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TB in South Africa – Deaths, TB epidemic, diagnosis of TB

Deaths from TB

According to the World Health Organisation (WHO) in 2013 89,000 people died from TB in South Africa.

South Africa Deaths from TB
HIV negative people HIV positive people Total deaths
2013 25,000 64,000 89,000
2012 31,000 88,000 119,000

However, according to the South Africa Mortality and Causes of Death Report 2013, TB mortality is much lower than the WHO estimates, although both sources agree that the number of deaths is decreasing, as shown below.

South African causes of death 2008 – 2013 Deaths from TB
Year 2013 2012 2011 2010 2009 2008
Number 40,542 48,409 55,102 63,281 69,791 75,281
Percentage of all deaths 8.8 9.9 10.7 11.6 12.0 12.6

According to the South African causes of death report, in 2011 TB was still the leading cause of death in South Africa among both men and women with 30,807 (11.8%) and 23,112 (9.5%) deaths respectively. With respect to age there were 1,426 deaths due to TB (3.1%) among those aged 0-14, 36,728 (18.1) among those 15-49, 10,983 (10.6%) among those 50-64 and 4,771 among those 65+ years.

Deaths from TB in South Africa

Deaths from TB in South Africa

In 2013 TB was the leading cause of death in South Africa with over 40,542 deaths notified.1“Mortality and causes of death in South Africa, 2013: Findings from death notification”, Statistics South Africa 2013 www.statssa.gov.za This was however a decrease from 2011 when 55,102 deaths were notified, and 2012 when 48,409 deaths were notified. These figures exclude deaths from TB and HIV co-infection which are internationally classified as HIV deaths.

There was also in 2013 a much higher numbers of deaths in men, 23,791 (9.9%) as compared with women 16,582 (7.6%). This may well be because of the numbers of miners who die from TB.

The discrepancy in both the numbers and the trends in TB mortality between the different sources is probably due to a number of different factors. For example differences in the data sources and in estimation methods. It is likely that this will become clearer over the next few years.

The TB epidemic in South Africa

According to the World Health Orgnaisation (WHO) South Africa ranks the third highest in the world in terms of TB burden, after India and China. Approximately 1% of the South African population develops TB disease every year. An estimated 80% of the South African population has latent TB. The highest prevalence of latent TB infection, estimated at 88%, has occurred among people in the age group 30-39 years in townships and informal settlements.

The number of cases detected for all forms of TB has steadily increased to 401,048 in 2010.

TB cases & incident rate 2006 to 2010

2006 2007 2008 2009 2010
All TB cases 341,160 353,870 388,880 406,080 401,048
Cure rate (%) 62.9 64 67.5 71.1
Treatment completion (success) rate (%) 73.8 73.9 76.4 77.1
Incidence rate (cases per 100,000 population) 719.9 739.5 798.7 823.4 802.2

The number of new smear positive TB cases has remained stable during the period from 2004 to 2010.

The TB epidemic is further compounded by MDR-TB with almost 7,386 laboratory confirmed MDR TB cases and 741 confirmed cases of extensively drug-resistant TB (XDR-TB) in 2010 in South Africa.

An HIV epidemic in South Africa is fueling the TB epidemic, with more than 70% of TB patients also living with HIV. There are more HIV statistics for South Africa.

The TB epidemic is worsened by poor adherence as a result of patients either not starting treatment, or not completing their course of treatment. As a result they develop resistance to the “normal” treatments and they require more expensive and more complex forms of treatment.2Report: South African Dept of Health Annual Performance plan 2014/15 – 2016/17 There is more about drug resistant TB in South Africa.

The Tuberculosis Strategic Plan for South Africa, 2007 – 2011

In 2006 the next strategic plan for TB had been launched, the plan for 2007 – 2011.3“Tuberculosis Strategic plan for South Africa”, 2007 – 2011, Department of Health (Government of South Africa), 2006 National Strategic Plan for South Africa 2007-2011

In the plan there was some mention of the more social aspects of TB, with it being said that:4“Tuberculosis Strategic plan for South Africa”, 2007 – 2011, Department of Health (Government of South Africa), 2006 National Strategic Plan for South Africa 2007-2011

“An overarching pillar for the elimination of TB is the need to decrease poverty and improve living and working conditions. ”

However there was little detail provided as to how this was to be achieved.

WHO TB review 2009

In 2009 a review of the South African TB programme was carried out by the WHO, and compared with earlier reviews it found ‘real improvements’ in all provinces except KwaZulu Natal and the Northern Cape.5“SA TB programme gets a cautious thumbs up”, health-e, July 2009 www.health-e.org.za/2009/07/20/sa-tb-programme-gets-a-cautious-thumbs-up/

WHO said that the biggest area of concern in South Africa remained the dual epidemic of HIV and TB with unacceptably high mortality rates.

Diagnosing TB in South Africa

Using the Genexpert machine for diagnosing TB in South Africa

Using the Genexpert machine for diagnosing TB in South Africa

South Africa has a large network of microscopy centres and laboratories with the capacity for culture and drug susceptibility testing using the MGIT liquid culture system. In 2011 the Genexpert system was introduced as a replacement for sputum smear microscopy for the diagnosis of pulmonary TB.

Between March 2011 and April 2013, more than 1.3 million Genexpert MTB/RIF tests were done which accounted for more than half of the global usage of the system. There has however been some difficulties with its implementation. It has not been universally utilized and there has been poor adherence ot the algorithm. Ensuring an uninterrupted supply of cartridges remains a challenge as does the recording and reporting of results.

