and submitted for presentation at the South African National TB Conference, IHI Africa Forum and ISQua Conference respectively as outlined in the Table below.
Table 4: Abstracts developed for presentation at various conferences to highlight work done by the project Conference Abstracts Submitted National TB 1. Integration of edutainment into Paediatric DR-TB programme: Conference The Buddy Beat TB Program in Seven Hospitals of South Africa 2. Awareness creation and demand generation for TB services: cross-promotion approach of using new media and mass media for maximum reach and impact 3. Improving capacity for local community-based organizations in managing TB patients referred to them by the health facilities in supported districts 4. An audit of mortalities of patients who received the DR-TB service package in Nelson Mandela Bay Metro 5. Data driven supervision using a simple tool; the joy of visualizing improvements 6. Engagement of Private GP’s in active TB case finding and management: A Public-Private Partnership model in OR Tambo District, South Africa Isqua Conference 7. Improving the quality of Tuberculosis services and care in 2020 community settings in South Africa
USAID Tuberculosis South Africa Project - Project Quarterly Report: January 2020 to March 2020 5 Conference Abstracts Submitted IHI Africa Forum 8. The Model for improvement, a weapon to assist in ending TB in South Africa by 2030: An effective and efficient strategy to improve the quality of life for TB and Finding Missing Patients. 9. Using QI interventions in hospitals lead to better patients care
1.1.5 Development of new creative messages to raise awareness on district specific TB epidemic profile and collaborate with NDOH on national campaigns (Phuthuma, Welcome Back, Cheka Impilo and other related campaigns)
During the reporting period, 45 radio interviews were conducted in eight community radio stations in nine districts (OR Tambo, West Coast, Nelson Mandela Bay Metro, Sara People reached Baartman, uMkhanyakude, Mangaung, eThekwini, Sekhukhune 1.68 Million and Cape Winelands) to create awareness and raise the profile of TB. Overall, the 45 interviews reached a combined total of over 1.68 million people. With the advent of COVID- 19 project staff in uMkhanyakude and Nelson Mandela Bay Metro used some of their radio slots to also provide support to district and provincial COVID-19 response efforts by creating awareness about the disease. The interview slots were interactive with listeners calling-in with questions about TB. Project staff used the opportunity to educate and clear misconceptions about TB. Topics covered during the interviews included; TB signs and symptoms, importance of self-screening, people at risk of developing TB, challenges of TB at community level, relationship between TB and HIV,
Figure 6: Project district coordinators for Sarah Figure 5: UMkhanyakude Figure 4: eThekwini project coordinator Baartman Simphiwe Mayaphi (L) and Nelson provincial project manager Mr. Snenhlanhla Memela being interviewed on Mandela Bay Metro Nomakaya Matutu (R) Zamani Dlamini on Mtuba Rise Intokozo FM. being interviewed on Nkqubela FM understanding more about TB medication side effects, how to diagnose TB in children, link between TB and COVID-19, symptoms of COVID-19, and the importance of infection control to prevent TB and COVID-19 infection.
Newspaper inserts: In addition to the radio interviews, the project also made use of print media through features in five newspaper/magazine inserts in the Cape Winelands District reaching a total of 174,675 readers. The project was featured in Jonga Magazine a department of health magazine highlighting the project’s collaboration with the department in addressing TB and pregnancy in teenagers. The project was also featured in the Paarl Post on 16th January in article about USAID TB South Africa Project’s Western Cape staff receiving Premier's
USAID Tuberculosis South Africa Project - Project Quarterly Report: January 2020 to March 2020 6 Service Excellence award in a ceremony that was held in December 2019. An article about a school TB (Esselenpark Secondary) awareness campaign in February was also published in “The Standard” newspaper.
Figure 7: Articles published in Cape Winelands District magazines and newspaper about the project's work
1.1.6 Increase visibility of the project through communication and media platforms
To reach patients in the prioritised 475 high TB burden facilities, the project uses a low-cost initiative which focuses on broadcasting TB videos on facility based television sets usually located in patient waiting areas. The videos are on topics such as; treatment of side effects, preventing TB in children, infection prevention and control and stigma reduction. Through this initiative a total of 247,212 patients were reached with TB messaging at waiting areas in 45 facilities across Figure 8: Patients watching TB videos while waiting seven districts (Fezile Dabi, eThekwini, Mangaung, City to be attended to at Bethesda hospital out-patient of Cape Town, uMkhanyakude, Cape Winelands and department in uMkhanyakude. Sekhukhune). Through this strategy, patients are given critical information about TB prevention, while waiting to receive care, regardless of what service they require.
Table 5: Districts distribution and reach through facility-based television District Number of facilities Total head count Cape Winelands 18 59,469 Sekhukhune 1 2,988 Mangaung 5 28,880 City of Cape Town 12 110,447 Fezile Dabi 2 3,758 eThekwini 1 6,478 uMkhanyakude 6 38,062 Total 45 250,002
Social media The project continues to use its social media platforms to create TB awareness and showcase its initiatives. In the reporting period project social media sites, Facebook and Twitter reached a total of 8,520 people. The highest number of people were reached via Facebook (6,968) while Twitter reached 1,552. The two platforms also gained a total of 111 new followers with
USAID Tuberculosis South Africa Project - Project Quarterly Report: January 2020 to March 2020 7 the most gained in March (48). In the same period the project website recorded 1,766 users. The project’s social media platforms were also used to disseminate messages about the link between TB and COVID-19 as shown below:
Figure 9: Banners on the Project’s Website, Facebook and Twitter pages about COVID19 and TB.
IR 1.2: Effective implementation of Infection Prevention and Control (IPC)
Summary of Achievements since the start of the new financial year
To institutionalize implementation of effective infection prevention and control measures in health facilities, the project People reached in FAST supports the department of health with a comprehensive IPC sites package which includes conducting facility IPC risk assessments, training on IPC guidelines as well as mentoring on IPC practices. 345,572 As part of improving IPC implementation, the project Patients diagnosed with implements the FAST intervention as well as the TB in FAST sites implementation of urine lipoarabinomannan assay (U-LAM), which seeks to increase TB case detection among HIV positive 1,243 patients who are seriously ill, regardless of CD4 count. Facilities with IPC To improve IPC practices at facility level, the project supported support 252 facilities (hospitals, clinics and community health centres) 252 across six provinces on IPC related activities in the reporting HIV positive people quarter. These activities included, FAST Strategy, IPC training, diagnosed with TB IPC risk assessment at hospital/PHC level and home risk assessments to identify risks and improve infection control 101 measures at hospital and household level. This brings the total number of facilities where IPC is being strengthened to 447 since the start of the new financial year, which translates to 40% of all facilities in supported districts. In terms of FAST implementation, a total of 345,573 people were reached resulting in the diagnosis of 1,243 cases were diagnosed in the FAST sites which reported in this quarter. To date, a total of 3,478 TB patients have been diagnosed in FAST sites since October 2019 and FAST has contributed nearly 57% of all missing TB patients reported by the project, illustrating the significant contribution that the initiative is making towards finding missing TB patients in South Africa.
USAID Tuberculosis South Africa Project - Project Quarterly Report: January 2020 to March 2020 8 Within FAST sites, the project has also started institutionalizing implementation of a package of support which includes quality improvement and Lateral Flow Assay Urinary lipoarabinomannan Assay (LF-LAM) for diagnosing TB among severely immunocompromised HIV positive patients. LF-LAM is currently being implemented in 42/86 FAST implementing sites across five of the six supported provinces, Between January to March 2020, only 22 of the 42 LF-LAM implementing sites reported and within these sites, a total of 411 HIV positive patients were eligible for LAM testing and (87%) of those eligible were tested with 101 (28%) testing positive for LF-LAM and 97 (96%) initiated on treatment. 1.2.1 Implement IPC package in all health facilities in the 14 districts to prevent TB transmission
During the reporting period, the project supported 252 facilities across six provinces on IPC related activities, which included, 252 support towards implementation of the FAST Strategy, IPC training, Facilities supported IPC risk assessments at hospital/PHC level and home risk to improve infection assessments to identify risks and improve infection control prevention (IPC) measures at hospital and household level. The measures of TB infection control implemented in different health care facilities include: administrative actions (early detection of likely pulmonary TB, respiratory isolation, conducting screening and / or diagnostics), engineering measures (reorganizing air flows in the environment, use of exhaust fans) and individual measures (use of surgical masks for patients with TB symptoms and respirators for health professionals and visitors). Implementation of these measures in facilities is evaluated on a monthly basis using the TB IPC Evaluation tool adopted from the WHO checklist. In the reporting period annual risk Figure 10: IPC risk assessment session in the City of assessments were conducted in 40 facilities. This is an Johannesburg ongoing evaluation of the quality of TB infection control and for the identification of needed improvements in infection-control measures. The table below provides a summary of findings and recommendations of risk assessments conducted in the Limpopo province. These findings illustrate the gaps that still exist in IPC in supported facilities as well as some of the recommended actions which are being implemented with the support of project staff.
USAID Tuberculosis South Africa Project - Project Quarterly Report: January 2020 to March 2020 9
Findings Remedial actions Administrative controls Modimolle Hospital • TB South Africa Project to work • IPC plan in place and Health education on TB, HIV and other medical condition is given to the patients with Vaalwater clinic in developing and health workers. Training and health education reports are available at the IPC managers office; an IPC plan for the hospital Visitors are screened for TB at OPD and given health education about TB symptoms and management; • The district/subdistrict TB • Staff members are periodically screened for TB and records are available. coordinator to assist the clinic to Vaalwater Clinic establish a TB screening program or • Infection control committee is in place and meetings which also address IPC are held monthly, however, make arrangements for this service facility does not have infection control plan and staff screening program. to access at F H Odendaal hospital • All patients coming into the clinic are screened for TB and presumptive clients are tested for TB. Environmental controls Modimolle Hospital • The Waterberg district/subdistrict • GUV lights were not functional and has been reported to the district that it needs to be fixed. TB coordinator to advice on the • Sputum booth in the wards is close to the nurses’ station, as a result it is not being used. Nurses service plan for the GUV lights supervise sputum collection at OPD and outside the wards where it is well ventilated. Vaalwater Clinic • Open window policy practiced as observed in the consulting rooms where windows were opened for cross ventilation. • UVGI lights are not functioning but have been reported to the district IPC manager. Personal Respiratory Protection Modimolle Hospital Recommendations: • N95 and surgical masks are available in the wards and OPD for staff and patients to use in order to • TB South Africa Project to provide prevent cross infections and contracting TB; Staff members who fail fit test are transferred to FH tools for the window policy and Odendaal hospital or the nearby clinics to work there because is less risky for them. Seal test is conduct fit testing for Vaalwater. conducted continuously to ensure that health workers are protected all the time. • The facility to fit testing for new staff Vaalwater Clinic and project to provide in-service • N95 and surgical masks available and are used by the nurses and patients who are coughing to prevent training to address storage issues of cross infection; Fit test not conducted for all staff members PPE
USAID Tuberculosis South Africa Project - Project Quarterly Report: January 2020 to March 2020 11 1.2.2 Expand and strengthen implementation of the FAST Approach from 86 facilities to 97 hospitals in 11 districts across 6 provinces
The project in collaboration with the National Department of Health (NDoH) supported FAST monthly performance reviews in Patients diagnosed the provinces of the Eatern Cape, Free State, Gauteng, KZN and with TB in FAST Limpopo The objective of the review sessions was for the facilities sites in current to share progress on FAST and LF-LAM implementation, discuss quarter challenges in the implementation of FAST and share possible solutions as well as to monitor LF-LAM implementation. The 1,243 meeting reiterated the importance of integrating CQI, LF-LAM and FAST. Challenges were identified including that the finding that not all hospitals are implementing LF-LAM and the FAST approach is not being implemented in all service areas or entry points and therefore not all units are reporting. Further it was found that although the CQI model is being used to identify areas that need improvement, accountability of the QI teams and practice for follow-through on improvement of performance is still a challenge.
Table 6: Overall FAST Implementation for the first six months of FY4 (October 2019 – March 2020)
FAST Performance Data for All Hospital Reporting Site Oct -Dec 19 Jan-Mar 20 Total DATA ELEMENT No #74 % No #46 % No % Headcount 735698 345573 1081271 Number screened 513423 70% 205674 60% 719097 67% Number presumptive 13463 3% 6792 3% 20255 3% Number tested by GeneXpert 8915 66% 4251 63% 13166 65% Number tested positive 1340 15% 728 17% 2068 16% Number diagnosed with DS-TB 1291 96% 687 94% 1978 96% Number diagnosed with RR TB 64 5% 37 5% 101 4% Number started on DS-TB treatment 1205 93% 633 92% 1838 93% Number DS-TB initial lost to follow-up 60 5% 35 5% 95 5% Number DS-TB died before treatment 22 2% 10 1% 32 2% started Number RR TB started on treatment 60 94% 29 78% 89 88% Number RR TB lost to follow up 4 6% 4 11% 60 59% before treatment started Number RR TB died before treatment 16 25% 5 14% 21 21% started Number tested by other Clinical 2565 0% 1087 0% 3652 0% Diagnostic Tests Number tested positive by other 1165 0% 515 0% 1680 0% Clinical Tests Number started on TB treatment 1112 432 1544
It must be noted that only 53% (46/86) of FAST sites reported in the January – March 2020 quarter, as compared to 86% (74/86) in October to December. Thus, the numbers are likely to change as the data set becomes more complete over the next few weeks. Overall, the currently available data, even though incomplete, shows that a total of 345,573 patients were reached with 60% (205,674) screened for TB. Of those screened 6,792 were presumptive and
USAID Tuberculosis South Africa Project - Project Quarterly Report: January 2020 to March 2020 12 4,251 of them (62%) tested for TB. Of those tested, a total of 1,243 cases were diagnosed in the FAST sites which reported in this quarter.
Progress trend (Baseline 2017 – Current 2020)
250% 20%
17% 14% 200% 14% 13% 15% 150% 98% 94% 93% 91% 10% 100% 63% 65% 63% 85% 50% 5% 65% 68% 41% 60% 0% 0% Baseline (Apr-Sep 17) Intervention Period (Oct Intervention Period (Oct Current Performance 17 -Sep 18) 18 -Sep 19) (Oct 19- Mar 20)
Screened Testing Rate Treatment Initiation Positivity Rate
Figure 1: FAST Screening, Case Detection & Treatment Initiation. (Source: project monthly/quarterly reports)
1.2.3 Implement LF-Lam in 97 hospital to increase case finding among people living with HIV
In addition to FAST implementation, the project supports implementation of Lateral Flow Assay Urinary lipoarabinomannan (LF-LAM) in 42/86 FAST implementing sites across five provinces, namely KwaZulu Natal (7/32) Eastern Cape (13/29 sites), Free State (4/11), Limpopo (15/15) and Gauteng (12/15). The low uptake of LF-LAM is due to lack of confidence of nurses in using the test as well as non-availability of test kits. To address these challenges, the project conducted refresher trainings and mentors’ staff in supported districts. Between January to March 2020, only 22 of the 42 LF-LAM implementing sites reported. Within these sites, a total of 411 HIV positive patients were eligible for LAM testing and (87%) of those eligible were tested with 101 (28%) testing positive for LF-LAM and 97 (96%) initiated on treatment.
