For the first time, the sub-district management team that I support as an Improvement Advisor put in place a program to collect sputum (phlegm) samples of household contacts of people with tuberculosis (TB) to in the home. Contacts are generally expected to travel to the local health facility for a TB assessment, but most do not arrive because of the inconvenience and the long waiting times in the facility.
TB is an airborne disease that can be passed from one person to another simply by sharing space; the TB bacteria can go into the air when an infected person coughs or speaks, and others close by may breathe in the bacteria. When a person is diagnosed with TB, a common way of tracking the source of the infection and slowing the spread of the disease is contact tracing — finding and testing the patient’s family members.
Listening to a patient who recently started on treatment for TB showed me that we must not only ask questions, but also explain the reason for the questions when identifying who has been exposed to the disease. This patient was diagnosed after his wife contracted TB, and he said they lived alone. When asked how many children they have, he mentioned four adults. However, another daughter had moved out only a month before, and she had two children under the age of 5. He did not realize that his daughter and grandchildren needed follow-up testing. Because of how it was asked, he did not realize that the question about children was about who had been exposed since he and his wife contracted TB.
A Pilot Program
Wellington Community Day Centre (CDC), in the Cape Winelands District of Western Cape, South Africa, had the second highest caseload of newly registered TB cases (348) in the sub-district in 2017. The facility was chosen for a pilot study to improve the process of finding new TB cases by improving the assessment of contacts. Not only were sputum samples to be taken in the household, but all contacts were to have a sputum test irrespective of whether they had symptoms or not, since people with TB can be asymptomatic. Although the highly sensitive automated test for TB used in the country is expensive, contacts are a relatively small category of at risk-people to test and have a high prevalence of TB.
The contact tracing and sputum collection was to be done by Right to Care, a non-governmental partner organization already working in the community who participated in planning the pilot project. The team drew up a step-by-step list of methods and materials – the Standard Operating Procedure –as a guide to standardize contact tracing and testing in the community and linkage to the health facility. In addition, the sub-district health team retrained the CHWs in quality TB screening and in addressing households with a lot of contacts for testing and referrals. On the day an identified TB patient (the index patient) began treatment for TB, the patient’s file was completed, including a list of household contacts for tracing, starting the Standard Operating Procedure. The test results typically come in from the facility by the end of the week on Friday. Contacts who tested positive were to be recalled on Monday to start treatment immediately.
As an Improvement Advisor, I collaborate with partner organizations and Department of Health sub-district teams to support tracing household contacts, helping to motivate them to do the contact tracing, focusing on the importance of their work. We held a CHW training that included a review of TB basics, signs and symptoms of TB, coughing techniques for sputum collection, lab form completion, health education, and infection control.
We needed a way to track activities and created a form that went through several adaptations, finally settling on one form per index patient on which that patient’s contacts were listed. This made it easy for the addresses to be shared between the CHW, and allowed additional contacts to be added if they were found at the home.
The new version of the contact tracing register has an entire form to list the household contacts of one index patient.
Also, as an Improvement Advisor, I know that what is not measured is generally not done well. Even though household contacts are at high risk for TB, contact tracing is not routinely measured in the facilities. We therefore introduced a way of measuring progress as part of the pilot study.
A community health care coordinator and supporter from the HIV and AIDS/sexually transmitted infection/TB unit analyze data for the week.
In the four weeks of the pilot, the program traced 84 contacts, collected 50 sputum samples, and identified four clients with TB.
Adapting to Challenges
Despite the great success of the intervention there are still many challenges to overcome and our team continues to adapt as we learn from this work.
The CHW workers and the TB sister, the focal person (typically a nurse) who oversees TB treatment in the facility, must always respect and maintain patient confidentiality throughout the 6 to 9 months that the patient is on treatment. TB still has a stigma and it is important to strengthen the relationship with the patient to make sure the patient completes treatment. For the same reason, when tracing contacts, it is important to consult with the index patient about whether the patient wants the people at home to know about the disease. We also found that the TB sister must remind the patient in the first three days of treatment about the importance of testing all people who have been exposed.
CHWs also have their own challenges in the community. For example, some people do not regard them as health care workers and react negatively when they try to screen for TB or request sputum samples. In addition, when a patient who started treatment tells the TB sister all the contacts who live in the house or informally in the backyard (a common practice in our area), the patient may not know all the information. Sometimes the patient only knows a first name or nickname, or does not know the ages of the contacts. Incorrect or incomplete information about names, ages, and location (for example, who is at school and who is working) makes it difficult to reach people at risk. Contact tracing is a time-consuming process, particularly as sometimes CHWs must visit homes multiple times if no one is there, and collecting addresses and contact details of at least two family members might help.
Finally, if a patient does not test negative for TB after treatment, contacts need to be screened and tested all over again. This time the household contacts may be at risk of contracting a drug resistant strain of the disease.
At Wellington CDC, from February to June 2019, the team collected 375 contact names. CHWs traced 146 contacts and collected sputum samples from 112. Eleven of these contacts tested positive and were connected to TB treatment. Thus, one TB patient was found for every 13 contacts screened which shows how worthwhile this extra effort by the CHWs is. This intervention is also patient friendly because it brings the services to the people rather than expecting them to go to the facility for screening.
The intervention was considered a success by the sub-district management team and was adopted for spread to the whole sub-district.
Carolin Diergaardt is an Improvement Advisor at IHI.