Optimizing the efficiency of household contact tracing for TB control in South Africa
Lead Research Organisation:
Aurum Institute
Department Name: UNLISTED
Abstract
Contact tracing in a household of person with TB is a well-known method for finding other people with TB earlier. Other benefits include the opportunity for HIV testing and linking people with HIV to health care.
There are problems with the approach including high costs, difficulties with finding household members and differences in the number of people with TB found.
Primary health care is currently being reorganised in South Africa. The new approach includes local outreach teams that deliver home and community based health services. Household contract tracing could be combined into these new teams.
Our project uses different research methods to develop, implement and evaluate a combined model of household contact tracing, potentially using the new outreach teams.
In Phase I we aim to understand more about the local outreach teams, and find out ways to help implement a new combined model household contact tracing. In Phase II, the new model will be implemented in three different districts in South Africa. In Phase III we will analyse our data to see if the new combined model is practicable, and can it find other household members with TB and allow an opportunity to test people for HIV and link people with HIV to health care. We will also collect costs of the new model.
There are problems with the approach including high costs, difficulties with finding household members and differences in the number of people with TB found.
Primary health care is currently being reorganised in South Africa. The new approach includes local outreach teams that deliver home and community based health services. Household contract tracing could be combined into these new teams.
Our project uses different research methods to develop, implement and evaluate a combined model of household contact tracing, potentially using the new outreach teams.
In Phase I we aim to understand more about the local outreach teams, and find out ways to help implement a new combined model household contact tracing. In Phase II, the new model will be implemented in three different districts in South Africa. In Phase III we will analyse our data to see if the new combined model is practicable, and can it find other household members with TB and allow an opportunity to test people for HIV and link people with HIV to health care. We will also collect costs of the new model.
Technical Summary
Household contact tracing (HHCT) for tuberculosis (TB) is a well-established method for detecting cases earlier and preventing further transmission. Other benefits include the opportunity for HIV testing and linkage to HIV care. HHCT has been included as a priority intervention for the 2015 South African Global Fund application (expected to start April 2016).
Past experiences with HHCT have highlighted high costs, difficulties with finding contacts and varied yield of TB in a routine setting. Alternative approaches that increase yield or reduce costs may be needed to increase feasibility and impact of this intervention. In South Africa, an important question is to what exten t should contact tracing activities stay exclusively within vertical TB programmes or be integrated into broader, community-based models of care? The primary health care (PHC) reengineering strategy for South Africa incorporates ward-based PHC outreach teams that deliver home & community based health services. TB contact tracing would seem to be particularly well suited to be integrated into this platform.
In this mixed-methods project, we aim to develop, implement and evaluate an integrated model of HHCT, potentially using the ward-based PHC outreach teams. In Phase I, we will use quantitative and qualitative research techniques to understand the context of ward-based teams, and explore barriers and facilitators to implementation of an integrated model for HHCT. A new model for HHCT will be defined, ideally integrated with the horizontal community-based health services. In Phase II, the new model will be implemented together with a data management system, to allow for monitoring and evaluation of the model. In Phase III, the model implemented and data collected in phase II will be analysed to answer the following questions:
• Is the integrated model feasible?
• Is the model successful in screening contacts for TB, testing people for HIV, identifying TB cases, linking cases to care in PHCs?
• Is the yield of TB increased by the addition of culture testing to the current programme?
• Is the model cost-effective in identifying TB cases, and can implementation be adapted to improve cost-effectiveness?
• What is the projected impact of contact tracing on transmission, and how do changes in implementation will modify the impact?
The project will be conducted in three districts of South Africa with different TB epidemic profiles: a) rural district in KwaZulu-Natal, with the highest rates of TB/drug-resistant TB in the country; b) urban district in Gauteng, lower TB incidence; c) semi-urban peri-mine district in North West, moderate TB incidence. We expect that the yield of TB and the logistics of conducting the contact tracing in these three areas will be different, and will allow for a more detailed understanding of what influences cost-effectiveness and impact of the intervention.