Table 7: LAM performance report for the first six months of FY4 (October 2019 – March 2020) LAM Report Performance Oct - Jan - DATA ELEMENT Dec % Mar % Total % 19 20 Number of HIV positive patients with low CD4 378 100 478 count (less than or equal to 100 cells/ul Number of HIV positive patients who are 824 311 1135 seriously ill regardless of low CD4 count Total Number of HIV positive patients eligible 1202 411 1613 Number of clients LAM tested 763 63% 359 87% 1122 70% Number tested LAM positive 277 36% 101 28% 378 34% Number initiated on TB treatment 261 94% 97 96% 358 95% Number done Xpert/MTB Rif 145 56% 37 38% 182 51% Number diagnosed RR positive 59 41% 25 68% 84 46% Number of RR positive on MDR-TB treatment 16 27% 2 8% 18 21% Initial death 0 0 0 Loss to follow 0 0 0
USAID Tuberculosis South Africa Project - Project Quarterly Report: January 2020 to March 2020 13 The table above shows that since the start of the new financial year, a total of 1,613 patients were eligible for LF-LAM testing, with 70% tested of which 378 tested positive for TB. It must be noted that uptake of ULAM is progressively increasing with testing rates increasing from 63% in October to December to 87% in January to March.
IR 1.3: Expand strategies to reach, screen and evaluate individuals with high TB risk
1.3.1 Continue with piloting the use of IGRA to determine feasibility of its use amongst HCWs in Free State, Gauteng and Eastern Cape
The project continues to pilot the use of IGRA to determine its feasibility and use amongst healthcare workers at Pretoria West Hospital in Gauteng province. By the end of February 2019, a total of 277 had been enrolled of which 44.5% were found LTBI positive. In March 2020, the study was scaled up and introduced in Pelonomi Hospital in the Free State Province, which is the second of the three provinces earmarked for the study. Recruitment and enrolment of study participants planned for March 2020 was suspended due to the COVID- 19 pandemic. At the time of reporting, a total of 20 participants had been enrolled and blood samples drawn.
Table 8: Lessons Learned and Corrective Actions
Enabling Factors Challenges Remedial Action • Buy-in and leadership from • Size of tertiary hospitals and • Project staff to build good hospital management and staff. workload means that HCWs relationships with hospital • Flexibility and support from unit are not always available and vast management and clinicians and managers to release staff for distances to be covered facilitate recruitment of blood draws. between different units. participants • The research officer to focus on doing the blood draws for those recruited • Efficient administration and • Conflicting schedules and • The study to resume after the planning. For example, all suspension of planned activities COVID-19 lockdown. paperwork and administration due to COVID-19 outbreak to be done prior to drawing blood to ensure everything is in place before commencement of study activities is in place • Agreement on calendar for • No office space allocated for • The nursing manager to look recruitment, feedback and research officer for space when the study information sharing. For resumes next quarter. example, particular days of the week (Thursdays/Fridays) allocated for reporting and providing feedback to hospital management
1.3.2 Delivery of TPT to 181,014 PLWHIV and >5 years 17,177) strengthened
South Africa is currently in the process of finalizing revisions in the TPT guidelines in newly diagnosed HIV patients as well as other eligible key populations. Although the revised guidelines have not been launched for implementation, the Nelson Mandela Bay Metro, started
USAID Tuberculosis South Africa Project - Project Quarterly Report: January 2020 to March 2020 14 implementation of the new guidelines in January 2020 with the project’s support. The CQI approach was used to ensure each sub-district within Nelson Mandela Bay meets the target of >90% eligible PLHIV clients are initiated on TPT. Analysis of the impact of CQI in TPT initiation for newly diagnosed HIV positive eligible clients has shown a steady sustainability in all three sub districts showing the current performance ranging between 80% to 100%.
HIV Positive new eligible client initiated on TPT 800 95% 600 90% 85% 400 80% 200 75%
0 70%
starton TPT eligible eligible forTPT
Total HIV positive new eligible client initiated on IPT HIVpositive clientsnew Total Total numberofnew client
Figure 2: NMBHD HIV positive new initiated on TPT TB contact under 5 years start on TPT in the Nelson Mandela Bay Metro During the TB cluster reviews conducted in NMBHD during the reporting quarter, it was noted that TPT initiation for asymptomatic TB contacts under 5 years varied significantly across the 3 subdistricts in the district. Sub district C’s performance was applauded during the reviews, as the sub district managed to reach 100%, with sub district A reaching 80% average in February 2020.
Sub district A: TPT Initiation for HIV positive new eligible client 700 88% 86% 600 84% 500 82%
400 80% 78%
300 76% screened 200 74% on TPT 72% 100 70% 0 68% Totalnumber of children5 yearsunder Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20
HIV positive client screened for TB HIV positive new eligible client initiated on IPT TB asymptomaticcontacts under 5 yrsstart
Figure 3: NMBHD Subdistrict A HIV positive new initiated on TPT
1.3.3 Work with NDoH and SAMA to develop and disseminate a 2-pager SOP of treatment guidelines for latent TB infections (LTBI)
LTBI guidelines are still under review and not ready for dissemination.
USAID Tuberculosis South Africa Project - Project Quarterly Report: January 2020 to March 2020 15 IR 2: Sustainability of Effective TB Response Systems Increased
IR 2.1: Strengthened management capacity at all levels
2.1.1 Strengthen leadership, governance and management of TB services at facility and community levels (Health Systems Strengthening)
Collaboration with Regional Training Centres (RTCs): During the quarter, the project engaged RTCs in three of the six supported provinces namely, KwaZulu Natal, Limpopo and Gauteng provinces. On January the 16th, the project participated in the KZN RTC Provincial Stakeholder Quarterly Meeting. The project’s presentation focused on all the trainings conducted in the previous quarter of October-December 2019 (didactic and onsite mentoring), and those planned for Figure 11: KwaZulu Natal Provincial Manager presenting January-March period for both uMkhanyakude at the RTC Stakeholder and eThekwini districts. The presentation highlighted improved results in patient care management as this is one of the strategies which seems to be more effective, like improvement in TB cascade and improvement of TB and DR- TB outcomes. The following activities were discussed and agreed as priorities for all training partners in the province: • Revision of NIMART training manual which should strengthen TB/HIV collaboration component • Training of nursing students on basic TB, HIV and DR-TB • Finding the missing 787 TB patients in KZN province • Training of HCWs including doctors on DR-TB clinical management and training of tracer teams on TB Management
In February 2020, the project and Limpopo Provincial RTC office co-hosted the RTC Provincial Quarterly Stakeholder Meeting for the province. A specific request for the project was to conduct ACSM training for RTC Coordinators with district and sub-district coordinators. During February the project also jointly conducted two trainings on TB Management and Infection Prevention and Control with the Gauteng Provincial RTC. The collaboration has been on-going in Tshwane district and the project is a recognized capacity building partner.
USAID Tuberculosis South Africa Project - Project Quarterly Report: January 2020 to March 2020 16 2.1.2. Scale up "Quality Improvement and Quality Assurance" support through continued secondment of a Technical Advisor and two Improvement officers (West Coast and Nelson Mandela Bay Municipality)
The project continues to support two Quality Improvement Officers appointed and seconded to NMBM in the Eastern Cape and West Coast District in the Western Cape.
2.1.3 Implement QA/QI Approach to address identified gaps in the district TB care cascade
Continuous Quality Improvement (CQI) activities were conducted in all the supported districts covering different activities. The support is conducted through learning sessions, facility visits and cluster follow up. However, implementation and reporting remain a challenge in four districts; namely Sekhukhune, Waterberg, Mangaung and uMkhanyakude. No project driven CQI activities were conducted in eThekwini in the reporting quarter, as the district is transitioning to the Global Fund partners. In OR Tambo, the project engaged in the orientation of the new Global Fund partner – Aquity Innovations. The report below covers some of the activities conducted in nine districts and the hospitals in CoJ and CoT.
District Level Support Limpopo - Sekhukhune District
100,0% 80,0% 60,0%
40,0%
91,8%
91,7%
90,6%
90,3%
89,9%
89,6%
88,3%
85,8%
82,8%
79,8%
79,3%
21,3% 65,5%
20,0% 12,6%
0,0%
Q4 2016 Q4 2017 Q1 2017 Q2 2017 Q3 2017 Q4 2018 Q1 2018 Q2 2018 Q3 2018 Q4 2019 Q1 2019 Q2 2019 Q3 2019 Q4 2020 Q1
TB Screening rate Target Figure 4: Screening rates in Sekhukhune district from Q4 2016 to Q1 2020 During the reporting month facility data performance audits were conducted at five high TB burden facilities in the Sekhukhune and quality improvement plans (QIPs) were developed to address gaps identified. Overall data for Sekhukhune shows significant improvements in the screening rate from 12% at base line to 91% in January-March 2020. Eastern Cape - Nelson Mandela Bay Metro In 2019, the project appointed a Quality Improvement Officer 15% in the Nelson Mandela Bay Increase in case finding Metro whose primary role has between October been to ensure full coverage of 2019 and March 2020 Figure 12: Park Centre Clinic CQI Facility CQI in the district. As of Support
USAID Tuberculosis South Africa Project - Project Quarterly Report: January 2020 to March 2020 17 March 2020, the district has achieved 100% coverage including a total of 31 high TB burden facilities contributing to 80% of the TB burden in the district. The support provided included TB QI facility visits and cluster QI implementation aimed at monitoring the implementation of QI activities to close the gaps in the District TB Program implementation. During the reporting period, a total of six clusters were reviewed covering 34 facilities in three sub- districts were done. Implementation of cluster reviews continues to support poorly performing clusters and facilities. An analysis of the data since the start of the new financial year shows that the increase in the screening rate from 84% to 88% had a corresponding 15% increase in case finding from 1,753 cases diagnosed to 2030 in March 2020.
Table 9: NMBHD TB Care Cascade, Q4 2019 to Q1 2020
Oct-Dec 2019 Jan-Mar 2020 Despite the overall performance of the district as well as some of the Headcount 519988 514433 improvements observed, a deeper Number Screened 435095 84% 451654 88% analysis at facility level shows that Presumptive TB 12214 3% 12334 3% Clients each facility has unique challenges Number Tested 11439 94% 11623 94% which, if not addressed, may Tested positive 1753 15% 2030 17% negatively impact on the district Started on performance. Thus, to improve 1731 99% 1987 98% treatment facility performance indicators, a facility performance tracker tool was used in conducting data audit in the eight facilities (See Table 10 below) to understand the specific gaps in the TB care cascade and to develop quality improvement plans to address the identified gaps.
Table 10: Analysis of facility gaps and recommended actions to be implemented in Nelson Mandela Bay Metro Faciliti Gap /Challenge Aim Statement Change idea es selected for QI High rate of TB To reduce TB patient lost to follow up from To generate weekly line lists to monitor
patients Lost to 23% (Q4 2018) to 15% by March 2020 missed appointments. Share with Aquity
follow up for tracing
Booysens Park Clinic Low treatment To increase TB success rate from 56% Q4 To generate weekly line lists to monitor
success rate 2018 to 70% Q1 2019 missed appointments. Share with Aquity
for tracing
Edameni Clinic High rate of TB To decrease TB patients Lost to Follow up Collaborate with Care Ministry in tracing
patients lost to from 9% Q4 2018 to 4% by 31 March 2020 TB patients LTFU for Q4 2018
follow up
Chatty Clinic
Poor testing rate of To increase testing rate of TB symptomatic Integration of TB sputum collection
TB symptomatic clients from 68% November 2019 to 90% services to PHC services.
clients February 2020
Clinic
Rosedale High rate of TB To decrease TB patients LTFU rate from Generate reports and share with Care
patients Lost to 19% to 10% by April 2020 Ministry for tracing
Follow Up
Mabandla Clinic
Low TB Screening To increase TB screening from 78% to 90% To allocate a staff member whose duty
t for five years and by April 2020 will be to champion TB screening at
older facility level
Middle Stree
USAID Tuberculosis South Africa Project - Project Quarterly Report: January 2020 to March 2020 18 Low screened for TB To increase TB screening from 79% to 90% To monitor TB screening data weekly
symptoms 5 years by end of March 2020 through data verification activities
c and older
Park Park Centre Clini Screened to TB To increase screened for under 5 years Staff capacity development on basic TB
under 5 years from 76% November 2019 to 90% March screening
2020
Veplaas Clinic
Eastern Cape - OR Tambo Three cluster reviews covering five subdistricts were conducted in the OR Tambo district in the reporting quarter. The facilitation sessions were done jointly by the project and the district TB Coordinator to transfer skills in the facilitation of CQI cluster meetings. The results of the TB QI implementation in the five sub districts show an increase in TB screening from 18% in October 2016, to 92% in October -December 2019. Similarly, the sputum testing rate for clients who are five years and older improved from 80% in October- December 2016 to 89% by February 2020.
TB Screening in O.R. Tambo District 91% 92% 93% 100% 86% 90% 91% 71% 73% 80% 67% 69% 64% 58% 60% 40% 18% 23% 20% 0% Oct - Jan -Mar Apr -Jun Jul-Sep Oct - Jan -Mar Apr -Jun Jul-Sep Oct-Dec Jan-Mar Apr-Jun Jul-Sept Oct - 20-Jan Dec 16 17 17 17 Dec 17 18 18 18 18 19 19 19 Dec19
Figure 5: TB screening in OR Tambo District
Sputum testing rate in OR Tambo for 5 years and older
99 120 84 84 86 90 87 88 89 100 80 74 71 80 78 76 80 61 60 40
Percentage 20 0
Figure 6: TB Sputum testing rate in OR Tambo Western Cape - West Coast Implementation of CQI in the West Coast district has reached full coverage and has been rolled out to all five subdistricts since October 2019. Support in the reporting quarter was provided to 19 facilities through cluster reviews, focusing on the TB cascade, completeness and accuracy of data, data clean-up activities and reporting of data. two clusters were
USAID Tuberculosis South Africa Project - Project Quarterly Report: January 2020 to March 2020 19 reviewed; namely Swartland and Bergrivier sub- districts. The main findings and results show that the TB screening rate in the district has increased progressively from a baseline of 63% in October 2016 to 80% in quarter 1 of 2020. The testing and treatment initiation rates have also been maintained above 90%. The challenge remains with rolling out CQI at the remaining hospitals as currently only three of the seven District hospitals are implementing CQI. Scaling up of CQI Figure 13: Facility support visit in the West Coast implementation at hospital level will be one of the key priorities for the next quarter.
