USAID Tuberculosis South Africa Project - Contract Number
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USAID Tuberculosis South Africa Project
Contract Number: AID-OAA-I-14-00035
Order Number: AID-674-TO-16-00002
Project Quarterly Report
January to March 2019
Submitted 30-April 2019
Submitted by: University Research Co., LLC (URC)
To: USAID Southern Africa
1 | USAID Tuberculosis South Africa Project – Quarterly Report 2 January to March 2019
USAID Tuberculosis South Africa Project Contract information: This project is made possible by the generous support of the American people through the United States Agency for International Development (USAID) under the terms of its Contract Agreement Number: Contract Number: AID-OAA-I-14-00035; Order Number: AID-674- TO-16-00002 (USAID Tuberculosis South Africa Project held by prime recipient University Research Company, LLC. and implemented by sub-recipients BEA Enterprises, Brigham and Women’s Hospital/Harvard/Partners in Health (BWH/PIH), Centre for Communications Impact (CCI) formerly JHHESA, NEXT, World Health Organization (WHO), and University of Pretoria. The USAID TB South Africa Project is funded and managed by the USAID Southern Africa mission. Prepared by: University Research Co., LLC Submitted by: Dr Gregory Jagwer Chief of Party USAID Tuberculosis South Africa Project Tel: +27 12 484 9300 Email: GregoryJ@urc-sa.com Web: https://tbsouthafrica.org.za Submitted to: Ms Cindy Dlamini Project Development Specialist-TB USAID Southern Africa, Health Office Tel: +27 12 452 2330 Email: cdlamini@usaid.gov Web: http://www.usaid.gov/southern-africa-regional For more information: Dr Neeraj Kak, Ph.D. Chief Innovation Officer, Senior Vice President University Research Co., LLC 5404 Wisconsin Ave Suite 800 Chevy Chase, MD 20815 Tel: +1 301 941 8626 Email: Nkak@urc-chs.com Web: www.urc-chs.com 2 | USAID Tuberculosis South Africa Project – Quarterly Report 2 January to March 2019
CONTENTS
Acronyms....................................................................................................................... 4
List of Tables ................................................................................................................. 5
List of Figures ................................................................................................................ 6
EXECUTIVE SUMMARY ............................................................................................. 7
INTRODUCTION ........................................................................................................ 7
ACCOMPLISHMENTS BY INTERMEDIATE RESULTS (IRs) ............................... 10
IR1: TB Infections Reduced ....................................................................................... 10
IR 1.1 Increased public awareness of the TB epidemic ......................................................... 10
IR 1.2 Effective implementation of infection prevention and control ................................ 20
IR 1.3 Improved TB screening, including among key populations ....................................... 26
IR2: Sustainability of Effective TB Response Systems Increased .......................... 27
IR 2.1 Strengthened management capacity at all levels ......................................................... 27
IR 2.2 Strengthened service delivery capacity at all levels .................................................... 29
IR 2.3 Improved data reporting and recording at all levels .................................................. 43
IR 3: Care and Treatment of Vulnerable Populations improved .......................... 47
IR 3.1 Increased contact tracing of key populations .............................................................. 47
IR 3.2 Improved TB case management among key populations .......................................... 49
IR 3.3 Strengthened comprehensive systems and partnerships for care........................... 49
FINDING MISSING TB PATIENTS ......................................................................... 59
PROJECT KEY OUTPUT AND PERFORMANCE INDICATORS ....................... 60
ETR/EDR reports by supported district ................................................................................... 62
ANNEXES ................................................................................................................... 69
Annex I: District 90 90 90 Cascade ........................................................................................... 69
Annex II: Financial Report ............................................................................................................ 79
3 | USAID Tuberculosis South Africa Project – Quarterly Report 2 January to March 2019
Acronyms ACSM Advocacy, Communication and Social Mobilization AFB Acid Fast Bacilli AIDS Acquired Immune Deficiency Syndrome ART Antiretroviral Therapy BC Bacteriological Coverage CHW Community Health Worker CO2 Carbon Dioxide CPT Cotrimoxazole Preventative Therapy CQI Continuous Quality Improvement DM Diabetes Mellitus DOT Directly Observed Treatment DOTS Directly Observed Treatment, Short Course DR-TB Drug-Resistant Tuberculosis DS-TB Drug-Susceptible Tuberculosis DVE Data Verification Exercise ETR Electronic Tuberculosis Register GXP GeneXpert® MTB/RIF (Xpert) HCT HIV Counseling and Testing HIV Human Immunodeficiency Virus ICSM Integrated Clinical Services Management IC Infection Control IEC Information, Education and Communication IPC Infection Prevention and Control IPCC Interpersonal Communication and Counselling IPT Isoniazid Preventive Therapy LDHF Low-Dose High-Frequency M&E Monitoring and Evaluation MDR-TB Multi-Drug Resistant Tuberculosis NDOH National Department of Health NGO Non-Governmental Organization NTP National Tuberculosis Control Program PEPFAR United States President’s Emergency Plan for AIDS Relief PMDT Programmatic Management of Drug-Resistant Tuberculosis PPP Public-Private Partnership PTB Pulmonary Tuberculosis QI Quality Improvement QIP Quality Improvement Plan RTCs Regional Training Centers RR Rifampicin Resistant SCR Smear Conversion Rate SOP Standard Operating Procedure STI Sexually Transmitted Infection TAT Turnaround Time TB Tuberculosis TOT Training of Trainers URC University Research Co. LLC USAID United States Agency for International Development WBOT Ward-Based Outreach Teams WC PDC Western Cape People Development Centre WHO World Health Organization XDR-TB Extensively Drug-Resistant Tuberculosis 4 | USAID Tuberculosis South Africa Project – Quarterly Report 2 January to March 2019
List of Tables
Table 1: IEC Distribution figures............................................................................................................................................... 12
Table 2: Project radio interviews and people reached ........................................................................................................ 17
Table 3: TB cascade in FAST hospitals from October 2017 to March 2019 ................................................................. 21
Table 4: Urinary lipoarabinomannan results in HIV patients, Eastern Cape, Free State and KwaZulu- Natal
provinces Q2 (January-March) 2019 ............................................................................................................................. 23
Table 5: Summary of results for Oct-Dec -2018, Limpopo is presented in the table below. ................................... 23
Table 6: Fezile Dabi chart audit findings .................................................................................................................................. 35
Table 7: Chart Audits in Waterberg ........................................................................................................................................ 36
Table 8: Details of the training numbers by district against targets Q1 and Q2 .......................................................... 43
Table 9: Adult contact management conducted by funded grantees ............................................................................... 48
Table 10: Child contact management conducted by funded grantees ............................................................................. 48
Table 11: TB Case finding by private GPs (Jan-Mar 2019) ................................................................................................. 51
Table 12: TB in Farms Jan – Mar 2019 Cascade data .......................................................................................................... 53
Table 13: Cascade data for people reached by grantees in Q1 & Q2 2019 .................................................................. 56
Table 14: Grantee Support and Supervisory visits conducted .......................................................................................... 57
5 | USAID Tuberculosis South Africa Project – Quarterly Report 2 January to March 2019
List of Figures
Figure 1: USAID TB South Africa Project Results Framework ........................................................................................... 9
Figure 2: Mrs S.M Hlabisa giving Health & awareness talk on TB symptoms at Lutheran church. .......................... 10
Figure 3: USAID Mission Director John Groarke addressing the crowd at the nation WTBD event in East London.