TB in the South African mines and the prisons

TB is an issue in both the prisons and the mines. In 2011 there were an estimated 760,000 new cases of TB related to South Africa’s mining sector, which was a third of all new cases in Africa that year, and a staggering 9% of all new cases worldwide.6“The ‘worst public health epidemic we’re facing today’? Tuberculosis in the Mining sector”, THINK AFRICA PRESS June 2013 www.health-e.org.za/2009/07/20/sa-tb-programme-gets-a-cautious-thumbs-up/

The incidence rate of TB among workers in South Africa’s mines is the highest in the world, somewhere between 3,000 and 7,000 cases per 100,000 people. As WHO classifies 250 cases per 100,000 people as a “health emergency” it is not surprising that the spread of TB in the mining sector has been described as “the worst public health epidemic that we’re facing today”.

South-African-Prison-Cell

South African prison cell © Robin Wood

In the prisons TB has been described as “raging out of control”.7“The losing battle against TB in prisons”, Daily Maverick, July 2013 www.dailymaverick.co.za/article/2013-07-01-the-losing-battle-against-tb-in-prisons/#.UgJf5VM1eX0 However, the Constitutional Court ruled in December 2012 that the state had been negligent in its approach to TB in prisons. A prisoner, Dudley Lee, had sued the Department of Correctional Services (DCS) for his infection with TB whilst he was incarcerated in Pollsmoor prison. The Constitutional Court recognised that:

“the responsible authorities were aware that there was an appreciable risk of infection and contagion of TB in crowded living circumstance. Being aware of that risk, they had a duty to take reasonable measures.”

The ruling effectively obliges the government to curb the spread of TB in correctional facilities, and the DCS and the Department of Health have drafted policy guidelines for the Management of Tuberculosis in Correctional Centres. However, it is unclear whether these guidelines will have much effect or whether they will simply be more policy documentation. Instead some people have called for the DCS to firstly respect it’s own regulations in the area of cell occupancy and related issues before it introduces more paperwork.8“The losing battle against TB in prisons”, Daily Maverick, July 2013 www.dailymaverick.co.za/article/2013-07-01-the-losing-battle-against-tb-in-prisons/#.UgJf5VM1eX0

The National Strategic Plan on HIV, STIs and TB 2012 – 2016

There had been a TB strategic plan for South Africa for 2001 – 2005 and another for 2007 – 2011. However, when it came to the next strategic plan there was no separate plan for TB, but rather one plan to cover HIV and all STIs as well as TB.9“National Strategic Plan on HIV,  STIs and TB 2012 – 2016”, SANAC, 2011 www.gov.za/documents/national-strategic-plan-hiv-stis-and-tb-2012_2016 The plan was launched by President Zuma on World AIDS Day 2011.10“Zuma’s new AIDS plan to include TB”, Mail&Guardian, Dec 2011 http://mg.co.za/article/2011-12-01-new-aids-plan-to-include-tb-zuma‎

The main goal relating to TB, is that over the five years, the number of new TB infections and deaths should be reduced by 50%, and the core indicators as to whether this goal is being reached is the prevalence and incidence of TB.

Progress Report on National Strategic Plan

In 2014 the South African National AIDS Council (SANAC) published its first progress report on the National Strategic Plan (NSP) for HIV, TB and STIs (2012 – 2016).

It was found that using the WHO estimates slow progress has been made in achieving the NSP TB incidence and mortality targets for TB, that is reducing new infections and deaths by 50%. Using the TB register estimates there has however been a decline in both figures which is in keeping with the increased number of people on antiretroviral treatment.

TB Targets: Successes & Challenges

It is not just the TB targets in the NSP that need to be achieved, but also such aspects of TB control as the cure rate for TB treatment, the prevention of TB and the control of drug resistant TB. These challenges also need to be seen alongside notable advances in childhood TB and the prevention of MTCT.11Churcyard G I et al Tuberculosis control in South Africa: Successes, challenges and recommendations S Afr Med J 2014;104(3 Suppl 1):244-248

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1. “Mortality and causes of death in South Africa, 2013: Findings from death notification”, Statistics South Africa 2013 www.statssa.gov.za
2. Report: South African Dept of Health Annual Performance plan 2014/15 – 2016/17
3. “Tuberculosis Strategic plan for South Africa”, 2007 – 2011, Department of Health (Government of South Africa), 2006 National Strategic Plan for South Africa 2007-2011
4. “Tuberculosis Strategic plan for South Africa”, 2007 – 2011, Department of Health (Government of South Africa), 2006 National Strategic Plan for South Africa 2007-2011
5. “SA TB programme gets a cautious thumbs up”, health-e, July 2009 www.health-e.org.za/2009/07/20/sa-tb-programme-gets-a-cautious-thumbs-up/
6. “The ‘worst public health epidemic we’re facing today’? Tuberculosis in the Mining sector”, THINK AFRICA PRESS June 2013 www.health-e.org.za/2009/07/20/sa-tb-programme-gets-a-cautious-thumbs-up/
7. “The losing battle against TB in prisons”, Daily Maverick, July 2013 www.dailymaverick.co.za/article/2013-07-01-the-losing-battle-against-tb-in-prisons/#.UgJf5VM1eX0
8. “The losing battle against TB in prisons”, Daily Maverick, July 2013 www.dailymaverick.co.za/article/2013-07-01-the-losing-battle-against-tb-in-prisons/#.UgJf5VM1eX0
9. “National Strategic Plan on HIV,  STIs and TB 2012 – 2016”, SANAC, 2011 www.gov.za/documents/national-strategic-plan-hiv-stis-and-tb-2012_2016
10. “Zuma’s new AIDS plan to include TB”, Mail&Guardian, Dec 2011 http://mg.co.za/article/2011-12-01-new-aids-plan-to-include-tb-zuma‎
11. Churcyard G I et al Tuberculosis control in South Africa: Successes, challenges and recommendations S Afr Med J 2014;104(3 Suppl 1):244-248