“In 2005, we had already started discussing decentralisation because of
poor case retention, high default rates, and refusal of treatment,” Dr Margot
said at the 2nd SATB Conference in Durban. Initially, the idea was
to set up decentralized sites with satellite centres in parts of the province
that were too far from King George V Hospital, the ‘Centre of Excellence,’ in
Durban. The plan was that the decentralised site would provide full patient
management, diagnosing, registering and commencing treatment, and providing
follow-up, while the satellite centres would basically just house the
management was really was thrust upon us by the outbreak in Tugela Ferry,” said
Dr Margot, noting that in this rural province, that meant relying on
mobile injection teams.
started running the community-based management programme in 2007 in
KwaZulu-Natal and it was restricted mainly to the Msinga district but it’s now
expanded right across the whole of the Msinyati district; and we’ve got it in
small pockets in other parts of the province,” said Dr Margot.
King George V Hospital remains the centre of excellence in Durban
that manages difficult patients, cases that need surgery and the XDR-TB case
are still being sent there at present.
(However, Dr Margot said that the management of “XDR-TB is going to have
to be decentralized as well because the personal and social issues are even
more pressing in the XDR-TB patients because of the length of time they stay.)”
Decentralised sites have been set up in districts depending on
the patient load and the geography. Upon diagnosis, patients are traced, then
admitted, registered, counselled and put on to treatment as an inpatient at the
decentralised site. Contact tracing and education of the patient and the
households/contacts occurs while the patient is still hospitalised.
“You don’t want to educate a patient going back into an
uneducated household, everybody needs to be educated around what the treatment
is, the side-effects, understand the journey of the patient and also around
infection control issues,” said Dr Margot.
The patient is hospitalised at the decentralised site for 2 to 4
weeks or a bit longer if there is a clinical reason.
“That gives you time to do the education, start the treatment,
monitor the side-effects early and do your adjustments. So by the time you
release the patient, you’re releasing, hopefully, a relatively stable patient
that started on their treatment, you adjusted the side-effects or whatever you
need to do with the treatment and you release them back into the community — a
relatively safe patient to go back to community-based management,” he said.
Once the patients are discharged, they are visited daily in their
own home by the mobile injection team (trained nurses provide the injections).
Dr James Brust of the Montefiore Medical Centre, who has working with the
programme in KwaZulu Natal, described this process in a bit more detail at the
2nd SATB in Durban.
“An injection team visits patients daily to provide intramuscular
injection of kanamycin, to observe oral dosing of medications and to provide
care and support and adverse event monitoring,” said Dr Brust. “Patients identify a family treatment
supporter, and all patients and their supporters are given extensive treatment
literacy support. We created a cartoon flip chart to educate patients about
drug resistant TB, about HIV, infection control, the importance of adherence
and so forth, translated into Zulu.”
“Patient education needs to be really strong in these units and I
think it is one of the keys. We need to set up, once you move to
community-based care, a good system with well-trained staff and a good system
monitoring the side-effects for patient safety,” said Dr Margot.
Monthly follow-up is then conducted at the decentralised MDR-TB
unit on an outpatient basis. According to Dr Brust, during each monthly visit,
patients are seen by their doctor/medical
officer; they have
their routine laboratory tests and a monthly sputum culture/DST. They have
CD4/viral load monitoring, chest x-rays and TSH (thyroid stimulating hormone)
done every six months. Audiology assessments are done at baseline, two months,
six months and periodically thereafter.
Once the intensive phase of treatment ends (when the injection
team is no longer required), a lay health worker/home-based carer is employed
to serve as the direct observed therapy supporter. The DOT supporter goes daily and reports about any adverse
events or disease progression on a weekly basis.
Dr Margot listed a number of key services that are needed to
support the decentralized units and community-based management of MDR-TB in
KwaZulu Natal, including good clinical, laboratory and pharmacy support.
Patient monitoring can be improved with chest X-Ray, and
audiology (the capacity to monitor for hearing loss sometimes associated with
second-line treatment). Patients and their families benefit from having a good
social worker, physio and occupational therapy as well as psychiatric support.
Good infection control is important for both the healthcare facilities and
home. The programme needs support from a surveillance officer and data capturer
to monitor the stats and handle all the paperwork. The decentralised unit
should also have strong linkages or integration with HIV services (for HIV
testing and counselling and ART. Outreach Community Teams (Tracing/Injection
teams) with one TB community officer and one staff nurse are obviously
necessary — as is good management support to pull all these elements together.