................................................................................................................................................................................................ 13
Figure 4: Minister of Health Dr. Aaron Motsoaledi at the project stall during the national WTBD commemorative
event in East London......................................................................................................................................................... 14
Figure 5: West Coast HCWs conducting door-to-door campaign as part of WTBD activities. ............................. 16
Figure 6: A TB survivor sharing her TB journey during a TB Day event in Boland. .................................................... 16
Figure 7: USAID TB South Africa Project Limpopo Provincial Manager having an interview. .................................. 17
Figure 8: The We Beat TB South Africa Facebook page .................................................................................................... 19
Figure 9: Percentage screened, tested and initiated on treatment in FAST hospitals April 2017 to March 2019
................................................................................................................................................................................................ 21
Figure 10: FAST TB Screening and case detection October 2017 to March 2019 ...................................................... 22
Figure 11: TAT and Time to initiation in days in FAST program in PMMH June to October 2018 ........................ 22
Figure 15: Project Coordinator and Villiers cluster team .................................................................................................. 34
Figure 16: Philadelphia Gateway clinic QIT ............................................................................................................................ 36
Figure 17: Motetema clinic QIT ................................................................................................................................................ 36
Figure 18: Dr Ongole orientating health worker at KwaMakutha CHC on the yellow file ...................................... 42
Figure 19: Dr Ongole facilitating a session at ........................................................................................................................ 42
Figure 20: Private GPs TB Cascade Progress ........................................................................................................................ 50
Figure 21: Mpilonhle Community Healthcare Worker providing services during the campaign at uMfolozi Sugar
Milling .................................................................................................................................................................................... 53
Figure 22: TB in Farms Q1 & Q2 2019 Cascade data ......................................................................................................... 53
Figure 23: TB screening at Lanseria taxi rank ........................................................................................................................ 54
Figure 24: TB screening at Kolonade taxi rank ..................................................................................................................... 54
Figure 25: Taxi Industry quarterly data comparison (FY3: Q1&Q2) ............................................................................... 54
Figure 26: Risk stratification Team with Missionvale staff: NMBHD ............................................................................... 57
6 | USAID Tuberculosis South Africa Project – Quarterly Report 2 January to March 2019
EXECUTIVE SUMMARY
The United States Agency for International Development (USAID) Tuberculosis South Africa
Project (2016-2021) has the primary objective of providing technical assistance to the
Government of South Africa (GoSA) to reduce the burden of tuberculosis (TB) in the country.
The intermediate results are to reduce TB infections, increase sustainability of effective TB
response systems, and improve care and treatment of vulnerable populations, as shown in the
figure below.
Intermediate Result 1: TB infections Reduced
The USAID TB South Africa Project continued work to
The USAID TB South Africa
reduce TB infections this quarter. Notably, the project
Project screened
trained 110 health care workers and facilitated interpersonal
communication and counseling for 2,179 patients. As well, the
project distributed 124,715 information, education and
102,640
communication materials this quarter. As the premier USAID people through
technical assistance partner in the country, the USAID TB World TB Day events alone
South Africa Project provided support to national and
provincial-level World TB Day events and screened 102,640 people, identified 6,772
presumptive patients and diagnosed 385 additional people with TB.
The project scaled up implementation of “Finding cases Actively, Separating safely and Treating
effectively” (FAST) strategy in 142 facilities nationwide as part of a comprehensive infection
prevention and control package. Innovative strategies like Urine-Lipoarabinomannan, home
risk assessments, carbon dioxide monitors, latent TB infection research and Rif alert
implementation continued this quarter.
Intermediate Result 2: Sustainability of Effective TB Response Systems Increased
The USAID TB South Africa Project continued technical
assistance provision on continuous quality improvement and The USAID TB South
Africa Project trained
training of HAST managers this quarter, having trained 691
additional staff. Engagement with Regional Training Centers
continued through stakeholder meetings and planning meetings 691
on FAST. Chart audits and data quality assessment activities additional staff
continued this quarter. As well, implementation of the DR-TB in this quarter alone
initiatives continued.
Intermediate Result 3: Care and treatment of vulnerable populations improved
The project continued its work toward improving care and
The USAID TB South treatment among vulnerable populations, having scaled up
Africa Project screened contact management activities for 4,390 contacts of 1,789 index
patients. 95% of contacts were screened, 82% of presumptive
75,409 patients were tested, and 97% of those who tested positive were
started on treatment. Through private providers, the project
people through the screened 27,677 people this quarter alone, initiating 135
small grants program in additional patients on TB treatment. Work with PEPFAR
this quarter alone District Support Partners continues along with activities
designed to reach farming communities and the Department of
Transport. The small grants component has funded 26 local non-governmental organizations
7 | USAID Tuberculosis South Africa Project – Quarterly Report 2 January to March 2019
through the end of this quarter, and has facilitated screening of 75,409 people, of whom 75%
were tested. Of those testing positive, 83% (n=167) were started on treatment.
