GUADALAJARA, Mexico — Every year, 500,000 men travel across southern Africa to work in South Africa’s mines. In doing so, they find themselves triply vulnerable to contracting tuberculosis.
Mines produce high levels of silica dust, which renders the lungs prone to bacterial infection. HIV is also prevalent in the region, and those with compromised immune systems are more likely to contract TB. Finally, confined work spaces and poor living conditions facilitate airborne transmission.
As a result, the incidence of TB among workers in South Africa’s mines is the highest in the world — 10 times higher than the level of a health emergency defined by the WHO. Moreover, the epidemic is mobile; men develop active TB and then return home and infect their communities. Each migrant worker who returns home with TB spreads the disease to an estimated 10 to 15 people in his community, according to the Stop TB Partnership.
Patients who travel across borders without consistent medical care risk going undiagnosed or, if they only sporadically access treatment, acquiring resistance to first-line treatments.
In response to this public health crisis, four countries earlier this year launched a landmark electronic referral system that aims to serve as a medical passport for patients. The pilot program is funded by the Global Fund to Fight AIDS, Tuberculosis and Malaria and was developed by a multistakeholder program called TIMS (TB in the Mining Sector in Southern Africa) that hopes to digitize and close the gaps.
“Cross-border migration is fueling the TB epidemic,” said Ivandra Chirrime, senior TB control specialist at the East, Central and Southern Africa Health Community, an intergovernmental health organization that promotes regional cooperation. “It’s very difficult to trace paper-based information and to make sure the miner in South Africa continues TB treatment when he goes back to Lesotho or Swaziland,” she told Devex at the 48th Union World Conference on Lung Health in Mexico last week.
The pilot began in September in two districts in each of four countries: Lesotho, Malawi, Mozambique, and Zambia. The system enables a patient to be traced across borders. For example, if a patient is referred from South Africa to Zambia, health care professionals in both countries will be able to trace the patient and receive notifications whenever the patient is sent to a health care facility.
Following the pilot, the World Bank hopes to scale up the system with its Southern Africa Tuberculosis and Health Systems Support project. It hopes the innovation will prove a new way to target TB in mobile populations, providing seamless care in the most interrupting of circumstances.
“It’s expected that this intervention will improve TB treatment outcomes, reduce the development of drug resistance due to treatment interruption … and reduce TB infectiousness within the families and communities of these individuals,” said Chirrime.
Mounting health crisis
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TB is among the top five causes of death in sub-Saharan Africa, accounting for 26 percent of the world’s TB cases. One-third of the world’s 22 high-burden countries are also in southern Africa, according to the World Health Organization’s 2016 global TB report.
“We’re making some progress but, despite some results, there’s still a huge burden. There’s still unacceptable rates of TB and HIV co-infections, incidence, and deaths,” Talkmore Maruta, senior laboratory specialist at the ECSA-HC, told the conference.
Among the challenges are the region’s weak prevention and treatment system, limited diagnostic capacities and quality assurance, and inadequate human resources.
“All patients in southern Africa should be accessing TB diagnostic and all patients should be tested with drug susceptibility testing,” said Licé Gonzalez-Angulo from the Research for TB Elimination department at the WHO’s Global TB Program. “More than 40 percent of patients aren’t being diagnosed.”
In 2014, Lesotho, Mozambique, South Africa, and Swaziland signed the Southern African Development Community declaration on the harmonization of TB management in the mining sector. The framework aims to give mine workers and their communities confidence that wherever they seek treatment they will be prescribed the same interventions.
Continuity in care
Now those medical guidelines will be complemented with digital patient tracking. Next year, it will be expanded into more communities, selected for their high rates of migrant labor.
“What we know is that treatment success rates in mining communities is low and mainly related to cross-border migration,” Chirrime said. “They don’t continue treatment.”
Chirrime expects this new project to make a significant difference in the continuum of care for cross-border miners and migrant populations. “We hope this will [address] the challenges currently faced, namely interruption of treatment and communication, in terms of the harmonization of treatment regimens across borders,” she said.
“Some patients may be diagnosed in one country and then referred to another. With this system you will know where the patient belongs and when the patient doesn’t show, you can trace the patient and see where he is,” she said.
Strengthening laboratory systems
In order for the unified care regime to work, laboratory and medical facilities will also need improvements.
“Lab officers need to be trained in quality management systems so they have a good understanding of health system requirements,” said Maruta, who is working through the SATBHSS project to train lab officers to conduct quality audits of their laboratories.
“The critical thing during audits is to identify areas that need improvement so we can start closing gaps,” he said.
Gonzalez-Angulo agrees. She said supporting countries to achieve quality assured, accessible, and sustainable TB diagnostic networks and laboratory services was one of the most important interventions moving forward.
“We have a lot of work to do,” Maruta added.
“We need to put our foot down and be more serious about controlling this monster of TB.”
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