Chairperson
Prof Gavin Churchyard, Chief Executive of Aurum Institute for Health Research
Prof Richard Chaisson, Professor of Medicine, Epidemiology and International Health at Johns Hopkins University School of Medicine
Representatives of Consortium to Respond Effectively to the AIDS/TB Epidemic
Representatives of Aurum Research Institute
TB and HIV researchers
Distinguished guests
Ladies and gentlemen
Good Morning
It is my honour and privilege to address you this morning at this meeting of TB and HIV researchers from different countries, including South Africa, Zambia, Brazil, United States and Britain. I would like to congratulate the Consortium to Respond Effectively to the AIDS/TB Epidemic (CREATE) and the Aurum Research Institute for organising this important meeting.
My brief this morning is to outline the "Progress in Tuberculosis Control in South Africa". It is important for the Government of South Africa to register its voice to CREATE, the consortium of innovative community-based studies aimed at reducing TB incidence in high burden TB/HIV countries and influencing global TB/HIV policy. This is more so, as South Africa is one of the worst affected countries and also one of the three countries chosen to participate in these studies.
According to the World Health Organisation (WHO) report 2009, Global Tuberculosis Control: Epidemiology, Strategy and Financing, South Africa's case detection rate has remained above target since 2003. We have not made much progress in tuberculosis control. Treatment success rates have remained low. We have high default and death rates.
South Africa reports the highest number of confirmed multi-drug resistant tuberculosis (MDR-TB) and extreme drug resistant tuberculosis (XDR-TB) in the Southern African Development Community (SADC) region. TB prevalence has increase almost three fold in the last ten years. South Africa is amongst the ten (10) worst performing countries on TB control. Our performance is worse than those of our neighbours, like Mozambique, despite the fact that we have better resources. We are in danger of not meeting our Millennium Development Goals (MDGs) as a result of these poor outcomes.
The WHO report mentioned above states that in 2007, South Africa ranked fifth in terms of the number of incident cases. It is second, only to Swaziland, amongst fifteen countries with the highest estimated TB incident rates per capita and corresponding incidence rates of HIV positive TB cases.
I am stating these facts to make us aware that we need a change of mind set and more sense of urgency to confront the scourge of TB. Program managers whose responsibility is to implement government programs against TB and our partners whose daily work is to assist us as a country to deliver better outcomes should not only be satisfied with drafting crisis plans. All should work in partnership to ensure that society gets involved in our fight against TB, as we have declared this a priority disease.
Your meeting today takes place just few days after the Honourable Minister of Health, Dr Aaron Motsoaledi, released the 2008 national antenatal sentinel HIV and syphilis prevalence survey, which confirms that South Africa has an established generalised HIV epidemic with an estimated prevalence of 10,6% (HSRC 2008) in the general population and an estimated prevalence of 29,3% in the antenatal population surveyed in 2008.
We are fully behind the Honourable Minister Motsoaledi's commitment to continue to work together with all sectors of our society in the fight against HIV and AIDS, as well as TB and challenges of HIV-TB co-infection. We subscribe to the call by South African National AIDS Council (SANAC) that TB and HIV must be treated together and, where possible, under one roof and in each facility. We also support the Minister's call for partnerships, with emphasis on the need to work with academics and researchers, as we continue to find new ways to respond to these challenges.
It is globally accepted that effective policy making leading to successful implementation must significantly draw from scientific investigation and analysis. In this regard, research plays a crucial role, not only in terms of giving new insights and knowledge, but also with regard to monitoring progress on policy implementation and assessing impact. In this case, policy making and program implementation means saving lives by reducing morbidity and mortality from ailments such as TB and HIV and AIDS.
We therefore welcome the invitation to share with you the progress that the Department of Health, supported by its partners, including those assembled here today, is making in the fight against TB. Our assessment draws from a joint review of our TB programme conducted by World Health Organisation (WHO) and other partners in July of this year.
We were pleased to learn from the review that overall, our TB programme is demonstrating significant progress since a similar review undertaken five years ago. However, WHO estimates that almost one percent (461 000) of South Africans develop TB annually. We had 388 782 of all types of TB cases in our notification system of which, 336 245 were pulmonary TB.
Although our current cure rate of about 65% is significantly better than the 51% we had in 2004, it is still way below the WHO recommended cure rate of 85% require to disrupt our high levels of infection. This is what compels us to state that we have not made much progress, and that we are running the risk of not meeting out MDGs.
A significant number of South Africans continue to perish from TB. Just a few months ago Statistics South Africa (StatsSA), released a very important report indicating that, for every 100 people who died in 2006, 13 of them died from TB.
This makes TB the number one cause of death in our country:
* in eight out of our nine provinces, with the exception of the Free State.
* among both men and women
* among people in the 15 to 64 year age category, who constitutes the economically active part of our population.
This has left us anxious and concerned. We are well aware that we have to more than double our efforts in order to scale our response so that it is commensurate with the challenge at hand. We are well aware that real success depends on strong partnerships between us as a department and other government departments, non-governmental organisations and research institutions such as yours.
Let us remember that the following are the main targets for global TB control that:
* the incidence of TB should be falling by 2012 (MDG target 6.c)
* the prevalence and death rates should be halved by 2015 compared with their level in 1990
* at least 70% of incident smear-positive cases should be detected and treated in DOTS programmes
* at least 85% of incident smear-positive cases should be successfully treated
Let me focus on a few critical areas of our TB programme:
1. National TB Strategic Plan
Our plans coalesced into a comprehensive single national TB strategy that we launched in 2007. This strategy should guide our efforts and hopefully those of our partners in addressing TB. This strategy sets out with some detail what needs to be done to further strengthen our TB control programme. It addresses, amongst others, issues related to nutrition, healthy lifestyles, infection control, community participation and inter-sectoral collaboration. We advise that all of our partners, including participants in this meeting, should use these policies and strategies. Ensuring that we all work from the same blueprint will not only ensure better coordination, but also to maximise our collective impact in this important fight against TB.