“You need to look at the stability of your doctor-base for the
decentralised unit, it proves to be a problem, so you need to look at that
carefully. And your outreach teams need to be people with really big hearts
that are really interested in their work, because a lot of them work under very
extreme conditions. So you need a really dedicated team,” said Dr Margot.
As for the cost for the vehicles, petrol, staffing etc — Dr
Margot presented calculations showing that to manage 30 patients on the
community-level, it would cost around R77,837.00 a month (US $11,000) (not
including drug costs). Hospital care for the same 30 patients at the
decentralised unit would cost almost 10 times as much — while the cost of care
at King George V would be close to 1 million rand a month (US $140,000).
“And the terrain - it’s not easy. The patients are spread far,
the terrain is heavy on vehicles and you can only do so many patients in a day
unlike in urban areas. So if things can be done in this area at these kinds of
costs, it’s going to be even more cost-effective in an urban area,” said Dr
The data coming out of three out of four of the decentralised
sites, regarding death, default/failure and culture conversion are quite good.
One extremely rural and under-resourced site which has had trouble with
physician coverage, Thulasizwe,
is struggling a bit, with a 26% death rate, and a failure rate is 3%, a 1% defaulter rate, and a 58% culture
“But, [apart from Thulasizwe], what is significant is that the
death rates are much lower than what we’re seeing in the standardised,
centralised control programmes in the country.
The defaulter rate is significantly different to what we’ve been seeing
in the centralized treatment centres. And we’re starting to see some really
good conversion rates coming out of the decentralised sites,” said Dr Margot.
The Health Department plans to continue decentralisation to other
districts in the province where the need exists. The programme is also looking
at nurse initiated MDR-TB care and decentralising to the clinic level.
“We obviously struggle with doctors in rural areas, and to find a
doctor that will work with just TB is far more difficult. But I think probably
50 to 60% of the patients have straightforward MDR-TB and if we can up-skill
nurses to do ART we can do the same thing with MDR, there’s no reason why we can’t
break the load on the doctors and do a lot of the patients through the nurses,”
said Dr Margot. “When there is no doctor, they are doing it anyway already so
we may as well train them, skill them, and get their skill recognized.”
So the province has launched a partnership with Johns Hopkins
School of Medicine, and the Medical Research Council (MRC). The partnership is
timely because the nursing regulations (section 56) are changing in South
Africa to expand the scope of practice for nurses with appropriate training to
prescribe ART and other drugs (potentially including TB drugs), and there is
also a movement to decentralise more care to the primary health care levels.
Assistant Professor Jason Farley of Johns Hopkins
University, who is also a
nurse practitioner, described the partnership in more detail at the 2nd
South African TB Conference.16 He noted that preliminary
data on nurse-based management for HIV and TB in South Africa and other
settings was positive, with good patient satisfaction but that “the
identification of what is appropriate training is quite different in different
parts of the country… and that there is a high staff turnover in those
In other words, it can be a challenged to maintain the nurses in
those sites once they have been given additional training and responsibilities.
He cited findings from the Lusikisiki Model of decentralised care
which showed that scale up of nurse-based prescribing must include:
Ensuring an adequate budget for a full
complement of clinic staff
Recruitment of adequate administrative staff to
ensure that nurses’ time is optimised towards direct patient care rather than
non-nursing tasks (taking away administrative and secretarial duties that would
otherwise consume nurse time).
Accreditation and increased remuneration of
Acknowledging the great disparity between
non-urban settings by paying rural allowances to staff working in the most
challenging rural areas.17
Taking these factors into consideration, the partnership has
designed a study of nurse-initiated/managed intensive MDR-TB treatment which
aims to develop nurse-based capacity at Thulasizwe and another site, and compare outcomes between
these sites and King George V Hospital. The success of this trial and
partnership could dictate how quickly the province can down-refer to other
facilities and to the primary care level where there is limited doctor
Eventually, Dr Margot says the plan is to down-refer some
functions to the clinic level. The clinics would begin to provide the monthly
follow-up and may begin to initiate treatment in non-complicated MDR-TB cases.
“But that would be in targeted areas/select
areas where there are high case loads and where we’ve capacitated the clinics
to do the work — a little further down the road once we’re strengthened and got
the decentralized sites running completely,” he concluded.