Browsing by Person "Grant, Alison D."

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A cluster randomised trial to evaluate the effect of optimising TB/HIV integration on patient level outcomes: The merge- trial protocol
(Elsevier, 2014-10) Kufa, T.; Hippner, P.; Charalambous, S.; Kielmann, Karina; Vassall, A.; Churchyard, G.; Grant, Alison D.; Fielding, K.
Introduction We describe the design of the MERGE trial, a cluster randomised trial, to evaluate the effect of an intervention to optimise TB/HIV service integration on mortality, morbidity and retention in care among newly-diagnosed HIV-positive patients and newly-diagnosed TB patients. Design Eighteen primary care clinics were randomised to either intervention or standard of care arms. The intervention comprised activities designed to optimise TB and HIV service integration and supported by two new staff cadres-a TB/HIV integration officer and a TB screening officer-for 24 months. A process evaluation to understand how the intervention was perceived and implemented at the clinics was conducted as part of the trial. Newly-diagnosed HIV-positive patients and newly-diagnosed TB patients were enrolled into the study and followed up through telephonic interviews and case note abstractions at six monthly intervals for up to 18 months in order to measure outcomes. The primary outcomes were incidence of hospitalisations or death among newly diagnosed TB patients, incidence of hospitalisation or death among newly diagnosed HIV-positive patients and retention in care among HIV-positive TB patients. Secondary outcomes of the study included measures of cost-effectiveness. Discussion Methodological challenges of the trial such as implementation of a complex multi-faceted health systems intervention, the measurement of integration at baseline and at the end of the study and an evolving standard of care with respect to TB and HIV are discussed. The trial will contribute to understanding whether TB/HIV service integration affects patient outcomes.
Algorithm-guided empirical tuberculosis treatment for people with advanced HIV (TB Fast Track): An open-label, cluster-randomised trial
(Elsevier, 2019-11-11) Grant, Alison D.; Charalambous, Salome; Tlali, Mpho; Karat, Aaron S.; Dorman, Susan E.; Hoffmann, Christopher J.; Johnson, Suzanne; Vassall, Anna; Churchyard, Gavin J.; Fielding, Katherine L.
Background Tuberculosis, which is often undiagnosed, is the major cause of death among HIV-positive people. We aimed to test whether the use of a clinical algorithm enabling the initiation of empirical tuberculosis treatment by nurses in primary health-care clinics would reduce mortality compared with standard of care for adults with advanced HIV disease.
Autopsy prevalence of tuberculosis and other potentially treatable infections among adults with advanced HIV enrolled in out-patient care in South Africa
(PLOS, 2016-11-09) Karat, Aaron S.; Omar, Tanvier; von Gottberg, Anne; Tlali, Mpho; Chihota, Violet N.; Churchyard, Gavin J.; Fielding, Katherine L.; Johnson, Suzanne; Martinson, Neil A.; McCarthy, Kerrigan; Wolter, Nicole; Wong, Emily B.; Charalambous, Salome; Grant, Alison D.; Cardona, Pere-Joan
Background Early mortality among HIV-positive adults starting antiretroviral therapy (ART) remains high in resource-limited settings, with tuberculosis (TB) the leading cause of death. However, current methods to estimate TB-related deaths are inadequate and most autopsy studies do not adequately represent those attending primary health clinics (PHCs). This study aimed to determine the autopsy prevalence of TB and other infections in adults enrolled at South African PHCs in the context of a pragmatic trial of empiric TB treatment (“TB Fast Track”).
