I started working on tuberculosis (TB) nearly a decade ago. Back then, if someone told me we’d achieve the progress we’ve made today, I would not have believed it. After years of increasing mortality and infection rates, we’re finally seeing fewer cases and deaths from TB nationwide. We’ve introduced new, life-saving tools, and more people successfully complete treatment than ever before.
This World TB Day, March 24, I’m especially optimistic because I believe that we are now poised to accelerate this progress and overcome the challenges that remain on the path to eliminating TB as a public health threat.
TB remains a formidable menace. The disease is the leading cause of death in South Africa, says Statistics South Africa. Nearly one in every 100 people in South Africa has TB, a rate three times higher than the rest of Africa and six times higher than the rest of the world.
What’s more, the HIV epidemic has fuelled the spread of TB, and the two epidemics form a deadly combination for many South Africans battling both at the same time.
Despite progress made, meeting the threat of TB head-on has been difficult because of gaps in our ability to successfully find, treat and cure all people with TB. Newly completed analysis of our national TB data reviewed the path individuals take in trying to access TB treatment, and the findings are sobering. Many people are falling off the pathway to getting tested for TB, treated and cured. Our data shows that almost one-fifth of people with TB symptoms in South Africa are never diagnosed. When patients are diagnosed, many do not start or successfully complete treatment.
Now that we have a better understanding of these gaps in TB care – which we call the “TB care cascade”– we have a better opportunity to close them.
Our new national TB plan lays out a strategy to do exactly that. By implementing interventions that are based on the latest data and have been shown to work, the plan will address gaps in each phase of the TB care cascade. These interventions are focused on key points where an individual might drop out of the system on the road to health.
For example, we’re planning to find more “missing cases” - people who have TB but don’t know it - by identifying all patients with TB symptoms in our health facilities. We’re going to provide a newer formulation of medication to prevent TB in people living with HIV, who we know are between 20-30 times more likely to contract TB because of their weaker immune systems.
We’re implementing technologies that can help keep track of patients’ progress throughout the public health system to ensure that they can continue their care regardless of where they go to receive it. And we’ll cut down treatment time for people with drug-resistant TB by introducing shorter treatment regimens with new medicines.
The new national strategy borrows lessons learned from other successes. South Africa’s incredible achievements in preventing HIV transmission from mothers to their children – a more than five-fold drop in the transmission rate between 2008 and 2015 – were due in part to the use of a similar cascade to monitor the country’s programme to prevent mother-to-child HIV transmission (PMTCT).
The data from the PMTCT cascade provided critical information on HIV transmission that was used to close the treatment gaps. By using quality improvement techniques, health workers were able to help mothers prevent the spread of HIV to their infants. We will replicate this approach to close gaps in the TB care cascade and help more people beat the disease.
I’m hopeful that our new national plan will have a great impact, but I also know that having a plan – even one informed by good evidence – is not good enough. We must turn this document into action.
To end TB as a public health threat in our country, we’re going to need high levels of commitment and engagement at all levels. Government leaders, health workers, civil society organisations, individuals, families and communities: we all must work together to ensure that the scourge of TB no longer creates the pain and suffering in our communities that we have seen for far too long.
The minister of health and members of Parliament have pledged strong support for our TB efforts, and now must translate that support into resources needed to implement the national strategy. At provincial level, it will be critical for political and public health leaders to roll out the proposed evidence-based interventions.
We must also hold ourselves accountable to reach national, provincial and district level targets and to achieve our collective goals. We are depending on frontline health workers such as nurses and doctors to use data to improve the TB programme and measure and evaluate their progress frequently, and we depend on local leaders to review progress at the facility and district levels.
These efforts would prove game-changing for South Africa, but could also serve as a model for other countries and help reduce the TB burden across the globe.
While our national progress against TB and global leadership in fighting the disease is a source of great pride, the reality is that if we do not accelerate our efforts, TB will remain a leading cause of death for South Africans for many years to come. If, however, we commit to working together to transform our national fight against TB, a TB-free South Africa will soon be in sight.
Yogan Pillay is the health department's deputy director general for HIV, TB and maternal, child and women's health.
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