Table 11: TB care cascade for West Coast West Coast Q1 2019 Q2 2019 Q3 2019 Q4 2019 Q1 2020 District No % No % No % No % No % 18597 18164 19571 18267 12482 Headcount 9 5 6 2 2 14185 13331 14490 13977 Screened 76% 73% 74% 77% 99476 80% 3 4 0 2 Presumptive 4318 3% 4783 4% 5225 4% 5202 4% 3059 3% Sputum sent 4290 99% 4761 100% 5188 99% 5066 97% 3011 98% Test positive 692 16% 638 13% 763 15% 726 14% 520 17% On treatment 635 92% 574 90% 701 92% 641 88% 496 95%
As part of the support, the impact of TB Screening on increasing the TB Case Detection since implementation of CQI in June 2017 was also reviewed. Of the five sub-districts in the West Coast, comparing the same Swartland SD case finding: 2017 - 2019 quarters year on year, there 282 300 245 is a significant increase in the 229 219 202 190 200 176 167 173 176 165 number of patients 128 diagnosed with TB over a 100 period of three years in the Swartland Sub-district, 644 0 Q1 Q2 Q3 Q4 in 2017 to 895 in 2019. The initial data review and 2017 2018 2019 analysis was done for 2017- Figure 7: Swartland Case Fining 2017-2019 2019 and the 2020 data is currently being verified and will be included in subsequent reports.
National Level Support At the National Level, the USAID TB South Africa Project has seconded a Quality Improvement Advisor working directly with the National TB program to support roll out of the National Quality Improvement Initiative. Through the QI advisor, the project supported QI in the selected Nine (9) QI priority districts (Sedibeng, Ekurhuleni, uMgungundlovu, Zululand, eThekwini, OR Tambo, Nelson Mandela Bay, West coast and Cape-winelands
USAID Tuberculosis South Africa Project - Project Quarterly Report: January 2020 to March 2020 20 districts) which were part of the demonstration phase. The activities implemented included, onsite support visits, coaching and mentoring as well as capacity building of the District Health Management Teams. The demonstration phase has now been completed and as part of the planning process for scale up to other districts. With support from Figure 14: National workshop hosted by the National Department of Health the project, the TB Control and Management cluster within the National Department of health hosted a national workshop to identify interventions that have shown impact for scale up, standardize and finalize the change package, standard operating procedures, tools and M&E framework for TB-QI.
Gaps and opportunities were identified and agreed upon including • The need for a QI Change Package that focuses on children; community; hospitals and underserved groups – (e.g. adolescents, men, rural) • There are still data and information system related issues which need urgent attention, e.g. validity of data on TIER.Net, no measure for contacts >5yrs in the DHIS, tracking of community screening on the DHIS, as well as lack of hospitals hospital data on the system. • Poor Outcomes, particularly number of cases that are not evaluated and those lost to follow up LTF • ICD codes: There is still a gap in the correct coding of deaths • Measuring success of the TBQI initiative across all spread districts
The project is part of the National Department of Health’s “Operation Phutuma”. Within this forum, the project is a strategic partner, supporting the NTP to implement the strategies for Finding the 160,000 Missing TB Cases. Implementation is across all districts and priority is on the 21 districts across all provinces and the project supports seven of these. CQI plays a critical role in ensuring the districts meet their set targets with a special focus on the identified 475 high burden facilities. District Nerve Centre weekly meetings have been identified as the reporting platforms to monitor facility TB Cascade dashboards. The project attends the weekly Phutuma meetings and is actively engaged in ensuring that as part of operation Phutuma, districts are supported to meet the 90-90-90 targets and meet the targets for missing TB patients and improve recording and reporting of missing TB patients at all levels.
USAID Tuberculosis South Africa Project - Project Quarterly Report: January 2020 to March 2020 21 2.1.4 Support the implementation of the "The Missing TB Patients Strategy" in the district to find the missing patients
To step up efforts to find the missing TB patients, the National TB program (NTP) has set an annual target of finding 80,000 patients by the end of the 2019/2020 financial year. Of the 80,000 missing TB patients targeted for 2019/2020, 37,665 (47%) are estimated to be in the 14 districts supported by the project. To work alongside government to meet these ambitious targets, the project has targeted to find at least 18,882 (50%) of the total 37,665 which are estimated to be in project supported districts. Between October 2019 and March 2020, the project used various strategies to find the missing TB patients including the FAST approach, community mobilization, contact management, targeting key populations, using diagnostic tests such as ULAM as well as updating of data and records in project supported districts. Through these strategies, a total of 6593 TB patients have been found, representing 35% of the targeted 18,882 cases to be found in the current financial year. These results are largely due to the FAST intervention, which contributed 57% of all TB cases diagnosed, as well as data cleaning exercises which took place in 10 of the 14 supported districts covering over 160 high TB burden facilities diagnosing the highest number of TB cases in the country. The community level interventions have made minor contributions owing to the reduction in the number of community-based organizations contracted by the projects which stands at only ten.
Table 12: Missing TB patients diagnosed by strategy Strategy Oct-Dec 19 Jan-Mar20 Total % FAST Approach 2505 1243 3748 57% Community mobilization, 559 68 627 10% Contact Management 59 59 118 2% Key populations 77 58 135 2% Diagnostics tests (U-LAM) 277 101 378 6% Linkage to care – Initial lost to follow- 55 76 131 2% up (ILTFU) Updating of records and data clean-up 312 1144 1456 22% TOTAL 3844 2749 6593
2.1.5 Brigham & Women's' Hospital - facilitate the effective and efficient implementation of TB IPC measures at health facilities
The project has not yet commenced. Various approvals are currently being facilitated through the department of health before activities can start.
IR 2.2: Strengthened service delivery capacity at all levels
2.2.1 Expand TB services through appointment of sessional staff (Doctors, Clinical Associates and Nurses)
In order to expand DR-TB services, the project has contracted three session doctors located in NMBM, O R Tambo and Waterberg districts. Primarily, the sessional doctors work directly with DoH at DR-TB decentralized sites to mentor, support and guide DoH staff.
USAID Tuberculosis South Africa Project - Project Quarterly Report: January 2020 to March 2020 22 2.2.1 Build capacity of 4,320 HCWs on DS/DR-TB management, FAST, IPC, Recording & Reporting, Data management, ACSM Guidelines and QA/QI in collaboration with RTCs
Table 13: Didactic Trainings Training Course Category # Male # Female Total Tenofovir/Lamivudine/Dolutegravir Doctors & Nurses 07 16 23 (TLD) Continuous Quality Improvement Nurses 11 31 34 Continuous Quality Improvement Nurses & Data 26 69 95 Cluster Review Capturers ACSM Guidelines Health Promoters 05 22 27 & Coordinators MDR-TB & EDR-Web Nurses & Data 06 08 14 Capturers Basic TB Management Training Nurses 03 17 20 Basic TB Management Training CHCWs 02 25 27 TB Diagnosis and Data Nurses & Data 07 17 24 Management Training Capturers DR-TB Management Training Doctors & Nurses 03 50 53 Basic TB Management Training Nurses 10 49 59 TB Infection Prevention & Control Nurses & Allied 03 190 193 Workers Total 83 494 577
Figure 15: TB IPC Training in Tshwane District
Capacity Building for Managers:
Table 14: Capacity Building for Managers Training Course # Male # Female Total District HAST Meeting 05 60 65 DR-TB Clinical File Audits 07 18 25 Community TB organizations Meeting 02 27 29 Provincial RTC Quarterly Meeting 04 13 17 District Health Plan Session 01 12 13 Eastern Cape NGO Meeting 11 42 53 KZN TB/DR-TB Technical Meeting 09 43 52 FAST Monthly Review 00 11 11 Provincial THIS Meeting 14 29 43 DR-TB Review Meeting 13 35 48 FAST Meeting 09 34 43 Sundays River Valley Data Clean Up Exercise 00 16 16
USAID Tuberculosis South Africa Project - Project Quarterly Report: January 2020 to March 2020 23 Training Course # Male # Female Total Kouga- Data Clean Up Exercise 04 24 28 FAST Meeting 03 21 24 DR-TB Review Meeting 10 48 58 Sub-District Operational Planning 09 22 31 Total 101 455 556
Capacity Building using Low-Dose High-Frequency Training Approach:
Table 15: Capacity Building using Low-Dose High Frequency Activity Category # Male # Female Total Onsite Mentoring & Coaching – Doctors, Nurses, 90 469 559 identified TB program gaps along Data Capturers, the care cascade Allied Workers and Lay Health Workers
Figure 16: Du Toit Agri, DOH and USAID TB South Africa TB Onsite training for farm health care workers and Fit testing training of Wolseley Clinic staff
Peer Learning Experience (Benchmarking):
In February, the project and the Limpopo provincial TB Unit co-hosted the Infection Prevention Control (IPC) Policy Peer Review feedback. Overall, the implementation of the IPC Plans is acceptable, however, the availability of Personal Protection Equipment (PPE) guidelines, proper PPE and adequate utilization thereof needs improvement. Ongoing tracking and periodic evaluation of performance of the TB IPC programme is required at every level. The effectiveness of the national IPC programme and implementation plan should be monitored and evaluated with a clear set of indicators and methodology in order to provide the data needed to guide the planning, coordination, implementation and identify areas for program improvement. Monitoring the results of IPC program will allow health facilities to determine if the IPC measures being implemented are working well or if changes are required to achieve better results. Surveillance of TB among Health Care Workers serves as an
Staff TB Screening, Provincially, Nov-Dec 2019
80 61,9 66,6 60 45,8 37 41,6 40 20 0 Capricorn Mopani Sekhukhune Vhembe Waterberg
Figure 8: Staff TB Screening, Limpopo Province
USAID Tuberculosis South Africa Project - Project Quarterly Report: January 2020 to March 2020 24 indication of performance of IPC Plan. It was recommended that all facility staff must be included in the TB medical surveillance programme in line with Occupational Health and Safety Act (Act No. 85 of 1993). 2.2.3 Strengthen decentralization of DR-TB services in the 14 supported districts
Decentralization of DR-TB services continues to be a top priority for the government of South Africa, including The USAID TB South ensuring the quality of clinical services provided. The Africa Project supported supported districts initiated 917 patients on DR-TB districts initiated treatment in Q4 Oct-Dec 2019 out of 1,166 laboratory diagnosed cases. 917 Decentralized MDR-TB sites have been established in 100% DR-TB patients sub-districts in project supported districts maintaining at least one MDR-TB treatment initiation site per sub-district as per the national policy framework on decentralized and deinstitutionalized management for South Africa. This is to make it easier for patients to be initiated onto treatment and retained in care closer to their homes. During the reporting quarter, the project deployed DR-TB sessional doctors to provide onsite mentorship to decentralized sites in Nelson Mandela Bay Metro, Waterberg and OR Tambo districts to strengthen clinical governance and to improve the quality of DR-
TB services provided.
-
TB TB
-
ricts ricts
dist
districts districts
service
- TB
-
-
Districts
Number of of Number
Province
Number of of Number sub DR without TB
Number of of Number sub DR with services of Number initiation Sites
DR (%) services Coverage of of Coverage Eastern 3 10/10 0 14 100% Cape Free State 2 8/8 0 11 100% Gauteng 2 13/13 0 24 100% Kwa-Zulu 2 7/7 0 13 100% Natal Limpopo 2 9/9 0 14 100% Western 3 12/12 0 137 100% Cape TOTAL 14 59/59 0 202 100%
During the reporting period, direct support provided to the DR-TB decentralised sites included conducting DR-TB clinical audits to review the clinical management and quality of care provided to DR-TB patients including management of adverse drug events as well as proper recording and reporting of patient progress and outcomes. In addition to this, the project also co-hosted DR-TB district review meetings in OR Tambo and Nelson Mandela Bay districts to review the management and performance of the DR-TB program within these two districts. Direct support provided in the reporting quarter included both off-site training and on-site mentoring of clinicians involved in the management of DR-TB (nurses, clinical associates, pharmacists and doctors). During off-site training, use of up to date treatment guidelines was emphasised, and topics covered encompassed definitions, diagnosis, baseline evaluation, drug regimens, medication side-effects monitoring, and recording of outcomes.
USAID Tuberculosis South Africa Project - Project Quarterly Report: January 2020 to March 2020 25 On-site mentoring focussed on adhering to DR-TB guidelines, proper recording in the patient’s file, and proper assignment of treatment outcomes to enable correct capturing of DR-TB data. Activities and support provided as well as some indicators reported during this quarter are summarised in MDR-TB Clinical Audits: During the reporting period, the project continued to assist the NDOH to institutionalize DR-TB Clinical Chart Audits in the supported districts, as part of improving quality of care for DR-TB patients. In the reporting month the project supported NMBM at Jose Pearson (Centre of Excellence facility in EC) to conduct clinical chart audits in embarking on a chart audit exercise which revealed gaps in clinical care that needed to be addressed. The strategy used by the project focuses Figure 17: MDR-TB Clinical Audits conducted in NMBM on strengthening clinical leadership and clinical governance through engagement of Hospital CEOs and Facility Managers to enable them to take ownership of the DR-TB program performance. The CEO provided a report outlining the facility’s performance, challenges experienced as well as contributing factors to their LTFU which is reported one of the highest in the province. Another critical aspect of the support provided for DR-TB decentralized sites is the capacitation and onsite mentorship of data capturers and TB program staff who work with the program data on a daily basis. During the Clinical Audit conducted, a clinical questionnaire tool was used to assess various elements of clinical care including admission and referral processes to the MDR-TB unit, diagnostics and treatment strategies, side effects documentation and reporting, and clinical evaluation and monitoring.
Table 16: Outcomes of the clinical questionnaire tool Score Admission and Diagnostics and Side effects referral to MDR-tb treatment strategies documentation and unit reporting NUMERATOR: Number 21 22 41 of questions answered YES DENOMINATOR: 30 40 65 Number of applicable questions Percentage 70% 55% 63.1%
These results clearly depict gaps in admission and referral processes, diagnostics and treatment as well as side effects documentation and reporting which were raised for immediate attention with the facility. Similar audits will be conducted in all supported districts as a quality improvement strategy supported by the sessional doctors to address quality of clinical care gaps for DR-TB patients. Addressing challenges with Pharmacovigilance (PV) for MDR-TB: The project contracted the Human Sciences Research Council (HSRC) to conduct a pharmacovigilance study on current PV practices in South Africa to improve reporting and management of adverse events. Structured interviews focusing on knowledge, beliefs and practices (target population:
USAID Tuberculosis South Africa Project - Project Quarterly Report: January 2020 to March 2020 26 doctors, nurses, pharmacists, quality assurance managers, operational managers, facility managers) were conducted.
