Two epidemics, two diseases, 200 kilometres and almost 20 years apart. Find out what they have in common.
The latest coronavirus may be new to South Africa, but the steps to control it aren’t. Here’s what we think the country can learn today about controlling the infectious disease from a familiar foe: Tuberculosis (TB).
It started with a single casualty visit and within just 22 days, the Netcare St Augustine’s Hospital accounted for more than one in every 10 diagnosed cases of the new coronavirus reported in KwaZulu-Natal by 20 April. The initial case, University of KwaZulu-Natal researchers argue, likely also led to smaller outbreaks at a nearby nursing home and a dialysis unit.
But what happened at St Augustine wasn’t exactly unique.
Almost 200 kms north and two decades earlier in 2005, an outbreak of extensively drug-resistant TB thrust the rural KwaZulu-Natal town of Tugela Ferry into international headlines. Extensively drug-resistant TB is resistant to both the two most common TB treatments and at least half the second-line medicines used to treat multidrug-resistant TB.
Later, in a 2013 study published in The Journal of Infectious Diseases, researchers linked the outbreak in part to transmission within the local hospital.
The new coronavirus, called SARS-CoV-2 and which causes a disease known as COVID-19, is thought to spread primarily via droplets that settle on surfaces, and microscopic droplets that hang in the air and can infect nearby people. TB, however, is spread slightly differently from person to person when much smaller microscopic TB bacilli are released into the air when someone with active TB coughs, speaks or sneezes, explains the US research organisation the Mayo Clinic. TB bacilli can travel further, and anybody “sharing air” indoors can be at risk.
And health facilities can be prone to outbreaks of both, as well as other infectious diseases because large numbers of sick and vulnerable people usually spend long hours in crowded, poorly ventilated corridors and waiting areas where— ideal conditions for passing bacteria or viruses from one person to the next.
So in 2017, we began a three-year study called Umoya omuhle, or “good air” in isiZulu, to look at — in part — how much South African clinics contribute to the spread of drug-resistant TB and how we could work with healthcare workers to change this. To do this, we’ve been working in two provinces to understand the realities about measures taken to reduce the risk of TB transmission in clinics. We found that even seemingly simple, well-known solutions such as masks or managing queues were perhaps unexpectedly difficult for healthcare workers to put into practice
Could this work hold lessons for South Africa’s fight against the new coronavirus?
We think so.
There’s more to masks than meets the eye
To prevent the spread of SARS-CoV-2 among healthcare workers, medical-grade masks need to be worn consistently and correctly, covering the mouth and nose. We’ve known for decades that healthcare workers should use specially-fitted respirator masks to protect themselves.
Global shortages of personal protective equipment such as masks, gloves and aprons, have led to sporadic shortages in many parts of the country since South Africa’s coronavirus outbreak started in March.
But we found that health care workers’ decisions about whether or not they use personal protective equipment (PPE) to protect themselves against TB were not only based on the availability of the gear. How they perceive their risk of developing the disease, its severity and its impacts, also play a crucial role in their uptake of PPE. Importantly, whether a healthcare worker dons a mask or not is also influenced by how much emphasis leaders within their health facility place on infection control.
Our work found that clinic staff struggled to wear masks for long periods of time because of the obvious discomfort — especially in hot and humid conditions — and because they also make it hard to communicate.
South Africa’s decision to make public mask-wearing compulsory during its COVID-19 outbreak may help to normalise a practice that was previously subject to much stigma. However, our experience suggests it will be difficult to sustain and if so, physical distancing is essential.
But here again, our research shows that how healthcare workers practice physical distancing in the context of TB depends very much on other kinds of norms around physical distance in a clinic, for example, how close a clinician may feel they have to be to show care and compassion towards patients.
‘We have floods of clients and no control on who is to come and from where’
How well healthcare workers are able to physically distance may also depend on space within a clinic. Well-established ways that patients use health facilities, such as crowding around consultation rooms or in corridors, will be difficult to change without providing alternate pathways. To achieve this, we must understand how people move within and outside health facilities.
One community health centre our team visited sees an average of 950 people each day. Healthcare workers there lamented that patients were forced to wait longer than they needed to, in part, because their files had to be collected from a single office.
“The clients are congested,” one worker explained. “We have floods of clients and there is no control on who is to come and from where.”
Another staff member went onto describe the lengths that the community health centre had gone to in order to reduce overcrowding and ensure that high-risk patients were seen first to avoid being exposed to TB or exposing others:
“There is no one who is able to pitch in and say, ‘I will be able to triage.’ We have tried all doors but the staff availability we don’t have,” the worker said. “We’ve tried with [the centre’s security guard] but he is not clinical and we can’t use him.”
Setting a date: Booking an appointment at a public clinic
The success of South Africa’s antiretroviral program has meant that large numbers of patients attend primary healthcare facilities for HIV services, adding to the many attending for other needs.
Overall, our work found that appointment systems and better queue and patient flow management are needed to manage the number of people arriving at or waiting inside health facilities at any given moment and reduce waiting times.
In 2012, the national health department introduced a system to deliver chronic medications to allow patients to pick up their medications at designated pick-up points outside of health facilities. About 3.1-million patients are now enrolled in the project, called the Centralised Chronic Medicine Dispensing and Distribution (CCMDD) programme, according to presentations made before Parliament earlier this year. Patients can now pick-up medication at more than 800 points around the country outside of their local clinics. The programme allows stable patients to reduce their number of clinic visits and helps to decongest clinics.
Likewise, under government’s Ideal Clinic initiative, several hundred clinics have started implementing the CCMDD programme in their facility and have also adopted an appointment system and streaming of patients directly to the service they require to reduce waiting times. These are very welcome changes, which should help reduce the risk of disease transmission in clinics. Any new interventions should build on these successes.
A breath of fresh air is a great thing to take
Finally, because TB is spread via the air, improvements in how air flows in and out of spaces are critical to stopping transmission in health facilities. Our preliminary findings suggest that fully opening doors and windows result in significant improvements in natural air circulation and that larger spaces tend to be better aired than smaller ones.
We expect that steps already being taken at some health facilities, such as moving waiting areas outdoors or preventing people from waiting in poorly ventilated corridors, will help reduce transmission of both TB and SARS-CoV-2.
South Africa’s COVID-19 response has been able to overcome some challenges previously faced by the fight against TB, including being prioritised by policymakers and a more coordinated approach to infection control. The formation of the country’s COVID-19 ministerial advisory committee, which advises the health minister, has reinforced the value of scientific evidence-based best practice in decision making.
Although TB infection control in South Africa has a few lessons for the COVID-19 outbreak response, the most important one may be the value of more cohesive infection control practices to our health system as a whole. There is mutual benefit from similar interventions for controlling the spread of both infections in health facilities. And in a country that bears the brunt of high levels of not only TB but also HIV and non-communicable diseases, we can’t afford to continue to focus on solutions that are aimed at tackling just a single issue.
Indira Govender is a clinical research fellow at the London School of Hygiene & Tropical Medicine, based at the Africa Health Research Institute (Somkhele). Karina Kielmann is a Reader in the Institute of Global Health and Development, Queen Margaret University, Edinburgh. Alison Grant is a Professor of International Health at the London School of Hygiene & Tropical Medicine (LSHTM).
Hayley MacGregor, Alison Swartz, Aaron Karat, Chris Colvin, Thomas Yates, Peter Beckwith, Anna Voce, Gimenne Zwama, Idriss Kallon, Karin Diaconu, Nicky McCreesh and Amy Thomas also contributed to this comment piece.