Newsletter: Edition 3

Dr Fareed Abdullah - tb think tank - newsletter edition 3

A note from TB Think Tank Co-Chair

If one of the reasons to have a Think Tank is for TB research and program experts to share ground breaking changes, then the meeting held in Kempton Park certainly did not disappoint. Dr Ndjeka’s announcement that Xpert testing topped 2.5 million in the last 12 months, ending three years of collective Think Tank dread that COVID-19 would permanently knock down TB testing in SA. This was met with relief all-round and joyous celebration on the day! Other good news followed.

The NDOH has approved BPaL-L for use in the country and the new drugs were already on tender, meaning we can move rapidly forward from clinical access and trials to wider implementation.The TPT guidelines has finally been approved (yes it did take long!) and the 4-month regimen for children is here. Shortened regimens for adults are going to be hotly debated so we can expect much more on that front.

On a more general level, the more generic NSP for HIV, TB and STIs has been finalised and the more detailed NDOH NTP Strategic Plan is nearing finalisation with significant TB Think Tank investments in ideas, time and technical support. The TB Recovery Plan 2.0, a joint NDOH/Think Tank product was concluded and publicly announced by the Minister of Health at the TB Indaba in Durban in June. The high level of political commitment displayed by the health sector leadership for the new TB effort was palpable and very encouraging.

Thanks to all of you for your active participation and interest in the TB Think Tank. It is the source of our strength and the foundation on which all of the work of the TB Think Tank Secretariat is built.

Dr Fareed Abdullah

TB THINK TANK ANNUAL GENERAL MEETING 2023
An important function of the TB Think Tank is to bring researchers and policy makers together to synergise efforts to inform country policy. The annual TB TT face-to-face meeting was held in Kempton Park to do just that as Task Teams met to advance their annual workplans.

Prof Norbert Ndjeka,TB Think Tank Chair and Chief Director of the national TB programme (NTP), opened the event with an overview of Recovery Plan success and a sneak peek of what is to come in the NTP Strategic Plan, two documents which were borne from the work of TB Think Tank Task Teams.

Participants nodded in agreement as Prof Ndjeka drew attention to the strategic vision for the next 5 years, which includes nuanced TB communication, optimised linkage to care, shorter treatment options, a stronger focus on TB prevention, and a commitment to data-informed decision making.

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Following the opening address, the TB Think Tank heard from four of its contributors who highlighted key issues in the country. Dr Marian Loveday, Chair of the Optimising Treatment Outcomes (OTO) Task Team, presented a summary of the current WHO-recommended 4-month drug-susceptible TB regimen with practical considerations that need to be addressed before wide implementation should be considered in South Africa.

Key questions still remain on how this regimen would perform amongst people living with HIV (who make up over half of the TB incidence in South Africa), how facilities without chest x-rays would determine disease extent, how feasible it would be to offer different regimens to different clients, and how drug resistance post-treatment would be monitored. The presentation led to a lively discussion on whether this is even a regimen that makes sense for South Africa or if the National Department of Health should wait for better options.

Dr Limakatso Lebina, Chair of the Finding Missing People with TB (FMP) Task Team, spoke about the systematic screening SOP released in 2022, and discussed potential updates. These included targeting universal testing among people living with HIV who have lower viral loads, are initiating antiretroviral treatment, or who are returning to treatment after a break. It also included clarification on culture as the first-line test for people with a recent history of TB.

There was debate on whether to include testing of all pregnant women at first ante-natal visit, with questions around the evidence to support better testing in this population. In the meeting of the FMP Task Team in the afternoon, members discussed formally updating the systematic screening SOP once more evidence is collected.

Dr Karen du Preez, Chair of the Paediatric, Adolescent, and Maternal TB Working Group, gave an introduction to the Paediatric TB Guidelines, which are currently in development. The new guidelines will take a modular format, similar to the approach used by the World Health Organisation. The modules include epidemiology of TB in children and key updates, diagnosing TB in children, general principles for management, treatment of drug-susceptible TB, treatment of drug-resistant TB, TB prevention in children and adolescents, as well as a quick reference guide. The presentation covered new sample types for diagnosing TB using WHO-recommended molecular diagnostics (e.g. GeneXpert) and shorter treatment regimens for latent and active TB in children and adolescents.

Dr Lucy Connell presented findings from a cross-sectional mixed methods evaluation of a pilot project implementing the use of digital chest x-rays (dCXR) with computer-aided detection (CAD) for TB screening at health facilities. Dr Connell praised the success of the pilot for undertaking nearly 90,000 visits at 23 facilities.

Overall, the diagnostic yield of TB was 1.2% with TB symptom screening alone, 1.4% with dCXR+CAD alone, and 1.6% with a combination of the two. She did note that the quality of collected sputum was a challenge, but highlighted that dCXR+CAD alone was able to pick up 84% of TB using less than half the number of GeneXpert cartridges (Number needed to test was 7 in this group compared with 25 in symptoms-screen only and 23 in the combined group).