Finding the Missing TB Patients
The USAID TB South Africa Project has been leading the
The USAID TB South
Africa Project identified
implementation of the missing TB patients’ activities, providing
technical leadership to the NDOH. During the reporting
3,967 period, the project continued to implement activities to
contribute to the government’s efforts in identify missing cases.
missing TB patients This quarter alone, the project has identified 2,090 additional
in this project year alone missing TB patients, which amounts to a total 3,967
missing TB patients since the beginning of FY19.
Achieving the 90-90-90 Targets
The project continued work toward achieving the In USAID TB South Africa Project
90% of head count screened for TB, 90% of those districts this quarter
with symptoms tested for TB, 90% of clients
diagnosed with TB put on treatment and 90% of
those started on treatment successfully complete
79%
Of all headcount was screened for TB,
treatment targets this quarter. Among all project
districts between October and December 2018,
79.1% of the total headcount was screened for TB.
93%
of those with symptoms were tested for
Of those with symptoms, 92.7% were tested for TB, TB, and
and among those who tested positive for TB, 82.7%
were started on treatment. Notably, only 4.7% of
patients were initially lost to follow up, and
83%
of those who tested positive for TB
only 0.2% of patients died before treatment started treatment
started.
8 | USAID Tuberculosis South Africa Project – Quarterly Report 2 January to March 2019
INTRODUCTION
The United States Agency for International Development (USAID) Tuberculosis South Africa
Project (2016-2021) has the primary objective of providing technical assistance to the
Government of South Africa (GoSA) to reduce the burden of tuberculosis (TB) in the country.
The project builds on the activities of the USAID Tuberculosis Program South Africa (2009-
2014) and the USAID TB CARE II project (2014-2015). The objectives of the project are to
reduce TB infections, increase sustainability of effective TB response systems, and improve
care and treatment of vulnerable populations, as shown in the figure below.
To achieve these
objectives, the
project is guided
by the World
Health
Organization’s
(WHO) End TB
Strategy. It
promotes an
effective multi-
sectoral
approach to TB
and
strengthening of
health systems to Figure 1: USAID TB South Africa Project Results Framework
improve the
quality of TB care in South Africa and expands patient-centered care as guided by the national
Integrated Clinical Services Management (ICSM) Model of Care.
The GoSA continued to prioritise finding the ‘missing TB patients’ as a key strategy to achieve
meaningful gains in ending the TB epidemic. The ‘missing TB patients’ pose a major obstacle
to achieving End TB Strategy targets by 2035 and will require further effort and resources.
This, therefore, remains an urgent priority to identify patients and provide effective linkage to
care.
Key NDOH interventions to identify
The USAID TB South Africa Project is a key partner to Missing TB Patients
the National Department of Health (NDoH) which, 1. Optimized TB screening
among others, supports initiatives to identify missing TB • Facility
• Community (hotspots)
cases. Activities to find missing TB cases are linked to 2. Efficient contact tracing of index cases
the National Health Screening and Testing Campaign, 3. Enhanced case detection among key
populations
which aims to diagnose people with HIV, TB, Diabetes • HIV positive pregnant women
Mellitus (DM) (diabetes) and hypertension as the first • Newly diagnosed HIV positive
patients
step to initiating them on appropriate treatment. The 4. Improving diagnostic yield through new
project led in the development of operational plans and diagnostic tools and revised algorithms
• GXP ultra
engagement of provinces for implementation. • Urine LAM
5. Improved quality standards in recording
This quarterly report outlines key activities and and reporting and tracking patient
transfers between facilities.
achievements of the USAID TB South Africa Project • CQI
between 1st January and March 31st, 2019, which is 2 • Record updates/ DQA/DVE
(QF), Financial Year 3, FY3.
9 | USAID Tuberculosis South Africa Project – Quarterly Report 2 January to March 2019
ACCOMPLISHMENTS BY INTERMEDIATE RESULTS (IRs)
IR1: TB Infections Reduced
The project continued to prioritize health promotion and communication in healthcare
facilities, communities and to the public to contribute to reducing TB infections through
sharing information about TB prevention and supporting adherence to treatment.
Communication focuses on promoting screening for TB, improving follow-up of patients who
drop out of treatment, stronger infection control in healthcare facilities and congregate
settings, effective treatment, and advocacy and social mobilization to increase public
awareness of the risks of contracting TB, and of effective prevention measures.
IR 1.1 Increased public awareness of the TB epidemic
To increase public awareness of the TB epidemic, USAID TB South Africa Project continued
to implement strategies to promote and provide capacity building support for advocacy,
communication and social mobilization (ACSM) activities. Increasing and improving the roll-
out of ACSM activities brings the extent of the TB epidemic and its impact on national
productivity and individual lives to the forefront of public attention. Patient adherence support
is further enhanced by working with national and district TB ambassadors in encouraging and
influencing people to seek treatment and TB patients to complete treatment. Specific
interventions implemented towards this end are elaborated below.
1.1.1 Expand implementation of targeted infection prevention and control
campaigns in high TB burden areas to contribute towards finding the missing TB
cases
The project continued to roll out targeted community activations and
dialogues as a strategy to ensure community and patient-led
communication around TB. Infection prevention and control (IPC)
campaigns were conducted in identified TB high burden areas in
supported districts. Campaigns contribute to improving TB
knowledge, encouraging uptake of services and supporting initiatives
to find missing TB patients in South Africa. During Q2, the project
implemented 95 IPC campaigns, reaching 13,740 people directly with
health communication. Through these campaigns, 53 new TB patients
were identified and linked to care across 12 districts (Waterberg,
West Coast, eThekwini, Sekhukhune, OR Tambo, Mangaung, Fezile Figure 2: Mrs S.M Hlabisa
giving Health & awareness talk
Dabi, Sarah Baartman City of Johannesburg, Tshwane, uMkhanyakude on TB symptoms at Lutheran
and Nelson Mandela Bay Metro) in six provinces. church.