Table 17: Number of interviews and adverse event report forms audited in 10 study sites Site Status Number of interviews Eastern Cape Site 1 Complete 30 KwaZulu-Natal Complete 32 Mpumalanga Complete 15 Northern Cape Complete 14 Western Cape Complete 21 Free State Complete 7 Gauteng Complete 23 North West Province Complete 12 Limpopo Complete 10 Total to date 173
Some of the recommendations coming from the study include: 1. Standardization of the adverse event report forms across facilities; 2. Evaluation of various methods of incorporating the form into the daily routine or standard patient examination; 3. Train all staff working with DR-TB patients (including non-RNs, social workers, physiotherapists, pharmacists, CHWs) regarding adverse event reporting and its value as part of a national intervention; 4. Implement a pre/post assessment of the training intervention (for research purposes); 5. Implement a formal audit for operational management purposes; 6. Consolidate guidelines from SAHPRA and NPC concerning reporting of adverse reactions associated with TB and HIV; 7. Clarify who can complete these forms and encourage feedback from the NPC on reports received; 8. Encourage the use of digital applications for reporting which will eventually replace paper-based reports and 9. Encourage PTC meetings at all study sites and provide training on basic analysis of reports in the facility and how they can be used at a facility level.
IR 2.3: Improved data reporting and recording at all levels
2.3.1. Work with DSPs data capturers to ensure capturing of TB data into the integrated information systems (TIER.Net) and appoint sessional data capturers where not possible
In order to reduce backlogs in the capturing of TB data, the project hired three data capturers who have been allocated to high volume facilities in Sub district A, B and C to support capturing on TIER.net module. The tables below illustrate the work done by the data captures in facilities on different indicators between January – March 2020.
USAID Tuberculosis South Africa Project - Project Quarterly Report: January 2020 to March 2020 27
Table 18: NMBHD Data Capturer Support
w w
Max Max Madlingozi Ne Brighton CHC Helenvale Clinic Linton Grange Laetitia Bam Total
efore
Before After B After Before After Before After Before After Before After %Change TB 161 Identification 219 782 21 100 13 67 17 280 281 385 551 193% 4 Report 2019 TB Identification 5 66 0 7 0 5 0 9 26 48 31 135 335% Report 2020 Integrated Missed 60 7 4 0 43 3 23 4 17 8 147 22 -85% Appointment Unconfirmed TB Outstanding 61 3 7 0 34 3 18 3 20 8 140 17 -88% outcomes list
The selected facilities were previously not capturing the number of presumptive patients on the TB Module on TIER.net. When the capturing is not done this leads to under reporting and a misrepresentation of the actual facility performance. At the five facilities indicated above (Max Madlingozi, New Brighton Clinic, Helenvale, Linton Grange and Laetitia Bam), the data capturers assisted with updating the records and ensuring that all patients are captured appropriately. For example, missed appointments and outstanding outcomes could not obtained from system generated reports which resulted in low treatment success rates. The information was available on patients’ folders but not captured on the system. Due to the assistance of the data capturers, the TB outstanding outcomes were reduced by 88% and missed appointments were also reduced by 85% as data capturers were able to update the outstanding outcomes and ensure that each patient had the correct outcome allocated as recorded in the patient files.
Table 19: Engagement of DOH and District Support Partner personnel to build capacity for recordning and reporting District Partner/ DoH Number Scope covered capacitated eThekwini TB HIV Care, 18 data capturers Onsite Mentorship on capturing case ID MatCH and Aurum registers, TB blue folders, patients diagnosed and started on TB treatment in the wards are captured before being discharged, generating and actioning TIER.Net line lists Tshwane Department of 3 IT technicians In-service training and installation of the Health latest TIER.Net (version 12.6)
OR Tambo AQUITY 4 data capturers Mentorship on the importance of capturing INNOVATION all the sputum results in the TIER.Net
USAID Tuberculosis South Africa Project - Project Quarterly Report: January 2020 to March 2020 28 system and checking the HIV status of all TB patients Mangaung Department of 30 participants (1 In-service training on the TB Identification district Health Operational Manager, 1 register and highlight the importance of Professional Nurse, 14 data flow and management per facility TB Focal nurses, 11 Data Capturers, 2 Data analysts and 1 District TB Coordinator) 4 districts 55 participants
In addition to the work of the project contracted data capturers, information offices and other personnel from district support partners present in project supported districts were mentored on various aspects of TB data reporting and recording including capturing of TB case ID registers, TB blue folders, installation of TIER.Net as well as monitoring and recording of HIV status of TB patients . A total of 55 personnel were capacitated in the reporting period from eThekwini, Tshwane, OR Tambo and Mangaung districts. Following these M&E mentorship sessions, standard Figure 18: Project M&E Officer recommendations were made including the fact that facilities should Presenting data gaps per facility back capture all outstanding patients on the TB identification register at Botshabelo sub district and that facility Managers should start interrogating their facility data before signing it off to sub district level. 2.3.2. Scale-up the implementation of mHealth applications to improve patient management and reporting capabilities among all the 35 NGOs
The ConnecTB application development has been halted awaiting approval of grant applications for sub grants. 2.3.3. Support the DoH to conduct quarterly provincial/ district program data reviews
A key element of the Project’s technical assistance is supporting the Department of Health to conduct quarterly TB program data reviews. This ensures that supported districts are able to assess the performance of the TB program, identify bottle necks and be assisted with closing identified gaps. In the reporting quarter 14 program reviews were co- hosted by the project together with the national department of health. These included (i) DR-TB quarterly program review in the KZN province (ii) HAST quarterly program review in uMkhanyakude district as well as a provincial quarterly review of the TB/HIV Information System (THIS) in the Eastern Cape Province.
Table 20: KZN DR-TB quarterly review challenges and remedial actions Challenges Remedial action Not all patients diagnosed are initiated on Use lab alerts to track patients and link them to care treatment Long time lag to treatment initiation Root cause analysis and improvement plans Low culture conversion rate and poor Put in place patient support, tracking and tracing systems and treatment outcomes - High number of loss follow up transferred patients to follow up, death rate and transferred patients not accepted at receiving facilities
USAID Tuberculosis South Africa Project - Project Quarterly Report: January 2020 to March 2020 29 Challenges Remedial action High Loss to follow up and death rate Track and trace patients back to care and intensify active case finding for vulnerable patients through planned strategies. Conduct district DR-TB death audit Backlog in data capturing due to competing Engage partners to support with HR in Hospitals and priorities and staff shortages especially in Community Health centres. hospitals thus affecting progress in Finding Missing TB patients
Summary of uMkhanyakude HAST quarterly review The HAST quarterly review in uMkhanyakude showed significant improvements in TB program outcomes from Q3 (Jul-Sept 2018) to Q4 (Oct-Dec 2018). The DS-TB treatment success rate improved from 82.3% to 86.8%, the; loss to follow up rate also declined marginally from 3.6% to 3.3%, however the death rate remains a challenge at 8.9% and 8.1% respectively. Challenges and remedial actions
Table 21: uMkhanyakude HAST quarterly review challenges and remedial actions Challenges Remedial action • Urgent death audit needed to understand root • High death rate causes and propose solutions • Few reports on LAM test for the whole • To liaise with the pharmacy about shortage of Lam district test kits in hospitals • Revise the reporting tools for Missing cases and • Missing cases target not met ensure that each facility is aware of and is supported to meet their missing cases targets. Challenges with FAST implementation • FAST refresher training in sites that are • 5/6 sites are reporting which is a 90% underperforming particularly Mseleni hospital. reporting rate. • To monitor quality recording of FAST data on • High staff turnover amongst TB monthly basis. coordinators. • To revise FAST champions in units through capacity • Lack of ownership, commitment and building. supervision for TB FAST program. • Re-orientate managers on FAST strategy. • Develop a system for reporting contacts traced. • Poor contact tracing in different districts • Capacitate TB tracer teams on TPT and poor TPT uptake • Revisit contact tracing SOP.
Eastern Cape Provincial review on THIS An Eastern Cape Quarterly provincial meeting was held on the 19th of February 2020 with the aim of reviewing provincial implementation of THIS and DHIS web. The specific objectives included addressing challenges in the TB and HIV program, addressing challenges identified with the transition from ETR to TIER.net, addressing poor performance on Webchats reports, ensuring that all districts have a common understanding on reporting systems, and to discuss poor performance on Finding TB Missing Cases. Overall recommendations • WebDHIS should be used for reporting a and TIER.Net should be used for managing patient information. • Tier reports should only be generated for facility level patient management.
USAID Tuberculosis South Africa Project - Project Quarterly Report: January 2020 to March 2020 30 • The algorithm on the TB HIV on ART Report should be revised. Currently, WebDHIS reports only those patients initiated within eight weeks, however reports are required for all patients with a known HIV status irrespective of when ART was initiated. • Provinces and Districts should purchase computers with capacity to process large volumes of data to avoid system failure and slow process of sending data dispatches. • A plan should be put in place to monitor transferred outpatients that did not reach facilities. 2.3.4 Scale up and ensure systems for regular data clean-up exercises in each of the 14 supported districts
A key highlight of the reporting quarter is the data cleaning exercise which took place in 10 of the 14 project supported districts covering over 160 out of 475 (30%) high TB burden facilities which diagnose the highest number of TB cases in the country. The data cleaning took place in all districts with the exception of the Western Cape (West Coast, Cape Winelands, City of Cape Town) and City of Johannesburg. Below are the before and after results of the data cleaning including the recommendations made in some of the districts. Sekhukhune A data clean-up exercise was conducted in all four subdistricts in Sekhukhune in February 2020, particularly to address the high number of “Not-evaluated” cases which skewed the treatment outcomes for the district. A total of 17 out of 43 high burden facilities were selected across the four subdistricts. The treatment success rate increased from 77% to 79% and treatment failure decreased from 7% to 0.8% respectively. There was no change in the death rate and the loss to follow up increased significantly from 1% to 6%.
Table 22: Sekhukhune Data Clean up findings DATA VALIDATION INDICATOR BEFORE CLEAN-UP AFTER CLEAN-UP Number Percentage Number Percentage All DS-TB in treatment outcome cohort 2195 2260 All DS-TB Successfully completed treatment 1695 77% 1776 79% All DS-TB Treatment failure 145 7% 18 0.8% All DS-TB Died 240 11% 256 11% All DS-TB Loss to follow up 16 1% 151 6.7%
Recommendations • The district should ensure that all symptomatic patients are captured in the TB identification module in TIER.net • Facilities should develop systematic processes for filling patient’s information without duplicating patients’ files for every clinical visit. • HPRS files should be updated to ensure that they have TB and HIV information for all patients. • Completion of clinical stationary information on the folders needs to be checked regularly by the OPM and focal TB nurses before they are sent to the data capturers. • Facility OPMs to be capacitated on utilizing TIER.net as a patient level management tool.
USAID Tuberculosis South Africa Project - Project Quarterly Report: January 2020 to March 2020 31 • Emphasis was made to conduct line listing weekly to see the gaps.
Free State Data clean up A data cleaning session was conducted in Ngwathe and Metsimaholo sub-district offices in January with DOH staff and data analysts from Ngwathe, Metsimaholo and Moqhaka Local Areas. In addition to reviewing the accuracy of the district’s data, the session capacitated the data analysts with the improved understanding of TB data capturing and the analysis of the 90-90-90 cascade. In Mangaung district data validation was conducted in three facilities (Batho clinic, Bowsprit clinic and Kagisanong clinic) in Botshabelo sub-district. During the process, data captured into WebDHIS was compared with primary data sources in facilities. Whilst there were no observable differences in the before and after picture for indicators like treatment failure and patients who died before treatment , there were marginal increases in the treatment success rate from 78% to 85% as well as a decline in numbers of patients who were lost to follow up – from 13% before the data cleaning to 6% after. The scenario confirms the importance of this exercise to be conducted regularly at the facility level in order to promptly correct data errors and irregularities.
Table 23: Free State before and after results of data validation for 2018 outcomes
DATA VALIDATION BEFORE CLEAN-UP AFTER CLEAN-UP INDICATOR Number Percentage Number Percentage Treatment Success 2470 78% 2474 85% - Cured 392 12.3% 475 16.2% - Treatment completed 2078 65.3% 1999 68.3%
Treatment failure 24 0.8% 25 0.9%
Treatment not completed - Died during treatment 260 8% 259 9% - lost to follow up 427 13% 168 6% Transferred to another unit 0 0 Patients not evaluated 0 0 Total All TB Cases 3181 2926
The exercise showed that there are indeed differences between data submitted at provincial and data at the facility level. Patients’ files were not evaluated and were not showing an outcome on the TB episode. Additionally, TB protocols/algorithm were not followed by clinicians when managing TB diseases e.g. GeneXpert and AFB tests are conducted at the same time and sputum for microscopy is not collected at seven weeks and 23 weeks and in some instances GeneXpert test are conducted at the end of treatment.
Table 24: Fezile Dabi before and after results of data validation for 2018 outcomes BEFORE CLEAN-UP AFTER CLEAN-UP INDICATOR No. % No. % Headcount 179434 215071 Number screened for TB 175386 97.7% 177115 82.3% Presumptive TB clients 4497 2.6% 3771 2.1% Number tested 3481 77.4% 3578 94.8% Number tested positive 346 9.9% 351 9.8% Number started on treatment 349 108% 345 98.2%
USAID Tuberculosis South Africa Project - Project Quarterly Report: January 2020 to March 2020 32 Number died before treatment 1 0% 7 1.9% started Number initially lost to follow up 7 0.2% 2 0.5%
Table 25: Outcomes of data validations in the Free State Facility Gaps identified Actions taken Batho clinic • TB case identification not captured on • TB focal nurse encouraged to make TIER.Net, and some patients are use of the TB identification register recorded in a “black book” by the TB instead of the “black book” in order focal nurse for data capturers to avoid missing • Total recorded in the tick registers not capturing of all the facility data correlating with the case identification • Data capturers to make sure that all register the source documents in the facility • TIER.Net system is unable to generate are captured in the systems used at monthly and outcome reports the facility • A call was logged with IT by the facility data capture to assist with uninstalling the software and re-installation Bloemspruit • Line lists are still not being generated • The Data capture to make sure that Clinic even after numerous support and line lists are generated and actioned by mentoring was provided by the project the TB focal nurse, the LAM and data staff analyst was made aware of this • Outcomes not recorded in the continuous challenge/gap patient’s files, therefore, resulting in • TB focal nurse to work closely with the data capture not able to update the data capture in ensuring that all the outcomes on TIER.Net line lists are generated and actioned Kagisanong • A total of 62 patients had outstanding • Facility Manager and the sub district Clinic TB treatment outcomes Data Analyst to intensify generation of • DHIS data not verified and validated at TIER.Net line lists facility level • Data analysts, Facility manager and • Data capturers not verifying data Data capturers to ensure that outliers recorded in the identification register, are commented on therefore resulting in under-reporting • Data analysts mentored on-site how to in WebDHIS analyze the data captured and • Inconsistent capturing of TB case reported at sub-district level and identification; in Oct 2019, room 8 provide continuous mentoring to data register recorded 76 presumptive capturers cases but only 68 captured on Web • Data analysts encouraged to verify data DHIS from all the rooms in the facility and make sure all the data is captured on Web DHIS. The facility data capture and facility manager were made aware of the gaps identified, and encouraged to capture all patients in the TB Identification register
Gauteng Data clean up TB report data clean-up Chiawelo CHC and Zola CHC
USAID TB SA Project supported two data clean-up visits at Zola CHC on the 12th February 2020 and Chiawelo Clinic on the 17th February 2020. The activity was to clean up and update DS-TB case finding data for the period January to December 2019 to ensure that all DS-TB diagnosed patients reported by NHLS appear on Facility Case ID registers, Facility, Sub District and District Tier.Net. The data
USAID Tuberculosis South Africa Project - Project Quarterly Report: January 2020 to March 2020 33 review team consisted of sub district coordinators, district TB managers including both local authority and district management.