Beyond checklists: Using clinic ethnography to assess the enabling environment for tuberculosis infection prevention control in South Africa
(Public Library of Science, 2022-11-09) Arakelyan, Stella; MacGregor, Hayley; Voce, Anna S.; Seeley, Janet; Grant, Alison D.; Kielmann, Karina
Sub-optimal implementation of infection prevention and control (IPC) measures for airborne infections is associated with a rise in healthcare-acquired infections. Research examining contributing factors has tended to focus on poor infrastructure or lack of health care worker compliance with recommended guidelines, with limited consideration of the working environments within which IPC measures are implemented. Our analysis of compromised tuberculosis (TB)-related IPC in South Africa used clinic ethnography to elucidate the enabling environment for TB-IPC strategies. Using an ethnographic approach, we conducted observations, semi-structured interviews, and informal conversations with healthcare staff in six primary health clinics in KwaZulu-Natal, South Africa between November 2018 and April 2019. Qualitative data and fieldnotes were analysed deductively following a framework that examined the intersections between health systems ‘hardware’ and ‘software’ issues affecting the implementation of TB-IPC. Clinic managers and front-line staff negotiate and adapt TB-IPC practices within infrastructural, resource and organisational constraints. Staff were ambivalent about the usefulness of managerial oversight measures including IPC protocols, IPC committees and IPC champions. Challenges in implementing administrative measures including triaging and screening were related to the inefficient organisation of patient flow and information, as well as inconsistent policy directives. Integration of environmental controls was hindered by limitations in the material infrastructure and behavioural norms. Personal protective measures, though available, were not consistently applied due to limited perceived risk and the lack of a collective ethos around health worker and patient safety. In one clinic, positive organisational culture enhanced staff morale and adherence to IPC measures. ‘Hardware’ and ‘software’ constraints interact to impact negatively on the capacity of primary care staff to implement TB-IPC measures. Clinic ethnography allowed for multiple entry points to the ‘problematic’ of compromised TB-IPC, highlighting the importance of capturing dimensions of the ‘enabling environment’, currently not assessed in binary checklists.
Commentary: Time to change the way we think about tuberculosis infection prevention and control in health facilities: insights from recent research
(Cambridge University Press, 2023-07-17) Yates, Tom A.; Karat, Aaron S.; Bozzani, Fiammetta; McCreesh, Nicky; MacGregor, Hayley; Beckwith, Peter G.; Govender, Indira; Colvin, Christopher J.; Kielmann, Karina; Grant, Alison D.
In clinical settings where airborne pathogens, such as Mycobacterium tuberculosis, are prevalent, they constitute an important threat to health workers and people accessing healthcare. We report key insights from a 3-year project conducted in primary healthcare clinics in South Africa, alongside other recent tuberculosis infection prevention and control (TB-IPC) research. We discuss the fragmentation of TB-IPC policies and budgets; the characteristics of individuals attending clinics with prevalent pulmonary tuberculosis; clinic congestion and patient flow; clinic design and natural ventilation; and the facility-level determinants of the implementation (or not) of TB-IPC interventions. We present modeling studies that describe the contribution of M. tuberculosis transmission in clinics to the community tuberculosis burden and economic evaluations showing that TB-IPC interventions are highly cost-effective. We argue for a set of changes to TB-IPC, including better coordination of policymaking, clinic decongestion, changes to clinic design and building regulations, and budgeting for enablers to sustain implementation of TB-IPC interventions. Additional research is needed to find the most effective means of improving the implementation of TB-IPC interventions; to develop approaches to screening for prevalent pulmonary tuberculosis that do not rely on symptoms; and to identify groups of patients that can be seen in clinic less frequently.
Decentralising DR-TB care: the trade-off between quality of care and service coverage in the early phase of implementation
(International Union Against Tuberculosis and Lung Disease, 2025-09-03) Jassat, Waasila; Moshabela, Mosa; Nicol, Mark P.; Dickson, Laurie; Cox, Helen; Mlisana, Koleka; Black, John; Loveday, Marian; Grant, Alison D.; Kielmann, Karina; Schneider, Hans G.