Past experiences with HHCT have highlighted high costs, difficulties with finding contacts and varied yield of TB in a routine setting. Alternative approaches that increase yield or reduce costs may be needed to increase feasibility and impact of this intervention. In South Africa, an important question is to what exten t should contact tracing activities stay exclusively within vertical TB programmes or be integrated into broader, community-based models of care? The primary health care (PHC) reengineering strategy for South Africa incorporates ward-based PHC outreach teams that deliver home & community based health services. TB contact tracing would seem to be particularly well suited to be integrated into this platform.
In this mixed-methods project, we aim to develop, implement and evaluate an integrated model of HHCT, potentially using the ward-based PHC outreach teams. In Phase I, we will use quantitative and qualitative research techniques to understand the context of ward-based teams, and explore barriers and facilitators to implementation of an integrated model for HHCT. A new model for HHCT will be defined, ideally integrated with the horizontal community-based health services. In Phase II, the new model will be implemented together with a data management system, to allow for monitoring and evaluation of the model. In Phase III, the model implemented and data collected in phase II will be analysed to answer the following questions:
• Is the integrated model feasible?
• Is the model successful in screening contacts for TB, testing people for HIV, identifying TB cases, linking cases to care in PHCs?
• Is the yield of TB increased by the addition of culture testing to the current programme?
• Is the model cost-effective in identifying TB cases, and can implementation be adapted to improve cost-effectiveness?
• What is the projected impact of contact tracing on transmission, and how do changes in implementation will modify the impact?
The project will be conducted in three districts of South Africa with different TB epidemic profiles: a) rural district in KwaZulu-Natal, with the highest rates of TB/drug-resistant TB in the country; b) urban district in Gauteng, lower TB incidence; c) semi-urban peri-mine district in North West, moderate TB incidence. We expect that the yield of TB and the logistics of conducting the contact tracing in these three areas will be different, and will allow for a more detailed understanding of what influences cost-effectiveness and impact of the intervention.
Organisations
Publications
DeSanto D
(2023)
A qualitative exploration into the presence of TB stigmatization across three districts in South Africa.
in BMC public health
| Description | Past experiences with household contact tracing have highlighted high costs, difficulties with finding contacts and varied yield of TB in a routine setting. Alternative approaches that increase yield or reduce costs may be needed to increase feasibility and the impact of this intervention. In South Africa, an important question is to what extent should contact tracing activities stay exclusively within vertical TB programmes or be integrated into broader, community-based models of care? The primary health care (PHC) reengineering strategy for South Africa incorporates ward-based PHC outreach teams that deliver home and community based health services. TB contact tracing would seem to be particularly well suited to be integrated into this platform. Our study explored issues with regards to the ward-based outreach teams and the difficulties that they encountered while doing their work. Using this data we introduced a quality improvement intervention at clinic level and a m-health application to improve recording and support for the household visits. We were able to evaluate the acceptability and feasibility of the m-health application and also measure costs of household visits. |
| Exploitation Route | As above, the findings are being used to adapt the programme to increase its effectiveness. In addition, these findings have also been used to support the South African strategic plan with regards to contact tracing and to motivate for other innovative solutions. |
| Sectors | Healthcare |