TB partners included the USAID TB SA Project, ANOVA and Isibani Development. The results on the two charts below shows the data before and after the data clean-up. At Chiawelo CHC a total of 56 (93%) patients were updated and reduced the number of missing TB cases in Sub District Figure 19: Data clean-up in Gauteng D, at Zola CHC a total of 66 (87%), seven patients to be traced at neighboring districts, provinces and countries as they could not be traced in the City of Johannesburg.
Chiawelo CHC DS-TB Data before and after clean-up Jan-Dec 2019
70 60 60 93% 56 60 73% 50 44 40 30 25% Before clean up 5% 2% 20 15 After clean up 10 3 1 1 0 Case Find total Tx start date Not Started on Tx
Figure 10: Chiawelo CHC Facility level data before and after clean-up comparing five sources (NICD alerts, Case ID register, District, Sub District & Facility Tier.Net)
Zola CHC DSTB Data Clean-up Jan-Dec 2019 Before and After clean-up 76 76 87% 80 66 62% 60 47 38% 40 29 9% 3% 1% 1% 3% 20 7 2 1 1 2 0 Case finding Rx start date Not started on Re-started on Duplicate Died Transferred Total Rx Rx
After clean-up Before clean-up
Figure 9: Zola CHC Facility level data before and after clean-up comparing five sources (NICD alerts, Case ID register, District, Sub District & Facility Tier.Net) Tshwane Health District A Web EDR data clean-up exercise was conducted for eight out of nine DR-TB decentralized sites in Tshwane Health District in collaboration with the district HAST Health Information Management to review Q1 to Q4 2019 DR-TB data. Additionally, another data cleaning exercise was conducted for Tshwane District Hospital to evaluate outcomes for Q3 2017 for the DR-TB long Regimen. Both exercises were conducted in collaboration with the Tshwane district health management and information officers. The objectives were to correct and follow-up on data errors and to update DR-TB case finding and treatment outcomes and
USAID Tuberculosis South Africa Project - Project Quarterly Report: January 2020 to March 2020 34 ensure they are captured on Web EDR for the eight Tshwane Health District DR-TB decentralized sites. The other focus was on actioning and updating of HIV and ART status of co-infected patients. The methodolgy involved taking action on all patients who appear as not evaluated and transfered out and confirm the true outcomes for those patients to improve on the DR-TB outcomes. The team also ensured that all co-infected patients have an HIV status indicated, HIV diagnosed date and ART start date.
TB-HIV Co-infected patients Tshwane District Hospital Q3 2017 Long Regimen
92% 14 13 13 12 12 62% 10 8 38% 8 Pre-Clean-Up 6 5 4 8% Post-Clean-Up 2 1 0 HIV Positive ART start date No ART start date
Figure 11: Data verification done between NICD alerts, facility TB register and facility level Web EDR for Q3 2017 DR-TB long regimen treatment started patients Some of the challenges observed which contributed to the discrepancies included incomplete information on clinical stationery (for example, DR-TB number and treatment start date not indicated). It was recommended that TB focal nurse s should ensure that all information on the clinical stationery is updated. Follow-up on missed appointment list should be done on all patients who missed their appointment before they are reported as LTFU, patient files have should have information on “next of kin” to facilitate tracing and follow-up. IR 3: Care and Treatment of Vulnerable Populations improved
Overall Summary During the reporting quarter, the project has retained its focus on reaching marginalized, vulnerable populations, in line with both local and international guidance. Communities considered to be most at-risk and hardest hit by the epidemic were Proportion of TB Patients Supported reached through door to door and 4% 3% Nelson Mandela Bay 5% awareness campaigns, contact Mangaung 5% tracing, treatment adherence 24% uMkhanyakude support, household infection 6% Fezile Dabi prevention and control as well as 6% OR Tambo establishing partnerships with other eThekwini 24% community based organizations 23% West Coast critical to the comprehensive Cape Winelands management of TB. In the Waterberg reporting quarter January to March Figure 12: Distribution of patients by district
USAID Tuberculosis South Africa Project - Project Quarterly Report: January 2020 to March 2020 35 2020, the USAID TB South Africa Project funded ten grantees in nine out of the 14 supported districts. A total of 2,690 active patients, comprised of 2,006 (75%) DS-TB and 684 (25%) DR- TB were offered DOT support by the grantees. The highest number of patients are supported in Nelson Mandela Bay district (646) followed by Mangaung with 639, uMkhanyakude (609), Fezile Dabi (173), OR Tambo (169), eThekwini (142), West Coast (128), Cape Winelands (101), and Waterberg (83). Through the awareness and door to door campaigns conducted, the grantees reached 7,432 people and screened 6,984 (94%) out of which 2,115 (30%) were TB presumptive. Of those presumptive, 2,115 (100%) were tested for TB and 64 (3%) were diagnosed with TB and 60 (93%) were linked to care. The 7% deficit is attributed to the late presentation of patients at the health facilities and misunderstanding of TB in the communities. In addition to the campaigns, the grantees conducted contact management on 253 index patients and reached 2,949 contacts and screened 2,928 (99%) with 43 new cases of TB diagnosed and 37 (79%) initiated on treatment which translates to a yield of 1,468 per 100,000 population. By the end of the first half of the project year, PY4, a total of 5,855 contacts were reached, which is 22% of the set target of 27,037, largely due to the limited coverage of the ten currently contracted NGOs. To ensure sustained implementation of these community-based activities, 38 members of Ward Based Outreach Teams (WBOTs) were trained on community based TB management including Local Area Managers, Health Promotion Practitioners, Social Workers, TB Roving Team Leads, TB Coordinator, Programme Partnerships representative and District Clinical Specialist Team members. In addition to the work conducted by local NGOs, facility level TB screening among key populations was conducted in five of the 14 supported districts. The key populations reached included pregnant women in uMkhanyakude, Farm workers in Sarah Baartman, Pregnant women and children in Fezile Dabi, as well as children ≤ 5 years in Waterberg and Sekhukhune. During the reporting period, collectively a total of 20,651 key population members were reached, 20,604 (99%) were screened for TB, 370 (2%) were presumptive, and 348 (94%) were tested for TB. Six (2%) people tested positive and they were all (100%) initiated on treatment. The rollout of the project developed key populations data collection tool and continued support at facility level in the remaining eight districts will be determined by the outcomes of the meeting with the WebDHIS developers at National Department of Health. In addition to the above, 74,445 children ≤5 years were reached from all the primary healthcare facilities in the districts, 64,974 (87%) were screened and 38 (0.1%) presumptive clients were identified. Eleven children ≤5 years were initiated on treatment. A total of 162,828 key populations have been reached at facility level with 38 cases identified. The project continued to strengthen comprehensive systems and partnerships for care through the TB in Farms intervention model. The model was implemented in five supported districts (Sarah Baartman in Eastern Cape province, uMkhanyakude in KwaZulu-Natal province, Waterberg and Sekhukhune in Limpopo province, and West Coast district in Western Cape) during the reporting period. A total of 38 farms were reached; 24 in Sarah Baartman district, two in uMkhanyakude, one in Sekhukhune, one in Waterberg andten0 in West Coast district. Collectively (Sarah Baartman, uMkhanyakude, Sekhukhune and Waterberg district), 2,337 farm workers were reached, all (100%) were screened for TB, 355 (15%) presumptive clients were identified, and all (100%) were tested, 41 (12%) patients tested
USAID Tuberculosis South Africa Project - Project Quarterly Report: January 2020 to March 2020 36 positive for TB (2xDR-TB) and 40 (98%) were initiated on treatment, including the two DR- Since October 2019 to March 2020, a total of 5,329 farm workers have been reached with a total of 86 cases identified. Thus far the annual target for FY4 of having five districts implementing the TB in Farms model, reaching the 90-90-90 target for screening, testing and treatment initiation has been achieved.
IR 3.1: Increased contact tracing of key populations
3.1.1 Appoint 35 local NGOs to increase screening and finding missing patients among prioritized key populations
Ten NGOs conducted 68 door-to-door and awareness campaigns during the reporting quarter. In terms of their performance against 90-90-90 targets on case finding, the grantees reached the 90% target on screening and testing. 64 new TB cases were found, and 60 (93%) of them put on treatment. The yield for January to March 2020 is 916 per 100 000 population.
Table 26: NGOs campaigns data Oct-Dec Jan-Mar Campaigns % % Total % 19 20 Number of people 10 491 7 432 reached 17 923 Number of people 10 093 96% 6 984 94% 17 077 95% screened Number of people with presumptive 2 129 21% 2 115 30% 4 244 25% signs Number of people 2 105 98% 2 115 100% 4 220 99% tested Number of people confirmed positive 92 4% 64 3% 160 4% TB Number of people 80 87% 60 93% 137 86% put on treatment
Tokoloho Foundation: Tokoloho Foundation participated in an awareness campaign in Sasolburg on the 29 February 2020, as per the invitation by the Provincial Department of Health. The purpose of the campaign was Teenage Pregnancy Awareness and to launch Maxima Female Condom. The SA Minister of Health Hon Dr Zweli Mkhize, attended the event. Figure 20: Tokoloho CHWs at a campaign
3.1.2 Implement contact management for all 12,000 TB index patients (4,900 DR-TB & 7,100 DS-TB) supported by NGOs to contribute towards finding missing TB patients, and 27,037 household contacts (<5 years of age 9860)
USAID Tuberculosis South Africa Project - Project Quarterly Report: January 2020 to March 2020 37 Through contact management the grantees reached 2,949 adult contacts and diagnosed 43 new cases. This is a slight increase by 2% (1) from 42 new cases found during the first quarter (October to December 2019) of PY4.
Table 27: Adult contact management data Adult contact management Oct-Dec 19 Jan-Mar 20 Total % Number of index patients 1 161 253 1 414 Number of contacts reached 2 328 2 949 5 277 Number of contacts screened 2 287 98% 2 928 99% 5 215 99% Number of contacts with presumptive 692 30% 911 31% 1 603 30% signs Number of contacts tested 666 96% 835 92% 1 501 93% Number of contacts confirmed positive 42 6% 43 5% 85 6% TB Number of contacts put on treatment 33 79% 34 79% 67 79%
The comparison of two quarters, October to December 2019, and January to March 2020, in Figure 13 shows that the grantees reached and screened more contacts in the later quarter than the last quarter of 2019. However, the case finding remained almost the same at 42 and 43 news cases for the two quarters respectively. The yield is 1,468 per 100,000 population.
Contact Management
34 Number of contacts put on treatment 33 43 Number of contacts confirmed positive TB 42 835 Number of contacts tested 666 911 Number of contacts with presumptive signs 692 2 928 Number of contacts screened 2 287 2 949 Number of contacts reached 2 328 253 Number of index patients 1 161 0 500 1 000 1 500 2 000 2 500 3 000 3 500
(Jan-Mar 20) (Oct-Dec 19)
Figure 13: Contact Management in two quarters (Oct-Dec 19) and (Jan-Mar 20)
3.1.3 Build capacity of WBOTs and other CBOs attached to the 475 high burden facilities and other DOH supported community institutions CBOs on TB care and management in the 14 districts
The project held an introductory meeting for risk stratification model in Fezile Dabi district and conducted a workshop that was attended by acting District Director, Local Area Managers, Outreach Team Leads, Community Health Care Workers and Tokoloho Foundation. The USAID TBSAP project team is working together with the district to identify the pilot sub-district for implementation of risk stratification at the WBPHCOT level.
The next steps to this introductory workshop are as follows: • Identification of the pilot sub-district
USAID Tuberculosis South Africa Project - Project Quarterly Report: January 2020 to March 2020 38 • Conduct a workshop on WBPHCOT model of support in May 2020. The Risk stratification approach continues to be implemented by all ten grantees and the reporting has improved. Figure 21 below shows the impact of risk stratification approach in provision of Direct Observed Therapy by the grantees. There was an increase in the volume of DR-TB patients supported after the implementation.
Increase in DR-TB Patients Support (Oct 18 - Mar 19 vs Oct 19 - Mar 20)
673 713 684 800 565 642 643 600 471 324 381 392 361 365 400 200
0
March March
January January
October October
February February
December December
November November 2018 2019 2019 2020
Figure 21: Impact of Risk Stratification in DR-TB support The Figure above illustrates the impact of prioritizing patients in community interventions. A comparison of two periods, October 2018 to March 2019 and October 2019 to March 2020 shows an increase in the number of DR-TB patients supported by the grantees as a result of allocating more resources and time to only high-risk DS-TB patients. This approach allows grantees to further conduct contact tracing of additional index patients under the care of their supported facilities. Between January and March 2020, 476 index patients were given to the grantees, with 1,358 contacts reached and screened 1,324 (97%) for TB. Of those screened, 308 (23%) were presumptive and of those presumptive 308 (100%) were tested for TB with 14 (5%) new cases of TB diagnosed and 11 (79%) were put on treatment.
Scaling Up of Contact Management Jan - Mar 20
Number of adult contacts started on treatment 79%; 11 Number of adult contacts diagnosed with TB 5%; 14 Number of adult contacts tested 100%; 308 Number of adult contacts TB presumptive 23%; 308 Number of adult contacts screened 97%; 1324 Number of adult contacts reached 1358 Number of index patients 476 0 200 400 600 800 1000 1200 1400 1600
Figure 22: Scaling up of contact management In addition to the community-based activities, the Grants Technical Team provides regular financial and technical capacity building to ensure that contracted grantees have the requisite capacity to achieve contract deliverable and milestones. During the quarter, quarterly visits, close out visits and financial risk compliance onsite assessments were done to ensure that contracted NGOs adhere to relevant grant implementation rules and regulations.
