Tuberculosis in South Africa
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Greetings from Cape Town,
in 1993, the WHO declared Tuberculosis (TB) a global emergency. In South
Africa Tuberculosis was declared the top national health priority by the
Minister of Health late last year. Subsequently TB was declared a
provincial emergency in the Western Cape Province. TB was the topic of
several sessions at the 18th African Health Science Conference currently
taking place in Cape Town.
Dr. Bernard Fourie, the Programme Leader of the National Tuberculosis
Research Programme of the Medical Research Council in South Africa
presented a gloomy picture of the future trends in the TB epidemic in his
country. With disease rates up to 60 times higher than what is currently
seen in the USA or Western Europe, South Africa is experiencing a
tuberculosis epidemic which is among the worst in the world. Whereas the TB
rate countrywide is 340 cases per 100 000 population, for the Western Cape
it is 511 cases per 100 000. Reasons for this are poverty, poor housing
conditions, the inadequate management systems, compounded by a legacy of
fragmentation of the health service and the consequences of the HIV-
epidemic.
In 1996, at least 25% of TB cases in South Africa had been directly
attributable to them having been infected with HIV. In some parts of the
country (Kwazulu-Natal) co-infection rates already exceed 40%. HIV-
infection will increasingly be responsible for producing a large load of
surplus TB cases over the next decade, with co-infection in TB cases
reaching more than 70% in 2005.
By then 13 in every 1000 South Africans (roughly 640 000 persons) will be
actively suffering from Tuberculosis, which is by then 4.5 times the
current rate in the country and 150 times that of the USA. Of the 13, nine
will also be HIV-infected and face premature death.
At most, 60% of all the TB cases are likely to be cured of their disease,
despite a treatment regimen which is very nearly 100% efficacious. The
financial implications are staggering: Given the approximately 500 million
Rand (1 US $ = 4.4 R) which was expended on TB in 1995, South Africa would
require R 18 billion over the next 10 years to only continue employing
current TB control strategies.
Some hospital based data from a rural district, presented by Dr. David
Wilkinson from the Centre for Epidemiological Research in South Africa
(CERSA) clearly supported the above outlined trends. Between 1991 and 1995
annual TB caseload in the rural Hlabisa health district in South Africa
increased from 301 to 839 cases. TB accounted for 4.7% of all hospital
admissions in 1989 and 8.3% in 1995. Incidence of TB increased from 145/
100 000 in 1991 to 413/100 000 in 1995 and the proportion of TB cases
attributable to HIV infection was estimated to be at least 44% in 1995.
Regarding treatment of TB, a randomised controlled trial of the effect of
clinic, community and self supervision of TB treatment on treatment
outcome, presented by Dr. J.H. Schoemann failed to show any difference
between the respective supervision methods and treatment outcome. This
could mean that the least expensive supervision method (self supervision)
is as effective as clinical treatment supervision.
Finally, H.v.d.Walt presented some thoughts about task-orientation versus
patient-centred care in the TB control programme. She cautioned that the
ritualistic task orientation of the clinic work (throwing the tablets into
the patient) worked against the ideals of patient centred care. Especially
Direct Observed Treatment (DOT) needs to be freed of police-like behaviour
of staff otherwise it might contribute to non-adherence to therapy.
Dr. Fourie is going to establish a communication network (conference list,
WEB page etc.) for those interested in TB in Southern Africa.
We shall announce the details later on AFRO-NETS.
Regards,
Dieter Neuvians
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