| Description | Capacity Development: Some members of this team have been able to increase their skills and are now involved in PhD studies on related topics. Rachel Mukora is currently finalising her PhD Thesis on feasibility, acceptability and cost-effectiveness of digital adherence tools for improved TB treatment adherence. Don Mudzengi has been able to explore a PhD in digital health and is in his second year. Dr Kavindhran Velen has developed his skills further by doing a Post-doctorate at the University of Sydney and is currently working for FIND Diagnostics in Geneva as their TB senior researcher. New proposals: Prof Charalambous and Dr K Velen were successful in obtaining a EDCTP grant to continue to study contact investigation and this project is expanded to two other countries, Lesotho and Tanzania. This project includes capacity building for laboratory techniques in Lesotho government laboratories and will fund numerous PhD and Masters students. |
| First Year Of Impact | 2020 |
| Sector | Healthcare |
| Impact Types | Societal |
| Description | Missing TB Cases Strategy: A few members of the Asibambisane team, including Dr Kavindhran Velen, Mr Piotr Hippner and Dr Salome Charalambous, were invovled in a national effort to put together a Missing TB Cases strategy for the National TB programme. |
| Geographic Reach | National |
| Policy Influence Type | Contribution to a national consultation/review |
| Impact | The National Missing TB cases strategy has been finalised and is currently being implemented. As the primary focus for this strategy is to find patients not yet known or notified as being on TB treatment by the NTP, the selected target excludes those recorded as initiated on treatment. The target is thus a staggering 160,000 (~162,155) TB patients as indicated in Table 1. A phased approach will be undertaken in finding these patients. The interventions will aim to improve case detection within the broader population and also missed opportunities within the health facilities. As there are multiple gaps in the cascade, no single intervention will identify all patients and a multi-pronged set of interventions will be applied informed by the available programmatic and published evidence. |
| Description | Policy Brief: The challenges faced by ward-based PHC outreach teams (WBOTs) when delivering household contact tracing (HHCT) services |
| Geographic Reach | National |
| Policy Influence Type | Implementation circular/rapid advice/letter to e.g. Ministry of Health |
| Impact | This document was used to explore the current value of ward based outreach teams for finding the missing TB cases as part of the Finding Missing TB Cases strategy that was proposed by the National TB Think Tank and is being implemented by the National Department of Health.. |
| Description | Community and Universal Testing for TB among contacts |
| Amount | € 3,720,000 (EUR) |
| Funding ID | RIA2019IR-2877 |
| Organisation | Aurum Institute |
| Sector | Charity/Non Profit |
| Country | South Africa |
| Start | 09/2020 |
| End | 09/2025 |
| Description | Describing the acceptability of AitaHealth, a mobile data collection application, for Tuberculosis (TB) contact tracing by outreach teams in South Africa |
| Form Of Engagement Activity | A talk or presentation |
| Part Of Official Scheme? | No |
| Geographic Reach | National |
| Primary Audience | Professional Practitioners |
| Results and Impact | Accepted for Oral presentation: 8th June 2021 We conducted an implementation science study in three districts in South Africa to optimise the efficiency of household contact tracing for TB control by replacing paper with a mobile data collection application called AitaHealth. A qualitative component of the study aimed to understand the acceptability of AitaHealth by outreach teams responsible for TB contact tracing. Data from only one district, KwaZulu Natal was available for the analysis. We conducted two focus group discussions (FGD) and four in-depth interviews (IDI) where twenty-four outreach team members and four stakeholders participated, respectively. We used deductive thematic analysis to analyse our data, focusing the analysis on the usability AitaHealth. |
| Year(s) Of Engagement Activity | 2021 |
| URL | https://www.tbconference.co.za/ |
| Description | Presentation at South African Newton Fund review meeting |
| Form Of Engagement Activity | A talk or presentation |
| Part Of Official Scheme? | No |
| Geographic Reach | International |
| Primary Audience | Professional Practitioners |
| Results and Impact | Presentation at South African Newton Fund review meeting: an interim review was held. A presentation including the study objectives, progress so far and future plans was done by myself. The review committee was made up of a few South African leading TB researchers. In addition, the other members of the audience included other holders of the Newton grant and their UK counterparts. The discussion was interesting and lively and most endorsed our study question and commented on our progress. |
| Year(s) Of Engagement Activity | 2018 |
