TB in South Africa
South Africa has one of the most serious TB epidemics in the world. A major TB epidemic in the pre HIV era has been followed by a rising number of TB cases as a result of HIV and TB co-infection. In addition there is now increasing resistance to some of the anti TB drugs.
TB the leading cause of death in South Africa
TB is the leading cause of death in South Africa with over 60,000 deaths notified in 2010.1 The World Health Organisation (WHO) estimates that in 2011 there were more than 500,000 cases of active TB disease, of whom an estimated 330,000 cases also had HIV infection.2 An estimated 80% of the South African population has latent TB.3
In South Africa TB is not spread evenly, disproportionally affecting males, the poor, the young and the non-white population groups.
The background to the TB epidemic in South Africa
TB incidence in South Africa rose steadily in the 20th century, peaking first in the 1960s with an incidence rate of over 350 cases per 100,000 population. There was then a decline in the 1970s (probably due to the exclusion of data from the black homelands) followed by a resurgence in the late 1990s.4
Health services in the apartheid era
Health services in the apartheid era
In South Africa during the apartheid era there had effectively been a dual health system, with a highly sophisticated service for the urban mainly white people which consumed 97% of the health budget, and a primitive health centre system for the majority black population.5
The health system for black people was ill equipped and lacked any commitment to TB control. The inadequate health services were directly responsible for under treatment of patients. For many years standard treatment consisted of a 12 or 18 month period in hospital taking para acid, isoniazid and streptomycin.
Even when care became "ambulatory" (out patient care) to save hospital costs and supposedly make it easier for patients, services were still generally hospital based, meaning that patients had to travel long distances to facilities making treatment inaccessible and unaffordable. In addition drug supplies were erratic in many areas, all of this contributing to a lack of cure for patients and the risk of them developing resistance.6
Multi drug resistant TB (that is resistance to two or more anti tuberculosis drugs) had emerged in South Africa by the 1980s, but was not thought to be a major problem.7 8 XDR TB (using the 2006 revised definition) was prevalent in the Western Cape as early as 1992.9
The evolving HIV epidemic in South Africa
From 1982 when the first case of AIDS was described in South Africa, until 1994 little was done by the apartheid government to contain the HIV epidemic. The first cases of AIDS in South Africa were identified in gay men, and the widespread belief that AIDS was a disease of gay men led to a sense of complacency in the general population and an excuse for the apartheid government not to act promptly.
The need for a community based HIV/AIDS program was first publicly acknowledged in 1990 by the Maputo statement on HIV and AIDS in southern Africa, issued jointly by the banned and exiled ANC and a range of anti apartheid organisations.10
TB in South Africa as apartheid comes to an endTB patient with their DOTS treatment supporter
A TB patient with their DOTS treatment supporter in Mpumalanga ©WHO/TBP/Gary Hampton
The major changes to TB control started in 1994 when South Africa enlisted expert outside help for the first time with a visit by Dr KarelStyblo, ex-director of scientific activities at IUATLD, to perform a rapid appraisal of the TB situation. He found that, amongst other things, the national policy (established in 1979) was not implemented, there was a lack of focus on infectious (smear positive cases) and the information system was inadequate.11
In 1995 a revised National Tuberculosis Control Programme (NTCP) was established based on the Directly Observed Short Course (DOTS) strategy of WHO, followed later in the year by guidelines for it's implementation. It aim was also to gradually replace the non-standardised short -course chemotherapy that had been applied throughout the country for several years.12 In 1995 a delegation of the WHO TB programme had visited South Africa to help establish Mpumalanga as a "pilot" province for the new programme.13
The 1996 Joint TB Programme Review
In 1996 the government of South Africa requested the assistance of the World Health Organisation in carrying out an evaluation of TB epidemiology and control activities with the aim of producing recommendations to improve TB control in South Africa.14
The review found that with an estimated population of 41.4 million and an estimated 130,000 TB cases in 1995, South Africa had one of the highest annual TB incidences (311 per 100,000 population) in the world. The TB incidence did however vary dramatically by both geographical region and population group.
Annual TB case rates per 100,000 population for different population groups 1995
The annual tuberculosis case rates per 100,000 population for different population groups were:
713 for Coloureds
207 for Blacks
51 for Asians
19 for Whites
Reported TB case rates & estimated smear positive (SM+) pulmonary TB incidence 1995
Province Reported all forms of TB (rate per 100,000 population) Estimated SM+ (rate per 100,000 population) Proportion of total population Proportion of all cases HIV + (%)
Western Cape 737 221 0.09 2.9
Eastern Cape 241 193 0.16 11.3
Northern Cape 442 133 0.02 4.5
Free State 513 103 0.07 23.0
Kwazulu Natal 120 129 0.21 35.9
North West 112 102 0.08 16.8
Gauteng 164 142 0.17 16.1
Mpumalanga 84 101 0.07 30.4
Northern Province 44 102 0.13 7.6
Total 223 140 1.0 18.9
The proportion of TB cases that were also HIV positive was also alarmingly high, particularly in the South African provinces of Kwazulu Natal and Mpumalanga.
The findings of the TB programme review were that there were both strengths and and weaknesses in the South African Tuberculosis Control Programme (TBCP). Amongst the strengths were the acceptance by the provinces of the use of the DOTs strategy being incorporated in the national policy guidelines, excellent human and financial resources and health infrastructure, and a reliable drug supply. Amongst the weaknesses were the failure of the national and provincial Department of Health to respond adequately to the TB epidemic, an incomplete implementation of the DOTS strategy, inadequate investment in TB management, and the absence of an appropriate TB microscopy service.
A number of major recommendations were made including that the Department of Health should publicly declare the seriousness of the TB epidemic in South Africa and the urgency of the necessary response.
Some comments were also made about the lack of advocacy and public awareness.
“Considering the severity of South Africa's tuberculosis epidemic, awareness of the problem among policy-makers is surprisingly low. The same interest which exists among journalists, government officials, and NGOs for addressing the AIDS epidemic or childhood immunisations does not currently exist for controlling the tuberculosis epidemic”
A year later, in 1997, there was a follow up visit by WHO to review the progress that had been made.15 In particular a number of Demonstration and Training Districts (DTDs) had been set up around the country to help with the implementation of the new strategy, with it being said by WHO that:
“While there is still a long way to go before TB is controlled in the country, we applaud the efforts to date. South Africa is on the right track”
TB and AIDS
The WHO may have thought that "South Africa is on the right track" but it didn't always seem that way in the public hospitals, where the changes as a result of the AIDS epidemic were becoming increasingly apparent. As one doctor said:16
“The TB ward has increasingly become a place where people come and die. The TB ward used to be somewhere that patients came, they had TB, but they were relatively well. They were given their medications; they then went home to take their medications. Now, what we are finding is that people come to the TB ward, and then they stay a long time and then they die. Or they go home and take their medications and then come back to the hospital to die.”
There were also occasions when patients with AIDS and TB weren't even given the TB medication available in South Africa. Another doctor recalls looking after a patient with AIDS when he was working in a military hospital in 1995.
“At that stage we didn't do anything in the military, nothing; we tested for opportunistic infections, but no definite treatment [for TB]. It was depressing, because we knew he wouldn't make it; and we knew we couldn't give him definite treatment. ”