10 | USAID Tuberculosis South Africa Project – Quarterly Report 2 January to March 20191.1.2 Scale-up implementation of patient-centered inter-
personal communications and counselling (IPC/C) The USAID TB South
package to improve retention in care Africa Project trained
There is evidence that patient-centered communication positively 110
impacts treatment outcomes (www.healthaffairs.org). The USAID health care workers and
TB South Africa Project developed an Interpersonal
Communication and Counselling (IPC/C) package to improve
capacities of healthcare workers to offer comprehensive support
2,179
Patients received IPC/C
and education to TB patients. It also helps families and patients to in this quarter alone
communicate about TB prevention, treatment adherence and
stigma at community level.
A focus during the period under review, implementation of the IPC/C package was focused
on improving and monitoring the quality of counselling provided to patients by healthcare
workers in facilities. In total, 110 healthcare workers (HCWs), including professional nurses,
community care workers. Training was done in Mangaung, Sarah Baartman and OR Tambo
districts were trained using the package. The rationale of this intervention is that they would
contribute to improvements in adherence to treatment, patient retention in care and
improved outcomes. During the reporting period, 2,179 TB patients received quality
counselling from healthcare workers who were trained using the package. Patients were
counselled on adherence, side effects of TB medication and nutrition, among others. Following
training, project coordinators regularly conducted on-site monitoring of counselling practice
to ensure appropriate and patient-centered implementation in all sites where HCWs were
trained.
1.1.3 Develop new and innovative messages to respond to district-level TB
challenges and disseminate via national and community media channels (e.g.
radio, television, billboards, store facia, rank TV, transit TV, mHealth apps)
The project continues to implement innovative interventions to create awareness about TB.
In Sarah Baartman, the project is facilitating the engagement of two theatre groups in Makana
Sub-District who will perform in identified strategic places, such as schools and farms, to
create awareness. A schedule for the month of April 2019 was developed and what remains
is the final approval of the group’s engagement. Implementation will, therefore, take place in
Q2.
Material development and dissemination
Patient education is at the center of the project’s efforts to improve TB IPC. World TB Day
was commemorated nationally and globally during the period under review. The project
supported national and provincial commemorative events with information, education and
communication (IEC) materials in respective local languages for dissemination during build-up
activities and commemorative events. The following IEC materials were distributed;
11 | USAID Tuberculosis South Africa Project – Quarterly Report 2 January to March 2019Table 1: IEC distribution figures
Item/description Quantity
TB diaries 105
TB in farms smart cards 6,400
TB brochures 79,800
TB smart cards 21,250
TB in farms posters 350
Buddy comic books 140
TB patient diagnostics booklet 400
DR-TB patient counselling flip chart 245
DR- TB patient counselling booklet 750
IPC posters (mask poster) 275
TB is curable message pins 5,000
Know your status key rings 5,000
TB is curable car license discs 5,000
124,715
1.1.4 Build capacities of DOH program managers (TB/HIV, PMTCT, NCDs, etc.)
and managers of funded NGOs in supported districts on ACSM
No activities were carried out this quarter, as implementation focused on World TB Day
commemorations.
1.1.5 Continue to increase TB awareness through commemoration of key
national health days: World TB Day, World Diabetes Day and, World AIDS Day
The project provided strategic support to national and provincial commemorative activities,
working closely with the National Department of Health and Provincial Department of Health
in all supported provinces. Independent and targeted activities to raise awareness of TB were
also conducted in supported districts. The global theme for this year’s World TB Day was
‘It’s Time…’
The project’s commemorative events around the national World TB Day commemoration
was two-fold, in line with the expanded theme adopted by South Africa, which was: ‘It’s time
for Religious Leaders and Parliamentarians to lead the fight to End TB in South Africa’. The first
event was on held on March 24t, at the Anglican Cathedral in Cape Town, Western Cape
province. The main national commemorative event was hosted on March 28th, at Sisa Dukashe
Stadium, Mdantsane, East London in Eastern Cape province. The project’s support was
predominantly geared towards the main event in East London, which had wider community
reach because it was an open stadium event.
12 | USAID Tuberculosis South Africa Project – Quarterly Report 2 January to March 2019The national event was led by the Minister of Health, Dr Aaron
Motsoaledi. The project facilitated the invitation of Mr John
Groarke, USAID Mission Director, as a speaker on the main
programme of the day and other activities and participation in other
activities with other invited guests. Mr Groarke shared a message of
support during the event, outlining the contribution of USAID to the
fight against TB in the country.
Although the national commemoration
The USAID TB South
of World TB Day was hosted in a non- Africa Project reached
project supported district, the project
Figure 3: USAID Mission Director
John Groarke addressing the supported all build-up activities with IEC
crowd at the nation WTBD event materials in response to requests by the
139,567
in East London. Screened
Provincial DOH. During build-up
activities, 121,260 people were reached with TB education and
screening services. A total of 97,685 people were screened for
102,640
Identified
TB, 376 new TB patients were found out of 6,540 clients with
presumptive TB. The project’s Eastern Cape staff members
participated in the event and provided TB screening services
6,772
Presumptive patients
during the main event. On March 24th at Sisa Dukashe Stadium, and diagnosed
project staff reached 560 people with information, screened 308
of them and identified 61 presumptive clients who were referred 385
for testing. The project also distributed 4,000 IEC and People with TB
promotional items on the day.
13 | USAID Tuberculosis South Africa Project – Quarterly Report 2 January to March 2019From the World TB Day activities in other districts,
8,091 people were reached, 4,955 were screened for
TB and 234 clients with presumptive TB identified. A
total of 232 presumptive people was either tested or
referred for further investigation. At the time of
compiling the report, only nine positive clients had been
found and linked to care.
Figure 4: Minister of Health Dr. Aaron Motsoaledi
at the project stall during the national WTBD The project also supported provincial commemorative
commemorative event in East London. events, as described below:
KwaZulu-Natal
uMkhanyakude
USAID TB South Africa Project District Coordinator, Mr. Zamani Dlamini, was the guest
speaker at the district commemorative event held at Hlabisa Hospital. He shared the work of
the project in the area, highlighting how the project works closely with the district DOH on
project initiatives. The address touched on the importance of increasing TB awareness and
case finding among key populations. A total of 168 people participated in the event. A total of
22 people consented to be screened for TB, although none tested positive.
eThekwini
The USAID TB South Africa Project participated in three
activities in this supported district. These include a
provincial TB indaba (traditional seminar) organized by the
Office of the President, on March 4th, 2019, which was also
a build-up event for the provincial World TB Day event
where the provincial TB Prevention Campaign as launched.