| Description | Stakeholder Meeting Gauteng and North West provinces |
| Form Of Engagement Activity | Participation in an activity, workshop or similar |
| Part Of Official Scheme? | No |
| Geographic Reach | Regional |
| Primary Audience | Policymakers/politicians |
| Results and Impact | Date: 02 March 2017 Venue: Max Price Boardroom AGENDA ASIBAMBISANE PHASE I CONSULTATION MEETING: OPTIMISING THE EFFICIENCY OF HOUSEHOLD CONTACT TRACING FOR TB CONTROL IN SOUTH AFRICA 09:00-10:00 Registration and Tea 10:00-10:15 Welcome and Agenda : 10:15-10:30 Purpose of the meeting and expected outcomes :Salome Charalambous 10:30-11:00 Asibambisane Study Outline :Kavi Velen 11:00-11:30 Preliminary Results from Qualitative Research Phase :Candice 11:30 - 123:300 Break-out sessionsDiscussion & break out groups : 123: 300 - 134:300 Lunch 134:00 - 134:30 Break out groupsReport back on the break out session : 14:30 - 14:50 Report back on the break out sessionDiscussion about best practices : 14:50 - 15:30 Discussion about proposed model :Alison 15:030 - 165:0015 Closing Remarks |
| Year(s) Of Engagement Activity | 2017 |
| Description | Stakeholder meeting - KwaZulu Natal |
| Form Of Engagement Activity | Participation in an activity, workshop or similar |
| Part Of Official Scheme? | No |
| Geographic Reach | Regional |
| Primary Audience | Policymakers/politicians |
| Results and Impact | A consultation meeting was held to feedback Phase I results to the district and local stakeholders in Kwazulu Natal Umkanyakude. The meeting was held at the African Health Research Institute (AHRI) at the Somkhele site on the 15th August 2017. The agenda was as follows: 10:00 - 10:15 Welcome and Agenda Sphephelo Dlamini 10:15 - 10:45 Asibambisane project and purpose of the meeting Salome Charalambous 10:45 - 11:30 Preliminary Results from the Qualitative Research Phase Lobenguni Simelane - Mahlinza/ Dumile Gumede 11:30 - 12:30 Key issues to be addressed Discussion and breakout sessions Salome Charalambous 13:15 - 14:15 Report back from break out session Rapporteurs 14:15 - 14:45 Discussion about proposed model Salome Charalambous 14:45 - 15:00 Closing remarks The following people attended the meeting: Meeting Attendees: NAME INSTITUTE Candice Chetty AURUM Salome Charalombous AURUM Nokukhanya Dube DoH Velelephi Mbatha DoH Nokulunga Dlamini DoH Siphiwo Lolwana DoH Sebenzile Msweli DoH Makhosi Mbuyisa DoH Khethiwe Madela Mpilonhle Sbusiso Mhlongo Mpilonhle Zodwa Radebe DoH Thabile Maphumulo DoH Maureen Mnyandu DoH Fikile Ndwandwe DoH Lindiwe Mkhwanazi DoH Olivier Koole AHRI Lobenguni Simelane-Mahlinza AHRI Dumisile Mthethwa AHRI Mthobisi Zikhali AHRI Bheki Mbonambi AHRI Thabile Mkhize AHRI Alison Grant AHRI/ LSHTM Safiyya Randera-Rees AHRI/ LSHTM Kavindhran Velen AURUM Sanj Karat AHRI/LSHTM Presentations Project presentation and purpose of meeting - Salome Charalambous Comments: The District TB Coordinator mentioned that she was happy with the sites that were selected for the project as they are in different settings; urban, peri- urban and deep rural. She said that this selection will give a picture of what is happening in the different settings. The Coordinator also asked if it was normal for the culture to take 6-8 weeks. Preliminary results of the qualitative phase - KZN - Lobenguni Simelane Mahlinza Comments: Salome pointed out that she sees the merit of identifying hotspots but the hottest spots were the households that live with a TB infected person. Preliminary results of the qualitative phase Gauteng and Bojanala - Candice Chetty-Makkan Comments: The TB coordinator made a comment on the WBOTs not being available in uMkhanyakude. She mentioned that the CCG model worked well in the district and that it would be difficult to implement the WBOT model since the district has transport challenges. The nurse team leader would not have transport to go out into the community. In the few clinics that hired WBOT team leaders, these were not functional because of transport challenges. Discussion points Challenges in HHCT - CCGs These are points that were raised in the groups about the different challenges that were faced by the CCGs in delivering health care services especially household contact tracing. • Patients tend to give incomplete or wrong addresses to health care workers, thus making it difficult for their contacts to be traced. • People change clinics without letting the other clinic know and then they are recorded as lost to follow up whereas they have moved to another clinic. • CCGs have a challenge of sputum being transported to the clinic as they are not provided with transport. This poses a challenge because by the