USAID Tuberculosis South Africa Project - Project Quarterly Report: January 2020 to March 2020 39 Table 28: Summary of Grants Technical Team financial and technical capacity building Date Type of activity Outcome 19 February Quarterly on-site Review of screening and DOT data. Discussion on achievements, 2020 assessment: Tokoloho challenges and solutions for reaching contract deliverables Foundation 21 February Cederberg Matzikama Six-month progress presentation to Department of Health 2020 AIDS Network District Management. (CMAN) 11/12 March Care Ministry DR Review of data on testing of asymptomatic contacts and DR-TB 2020 project close-out Treatment Outcomes (TOs); a project close out was also conducted and included a financial risk and compliance assessment. Review of all contract deliverables was also done. 17 March Mpilonhle: support visit Guidance on implementation of the risk stratification model as 2020 well as the performance-based payment process related to it.
Figure 23: Tokoloho Foundation onsite quarterly assessment: District Figure 24: Care Ministry DR project close-out at Care TB Manager and partnerships Manager, Tokoloho Project Manager, Ministry offices Grants Team and FS Project Provincial Manager
IR 3.2: Improved TB case management among key populations
3.2.1 Promote TB screening among children under 5 years
On child contact management, the grantees reached 147 children and diagnosed one who was initiated on treatment. The grantees screened 100% of the reached but failed to reach the 90% testing rate. 57 children were initiated on IPT.
Table 29: Child contact management Oct- Jan-Mar Child contact management % % Total % Dec 19 20 Number of contacts reached 172 147 319 Number of contacts screened 172 100% 147 100% 319 100% Number of contacts with presumptive signs 50 29% 97 66% 147 46% Number of contacts tested 37 74% 83 86% 120 82% Number of contacts confirmed positive TB 2 5% 1 1% 3 2% Number of contacts put on treatment 1 50% 1 100% 2 67%
3.3.2 Facilitate TB screening of key populations in project supported facilities; pregnant women, people living with diabetes, children under 5 years-old, people living with HIV and farm workers:
a) Facility level key populations screening
USAID Tuberculosis South Africa Project - Project Quarterly Report: January 2020 to March 2020 40 The project aims to strengthen TB management, including recording and reporting among key populations (pregnant women, children under 5 years, people living with HIV (PLHIV) and people living with diabetes (PLDM)) at facility level across all 14 districts. While the aim is to report on key populations across all supported districts, implementation has been introduced in fewer districts and will be rolled out. The roll out plan will be determined by the outcomes of the meeting with the WebDHIS developers at National Department of Health. During the reporting period, TB screening among key populations was conducted in five districts, uMkhanyakude (pregnant women), Sarah Baartman (all key populations), Fezile Dabi (Pregnant women and children ≤5 years) and Waterberg and Sekhukhune (children ≤5years). Collectively (excluding Sekhukhune and Waterberg district’s children ≤5 years data), 20,651 key populations were reached, 20,604 (99%) were screened for TB, 370 (2%) were presumptive, and 348 (94%) were tested for TB. Six (2%) people tested positive and they were all (100%) initiated on treatment. The newly diagnosed TB patients were people living with HIV (PLHIV) from Sarah Baartman district. Additionally, 74,445 children ≤5 years were reached from all the primary healthcare facilities in the districts, 64,974 (87%) were screened and 38 (0.1%) presumptive clients were identified. Eleven children ≤5 years were initiated on treatment. It is not feasible to calculate the treatment initiation rate as the denominator (children ≤5years tested positive for TB) is unavailable.
Table 30: Consolidated facility level key populations TB case finding data for Q2/FY4: January – March 2020 Pregnant Children Indicators PLHIV PLDM Total women ≤5 years % Number of people reached 17 064 2 429 876 282 20 651 Number of people screened 17 042 2 466 843 253 20 604 99% Number of people presumptive 316 15 39 0 370 2% Number of people tested 294 15 39 0 348 94% Number of people tested 0 0 6 0 6 2% positive Number of people diagnosed 0 0 6 0 6 100% with DS-TB Number of people initiated on 0 0 6 0 6 100% DS-TB treatment Number of people diagnosed 0 0 0 0 0 0% with DR-TB Number of people initiated on 0 0 0 0 0 0% DR-TB treatment
b) Community level key populations: Migrant/seasonal laborers; Farmworkers The project continued to improve TB case management among farm workers through the TB in Farms intervention model. The purpose remains to improve the care and treatment of farm workers and contribute towards finding the missing TB patients among this population. The package of services includes TB screening, testing and treatment initiation. The model was implemented in five districts (Sarah Baartman in Eastern Cape province, uMkhanyakude in KwaZulu-Natal province, Waterberg and Sekhukhune in Limpopo province, and West Coast district in Western Cape) during the reporting period. Implementation of activities varied in the districts; while health services were provided by enrolled nurses in Sarah Baartman district, services in West Coast, uMkhanyakude and Waterberg districts were provided by
USAID Tuberculosis South Africa Project - Project Quarterly Report: January 2020 to March 2020 41 project funded NGOs, Cederberg Matzikama Aids Network (CMAN), Mpilonhle and Kgatelopele respectively. A total of 38 farms were reached; 24 in Sarah Baartman district, two in uMkhanyakude, one in Sekhukhune, one in Waterberg and ten in West Coast district. Note, reported data excludes West Coast district as the data is reported under project funded NGOs campaigns data under IR 3.1.1. Collectively (Sarah Baartman, uMkhanyakude, Sekhukhune and Waterberg district), 2,337 farm workers were reached, all (100%) were screened for TB, 355 (15%) presumptive clients were identified, all (100%) were tested, 41 (12%) patients tested positive for TB (2xDR-TB) and 40 (98%) were initiated on treatment, including the two DR-TB patients.
Table 31: Consolidated TB in Farms data for Q2/FY4 Indicator Jan 2020 Feb 2020 Mar 2020 Total % Number of farm workers reached 616 829 892 2, 337
Number of farm workers screened 616 829 892 2, 337 100%
Number of farm workers presumptive 102 124 129 355 15%
Number of farm workers tested for TB 102 124 129 355 100% Number of farm workers tested positive 18 13 10 41 12% for TB Number of farm workers diagnosed 18 12 9 39 95% with DS-TB Number of farm workers initiated on 18 12 8 38 97% DS-TB treatment Number of farm workers diagnosed 0 1 1 2 5% with DR-TB Number of farm workers initiated on 0 1 1 2 100% DR-TB treatment
TB CASE FINDING IN THE FARMS FY4:Q1ANDQ2
2 9922 9922
2 3372 3372
506 506
355 355
45
43
41 40
# OF PEOPLE # OF PEOPLE # OF PEOPLE # OF PEOPLE # OF PEOPLE # OF PEOPLE R E A C H E D S C R E E N E D T B TESTED FOR T E S T E D INITIATED ON PRESUMPTIVE T B POSITIVE FOR TREATMENT T B
Oct-Dec 2019 (Q1/FY4) Jan-Mar 2020 (Q2/FY4) Apr-Jun 2020 (Q3/FY4) Jul-Sep 2020 (Q4/FY4)
Figure 14: TB in farms data for FY4: Q1 and Q2
USAID Tuberculosis South Africa Project - Project Quarterly Report: January 2020 to March 2020 42 Figure 25: TB awareness campaign at Morewag farm Figure 26: TB screening campaign at Allendal farm
IR 3.3: Strengthened comprehensive systems and partnerships for care
3.3.1 Engage private practitioners in community settings to improve TB case finding and linkage to care:
No activities were conducted during the reporting period. Next2People foundation’s contract ended on the 2nd December 2019 and they are awaiting approval from USAID.
3.3.2 Map and collaborate with PEPFAR and other District Support Partners (DSPs) to improve TB case finding, linkage to care and treatment outcomes:
Table 32: Summary table of DSPs in project supported district. As of March 2020, there are a total of ten DSPs across seven of14 supported districts, as the other seven districts don’t have DSPs apart from the project (uMkhanyakude, Mangaung, Fezile Dabi, Sarah Baartman, West Coast, Sekhukhune and Waterberg). The project engaged six district support partners across four districts; Aquity Innovations and TB/HIV Care in OR Tambo district, Wits Reproductive Health and HIV Institute (Wits RHI) in Tshwane district, Aurum Institute in eThekwini district, and Institute for Healthcare Improvement and NoRSA Community Care in Cape Winelands district. Engagements ranged from technical assistance on TB/HIV integrated services and capacity building on basic TB management, TB Infection Prevention and Control (IPC), FAST, LF-LAM and data management.
USAID Tuberculosis South Africa Project - Project Quarterly Report: January 2020 to March 2020 43 a) Aquity Innovations: OR Tambo district, Eastern Cape province
The project provided technical assistance and conducted capacity building through the low dose, high frequency methodology to Aquity Innovations staff during facility support visits. Four data capturers from Stanford Terrace clinic were supported and capacitated on TB data capturing where the importance of capturing all sputa results in TIER.Net was emphasized as it impacts on the patient outcomes. Checking the HIV status of all TB patients in their files and capturing it correctly on the system was also highlighted as it was noted that the HIV status of most TB patients was recorded as ‘unknown’ on the system opposed to positive or negative. During a support visit to St Elizabeth Hospital (FAST implementing site), five data capturers were capacitated on EDRweb and linkage to care, and five nurses were mentored on FAST, recording in the TB identification register, LF-LAM and DR-TB patient management. Aquity Innovation staff will continue to be mentored and supported by the project during facility visits. The project participated in a meeting held by the OR Tambo district HAST Manager and Aquity Innovations to discuss areas of collaboration between the project and Aquity Innovations as the new district support partner funded by Global Fund. While both partners are mandated to support the district on the TB program, a support plan has been proposed to the NDOH (awaiting approval). b) Wits Reproductive Health and HIV Institute (Wits RHI): Tshwane district, Gauteng Province The project conducted two training sessions in collaboration with Wits RHI in Tshwane district which were coordinated by the Regional Training Centre (RTC) at Kalafong Tertiary Hospital (FAST implementing site). The first training was on basic TB management facilitated on the 24th to 26th February 2020 and the second training was on TB Infection, Prevention and Control (IPC) facilitated from the 27th to 28th February 2020. The project provided all training materials and stationery for the trainings and facilitated all TB related modules while Wits RHI facilitated the TB/HIV integrated modules and information system. Both trainings were attended by 49 healthcare workers from 36 facilities in the district (25 clinics - Soshanguve block x clinic, K T Motubatse clinic, Phedisong 6 clinic, Soshanguve Block JJ clinic, Kekana gardens clinic, Phomolong clinic, Kekana stad clinic, Holani clinic, Soshanguve Block TT clinic, Soshanguve clinic 2, Zithobeni clinic, New Eerterus clinic, Dr FF Rebeirro clinic, Attridgeville clinic, Skinner street clinic, Refilwe clinic, Olievenhoutbosch clinic, Nellmapius clinic, Suurman clinic, Jackhindon clinic, Karen park clinic, Rayton clinic, Lotus gardens clinic, Zamile clinic, Pretorius Park clinic; three (3) CHC’s - Temba CHC, Phedisong 4 CHC, Laudium CHC; four (4) hospitals - Odi Hospital, Mamelodi Hospital, Kalafong Hospital, Pretoria West Hospital; and four (4) other centres - Zonderwater correctional centre, Baviaanspoort correctional centre, Cullinan Rehab, and Desmond Tutu Youth Care Centre).
USAID Tuberculosis South Africa Project - Project Quarterly Report: January 2020 to March 2020 44 c) Aurum Institute: eThekwini district, KwaZulu Natal Province The project collaborated with the Aurum Institute on training ten new DR-TB decentralized sites (Wentworth hospital, Inanda CHC, KwaMashu CHC, Clairwood Hospital, KwaDabeka CHC, Hlengisizwe CHC, Tongaat CHC, Phoenix CHC, Osindisweni Hospital and Prince Mshiyeni Hospital) on MDR-TB and EDRweb in January in eThekwini district. The project facilitated feedback on the MDR-TB clinical audits that were conducted in the last quarter in four of ten of the new decentralized sites namely Wentworth Hospital, Inanda CHC, KwaMashu CHC and Clairwood Hospital. The major gap that was identified during the clinical audits was the lack of training of data capturers on EDRweb. Aurum facilitated a practical session on capturing of data on the system (EDRweb). The clinical audits were only conducted in four out the ten sites because the audit tool was being revised by National Department of Health (NDOH), and the district advised that all audits be put on hold until the revised tool is available. The remaining six sites will be audited once the revised tool has been finalized and circulated by NDOH. d) Institute for Healthcare Improvement (IHI) and NorSA Community Care, Cape Winelands district, Western Cape Province The project engaged with IHI and NoRSA in Cape Winelands district during the reporting period. NoRSA Community Care was capacitated on TB Qi during a training the project facilitated at Wolseley clinic from the 9th to 10th January 2020, and IHI was engaged during a district HAST meeting which was held on the 10th February 2020 where TB/HIV poor performing facilities were identified. e) TB/HIV Care: OR Tambo district, Eastern Cape Province The project conducted a DR-TB management training in the last quarter for 32 TB/HIV Care nurses. The training aimed to result in strengthened TB/HIV collaborative efforts. It was agreed prior to the training that the impact of the training will be monitored in the 14 high burdened facilities supported by both the project and TB/HIV Care. The following indicators were monitored for improved TB/HIV integration;
• Number of HIV positive people screened for TB • Number of HIV positive clients initiated on TPT
The baseline for the indicators was October – December 2019 and progress is monitored quarterly against the above-mentioned indicators.
USAID Tuberculosis South Africa Project - Project Quarterly Report: January 2020 to March 2020 45 Table 33: TB/HIV Integrated services progress update Sub - Facility Oct-Dec 2019 Jan-March 2020 District HIV screened HIV+ eligible HIV+ new HIV screened HIV + eligible HIV+ new for TB rate for TPT started on for TB rate for TPT started on TPT TPT Ingquza Flagstaff clinic 49.7% 71 71 60.6% 119 119 Hill Holy Cross 83.9% 91 71 86.1% 119 99 gateway St Elizabeth 89.9% 123 98 87.7% 100 88 gateway Lusikisiki 57.1% 46 46 32.7% 80 86 Village clinic KSD Civic Centre 101.5% 138 138 100% 129 129 clinic Mthatha 100% 227 198 99.5% 158 139 gateway Mqanduli 98.6% 69 69 97.3% 96 97 CHC Ngangelizwe 98.6% 212 212 186.7% 258 258 CHC
Stanford 94% 157 157 100% 135 134 clinic Mhlontlo Mhlakulo 95.5% 44 44 102% 27 25 Qumbu CHC 88.8% 63 62 88.7% 80 77 Tsolo clinic 88.2% 89 89 91.9% 86 85 Nyandeni Ntaphane 79.2% 109 92 102.6% 119 88 Port St Port St Johns 89.4% 89 87 84.4% 108 108 Johns CHC
The performance per sub-district remains fairly the same when comparing the baseline data and the current reporting period (January – March 2020). There are facilities that maintain a 100% TPT initiation rate among eligible patients; Flagstaff clinic, Civic Centre clinic, and Ngangelizwe CHC, while some initiate slightly less. The project will continue to provide support to the facilities initiating less patients than those that are eligible for TPT to reach and maintain a 100% TPT initiation rate.
