Impact of community tracer teams on treatment outcomes among tuberculosis patients in South Africa

BMC Public Health, Aug 2012

Background Tuberculosis (TB) indicators in South Africa currently remain well below global targets. In 2008, the National Tuberculosis Program (NTP) implemented a community mobilization program in all nine provinces to trace TB patients that had missed a treatment or clinic visit. Implementation sites were selected by TB program managers and teams liaised with health facilities to identify patients for tracing activities. The objective of this analysis was to assess the impact of the TB Tracer Project on treatment outcomes among TB patients. Methods The study population included all smear positive TB patients registered in the Electronic TB Registry from Quarter 1 2007-Quarter 1 2009 in South Africa. Subdistricts were used as the unit of analysis, with each designated as either tracer (standard TB program plus tracer project) or non-tracer (standard TB program only). Mixed linear regression models were utilized to calculate the percent quarterly change in treatment outcomes and to compare changes in treatment outcomes from Quarter 1 2007 to Quarter 1 2009 between tracer and non-tracer subdistricts. Results For all provinces combined, the percent quarterly change decreased significantly for default treatment outcomes among tracer subdistricts (−0.031%; p < 0.001) and increased significantly for successful treatment outcomes among tracer subdistricts (0.003%; p = 0.03). A significant decrease in the proportion of patient default was observed for all provinces combined over the time period comparing tracer and non-tracer subdistricts (p = 0.02). Examination in stratified models revealed the results were not consistent across all provinces; significant differences were observed between tracer and non-tracer subdistricts over time in five of nine provinces for treatment default. Conclusions Community mobilization of teams to trace TB patients that missed a clinic appointment or treatment dose may be an effective strategy to mitigate default rates and improve treatment outcomes. Additional information is necessary to identify best practices and elucidate discrepancies across provinces; these findings will help guide the NTP in optimizing the adoption of tracing activities for TB control.

A PDF file should load here. If you do not see its contents the file may be temporarily unavailable at the journal website or you do not have a PDF plug-in installed and enabled in your browser.

Alternatively, you can download the file locally and open with any standalone PDF reader:

http://www.biomedcentral.com/content/pdf/1471-2458-12-621.pdf

Impact of community tracer teams on treatment outcomes among tuberculosis patients in South Africa

Liza E Bronner 0 Laura J Podewils 0 Annatjie Peters 2 Pushpakanthi Somnath 1 Lorna Nshuti 1 Martie van der Walt 1 Lerole David Mametja 3 0 Division of TB Elimination, Centers for Disease Control and Prevention , 1600 Clifton Road NE Mailstop E-10, Atlanta, GA 3033 , USA 1 TB Epidemiology and Intervention Research Unit, South African Medical Research Council , 1 Soutpansberg Road, Private Bag X385, Pretoria 0001 , South Africa 2 Global AIDS Program, Centers for Disease Control and Prevention , 877 Pretorius Street, Arcadia 0007 , South Africa 3 Tuberculosis Control and Management, Republic of South Africa National Department of Health , Private Bag X828, Pretoria 0001 , South Africa Background: Tuberculosis (TB) indicators in South Africa currently remain well below global targets. In 2008, the National Tuberculosis Program (NTP) implemented a community mobilization program in all nine provinces to trace TB patients that had missed a treatment or clinic visit. Implementation sites were selected by TB program managers and teams liaised with health facilities to identify patients for tracing activities. The objective of this analysis was to assess the impact of the TB Tracer Project on treatment outcomes among TB patients. Methods: The study population included all smear positive TB patients registered in the Electronic TB Registry from Quarter 1 2007-Quarter 1 2009 in South Africa. Subdistricts were used as the unit of analysis, with each designated as either tracer (standard TB program plus tracer project) or non-tracer (standard TB program only). Mixed linear regression models were utilized to calculate the percent quarterly change in treatment outcomes and to compare changes in treatment outcomes from Quarter 1 2007 to Quarter 1 2009 between tracer and non-tracer subdistricts. Results: For all provinces combined, the percent quarterly change decreased significantly for default treatment outcomes among tracer subdistricts (0.031%; p < 0.001) and increased significantly for successful treatment outcomes among tracer subdistricts (0.003%; p = 0.03). A significant decrease in the proportion of patient default was observed for all provinces combined over the time period comparing tracer and non-tracer subdistricts (p = 0.02). Examination in stratified models revealed the results were not consistent across all provinces; significant differences were observed between tracer and non-tracer subdistricts over time in five of nine provinces for treatment default. Conclusions: Community mobilization of teams to trace TB patients that missed a clinic appointment or treatment dose may be an effective strategy to mitigate default rates and improve treatment outcomes. Additional information is necessary to identify best practices and elucidate discrepancies across provinces; these findings will help guide the NTP in optimizing the adoption of tracing activities for TB control. - Background Tuberculosis (TB) is a leading cause of morbidity and mortality worldwide, infecting an estimated 9.4 million persons and causing death in 1.7 million persons annually [1]. The World Health Organization (WHO) ranks South Africa as having the third highest TB incidence rate among the top 22 high-burden TB countries, with an estimated 405,982 persons diagnosed with TB each year (incidence rate 971/100,000) [1]. Patient default from treatment is one of the most important problems in TB control [2,3]. In 1996, the South Africa National Tuberculosis Program (NTP) adopted the Directly Observed Treatment Short-Course (DOTS) strategy nationwide for the treatment of TB patients. While the NTP has implemented several strategies over the past decade to improve access to treatment and support treatment compliance among TB patients, at 76% the treatment success rate remains well below WHO targets of 85% cured or completing treatment necessary to mitigate the spread of TB [1,4-6]. Default from TB treatment poses a serious health risk to TB-infected individuals and to the community. The number of TB patients who default from TB treatment in South Africa, defined as missing at least 2 consecutive months of treatment [6], remains high ranging from 5.9 14.7% [1,4]. TB treatment defaulters, especially those who are smear positive, propagate ongoing community transmission and promote the development and acquisition of drug-resistant TB strains resulting in a higher number of TB cases [3,7,8]. Previous studies have shown that over one-third of patients who default from treatment are culture-positive for TB and therefore infectious at the time of default [3,7]. Additionally, research in India found that patients who defaulted from treatment had a standardized mortality ratio of 14.3 versus 2.0 in patients who completed treatment [9]. Research has shown that TB patient tracing activities are an effective method to significantly reduce TB treatment default [8,10,11]. However, there is little research documenting the effect of tracing on TB treatment out (...truncated)


This is a preview of a remote PDF: http://www.biomedcentral.com/content/pdf/1471-2458-12-621.pdf

Liza E Bronner, Laura J Podewils, Annatjie Peters, Pushpakanthi Somnath, Lorna Nshuti, Martie van der Walt, Lerole Mametja. Impact of community tracer teams on treatment outcomes among tuberculosis patients in South Africa, BMC Public Health, 2012, pp. 621, 12, DOI: 10.1186/1471-2458-12-621