Participants included traditional leaders, traditional health
practitioners, religious leaders and ward councilors. The
indaba aimed to derived district-specific solutions to
address TB through facilitating inclusive dialogue with key
stakeholders for an enhanced multisectoral response to the
TB epidemic in the area. The project was also represented
in the provincial World TB Day commemoration held on
March 15th, 2019. King Goodwill Zwelithini of the Zulu
graced the event, and Deputy President David Mabuza,
United States Consul General Sherry Sykes participated in the event. Ms Sykes delivered a
message of support, participated in a television interview, to further spread the information
about the United States support for the Government of South Africa in the fight against TB.
The indaba focused on the role of traditional leaders as key players in the fight against TB. As
part of the day’s activities, dignitaries visited 10 households of TB patients, and the project
supported this activity by disseminating TB patients with ‘My survival kits’. These kits contain
various necessities for TB patients, including pill boxes, IEC materials, tissues to cover their
cough and masks. USAID TB South Africa Project-funded NGOs, Breakthru Community
14 | USAID Tuberculosis South Africa Project – Quarterly Report 2 January to March 2019Action (BCA) and Muslim AIDS Programme (MAP), provided TB screening services on the day of the event. Fezile Dabi The project supported TB activities over a two-month period in Ngwathe and Moqhaka local areas. The first was a joint inter-sectorial TB Jamboree at Mosipidi Hall and a taxi rank activation conducted by Tokoloho Foundation on March 14th, 2019. The second event was an awareness campaign by Viljoenskroon Hospice on March 20th, 2019 at Seeisoville Stadium. Waterberg The district hosted three World TB Day-linked activities: an awareness campaign at Modimolle DR TB hospital, a TB activation at Modimolle Taxi Rank and a campaign at Bela Bela Clinic. Tshwane During March, TB screening and HIV testing services were conducted in Winterveld and surrounding areas as part of build-up activities for the provincial World TB Day commemorative event, which was also planned to take place in Winterveld. A total 3,393 people were screened for TB and 72 collected sputa was tested, but no results had been received by the time of writing this report. The project also participated in an event hosted by Pretoria West District Hospital, which comprised an awareness-raising and TB screening campaign on March 8th, 2019. The campaign targeted all people coming to the hospital, including visitors and staff members. A total of 507 patients and visitors were reached and screened for TB;171 staff members were screened (total 678) and 44 TB presumptive clients were identified. Of those identified, 42 were tested but none were positive for TB. The project also participated in the Odi District Hospital commemorative event held on March 26th, 2019. City of Johannesburg A World TB Day event was conducted at South Rand District Hospital on March 27th, 2019. Health education on TB was provided to patients visiting the hospital. A total of 150 people were reached, 86 people were screened, 16 presumptive clients were identified and 12 were tested through GeneXpert. All samples were negative, and four people were referred to the out-patient department (OPD) for further investigations. Sarah Baartman Project-funded grantee, KwaNomzamo HBC conducted a World TB Day event on March 27th in Humansdorp, reaching 75 people. The purpose of the event was to educate people about TB, create general awareness about the disease and screen community members in attendance to identify presumptive clients. Only 12 people were screened, identifying three presumptive clients who subsequently tested negative for TB. Mangaung World TB Day was commemorated on different days in Mangaung. The provincial event was held on 24th March in Qwaqwa. The project provided TB screening services and shared TB information. Data from the event was still outstanding at the time of reporting. On March 20th, World TB Day was commemorated at Red Church in Khayalisha informal settlements. On the same day, Botshabelo sub-district held its own event. 15 | USAID Tuberculosis South Africa Project – Quarterly Report 2 January to March 2019
West Coast
The project participated in three district World TB Day
events in West Coast. One event was held at the
Infectious Disease Hospital in Malmesbury, where drug-
resistant TB (DR-TB) patients are hospitalized. Forty-five
(45) people participated in the event and a staff member
who was diagnosed with TB shared her personal journey
with attendees. The project also participated in door-to-
door campaigns in Clanwilliam and Vredendal as part of
Cederberg and Matzikama sub-districts’ World TB Day
Figure 5: West Coast HCWs conducting door-to-
activities. The campaigns were implemented in door campaign as part of WTBD activities.
collaboration with the DOH. A total of 167 people were
reached and screened, 40 presumptive patients were identified and screened. A total of six
patients tested positive and all were initiated on appropriate treatment.
Cape Winelands
Project-funded NGOs BRAM HBC and Boland Hospice
collaborated with the DOH to host World TB Day related
activities. On March 25th, the project, together with
Boland Hospice, participated in an awards ceremony for
50 clients who had successfully completed their TB
treatment. A total of 130 community members and TB
Figure 6: A TB survivor sharing her TB journey
clients attended the event.
during a TB Day event in Boland.
On March 13th, BRAM HBC also had an event at WA
Rossouw Primary in Montagu. A total of 289 learners were reached and screened on the day.
WA Rossouw learners participated throughout the program and did a “We Beat TB’’ war cry.
Learners also participated in a question and answer session to determine information
retention. As part of the event, the project unveiled a mural with TB messages which it
sponsored.
City of Cape Town
Two World TB Day events were commemorated in the district. One was held at Lady
Michaelis CHC. A total 126 people was reached, with three symptomatic patients tested. Only
one patient tested positive for drug-sensitive TB (DS-TB) and was successfully followed up
and placed on treatment. The other event was held at District Six CHC, reaching 2,355
people. Only 46 were symptomatic and tested for TB and two patients tested positive for
DS-TB and linked to care.
1.1.6 Increase the project’s contribution to TB research and knowledge through
write-ups, presentations at local and international conferences, and material
dissemination at strategic events
During the reporting period, the project did not participate in any activities. However, 24
abstracts were written and submitted on project activities for consideration for the upcoming
50th Union Conference on Lung Health, scheduled for November 2019, in Hydrabad, India.