A policy of decentralised care for drug-resistant TB (DR-TB) was introduced in South Africa in 2011. We describe a trade-off between increasing coverage of services and poor quality of care, in the early phase of policy implementation. This was a mixed methods case study, comparing implementation in KwaZulu-Natal and Western Cape provinces; with interviews and quantitative analysis of routine DR-TB programme data. We analysed qualitative data, thematically organizing findings into inputs, processes, and outputs to explore how decentralisation influenced quality of DR-TB care. Decentralisation of DR-TB care expanded access across provinces but there was wide variation in pace, planning and structural readiness. Where rapid scale-up outpaced capacity-building, weaknesses in resourcing, workforce, and clinical governance compromised quality of care. Two illustrative examples highlight that decentralisation to inadequately resourced sites resulted in morbidity to patients who did not receive effective monitoring for adverse events; and decentralising services to inadequately capacitated clinicians resulted in incorrect initiation in more complex cases and late referral of clinical complications. Attempts to decentralise DR-TB treatment in the context of complex treatment algorithms and limited health system capacity resulted in trade-offs of care quality. We argue that quality of care should be an essential consideration in early implementation of health programmes.
Direct estimates of absolute ventilation and estimated Mycobacterium tuberculosis transmission risk in clinics in South Africa
(Public Library of Science, 2022-11-02) Beckwith, Peter G.; Karat, Aaron S.; Govender, Indira; Deol, Arminder K.; McCreesh, Nicky; Kielmann, Karina; Baisley, Kathy; Grant, Alison D.; Yates, Tom A.
Healthcare facilities are important sites for the transmission of pathogens spread via bioaerosols, such as Mycobacterium tuberculosis. Natural ventilation can play an important role in reducing this transmission. We aimed to measure rates of natural ventilation in clinics in KwaZulu-Natal and Western Cape provinces, South Africa, then use these measurements to estimate Mycobacterium tuberculosis transmission risk. We measured ventilation in clinic spaces using a tracer-gas release method. In spaces where this was not possible, we estimated ventilation using data on indoor and outdoor carbon dioxide levels. Ventilation was measured i) under usual conditions and ii) with all windows and doors fully open. Under various assumptions about infectiousness and duration of exposure, measured absolute ventilation rates were related to risk of Mycobacterium tuberculosis transmission using the Wells-Riley Equation. In 2019, we obtained ventilation measurements in 33 clinical spaces in 10 clinics: 13 consultation rooms, 16 waiting areas and 4 other clinical spaces. Under usual conditions, the absolute ventilation rate was much higher in waiting rooms (median 1769 m3/hr, range 338–4815 m3/hr) than in consultation rooms (median 197 m3/hr, range 0–1451 m3/hr). When compared with usual conditions, fully opening existing doors and windows resulted in a median two-fold increase in ventilation. Using standard assumptions about infectiousness, we estimated that a health worker would have a 24.8% annual risk of becoming infected with Mycobacterium tuberculosis, and that a patient would have an 0.1% risk of becoming infected per visit. Opening existing doors and windows and rearranging patient pathways to preferentially use better ventilated clinic spaces result in important reductions in Mycobacterium tuberculosis transmission risk. However, unless combined with other tuberculosis infection prevention and control interventions, these changes are insufficient to reduce risk to health workers, and other highly exposed individuals, to acceptable levels.
Diverse clinical and social circumstances: Developing patient-centred care for DR-TB patients in South Africa
(The Union, 2021-09-21) Mitrani, Leila; Dickson-Hall, Lindy; Le Roux, Sacha; Grant, Alison D.; Kielmann, Karina; Mlisana, Koleka; Moshabela, Mosa; Nicol, Mark P.; Black, John; Cox, Helen
Objective: To describe the medical, socio-economic and geographical profiles of patients with rifampicin-resistant TB (RR-TB) and the implications for the provision of patient-centred care.
Drug-resistant tuberculosis patient care journeys in South Africa: A pilot study using routine laboratory data
(Ingenta, 2020-01-01) Hill, Jeremy Stewart; Dickson-Hall, Lindy; Grant, Alison D.; Grundy, Chris; Black, John; Kielmann, Karina; Mlisana, Koleka; Mitrani, Leila; Loveday, Marian; Moshabela, Mosa; Le Roux, Sacha; Jassat, Waasila; Nicol, Mark; Cox, Helen Suzanne
SETTING: Thirteen districts in Eastern Cape (EC), KwaZulu-Natal (KZN) and Western Cape (WC) Provinces, South Africa.
