Optimizing the efficiency of household contact tracing for TB control in South Africa

Lead Research Organisation: The Aurum Institute

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.

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.

Publications

10 25 50
 
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 Participation in a national consultation
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 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 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 2014,2018
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/