Proportion of headcount testing positive (PHP) while dCXR+CAD were present at facilities varied by facility due to different practices, but all showed an improved headcount compared to 2019 levels while dCXR+CAD were available at facilities (range 1.96-9.55 times increase). A major limitation was non-consensus on which groups to target and when to test by GeneXpert.

Questions also remain on when to start treatment before bacteriologic confirmation. The FMP Task Team has already spearheaded a working group to grapple with these issues, which will lead to the development of a standardised algorithm and country-wide Standard Operating Procedure for the use of dCXR with CAD.

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Presentations concluded with Dr Neil Martinson discussing the coming Supporting, Mobilizing, and Accelerating Research for TB Elimination (SMART4TB) research opportunities in implementation science that will soon be available in South Africa. The purpose of the grant is to leverage high-quality TB diagnostic research sites and existing protocols to rapidly initiate evaluations that will enable WHO review of promising novel tests.

Examples of implementation science questions that may be eligible for funding included, but are not limited to: cause for rejection of sputum samples; reducing costs per TB test (e.g. pooling); the use of chest x-ray or CRP to target testing; research on non-sputum specimens types (urine, tongue swab, oral rinse, extended spot); finding more people with TB earlier; improving preventive treatment uptake (especially with shorter regimens); User and client requirements for an EMR system; improving linkage to care; improving treatment completion; and treatment of subclinical/minimal/asymptomatic TB disease; reducing catastrophic costs; and preventing TB recurrence. A special stream of funds will be ear-marked for developing early-career researchers. Please click here to access the video of Dr Martinson’s presentation.

The day concluded with Task Teams breaking up to advance workplans for the 2023-24 fiscal year. Details of workplans will be shared when finalised at a meeting of the Executive Committee.

The TB Think Tank Task Teams & working group break away session in pictures.

TB THINK TANK AT TB NDABA 2023

TB-Indaba-event

The Minister of Health, Dr Joe Phaahla, hosted an NTP organised and remarkably attended TB Indaba event in advance of the 2023 South African AIDS Conference in eThekwini.

Over 200 stakeholders attended from various sectors, including the Health Department staff, the Mining sector, research and development partners, and civil society. The minister officially opened the ceremony by acknowledging the good progress made via collaborative efforts in the implementation of the TB recovery plan in 2022. TB testing has surpassed 2.5 million, up from 1 884 801 in 2021.

Furthermore, the TB notifications jumped from 187 735 in 2021 to 224 700 in 2022, indicating better case finding. The minister went on to launch the TB Recovery Plan 2.0, which will usher in the National TB Programme’s Strategic Plan for the next five years. The main aim of the event was to engage stakeholders in a dialogue on TB program successes, challenges, future priorities, and new developments in TB diagnostics, treatment, and prevention.

Other notable dignitaries opening the proceedings included Mr Ramphelane Morewane, Acting Deputy Director -General HIV/AIDS, TB And MCWH NDoH; Dr SSS Buthelezi Director General Health National Health NDoH and Prof Norbert Ndjeka, Chief Director of the TB Cluster NDoH. The day’s events included breakaway sessions on: TB in the Mines, the private sector, Clinical innovations in TB, civil society, cross-border TB, and TB data systems and data use.

Highlights the breakaway session included:

  • A discussion on strategies to improve healthcare access and provision, the National TB programme and donor support and the rollout of compensation for current and ex-mine workers. The process will require mapping all organisations that work with current and ex-mine workers to avoid fragmentation and address, among other things, the economic, social, health, and psychological issues of mine workers through a multifaceted approach involving directorates from government and private departments. The function of the National TB programme will be to incorporate TB in the mines in the programme’s priorities to ensure increased capacity to optimise the assessment of ex-mine workers for compensation and to strengthen data systems for programme management.
  • Discussion around the complexities of finding TB in private GPs’ offices and private pharmacies. In this breakaway, key management issues were identified and pilot models for public-private mixing to support TB care were presented. The key synergies were identified, and a hybrid model proposed.
  • Impressive developments in TB diagnosis, treatment, and prevention were presented. These included the 4-month WHO recommended treatment option for drug-sensitive TB, the current non-sputum testing options such as the use of tongue swabs to test for TB, as well as the TB vaccines where there are currently eight candidate vaccines at various clinical trial phases. The group advocated for continuing and strengthened assistance to mine workers through: the empowerment of shop stewards to be day-to-day champions of the Ubuntu Project, more companies joining RMA in providing similar support, and sustained collaboration with the Mine Health and Minerals Council of South Africa and SANAC labour sector.
  • The cross-border group highlighted the impact of challenges associated with migration, such as late presentation and delayed TB diagnosis, treatment interruptions, and drug-resistant TB. It was of note that the magnitude of migrant TB is not well documented, a need which must be addressed. Among a long list of action items was the highlight of developing an effective cross-border referral system, strengthening the current TIMS cross-border referral system for miners, and expanding it beyond the mining sector into all migrant populations.
  • Civil society organisations highlighted the Ubuntu Initiative, in which the National Union of Mine Workers and Show me your Number have joined forces to support men in taking responsibility for their wellness and combatting gender-based violence. The work was supported by Rand Mutual Assurance, NUM in collaboration with mineral Council of South Africa, and SANAC. The group advocated for continuing and strengthened assistance to mine workers, through the empowerment of shop stewards to be day-to-day champions of the Ubuntu Project, more companies joining RMA in providing similar support and sustained collaboration with the Mine Health and Minerals Council of South Africa and SANAC labour sector.