Estimating the contribution of transmission in primary healthcare clinics to community-wide TB disease incidence, and the impact of infection prevention and control interventions, in KwaZulu-Natal, South Africa
(BMJ, 2022-04-08) McCreesh, Nicky; Karat, Aaron S.; Govender, Indira; Baisley, Kathy; Diaconu, Karin; Yates, Tom A.; Houben, Rein M. G. J.; Kielmann, Karina; Grant, Alison D.; White, Richard
Background: There is a high risk of Mycobacterium tuberculosis (Mtb) transmission in healthcare facilities in high burden settings. WHO guidelines on tuberculosis (TB) infection prevention and control (IPC) recommend a range of measures to reduce transmission in healthcare settings. These were evaluated primarily based on evidence for their effects on transmission to healthcare workers in hospitals. To estimate the overall impact of IPC interventions, it is necessary to also consider their impact on community-wide TB incidence and mortality. Methods: We developed an individual-based model of Mtb transmission in households, primary healthcare (PHC) clinics, and all other congregate settings. The model was parameterised using data from a high HIV prevalence community in South Africa, including data on social contact by setting, by sex, age, and HIV/antiretroviral therapy status; and data on TB prevalence in clinic attendees and the general population. We estimated the proportion of disease in adults that resulted from transmission in PHC clinics, and the impact of a range of IPC interventions in clinics on community-wide TB. Results: We estimate that 7.6% (plausible range 3.9%–13.9%) of non-multidrug resistant and multidrug resistant TB in adults resulted directly from transmission in PHC clinics in the community in 2019. The proportion is higher in HIV-positive people, at 9.3% (4.8%–16.8%), compared with 5.3% (2.7%–10.1%) in HIV-negative people. We estimate that IPC interventions could reduce incident TB cases in the community in 2021–2030 by 3.4%–8.0%, and deaths by 3.0%–7.2%. Conclusions: A non-trivial proportion of TB results from transmission in clinics in the study community, particularly in HIV-positive people. Implementing IPC interventions could lead to moderate reductions in disease burden. We recommend that IPC measures in clinics should be implemented for their benefits to staff and patients, but also for their likely effects on TB incidence and mortality in the surrounding community.
Estimating ventilation rates in rooms with varying occupancy levels: Relevance for reducing transmission risk of airborne pathogens
(PLoS, 2021-06-24) Deol, Arminder K.; Scarponi, Danny; Beckwith, Peter; Yates, Tom A.; Karat, Aaron S.; Yan, Ada W. C.; Baisley, Kathy S.; Grant, Alison D.; White, Richard G.; McCreesh, Nicky; Lo Iacono, Giovanni
Background: In light of the role that airborne transmission plays in the spread of SARS-CoV-2, as well as the ongoing high global mortality from well-known airborne diseases such as tuberculosis and measles, there is an urgent need for practical ways of identifying congregate spaces where low ventilation levels contribute to high transmission risk. Poorly ventilated clinic spaces in particular may be high risk, due to the presence of both infectious and susceptible people. While relatively simple approaches to estimating ventilation rates exist, the approaches most frequently used in epidemiology cannot be used where occupancy varies, and so cannot be reliably applied in many of the types of spaces where they are most needed. Methods: The aim of this study was to demonstrate the use of a non-steady state method to estimate the absolute ventilation rate, which can be applied in rooms where occupancy levels vary. We used data from a room in a primary healthcare clinic in a high TB and HIV prevalence setting, comprising indoor and outdoor carbon dioxide measurements and head counts (by age), taken over time. Two approaches were compared: approach 1 using a simple linear regression model and approach 2 using an ordinary differential equation model. Results: The absolute ventilation rate, Q, using approach 1 was 2407 l/s [95% CI: 1632–3181] and Q from approach 2 was 2743 l/s [95% CI: 2139–4429]. Conclusions: We demonstrate two methods that can be used to estimate ventilation rate in busy congregate settings, such as clinic waiting rooms. Both approaches produced comparable results, however the simple linear regression method has the advantage of not requiring room volume measurements. These methods can be used to identify poorly-ventilated spaces, allowing measures to be taken to reduce the airborne transmission of pathogens such as Mycobacterium tuberculosis, measles, and SARS-CoV-2.