3.3.3 Implement activities targeting men and adolescent and young people by engaging key stakeholders (Department of Transport and Department of Basic Education) to expand and strengthen collaborated TB and TB/HIV integrated responses in the respective sectors:
Project funded NGO, Mpilonhle conducted TB screening campaigns at two schools during the reporting period namely; at Ezifundeni High School in February 2020 and at Mgwazeni Secondary school in March 2020 in uMkhanyakude district, KwaZulu-Natal province. At Ezifundeni High School, three of the learners from the school were contacts that tested positive for TB of index patients that are Figure 27: TB screening at supported by the NGO. Ezifundeni High School
USAID Tuberculosis South Africa Project - Project Quarterly Report: January 2020 to March 2020 46 Collectively, 375 learners were reached, 268 (71%) were screened for TB and 158 (59%) presumptive clients were identified, all (100%) were tested and all tested negative. For Ezifundeni High School, a total of 150 learners in the school were screened, sputum was collected from 128 learners and all tested negative. At Mgwazeni Secondary School, a total of 225 learners were reached but only 118 were screened due to the examination schedule. Sputum was collected from 30 learners and all tested negative. Comprehensive data for these activities is reported under the funded NGOs campaign data in Figure 28: TB screening at Mgwazeni High School IR3.1.1.
USAID Tuberculosis South Africa Project - Project Quarterly Report: January 2020 to March 2020 47
Annexures
Annex I: 90 90 90 Cascade Performance
90% of head count screened for TB.; 90% of those with symptoms tested for TB.; 90% of clients diagnosed with TB put on treatment. 90% of those put-on treatment successfully complete treatment.
Table 35: USAID TB SA Project supported districts cascade data 2016 to 2020 USAID TB SA Project supported districts cascade data 2016 2017 2018 2019 2020
Oct-Dec Jan-Mar Apr-Jun Jul-Sep Oct-Dec Jan-Mar Apr-Jun Jul-Sep Oct-Dec Jan-Mar Apr-Jun Jul-Sept Oct-Dec Jan-Mar 2016 2017 2017 2017 2017 2018 2018 2018 2018 2019 2019 2019 2019 2020 No. % No. % No. % No. % No. % No. % No. % No. % No. % No. % No. % No. % No. % No. % Headcoun 10716 11230 75746 75927 74052 84109 87505 92742 96425 94331 96431 97671 86973 18088 t 802 248 45 31 77 08 68 95 01 89 53 06 29 157 No. 73618 78188 58182 55696 59882 68574 72718 76971 76370 77131 74863 78742 73941 16033 68,7% 69,6% 76,8% 73,4% 80,9% 81,5% 83,1% 83,0% 79,2% 81,8% 77,6% 80,6% 85,0% 88,6% screened 09 30 04 97 44 58 39 08 22 01 11 96 94 880 for TB Presumpti 22889 26761 26659 17731 15128 16472 18662 22237 16931 16634 18798 21741 14372 29268 3,2% 3,4% 4,6% 3,2% 2,5% 2,4% 2,6% 2,9% 2,2% 2,2% 2,5% 2,8% 1,9% 1,8% ve TB 3 7 6 7 1 5 1 3 6 6 7 4 7 5 clients 19260 21752 15901 14232 13299 13998 16550 19386 15547 15389 17008 18189 13634 26773 84,1% 81,3% 59,6% 80,3% 87,9% 85,0% 88,7% 87,2% 91,8% 92,5% 90,5% 83,7% 94,9% 91,5% No. tested 1 3 9 5 8 9 1 9 0 1 9 0 1 8 No. tested 14836 7,7% 12896 5,9% 11277 7,1% 12704 8,9% 13158 9,9% 14880 10,6% 15062 9,1% 18733 9,7% 17176 11,0% 17591 11,4% 16701 9,8% 18571 10,2% 15453 11,3% 28362 10,6% positive No. started on 14101 95,0% 12114 93,9% 11174 99,1% 11957 94,1% 12753 96,9% 14143 95,0% 14895 98,9% 17640 94,2% 16918 98,5% 17001 96,6% 16260 97,4% 17912 96,5% 14826 95,9% 27262 96,1% treatment No. initially 488 3,3% 626 4,9% 175 1,6% 318 2,5% 306 2,3% 707 4,8% 918 6,1% 1249 6,7% 952 5,5% 751 4,3% 533 3,2% 558 3,0% 508 3,3% 1551 5,5% lost to follow up No. died before 106 0,7% 156 1,2% 33 0,3% 145 1,1% 44 0,3% 43 0,3% 28 0,2% 28 0,1% 24 0,1% 13 0,1% 19 0,1% 39 0,2% 7 0,0% 14 0,0% treatment started
USAID Tuberculosis South Africa Project - Project Quarterly Report: January 2020 to March 2020 49
100% 89% 100% 85% 100% 80% 80% 80% 60% 60% 60%
40% 40% 40%
20% 20% 20%
0% 0% 0%
Jul-Sep17 Jul-Sep18 Jul-Sep17 Jul-Sep18 Jul-Sep17 Jul-Sep18
Jul-Sept19 Jul-Sept19 Jul-Sept19
Jan-Mar 19 Jan-Mar 19 Jan-Mar 20 Jan-Mar 19 Jan-Mar
Apr-Jun 19 Apr-Jun 19 Apr-Jun
Jan -Mar 17-Mar Jan 18-Mar Jan 20-Mar Jan 17-Mar Jan 18-Mar Jan 17-Mar Jan 18-Mar Jan 20-Mar Jan
Apr -Jun 17 Apr -Jun 18 Apr -Jun 17 Apr -Jun 18 Apr -Jun 17 Apr -Jun 18 Apr
Apr-May 19 Apr-May
Oct-Dec Oct-Dec 18 Oct-Dec 19 Oct-Dec 18 Oct-Dec 19 Oct-Dec 18 Oct-Dec 19
Oct -Dec 16-Dec Oct 17-Dec Oct 16-Dec Oct 17-Dec Oct 16-Dec Oct 17-Dec Oct
Screening Screening target line Tested Testing target line Tx Initiation Tx initiation target line
Figure 15: Screening rates for TBSAP districts Oct 16-Jan 20 Figure 16: Testing rates for TBSAP districts Oct 16-Jan 20 Figure 17: Tx initiation rates for TBSAP districts Oct 16-Jan 20
1st 90: Screening: The project supported districts have witnessed a 20% increase in screening rates from the October to December 2016 baseline of 68.7% to the 89% in January to March 2020. The project is meeting the projected target line except in three districts namely eThekwini, West Coast and City of Cape Town. 2nd 90: Testing: The proportion tested increased from 84% in Oct-Dec 2016 to 92% in Oct-Dec 2018; it has remained above 90% up to January to March 2020 at 91.5%. 3rd 90: Treatment: The proportion initiated on treatment has remained above the 90% target from the baseline of 95%. The current performance (January to March 2020) is at 96.1%. The district by district 90-90-90 performance is included as Annex 1.
USAID Tuberculosis South Africa Project - Project Quarterly Report: January 2020 to March 2020 50 WebDHIS/EDR reports by supported district a. Background This section reports data from WebDHIS in project supported districts, comparing the periods July to September 2019 and Oct-Dec 2019 for all notified TB cases and HIV -co-infected TB cases. Treatment Outcomes for July to September 2018 and October to December 2018. This data is liable to change as provinces and districts are in preparation to conduct data clean ups. The TB cases notified in this quarter are from the 14 project supported districts. Treatment outcome reports are from all the 14 project supported districts b. Case finding by districts 30000 Case Notification There were 22,294 TB cases reported in Q4 25000 (Oct-Dec 2019) an increase 590 (2.7%) from the 21,704 patients reported in the Q3 (Jul-Sep 20000 2019). The cohort performance reported is 15000 liable to change as more data is being reported from TIER.Net into the National Department 10000 of Health mainstream database (WebDHIS). 5000
0 Tshwa Johann Figure 29:DS-TB Case Notification from project supported districts Sarah Umkha Cape City of OR Ethek West Manga Fezile Water Sekhuk ne esburg Baartm NMBM nyakud Winela Cape Project Tambo wini Coast ung Dabi berg hune Health Health an e nds Town Metro Metro Jul-Sep 18 1273 1716 2733 5102 550 808 1854 1227 811 736 625 1897 2560 21892 Oct-Dec 18 1181 1333 2346 4650 545 786 1818 491 305 371 667 480 1621 2958 19552 Jan- Mar 19 1297 1840 2614 5525 727 994 1932 1791 863 480 672 509 1916 2762 23922 Apr-Jun 19 1142 1699 2436 4674 602 960 1886 1778 781 545 566 429 1737 2469 21704 Oct -Dec 19 1183 1728 2289 5043 168 1001 2048 3590 882 520 490 328 1783 1241 22294
USAID Tuberculosis South Africa Project - Project Quarterly Report: January 2020 to March 2020 51 c. DS-TB Treatment success rate by district by Quarter: Jul 2017 to Dec 2018 Of the 22,240 TB cases reported in Q4 (Oct-Dec 2018), 16,764 (75%) patients were successfully treated in the fourteen supported districts. This is a three percentage drop from the previous quarter (Jul-Sep 2018) and 15% short of the 90% target by 2021. The district with a significant drop in performance in this quarter is Mangaung with a success rate of 51.2% from 66,4% in the previous quarter, Fezile Dabi with 57.9% from 78.4% and Tshwane Metro with 50.6% from 75.7% in the previous quarter.
DS-TB Treatment success rate for all TB cases: Jul-17 to Dec 2018 by quarter 120% 110% 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% City of Cape CT - City of Sarah OR Umkhany West Fezile Waterber Sekhukhu Tshwane NMBM Ethekwini Wineland Southern Mangaung Johannesb Project Baartman Tambo akude Coast Dabi g ne Metro s Sub- urg district TSR Jul - Sep 17 62,9% 88,7% 79,0% 66,0% 85,1% 81,7% 79,0% 73,5% 65,0% 74,1% 77,3% 74,8% 72,2% 70,7% 73% TSR Oct-Dec 17 70,4% 71,4% 77,8% 65,8% 80,9% 82,7% 78,2% 76,5% 78,6% 67,0% 82,0% 80,0% 72,1% 64,1% 72% TSR Jan-Mar 18 74,3% 79,4% 83,0% 78,6% 86,1% 85,5% 80,2% 80,2% 80,1% 82,4% 78,7% 76,3% 78,5% 84,1% 80% TSR Apr-Jun 18 74,2% 72,1% 79,9% 81,0% 83,9% 84,8% 78,2% 78,8% 74,1% 76,0% 82,3% 80,3% 75,9% 83,9% 79% TSR Jul-Sept 18 73,3% 70,3% 80,8% 79,4% 82,3% 84,8% 80,5% 76,4% 66,4% 78,4% 83,5% 76,6% 75,7% 81,6% 78% TSR Oct - Dec 18 73,3% 73,1% 79,5% 77,2% 86,8% 81,3% 79,6% 76,1% 51,2% 57,9% 77,4% 75,3% 50,6% 78,6% 75%
TSR Jul - Sep 17 TSR Oct-Dec 17 TSR Jan-Mar 18 TSR Apr-Jun 18 TSR Jul-Sept 18 TSR Oct - Dec 18
Figure 18: Treatment success rate for all TB cases in project supported districts
USAID Tuberculosis South Africa Project - Project Quarterly Report: January 2020 to March 2020 52 d. DS-TB Lost to follow up (LTFU) Of the 22,240 TB cases reported, in Q4 (Oct-Dec 2018) 2,501 (11.2%) patients were lost to follow up. A 0.4% drop from the previous quarter. (Jul-Sep 2018). The districts with high LTFU are Sarah Baartman with eighteen percent (18%), Cape Winelands, City of Cape Town SWSS and Tshwane Metro all with 13% in the reporting quarter.
DS-TB Loss to follow up for all TB cases: Jul 2017 to Dec 2018 by quarter.
20,0%
10,0%
0,0% City of Cape Cape City of Sarah OR Umkhany West Town - Fezile Waterber Sekhukhu Tshwane NMBM Ethekwini Wineland Mangaung Johannesb Project Baartman Tambo akude Coast Southern Dabi g ne Metro s urg Sub- district LTFU Jul-Sep 17 18,9% 2,4% 9,8% 8,1% 2,7% 3,5% 13% 13,3% 6,9% 4,3% 2,4% 7,8% 14,3% 9,1% 8,9% LTFU Oct-Dec 17 20,0% 3,7% 11,2% 8,6% 4,1% 9,6% 12% 15,2% 9,7% 6,2% 7,4% 7,5% 12,8% 11,1% 10,0% LTFU Jan-Mar 18 16,1% 10,6% 8,9% 14,5% 3,3% 8,4% 13% 12,0% 12,3% 4,2% 5,7% 4,9% 12,8% 8,6% 11,1% LTFU Apr-Jun 18 18,3% 12,2% 10,9% 12,5% 4,4% 9,0% 18,7% 13,2% 11,6% 5,7% 5,8% 6,8% 14,4% 8,8% 11,9% LTFU Jul-Sept 18 18,1% 12,0% 10,9% 13,5% 3,6% 8,1% 11,9% 12,2% 13,8% 8,6% 6,0% 6,8% 12,8% 9,8% 11,6% LTFU Oct- Dec 18 18,2% 10,7% 11,0% 12,4% 3,3% 11,8% 13,3% 13,1% 9,8% 7,3% 9,7% 7,9% 13,1% 9,3% 11,2% LTFU Jul-Sep 17 LTFU Oct-Dec 17 LTFU Jan-Mar 18 LTFU Apr-Jun 18 LTFU Jul-Sept 18 LTFU Oct- Dec 18 Figure 19: LTFU in project supported districts: Jul 2017 to Dec 2018 by quarter.
USAID Tuberculosis South Africa Project - Project Quarterly Report: January 2020 to March 2020 53 e. DS-TB Mortality Rate
Of the 22,240 DS TB cases reported in Q4 (Oct-Dec 2018),1,296 (6%) died in the 14 supported project districts. This is the same as in the previous quarter (Jul-Sep 2018). eThekwini (4.6%), West Coast (2.7%), Cape Winelands (4.1%) and City of Cape Town - Southern Sub-district (3.9%) have mortality rates below the 5% target. The districts contributing the highest mortality above 10% are Waterberg (11.9%), Sekhukhune 11.3% and Tshwane 11.3%.