1.1.7 Integrate TB messages into mainstream and community media
16 | USAID Tuberculosis South Africa Project – Quarterly Report 2 January to March 2019The project continues to leverage use of mass media to
widely disseminate TB communication for public
consumption. A key strategy is to use partnerships with
community radio stations to create TB awareness in the
14 supported districts and nationally. During Q2, the
project participated in 29 radio interviews, 28 of which
were on community radio stations. One radio station, Figure 7: USAID TB South Africa Project Limpopo
Lesedi FM was also used to share information. The Provincial Manager having an interview.
interviews reached a combined 4.2 million people as
outlined in Table 2. Most of the interviews were aired in March, as part of World TB month
activities. Topics covered included TB symptoms, TB prevention, TB and stigma to TB
treatment.
Table 2: Project radio interviews and people reached
District Radio station Number of Number of
interviews people reached
eThekwini Isolozansi, Vuma FM & 5 130 000
Inanda
NMBM Nqkubela FM 4 12,000
uMkhanyakude Mtuba Rise FM 1 130,000
OR Tambo UNITISA 1 500,000
West Coast Radio Namakwaland 2 74,000
Mangaung Lesedi, Mosupatsela 3 3 million
Community Radio & CUT
Community Radio
Cape Winelands Paarl FM 2 200,000
Tshwane Radio Pulpit, Pheli FM, 5 211,000
UNISA FM, Soshanguve FM
and Moretele FM
City of Cape Town Voice of the Cape 1 8,000
City of Johannesburg - - -
Total 29 4.2 million
Additionally, the project developed a poster on the link between TB and diabetes, which was
featured as part of a scene background in one of the most popular drama series on national
TV, Uzalo. The drama series is set in KwaZulu-Natal and screened on SABC 1, which is a
national TV channel. By being featured on the show, the project benefited in that show has a
reported viewership of 9.1 million.
17 | USAID Tuberculosis South Africa Project – Quarterly Report 2 January to March 2019Furthermore, two articles on the work of the project were published in Western Cape
province. The first, entitled Centre drives TB awareness and describes a World TB Day event
held in the sub-district. The second article profiled work being implemented through the
USAID TB South Africa Project in Cape Winelands District. The article is entitled Tackling TB
at Grassroots Level and it focused on successful implementation of quality improvement plans
by health facilities in Drankenstein Sub-District in an award-winning process. Provincial
Manager Ms Alice van Zyl was interviewed for the piece, which appears in pages 22 and 23 in
the Better Together magazine, March issue.
1.1.8 Scale up engagement of 50 TB champions and 50 ambassadors who are
beneficiaries of the project to advocate for improved access to quality TB
services
To inspire community members to fight TB, the project uses local TB survivors as
ambassadors to speak openly about their experience with the disease. Studies suggest that
patients relate better to personal experiences of survivors and their successes bring hope and
encouragement for patients to adhere to treatment1. The model works well, as people at
grassroots level learn from survivors that TB can be prevented, and it can also be cured.
During the quarter under review, 10 TB ambassadors were identified and engaged in five
districts (two in uMkhanyakude, two in Fezile Dabi, one in eThekwini, one in Waterberg, one
in Sarah Baartman, one in Nelson Mandela Bay Metro and two in Mangaung). Ambassadors
are provided with platforms to talks during community awareness campaigns.
In uMkhanyakude and eThekwini, ambassadors participated in community dialogues that took
place during the reporting period. One community dialogue was conducted in uMkhanyakude
with a diverse group of participants, including community leaders, traditional health
practitioners and religious leaders. Two community ambassadors also participated and shared
their journeys with TB. Since the event was the initial one, the community agreed that it was
necessary to host another dialogue and create space for in-depth health education.
In the same period, two community dialogues were hosted in eThekwini. Dialogues were
conducted by funded grantees Asiphile e-Uganda and BCA. The former conducted a dialogue
in February, reaching 30 community members, while the latter hosted a dialogue for 52
participants in March 2019.
Waterberg District also hosted a dialogue in Modimolle. During the dialogue, a former patient
volunteered to become a TB ambassador and spoke about their TB journey. In Fezile Dabi, a
similar scenario unfolded as two former TB patients also volunteered to add their voices to
the fight against TB during a community dialogue that was conducted in Parys.
1.1.9 Increase visibility of the project through communication and media
platforms
1
www.kznonline.gov.za/hivaids/councils
18 | USAID Tuberculosis South Africa Project – Quarterly Report 2 January to March 2019The project The USAID TB South Africa
continues to use Project reached
social media as a
vehicle to create
awareness about TB
60,226
people through Facebook and Twitter
and the work of the
project in the 14 in this quarter alone
supported districts.
Figure 8: The We Beat TB South Africa In Q2, the project’s social media platforms, Facebook
Facebook page
and Twitter, reached a total of 60,226 people. The social
media sites were busiest in March 2019, which is World TB month. The two platforms
reached almost the same number of people, with Facebook reaching 25,131 and Twitter
reaching 25,095. Sixty new followers were gained on both platforms during the period under
review. Additionally, 10,000 Facebook users were reached courtesy of Namakwaland FM’s
Facebook page. The station profiled two radio interviews in which Ms Ina Cillie, Project
Coordinator West Coast, participated in March 2019.
Social media platforms are innovatively used to create discussions about TB by survivors and
the public, to allow them to become content creators and share their experiences with
treatment. As part of commemorations of World TB Day, 31 stories of TB survivors were
posted on Facebook under the banner ‘It’s time to share our TB journeys toward healing’.
These stories were very popular and contributed to driving traffic to the project website,
which also recorded sharp increases in usership during the period under review.
The project also uses its website (www.tbsouthafrica.org.za) to reach people and registered
6,670-page views from 1,539 users during Q2.
1.1.10 Implement paediatric DR-TB patient support in seven participating
hospitals (Sonstraal, Brewelskloof, Sizwe, Brooklyn Chest, King Dinuzulu, Jose
Pearson & Pelonomi) through structured activities that include use of the Buddy
Beat TB package
Buddy Beat TB (Buddy) package was not rolled out during the reporting period; however,
there are plans to continue rolling out Buddy to other hospitals. Empilweni Hospital in Nelson
Mandela Bay Metro has indicated interest in implementing Buddy, and interactions between
the hospital and the Nelson Mandela Bay Metro Project Coordinator have begun. As part of
World TB Day activities, one implementing site, Brewelskloof Hospital, hosted a family day
19 | USAID Tuberculosis South Africa Project – Quarterly Report 2 January to March 2019for pediatric TB patients who were also joined by adult patients. The event was used to
educate the patients in a fun and interactive way.