time the sputum gets to the lab it might not be in an acceptable state. • There is poor collaboration between stakeholders working with TB in the community. There is an organisation in this community that has employed CCGs that work with TB. These CCGs do not work together with DoH and DSD CCGs. They also have different reporting systems and working tools. • The DoH CCGs were once provided with tablets for documentation purposes but they had a challenge because there are places that do not have connection to any mobile network. They had to complete paper forms and then upload to the tablet when they get to a place with network. The provider of the tablets assumed that the CCGs cooked the data because the application showed that the data was loaded in one location and took them back. The groups then presented recommendations on how HHCT could be improved and how the CCGs could be utilised to do HHCT in a more efficient way. A suggestion was made about improving the current WBOTS model rather that implementing a new model. One group raised the issue of community education as important to improving delivering of HHCT. If the communities are well educated about TB services, they will welcome CCGs that do HHCT. To restore the dignity of CCGs, they need to be taken through extensive training, follow up trainings, and given uniforms with name tags. Philamntwana centres can be used as points of sputum collection for people who cannot go to health facilities and as dropping centres for CCGs. These are centres in areas that do not have health facilities close by. There are CCGs that work in these centres and specialise in caring for children. Sputum can be collected at these centres where they can be collected by clinic/ hospital cars. War rooms can be used as a platform to discuss TB issues as there are a number of stakeholders that participate (DoH, DoE etc). They have monthly meetings, nurses in those wards can report about TB activities during these meetings. Another recommendation was that CCGs use cooler boxes for sputum sample storage after collection. These could be ordered by the Operational Managers of each clinic. Household addresses should be clearly written down with clear directions and landmarks. Next steps: • Conceptualise the model • The budget for each site needs to be worked out. |
| Year(s) Of Engagement Activity | 2017 |
| Description | Submitted abstracts and accepted for oral presentations to SA TB Conference |
| Form Of Engagement Activity | A talk or presentation |
| Part Of Official Scheme? | No |
| Geographic Reach | Regional |
| Primary Audience | Professional Practitioners |
| Results and Impact | The two submitted abstracts were presented as an oral presentation and a poster at the 5th SA TB conference hosted in Durban in June 2018. The poster was titled "Exploring system level enablers and barriers of household contact tracing across three districts of South Africa: Perspectives from key stakeholders" and the oral presentation was "Community perceptions of tuberculosis prevention, access to care, and stigma in uMkhanyakude district, KwaZulu-Natal" |
| Year(s) Of Engagement Activity | 2018 |
| URL | http://www.tbconference.co.za/ |
| Description | Symposium Presentation at South African TB conference |
| Form Of Engagement Activity | A talk or presentation |
| Part Of Official Scheme? | No |
| Geographic Reach | Regional |
| Primary Audience | Professional Practitioners |
| Results and Impact | The study was part of a symposium on TB Contact Tracing at the 5th SA TB conference. Two topics were presented by members of the study team: WBOT Contact Tracing: Exploring system level enablers and barriers of household contact tracing across three districts of South Africa by Dr Candice Chetty and An optimized model for use of community care givers for TB contact tracing by Dr Richard Lessells. |
| Year(s) Of Engagement Activity | 2018 |
| URL | http://www.tbconference.co.za/ |
| Description | Symposium Presentation at South African TB conference |
| Form Of Engagement Activity | A talk or presentation |
| Part Of Official Scheme? | No |
| Geographic Reach | Regional |
| Primary Audience | Postgraduate students |
| Results and Impact | The Masters student, Mr Wellington Maruma, presented his project, "Exploring motivators and challenges to the collection of Tuberculosis contact tracing information by the ward based outreach teams in Ekurhuleni, Johannesburg: A cross sectional study", as part of a symposium to promote an Implementation Science Masters programme by the University of the Witwatersrand. |
| Year(s) Of Engagement Activity | 2018 |
| URL | http://www.tbconference.co.za/ |