GET TO KNOW THE TB THINK TANK

TB-Prevention-Task-Team-Lead-Mrs-Tebogo-Sole-Moloto

We are excited to profile our first TB Think Tank member in this newsletter edition, the newly elected TB Prevention Task Team Lead Mrs Tebogo Sole-Moloto. She is a Research Scientist at the South African Medical Research Council (SAMRC) and a registered Research Psychologist with the Health Profession Council of South Africa (HPCSA). Her main interests are on the mobile health technologies and applying psychological principles to understand medication adherence in the context of TB. Tebogo, has been with SAMRC for five years and has been involved in public health research in TB/HIV and behavioural research projects.

At present, the Task Team Lead is a co-Principal Investigator for two CDC funded TB research activities, namely: 1) “Understanding missed opportunities for anti-retroviral initiation and linkage to care of HIV- presumptive tuberculosis patients in South Africa” and 2) “Adherence to Tuberculosis Preventive Treatment (TPT) and determining reasons for non-adherence in South Africa”.

Her professional achievements include a peer review publication, international conference presentations (including the 51st Union World Conference on Lung Health in 2020), receiving the scholarship from the Bongani Manyosi National Health Scholars Programme 2021 RFA. Her most recent achievement was participating in the 7th South African Tuberculosis (SA-TB) Conference 2022 organising committee as an abstract reviewer for Track 3 (Implementation/Health systems).

TB SURVEY

Request for survey participants for LSHTM Master’s study on offering non-TB services to people with TB and their household members

We would like to invite you to participate in a modified Delphi survey on opportunities and challenges of offering additional (non-TB) services to people with TB and/or their household members. This survey is being conducted by researchers at the London School of Hygiene & Tropical Medicine.

The overall aim of the project is to build consensus regarding integrated services, understand the practical implications, and inform future research and programmatic development of integrated service delivery for people affected by or at risk of TB. We would be very grateful for your contribution to this project, drawing on your valuable insight and experience.

To briefly explain, we are currently inviting you to the first round of an online survey, which will take between 20-35 minutes to complete. If you participate, we will share the findings with you and invite you to participate in further rounds of surveys, however you have no obligation to participate in any further round. The survey is currently available in English, however within the next week Spanish, Portuguese and French language versions will be made available (at the same link).

We are interested in hearing a wide range of perspectives and therefore would also be very grateful if you would forward this email or share the survey with other individuals and networks who may have valuable input. If you do, it would be helpful if you could copy Tenzin Kunor (tenzin.kunor1@student.lshtm.ac.uk) onto the email(s) so we can understand the reach the survey has had. You are also welcome to share the survey using social media networks with the following link (https://forms.office.com/e/GLxPZCA041).

Thank you very much and we are looking forward to learning from you. Please do not hesitate to get in touch if you have any questions or comments.

WEBINARS

The TB Think Tank debuted its Webinar Series on the 17th of April 2023. These sessions have been taking place monthly from then on with an audience expanded beyond the Think Tank membership to include the public.

The URLs to the first four webinar sessions are provided below.

  1. 17 April 2023: Assessment of TB healthcare service provision under the COVID-19 epidemic and the epidemiological impact of TB health service disruptions in South Africa: A TB Think Tank Project
  2. 15 May 2023: TB MATE Project: The use of medication monitors and a differentiated care approach to improve TB adherence
  3. 19 June 2023: Pathogenesis and risk factors of long-term pulmonary sequelae defining the individual outcome and public health impact of disease. The upcoming webinar session scheduled for the 17th July will cover The TB Investment Case: Preliminary outputs.
  4. 17 Jul 2023: The TB Investment Case: Preliminary output

The Secretariat invites the Think Tank members to email their topics for allocation into available future webinar session slots.

The next webinar will be on 21st of August discussing the ‘Reducing initial loss to follow up among TB patients in South Africa. Key findings and lessons learned from the LINKEDin study’ See you there!

NETWORK PUBLICATIONS

Recent publications from TB Think Tank Members

All the TB Indaba presentations are available on this link.

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