IR 1.2 Effective implementation of IPC
To address the risk of transmission in supported facilities, the project provides technical
support on effective implementation of IPC at facility level. The project continued to focus on
improving implementation of IPC recommendations at national, facility and community levels,
and in congregate settings.
The project supported Eastern Cape, KwaZulu-Natal, Gauteng, Limpopo, Free State and
Western Cape provinces on IPC related activities, which include, FAST Strategy (Finding TB
cases, Actively screening, Separating safely and Treating) and IPC training. IPC risk
assessments were conducted at one hospital, 40 Primary Health Care (PHC) facilities and 250
households in this quarter alone to identify risks and improve infection control measures at
facilities and homes of patients.
1.2.1 Expand implementation of the FAST Approach in 130 hospitals within
supported districts to increase TB case detection
The project continued the implementation of the FAST The USAID TB South Africa
Approach as a key strategy to address infection control Project implements FAST in
142
gaps in South Africa. Transmitted infection is responsible
for more than half of multi drug-resistant TB (MDR-TB)
cases; however, evidence demonstrates that transmission
facilities in the TB high burden districts
is not from TB patients on effective treatment, but rather
from unsuspected cases. The FAST Approach is a quality
improvement intervention, aimed at preventing the spread of TB in congregate settings
through universal screening, subsequent separation of presumptive TB patients and prompt
molecular diagnostic and subsequent treatment initiation. During the reporting period, FAST
coverage increased from 81 hospitals in the last quarter to 142 (directly supported (69/87=
79%) Non—supported facilities (73/86= 85%) across five provinces. Eastern Cape, KwaZulu
Natal and Limpopo have adopted FAST as the key strategy for supporting TB in the hospitals.
The table below shows the distribution of facilities implementing the FAST Approach.
Table : Distribution of facilities implementing FAST
No. of facilities implementing Type of facility Project Supported/Non-
FAST Quarter 2 (Jan–Mar 19) supported district
=142
69 6 = Academic/Tertiary hospital Project Supported
1 = Provincial hospital
52 = District hospital
9 = Regional hospital
1 = Central hospital
73 6 = Provincial hospital Non-supported
48 = District hospital
8 = Regional hospital
2 = CHC
9 = Specialized hospital
The project has adopted a Master Trainer Model of support to expand implementation of the
FAST Approach nationally. This activity is a collaboration between the project, TB Directorate
and Regional Training Centre (RTC) (Province) & National TB Programme (NTP). The first
20 | USAID Tuberculosis South Africa Project – Quarterly Report 2 January to March 2019Training of Trainers (TOT) was in March 2019 in KwaZulu-Natal, for both supported and
non-supported districts. Master trainer candidates included the RTC Manager, Deputy
Director ACSM, District TB Coordinators, District Trainers, Monitoring and Evaluation
(M&E) Mangers, Occupational Health and Safety (OHS) managers, PHC Trainers, IPC
Coordinators and HAST Coordinators from each district. The implementation plans were
developed and champions, to facilitate FAST activities, were identified. FAST champions from
implementing sites shared experiences in a peer learning session.
FAST Periodical Performance
Figure 9: Percentage screened, tested and initiated on treatment in FAST hospitals April 2017 to March 2019
Table 3: TB cascade in FAST hospitals from October 2017 to March 2019
Oct-Dec 17 Jan-Mar 18 Apr-Jun 18 July-Sept 18 Oct-Dec 18 Jan-Mar 19
#7 #19 #42 #47 #30 #62
No % No % No % No % No % No %
Headcount 2531 3452 3960 4620 6888 7634
78 24 45 47 47 80
Number of patients 1405 56% 1806 52% 2496 63% 2766 60% 4705 68% 5097 67%
screened for TB 71 11 02 85 38 34
Number presumptive 5185 4% 5675 3% 9809 4% 1403 5% 1251 3% 1633 3%
8 8 7
Number tested by 3907 75% 3653 64% 5896 60% 9935 71% 8100 65% 1118 68%
GeneXpert 0
Number tested positive 697 18% 645 18% 787 13% 1092 11% 1368 17% 1826 16%
Number diagnosed with 596 86% 631 1 722 92% 1009 92% 1333 97% 1785 98%
DS-TB
Number diagnosed with 27 4% 11 2% 67 9% 38 3% 82 6% 71 4%
RR-TB
Number started on DS- 578 97% 613 97% 689 95% 998 99% 1202 90% 1685 94%
TB treatment
Number DS-TB initial lost 7 1% 4 1% 9 1% 30 3% 89 7% 81 5%
to follow-up
Number DS-TB died 9 1% 14 2% 16 2% 15 1% 9 1% 10 1%
before treatment started
Number RR-TB started 24 89% 9 82% 37 55% 32 84% 32 39% 52 73%
on treatment
The project made noticeable progress on TB screening from 56% in Q1 (October to
December 2018) to 67% in Q2 (January to March 2019). However, FAST data presented in
21 | USAID Tuberculosis South Africa Project – Quarterly Report 2 January to March 2019the reporting period is only from 62 hospitals. The TB case detection has gradually improved
during the intervention period; from 1,368 in Q1 to 1,826 in Q2.
FAST TB Screening and case detection
80% 68% 67%
63% 60%
56%
60% 52%
40%
18% 18% 17% 16%
20% 11%
13%
0%
Oct-Dec 17 Jan-Mar 18 April-Jun 18 Jul-Sep 18 Oct-Dec 18 Jan-Mar 19
TB screening TB case detection
Figure 10: FAST TB Screening and case detection October 2017 to March 2019
Improving sputum turnaround
time is critical to ensuring that
confirmed TB patients are linked
to care timeously. Time indicators
were monitored, and results
reported in the table on the right
are from one hospital during June
to October 2018.The frequency
of time to diagnosis of 0.3days,
increased to one day because of a
Figure 11: TAT and Time to initiation in days in FAST program in PMMH
high influx of sputum samples sent June to October 2018
to the laboratory for testing,
because of increased screening. Time to initiation of appropriate treatment decreased to
one day at Prince Mshiyeni Memorial hospital in eThekwini district.