2. Policies that improve access to diagnosis and effective treatment
Access to correct diagnosis and early effective treatment is based on approved policies and guidelines, specifically those dealing with the general management of TB. Guidelines for the control and management of ordinary TB have been revised and are currently being used in all of our facilities.
Final draft guidelines on drug resistant TB have been prepared and are to be finalised and implemented before the end of this year. Although our current policy instructs us to hospitalise all diagnosed drug-resistant TB patients, resource limitations, especially, limited hospital beds, have forced us to have a re-think on the policy.
The department is currently reviewing models of community-based treatment of MDR patients, from countries such as Peru and the Philippines with the intention of adjusting our hospitalisation policy so that, where appropriate, MDR-TB patients can be treated in the community. We hope to make decisions on this in the near future.
In taking these decisions, we will also be mindful of the statement of the World Health Organisation (WHO) Regional Committee for Africa made at its 59th Session held in Kigali, Rwanda, when it met on 31 August to 4 September 2009, which states that:
"in most TB control programs, there is a general lack of infection control at community and health facility level that is necessary for reducing transmission of TB, MDR-TB and XDR-TB. This is a result of the introduction of short-course chemotherapy as the treatment of choice in 1993 which deviated from the policy of isolating TB patients during treatment. The recent upsurge of MDR-TB and XDR-TB has, however, raised awareness about the need to re-introduce stringent infection control measures to break transmission of all forms of TB in communities and health-care settings."
South Africa participated in the validation of the line probe assay for rapid diagnosis of MDR-TB developed by the Foundation for Innovative New Diagnostics (FIND) which is currently being implemented in South Africa. This technology will both improve the sensitivity and specificity of tests done as well as reduce the turnaround time for results.
3. National and sub-national health laboratory networks, including human resources capacity
There are 364 microscopy sites and 1 supranational laboratory in South Africa. In addition, there are 15 culture and Drug Sensitivity Test (DST) laboratories that have enabled the country to exceed the global norm of 1 laboratory for every five million people. However, Turn-around-Times (TAT) need to be significantly improved from the current 62% of health facilities receiving their results within 48 hours.
The large proportion of TB patients, estimated by the WHO to be about 30%, is still being diagnosed clinically and/or through radiological investigations. This is a major concern. We are accelerating training and other forms of intervention to discourage this practice.
4. Human resources
The decline in the production of human resources complicated by migration, with health professionals immigrating to other parts of the developed world severely undermines capacity. The decision by government to re-open nursing schools and some of the nurse training institutions that were previously closed, combined with other strategies is expected to significantly improve our human resources capacity but in the medium to long term.
5. Procurement and the management of TB medicines supplies
Although second line anti-TB drugs are expensive, South Africa provides TB treatment to all its citizens without any user charges. Centralised tendering and provincial stock management and storage has ensured regular, uninterrupted drug supply and management with stock-outs greatly minimised.
6. Drug resistant TB
The onset of both multi-drug TB (MDR) and extremely drug resistant TB (XDR-TB) and their lethal combination with HIV in some areas of the country pose major challenges for the future, possibly in a manner that this country has never faced before. Their management demand more from health workers than what they ordinarily are required to offer, as they have to maintain the delicate balance of respecting patient's human rights (including the right of free movement) and the need to ensure public health safety in view of a fatally contagious ailment. The associated problems of compromised psychosocial well being of infected patients place additional strain as health workers often have to extend their service into areas that their training may not have adequately prepared them for.
7. Infection control
Although there are infection control policies and guidelines with better compliance in drug-resistant treatment units, there are major lapses in many institutions, including general hospitals. Smear positive patients are usually found in open wards, mixed with susceptible patients, including HIV positive, diabetic and elderly patients.
In response, the department is pushing for more intensive training on infection control in partnership with other institutions, including the CSIR. Existing policies and guidelines will be tailored to specific health facilities with individualised action plans.
8. Mobilisation of financial resources
South Africa has continued to increase resources for TB management, with some of the funds earmarked for specific needs, including infrastructure development. However, we are still far from resource levels demanded by our National TB Strategic Plan. Although costing studies still have to be undertaken to determine financial resources being spent on TB, the National Treasury estimates that about R1,8 billion is available, mainly through provinces for TB.
This is well below the R4,5 billion the National Strategic Plan estimated is required for successful control and management of TB. In the meantime, successful funding bids to international funders have injected additional resources. For example, funds have been received from the Global Fund to construct additional drug-resistant TB units in seven of the nine provinces, altogether to provide an additional 350 beds.
In conclusion, we should accept that we are not making good progress. We run the risk of not being able to meet our Millennium Development Goals (MDGs). We need to redouble our efforts and improve our outcomes. Let us remember that TB is more than a medical problem. It is worsened by poverty and poor socio-economic conditions, poor nutrition, overcrowded housing, and poor working conditions such as in dust filled mines and general stress. Solutions will therefore always require multi-sectoral partnerships that straddle government, researchers, civil society organisations, academic institutions, researchers and communities in general.
In this regard, we are pleased that the organisers of this meeting saw it appropriate to request our participation. We look forward to hearing about the conclusions from your deliberations, and more importantly suggestions on how we can, together with you, continue to make sustainable improvements in our response to the TB epidemic.
We request that you familiarise yourselves with the 2009 Health Sector Programme of Action and the Ten Point Plan and decide on what contributions you will make to make these a success.
We value your partnership. We believe that together with you, we can do more.
Thank you.
Issued by: Department of Health
12 October 2009
Source: Department of Health (http://www.doh.gov.za)