Mortality rate for all DS TB cases
20,0% 18,0% 16,0% 14,0% 12,0% 10,0% 8,0% 6,0% 4,0% 2,0% 0,0% City of Cape Cape City of Sarah OR Ethekwin Umkhany West Town - Mangaun Fezile Waterbe Sekhukh Tshwane NMBM Winelan Johannes Project Baartman Tambo i akude Coast Southern g Dabi rg une Metro ds burg Sub- district Mortality rate Jul- Sep 17 5,8% 3,1% 6,7% 3,4% 8,0% 3% 4% 4% 7,9% 15,4% 10,3% 13,7% 7,7% 5,0% 6% Mortality rate Oct-Dec 17 5,1% 2,9% 6,4% 3,3% 8,2% 4,1% 4,0% 3,5% 7,0% 15,3% 8,6% 8,1% 7,1% 5,1% 5,2% Mortality rate Jan-Mar 18 8,0% 6,3% 6,5% 4,5% 8,6% 3% 4% 3% 5,2% 10,1% 10,0% 14,2% 7,6% 5,8% 6% Mortality rate Apr-Jun 18 6,6% 7,5% 7,5% 4,0% 9,4% 3,2% 4,2% 4,4% 8,6% 15,4% 11,5% 11,0% 8,7% 5,9% 6,5% Mortality rate Jul-Sept 18 6,5% 5,8% 6,7% 4,5% 8,9% 4,7% 3,4% 3,6% 9,1% 11,8% 9,8% 11,7% 9,1% 6,2% 6,3% Mortality rate Oct -Dec 18 6,1% 5,5% 6,9% 4,6% 8,1% 2,7% 4,1% 3,9% 5,5% 9,2% 11,9% 10,3% 11,3% 5,7% 5,8%
Mortality rate Jul- Sep 17 Mortality rate Oct-Dec 17 Mortality rate Jan-Mar 18 Mortality rate Apr-Jun 18 Mortality rate Jul-Sept 18 Mortality rate Oct -Dec 18
Figure 20: Mortality rate for all TB cases project supported districts
USAID Tuberculosis South Africa Project - Project Quarterly Report: January 2020 to March 2020 54 f. DS-TB/HIV Collaborative The DHIS system does not generate reports showing the number of TB patients with a known HIV status. The project has therefore used the TIER.Net reports which has this indicator. The total number of notified TB cases in TIER for Q4 (Oct-Dec 2019) is 25,763 of which 18,030 (84.2%) have a known HIV status. Among the 11,344 co-infected 10,261 (90.5%) were on ART.
ART Uptake 100,0% 90,0% 80,0% 70,0% 60,0% 50,0% 40,0% 30,0% 20,0% 10,0% 0,0% City of Sarah Umkhanyak Cape City of Tshwane OR Tambo NMBM Ethekwini West Coast Mangaung Fezile Dabi Waterberg Sekhukhune Johannesbu Project Baartman ude Winelands Cape Town Metro rg Jul-Sep 18 93,7% 94,30% 91% 87,1% 63,9% 48,3% 89,2% 70,1% 81,4% 82,4% 86,3% 72,3% 81,0% Oct-Dec 18 94% 92% 88% 79% 75% 63% 46% 61% 78% 68% 79% 69% 86% 91% 80% Jan-Mar 19 93% 92% 94% 62% 87,4% 75% 59% 70% 85% 82% 64% 58% 89% 83% 92% Apr -Jun 19 78% 80% 77% 64% 65% 84% 74% 69% 67% 67% 73% 56% 65% 67% 69% Jul -Sept 19 95% 94% 96% 82% 86% 61% 69% 84% 73% 84% 89% 80% 96% 66% 85% Oct -Dec 19 93% 94% 85% 89% 60% 68% 81% 65% 83% 88% 73% 93% 84% Jul-Sep 18 Oct-Dec 18 Jan-Mar 19 Apr -Jun 19 Jul -Sept 19 Oct -Dec 19
Figure 21: ART Uptake in project supported districts
USAID Tuberculosis South Africa Project - Project Quarterly Report: January 2020 to March 2020 55 g. South Africa DR-TB initiation rate as reported on Developmental Information Solutions (DIS)
Table 36: South Africa DR-TB initiation rates Oct 2018 to Sept 2019 by quarter Number of multi-drug resistant Number of multi-drug resistant tuberculosis cases % initiation tuberculosis cases detected that have initiated second line treatment
Jul-Sep 2018 2830 2513 89% Oct-Dec 18 2805 2419 86% Jan-Mar 19 2824 2417 86% Apr-Jun 19 2488 2154 87% Jul-Sep 2019 2419 2327 96%
The proportion initiated on DR-TB treatment is at 96% as of July-Sept 2019; which is very high compared to the global average of only 33%. h. DR TB Notifications RR/MDR TB initiations by District Q4 2020
Table 37: Q4 (Oct-Dec 2019) DR TB intitian rates by distrcits
DR-TB Treatment Initiation (Q4-Oct -Dec 2019)
No.RR/MDR TB No. RR % initiated on Province District Cases Started on diagnosed by the treatment Treatment lab
N Mandela Bay MM 98 147 67% EC O Tambo DM 49 69 71% Sarah Baartman DM 33 62 53% Fezile Dabi DM 14 15 93% FC Mangaung MM 41 31 132%
USAID Tuberculosis South Africa Project - Project Quarterly Report: January 2020 to March 2020 56 Johannesburg MM 120 129 93% GP Tshwane MM 33 58 57% eThekwini MM 218 247 88% KZN uMkhanyakude DM 27 46 59% Sekhukhune DM 8 24 33% LP Waterberg DM 13 19 68% Cape Town MM (SWSS) 195 236 83% WC Cape Winelands DM 40 57 70% West Coast DM 28 26 108% Totals 917 1166 79%
DR-TB Treatment Initiation (Q4-Oct -Dec 2019)
No.RR/MDR No. RR % initiated TB Cases Province District diagnosed on Started on by the lab treatment Treatment
N Mandela Bay MM 98 147 67% EC O Tambo DM 49 69 71% Sarah Baartman DM 33 62 53% Fezile Dabi DM 14 15 93% FC Mangaung MM 41 31 132% Johannesburg MM 120 129 93% GP Tshwane MM 33 58 57% KZN eThekwini MM 218 247 88%
USAID Tuberculosis South Africa Project - Project Quarterly Report: January 2020 to March 2020 57 uMkhanyakude DM 27 46 59% Sekhukhune DM 8 24 33% LP Waterberg DM 13 19 68% Cape Town MM (SWSS) 195 236 83% WC Cape Winelands DM 40 57 70% West Coast DM 28 26 108% Totals 917 1166 79%
USAID Tuberculosis South Africa Project - Project Quarterly Report: January 2020 to March 2020 58 i. DR-TB Treatment Success analysis by district Q3 (Ju-Sep) and Q4 (Oct-Dec) 2018 short regimen
Out of the 554 DR-TB patients who completed treatment the DR-TB short regimen from 14 supported districts in Q4, 371 (67%) were successfully treated compared to 65% (378/584) in Q3. Treatment success rate for Q4 ranged from 82% (9/11) for Sekhukhune) to 20 % (3/15) for West Coast.
Treatment success rate by district Q3 and Q4 DR TB short regimen 85% 90% 82% 85% 80% 81% 80% 78% 80% 73% 68% 68% 69% 69% 69% 69% 67% 70% 63% 63% 64% 64% 65% 59% 62% 60% 56% 50% 47%48% 50% 46%
40% 31% 30% 20% 17% 20% 10% 0%
Q3 % TSR Q4 % TSR
Figure 22: Treatment success rate by district for DR-TB short regimen: Q3 and Q4 2018
USAID Tuberculosis South Africa Project - Project Quarterly Report: January 2020 to March 2020 59 j. DR-TB Loss to follow up analysis by district Q4 and Q4 2018 short regimen Out of the 554 DR-TB patients who completed the DR-TB short regimen from the 14 supported districts in Q4, 62 (11%) were lost to follow up compared to 15% (87/584) in Q3. Loss to follow up rate for Q4 ranged from 27% (7/27) for City of Cape Town to 0% (0/11, 0/9 and 0/15) for Sekhukhune, Waterberg and West Coast respectively.
Loss to follow up rate by district Q3 and Q4 DR TB short regimane 2018 30% 27% 26% 26% 25% 23% 20% 19% 19% 20% 19% 16% 15% 14% 15% 15% 13% 12% 11% 10%9% 10% 10% 8% 8% 8% 8% 8% 7% 8% 5% 6% 5% 0% 0% 0% 0%
Q3% Loss to Q4 % Loss to follow-up follow-up
Figure 23: Loss to follow up rate by district for DR-TB short regimen: Q3 and Q4 2018
USAID Tuberculosis South Africa Project - Project Quarterly Report: January 2020 to March 2020 60 k. DR-TB Mortality analysis by district Q3 (Jul-Sep) and Q4 (Oct-Dec) 2018 short regimen Out of the 554 DR-TB patients who completed the DR-TB short regimen from the 14 supported districts in Q4, 70 (13%) died while on treatment compared to 12% (71/584) in Q3. Mortality for Q4 ranged from 4% (1/21) for Cape Town to 31% (4/13) for Mangaung.
Mortality rate by district Q3 and Q4 DR TB short regimen
35% 33% 31%
30% 24%
25% 23%
22%
21%
20%
20%
19% 18%
20% 18%
17%
17%
15%
14% 14%
15% 13%
12%
11%
11%
10% 10%
10%
7%
6% 5%
5% 4%
0% 0% 0% 0% 0%
Q3 % Died Q4 % Died
Figure 24: Mortality rate by district Q3 and Q4 DR-TB short regimen
USAID Tuberculosis South Africa Project - Project Quarterly Report: January 2020 to March 2020 61 l. DR-TB Treatment Success analysis by district Q3 (Jul-Sep 2017) and Q4 (Oct-Dec 2017) long regimen
Out of the 358 DR-TB patients who completed the long regimen in Q4 (Oct-Dec 2017) in the 14 supported districts, 180 (50%) were successfully treated compared to 56% (279/499) in Q3. Treatment success rate for Q4 ranged from 100% (1/1) for uMkhanyakude to 15% (5/33) for City of Cape Town.
Figure 25: Treatment success rate by district Q3 (Jul-Sep 2017) and Q4 (Oct-Dec 2017) DR-TB long regimen
USAID Tuberculosis South Africa Project - Project Quarterly Report: January 2020 to March 2020 62 1. DR-TB Loss to follow up analysis by district Q3 (Jul-Sep 2017) and Q4 (Oct-Dec 2017) 2017 long regimen Out of the 358 DR-TB patients who completed DR-TB long regimen from the 14 supported districts in Q4 (Oct-Dec 2017), 60 (17%) were LTFU compared to 13% (66/499) in Q3 (Jul-Sep 2017). LTFU for Q4 ranged from 40% (4/10) for Sarah Baartman to 0% (0/18 and 0/1) for OR Tambo and uMkhanyakude respectively.
Loss to follow up rate by district Q3 and Q4 DR TB long regimen 2017
45% 40% 40%
35%
30% 30%
30% 26% 25%
25% 21%
20%
19%
17%
17% 17% 17% 17%
16% 16%
20% 16%
15%
14%
14%
13% 12%
15% 11,5%
10%
8,9% 7%
10% 6% 4%
5% 3%
0% 0% 0%
Q3 % Loss to Q4 % Loss to follow-up follow-up
Figure 26: Loss to follow up rate by district Q3 (Jul-Sep 2017) and Q4 (Oct-Dec 2017) DR-TB long regimen.
USAID Tuberculosis South Africa Project - Project Quarterly Report: January 2020 to March 2020 63 m. DR-TB Mortality analysis by district Q3 (Jul-Sep 2017) and Q4 (Oct-Dec 2017) long regimen Out of the 358 DR-TB patients who completed DR-TB long regimen from the 14 supported districts in Q4 (Oct-Dec 2017), 69 (19%) died compared to 20% (99/499) in Q3 (Jul-Sep 2017). The mortality rate for Q4 ranged from 40% (4/10) for Sarah Baartman to 0% (0/6 and 0/1) Fezile Dabi and uMkhanyakude respectively.
Mortality rate by district Q3 and Q4 DR TB long regimen: 2017
60% 50%
50% 40%
40%
36%
34%
33% 33%
29% 27%
30% 26%
25%
23%
20%
20%
19%
19%
19% 19%
18% 18%
20% 17%
15%
14%
14%
13%
12%
10% 8%
10% 6%
0% 0% 0%
Q3 % Died Q4 % Died
Figure 27: Loss to follow up rate by district for DR-TB long regimen: Q3 (Jul-Sep 2017) and Q4 (Oct-Dec 2017)
USAID Tuberculosis South Africa Project - Project Quarterly Report: January 2020 to March 2020 64
Annex III: Finding Missing TB Patients
To step up efforts to find the missing TB patients, the National TB program (NTP) has set an annual target of finding 80,000 patients by the end of the 2019/2020 financial year. Of the 80,000 missing TB patients targeted for 2019/2020, 37,665 (47%) are estimated to be in the 14 districts supported by the project. To work alongside government to meet these ambitious targets, the project has targeted to find at least 18,882 (50%) of the total 37,665 which are estimated to be in project supported districts. Between October 2019 and March 2020, the project used various strategies to find the missing TB patients including the FAST approach, community mobilization, contact management, targeting key populations, using diagnostic tests such as ULAM as well as updating of data and records in project supported districts. Through these strategies, a total of 6593 TB patients have been found, representing 35% of the targeted 18,882 cases to be found in the current financial year. These results are largely due to the FAST intervention, which contributed 57% of all TB cases diagnosed, as well as data cleaning exercises which took place in 10 of the 14 supported districts covering over 160 high TB burden facilities diagnosing the highest number of TB cases in the country. The community level interventions have made minor contributions owing to the reduction in the number of community-based organizations contracted by the projects which stands at only ten.
Table 38: Missing TB patients diagnosed by strategy Strategy Oct-Dec 19 Jan-Mar20 Total % FAST Approach 2505 1243 3748 57% Community mobilization, 559 68 627 10% Contact Management 59 59 118 2% Key populations 77 58 135 2% Diagnostics tests (U-LAM) 277 101 378 6% Linkage to care – Initial lost to follow- 55 76 131 2% up (ILTFU) Updating of records and data clean-up 312 1144 1456 22% TOTAL 3844 2749 6593
USAID Tuberculosis South Africa Project - Project Quarterly Report: January 2020 to March 2020 65