Decentralized Care for Rifampin-Resistant Tuberculosis, Western Cape, South Africa

Abstract

In 2011, South Africa implemented a policy to decentralize treatment for rifampin-resistant tuberculosis (TB) to reduce durations of hospitalization and enable local treatment. We assessed policy implementation in Western Cape Province, where services expanded from 6 specialized TB hospitals to 406 facilities, by analyzing National Health Laboratory Service data on TB during 2012–2015. We calculated the percentage of patients who visited a TB hospital < 1 year after rifampin-resistant TB diagnosis, the median duration of their hospitalizations, and the total distance between facilities visited. We assessed temporal changes with linear regression and stratified results by location. Of 2,878 patients, 65% were from Cape Town. In Cape Town, 29% visited a TB hospital; elsewhere, 68% visited a TB hospital. We found that hospitalizations and travel distances were shorter in Cape Town than in the surrounding areas.

Spatial heterogeneity of extensively drug resistant-tuberculosis in Western Cape Province, South Africa

“…There are several potential reasons for spatial clustering of second-line drug resistant TB. For example, social conditions that coalesce with disease transmission, such as homelessness, the HIV epidemic, high population density, and increased migration, and could all be associated with the clustering we observed here 19 – 23 . Access to appropriate support throughout treatment may also vary by location and could be driving spatial clusters of acquired XDR-TB.…”

“…Individuals with TB were identified from routinely collected laboratory data from the Western Cape National Health Laboratory Services (NHLS) in South Africa between January 1, 2012 to July 31, 2015. Our method of data abstraction and processing has been previously described 19 , 20 . The NHLS processes tests for the South African public health care system and accounts for 93% of all TB tests nationally 21 .…”

“…The NHLS centralized laboratory database lacks unique individual identifiers; thus, we used a person-matching algorithm to link specimens to individuals, also described elsewhere 19 , 20 . Since our study period was three years, we defined any multiple positive tests to be due to one disease episode.…”

“…The NHLS database includes the facility code that each sample specimen was submitted from. We used these facility codes to identify a “home clinic” for each individual as a proxy for where the person was living at the time of diagnosis, which is a reasonable approximation given previous research has shown that TB patients do not travel far distances to receive their diagnosis in the Western Cape 19 , especially after decentralization of MDR-TB/RR-TB care 22 . This home clinic was defined as the location of their clinic visit closest in time to their RR-TB diagnosis.…”

Re-evaluating the merits of decentralization as a core strategy for effective delivery of drug-resistant tuberculosis care in Pakistan

“…However, despite the World Health Organization’s (WHO) endorsement of a decentralized model of care delivery for DR-TB in 2011, several challenges continue to be faced by implementers, many of which are context-specific and require local solutions ( Vanleeuw et al. , 2020 ; Leavitt et al. , 2021 ).…”