ongoing research in tuberculosis in South Africa

The AFDOT Project
(Source Sheldon Allen, Judy Dick, MRC)
This project is funded by the European Union and research partners include:

• The Health Systems Research Unit of the Medical Research Council, South Africa
• The Department of Politics and Health Systems of Free University of Brussels, Belgium
• The Liverpool School of Tropical Medicine, The United Kingdom
• The National TB Control Programme of Burkina Faso, North West Africa.

The aim of the African Dots Project (AFDOT) is to evaluate the effectiveness of Directly Observed Treatment (DOTS) in tuberculosis patients in sub-Saharan Africa. Two geographical sites have been selected for study, one in Burkina Faso in North West Africa and one in the Western Cape in South Africa.

The study will include the development of a multi-faceted patient-centered package of care:

• Providing staff with training for improving consultation skills
• Providing patients with brief motivational interviewing
• Providing a patients with a health education booklet
• Providing user-friendly pre-packaging of TB medication
• Providing patients with an adherence chart

To support the implementation of these interventions in Primary Health Care facilities the study will describe the management of organizational change and provide supportive management-related interventions. Participatory action research will be developed to find local solutions to local challenges.

Integrating Traditional Healers into a Tuberculosis Control Programme in Hlabisa
(Source Colvin, M. et al: http://www.mrc.ac.za/policybriefs/polbrief4.htm)
South Africa is experiencing an epidemic of HIV/AIDS and tuberculosis and in the rural district of Hlabisa in KwaZulu-Natal, admissions of adults to health facilities with TB increased by 360% between 1991 and 1998. This study evaluated the usefulness of using traditional healers as TB supervisors in a community-based Directly Observed Treatment (DOTS) programme.
Twenty-five traditional healers volunteered to participate in the study and attend two training workshops on the management of TB.

The results of this study were to show that 89% of those supervised by traditional healers completed their treatment compared with 67% of those supervised by others. Clients treated by traditional healers expressed a high level of satisfaction with their care. The major advantage of this type of care was seen to be the easy access to traditional healers, who typically lived near to clients, and the short waiting times when attending for treatment. Other reasons for client satisfaction were related to the caring attitude of the traditional healers who enquired about their clients well being and who often conducted home visits to those too ill to leave their homes. The death rate among those supervised by traditional healers was 6%, whereas it was 18% for those for those supervised by others.

The in vitro efficacy tests against Mycobacterium tuberculosis of plants used in the traditional treatment of tuberculosis
(Source Siyabulela Calvin Ntutela, MRC: Indegiounes Knowledge Unit in collaboration with University of Cape Town)
This project looks at the role of traditional healers in the Eastern Cape, KwaZulu-Natal, Western Cape, Northern Cape, the Free State and Mpumalanga and the herbal medicines they use to treat TB. 5 Community members were asked to recommend traditional healers who were interviewed by the research team. They were asked several questions in order to evaluate their knowledge and understanding of TB, including their method of diagnosis of TB, their understanding of the symptoms of TB, their knowledge of the causative agents(s), and the difference between TB and other pulmonary disorders. The researchers were particularly interested in the plants that traditional healers used to treat TB and twenty-seven plants were collected and analysed for antimycobactrial activity against TB. Two compounds were extracted from the plants that were previously unknown for there antibacterial activity and are the subject of ongoing research.

Early Bactericidal Activity Studies
(Source Frik Sirgel, TB Research Programme, MRC in collaboration with St George's Hospital, London, Stellenbosch University, King George V Hospital, Durban)
Traditionally, the management of TB treatment relies on the following principle. TB drugs must be taken regularly, and for a sufficient period of time, usually six months, in order to destroy the TB bacterium. Effective treatment is believed to depend upon the initial phase during which drugs are used in combination to kill rapidly multiplying populations of the TB bacterium, prevent the emergence of drug resistance, followed by a phase in which drugs sterilise and kill the remaining bacterium. In multi drug resistant TB, the two most effective drugs, INH and Rifampicin are no longer effective and alternative treatment is far more costly and less effective. The aim of this research is to develop methods for the assessment of new drugs, particularly those that have a high sterilising effect and have the potential to shorten the length of treatment for patients.
Early studies were developed to establish a technique that could be used for the rapid, cheap and accurate assessment of the activity of anti-tuberculosis agents. Scientists were to find that although they collected valuable information concerning the required and correct dosage of TB drugs in the initial stages of treatment, it did not describe adequately the sterilising activity required to destroy slowly growing, and persistent bacterium. This has lead scientists to develop research methods that can help detect the effectiveness of new drug regimes.

The Farm Lay Health Worker Project
(Source Judy Dick et al MRC in collaboration with the Boland Municipality and Farming Communities in the Western Cape)
Farming communities in the western Cape have a TB cure rate of only 100 people per every 10 000 members of the community infected with TB. Access to health care is seen as a major problem in reducing the numbers of people infected with TB. This project provides affordable and easy access to farm workers and their families in the early detection of TB, and is successful in maintaining good client relationships were people are able to speak in their own language, and understand their problems within the context of their environment.

Working with 230 farmers in the Boland Winelands district farm workers are asked to sponsor a member of their community for Lay health Worker training. The person then undergoes an Adult Basic Education Training (ABET) programme which is needs based and people are taught what they what to know: they have lots of questions about health, family life and substance abuse. Armed with their new-found skills and primary health care knowledge workers return to their communities and provide the following service, monthly weighing and TB screening of their fellow farm workers, referral of people with TB symptoms to the local clinic, administer DOTS treatment, support TB families, treat minor ailments, educate their communities about basic health issues and support and act as an important link between the employees, farm management and the health services. The Lay health workers have become catalyst in getting people to talk to each other. As an example, TB action committees have been formed involving employers, employees, farm lay workers, community resources such as schools, churches, social workers, NGO's, health representatives and the agricultural private sector. These committees have taken responsibility for the lifestyle challenges faced by the farming community by organizing and developing capacity building events, recreational activities and health promotion activities for women, men and the youth.

Action TB
(Source National TB Control Programme).
Action TB is an initiative developed by the pharmaceutical company Glaxo-Wellcome which funds research for TB in South Africa. This international research programme aims to develop new targets for anti-TB drugs, and help promote a better understanding of the disease. Eighty scientists are employed in South Africa that brings together professionals from academic institutions and the commercial sector. It is the largest research programme of its kind in Southern Africa.