Progress review meetings on FAST performance were held for hospitals in all provinces.
The project supported the hospitals to address identified gaps, including inadequate
screening rate and low detection rate and to understand better the data flow. Clinicians at
Pretoria West hospital were trained on Basic TB Management to address the low detection
of cases using GeneXpert (GXP).
To successfully implement FAST, stakeholder buy-in is critical. Dedicated implementation
team efforts are also required to lead implementation of the FAST activities, and data
collection and reporting using a patient registers and the FAST reporting tool. Orientation of
laboratory staff on FAST to ensure regular collection and delivery of specimens to the lab,
delivery of test results and treatment initiation was conducted.
Urine-Lipoarabinomannan (U-LAM) implementation:
The project has supported implementation of Urinary lipoarabinomannan (U-LAM) in FAST
sites across four provinces, KwaZulu-Natal, Eastern Cape, Free State and Limpopo. Due to
the moratorium on official travel for the Limpopo DOH, reports for Q2 for non-supported
districts are not available. Data presented below is for FAST sites in KwaZulu-Natal, Eastern
22 | USAID Tuberculosis South Africa Project – Quarterly Report 2 January to March 2019Cape province. Of 190 HIV positive tested, TB was detected in 63/190 (33.2%) patients and
100% initiated on treatment. The cumulative case detection using U-LAM for all four provinces
over two quarters is 267 (35%). The low detection case rate observed this quarter of 63 from
983 reported in the last quarter is a result of the data not reported from Limpopo.
Table 4: Urinary lipoarabinomannan results in HIV patients, Eastern Cape, Free State and KwaZulu-Natal provinces Q2 (January-
March) 2019
Eastern KwaZulu- Free State Total
Cape Natal
HIV positive LAM Test 190 - - 190
LAM positive 52 9 2 63
LAM test positive started on treatment 52 9 2 63
Table 5: Summary of results for October to Decemer2018, Limpopo is presented in the table below.
Data element Capri- Mopani Sekhu- Vhembe Water- Province
corn khune berg
Number of HIV positive patients
with low CD4 count (less than or 97 75 103 127 177 579
equal to 100 cells/ul
Number of HIV positive patients
who are seriously ill and regardless 61 35 64 62 92 314
of low CD4 count
Number of clients LAM tested 179 51 131 189 269 819
Number tested LAM positive 72 15 36 30 51 204
Number initiated on TB treatment 70 15 35 30 49 199
Initial death 2 0 1 0 1 4
Loss to follow 0 0 0 0 0 0
LAM positive done Xpert/MTB Rif 70 15 35 30 33 183
Number diagnosed RR positive 0 0 1 1 1 3
Number of RR positive on MDRTB
0 0 0 1 1 2
treatment
1.2.2 Scale-up IPC practices in homes of 6,000 identified TB index patients
through the NGO program to prevent TB transmission
Patients with confirmed infectious TB disease are sometimes The USAID TB South
sent home after initiation of treatment, even though they are still Africa Project conducted
infectious and more likely to have already transmitted TB
infection to members of their household. Therefore, steps must
be taken to prevent further spread of infection at home and to
250
home risk assessments
screen all household contacts for TB disease or infection. Health in this quarter alone
care workers are also at particularly high risk of infection with
TB because of frequent exposure to patients with infectious TB disease during home visits.
The USAID TB South Africa project, in response to gaps identified in the community,
developed a household IPC risk assessment tool. The tool is intended to assist in the
assessment of infection control measures, which addresses patient factors, environmental
factors and use of personal protective equipment (PPE).
Household risk assessments, a quality of care assessment developed by the project, have been
conducted in 914 households, utilising HCWs (through funded NGOs) since October 2018,
of which 250 were done in the reporting quarter. There were 282 risk assessments conducted
in eThekwini, 82 in Mangaung, 250 in Cape Winelands, three in Sekhukhune and 47 in Sara
23 | USAID Tuberculosis South Africa Project – Quarterly Report 2 January to March 2019Baartman. Key findings have enabled the development of multi stakeholder teams, which include facility management and environmental officers to address patient challenges. Education emphasized cough hygiene, opening of windows and doors for adequate ventilation, and the importance of hand-washing. 1.2.3 Implement IPC package in 300 health facilities to prevent TB transmission Effective TB-IPC practices by nurses may be hampered by the lack of clear TB policy directives and guidelines, non-availability of PPE, the lack of TB training for staff and patients, and a persistent work overload. The risk assessment was therefore conducted to evaluate the risk for transmission of TB in each area and occupational group in the facility, and to determine the type of administrative, environmental, and respiratory-protection controls needed. The project has conducted an additional 90 risk assessments since October 2018, 41 of which were conducted during this quarter in Eastern Cape, Free State, KwaZulu-Natal, Western Cape and Limpopo provinces. A summary of findings of the IPC risk assessment conducted on IPConnect in 28 out of 41 facilities during Q2 is illustrated below. Twenty-four percent (24%) of sites assessed did not have IPC guidelines, 36% had written TB IPC plans; and almost 38% did not have a TB screening program for HCWs. 1.2.4 Monitor IPC practices in 30 health care facilities using CO2 monitors IPC measures are not optimally implemented in health facilities. The lack of infrastructure is a serious obstacle to implementation of IPC. The waiting rooms, outpatient clinics, emergency departments and inpatient wards are often ventilated at levels well below those recommended for the control of TB transmission. The project, in collaboration with Council for Scientific and Industrial Research (CSIR), has developed a carbon dioxide (CO₂) monitor, that can serve as a real-time alarm for the management and operational response of indoor areas with high potential for airborne disease transmission. Through the FAST strategy, the project continued to expand the use of CO2 monitors to evaluate environmental controls and ensure efficacy of IPC measures. To date, 29 (two Odi, four Jubilee, four Tshwane, two Matlala, two Worcester CDC, one De Doorns clinic, one Nelson Mandela Academic Hospital (NMAH) and one Worcester CDC) CO2 monitors are deployed in 10 facilities. Twelve (12) of the monitors were installed in the reporting quarter, two in different units at Mshiyeni Hospital and 10 in King Dinuzulu hospital. 24 | USAID Tuberculosis South Africa Project – Quarterly Report 2 January to March 2019
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