Estimating waiting times, patient flow, and waiting room occupancy density as part of tuberculosis infection prevention and control research in South African primary health care clinics
(Public Library of Science, 2022-07-20) Karat, Aaron S.; McCreesh, Nicky; Baisley, Kathy; Govender, Indira; Kallon, Idriss I.; Kielmann, Karina; MacGregor, Hayley; Vassall, Anna; Yates, Tom A.; Grant, Alison D.
Transmission of respiratory pathogens, such as Mycobacterium tuberculosis and severe acute respiratory syndrome coronavirus 2, is more likely during close, prolonged contact and when sharing a poorly ventilated space. Reducing overcrowding of health facilities is a recognised infection prevention and control (IPC) strategy; reliable estimates of waiting times and ‘patient flow’ would help guide implementation. As part of the Umoya omuhle study, we aimed to estimate clinic visit duration, time spent indoors versus outdoors, and occupancy density of waiting rooms in clinics in KwaZulu-Natal (KZN) and Western Cape (WC), South Africa. We used unique barcodes to track attendees’ movements in 11 clinics, multiple imputation to estimate missing arrival and departure times, and mixed-effects linear regression to examine associations with visit duration. 2,903 attendees were included. Median visit duration was 2 hours 36 minutes (interquartile range [IQR] 01:36–3:43). Longer mean visit times were associated with being female (13.5 minutes longer than males; p<0.001) and attending with a baby (18.8 minutes longer than those without; p<0.01), and shorter mean times with later arrival (14.9 minutes shorter per hour after 0700; p<0.001). Overall, attendees spent more of their time indoors (median 95.6% [IQR 46–100]) than outdoors (2.5% [IQR 0–35]). Attendees at clinics with outdoor waiting areas spent a greater proportion (median 13.7% [IQR 1–75]) of their time outdoors. In two clinics in KZN (no appointment system), occupancy densities of ~2.0 persons/m2 were observed in smaller waiting rooms during busy periods. In one clinic in WC (appointment system, larger waiting areas), occupancy density did not exceed 1.0 persons/m2 despite higher overall attendance. In this study, longer waiting times were associated with early arrival, being female, and attending with a young child. Occupancy of waiting rooms varied substantially between rooms and over the clinic day. Light-touch estimation of occupancy density may help guide interventions to improve patient flow.
Health system influences on the implementation of tuberculosis infection prevention and control at health facilities in low-income and middle-income countries: A scoping review
(BMJ, 2021-05-11) Zwama, Gimenne; Diaconu, Karin; Voce, Anna S.; O'May, Fiona; Grant, Alison D.; Kielmann, Karina
Background Tuberculosis infection prevention and control (TB-IPC) measures are consistently reported to be poorly implemented globally. TB-IPC guidelines provide limited recognition of the complexities of implementing TB-IPC within routine health systems, particularly those facing substantive resource constraints. This scoping review maps documented system influences on TB-IPC implementation in health facilities of low/middle-income countries (LMICs).
‘It has become everybody’s business and nobody’s business’: Policy actor perspectives on the implementation of TB infection prevention and control (IPC) policies in South African public sector primary care health facilities
(Taylor & Francis, 2020-11-08) Colvin, Christopher; Kallon, Idriss; Swartz, Alison; MacGregor, Hayley; Kielmann, Karina; Grant, Alison D.
South Africa is increasingly offering screening, diagnosis and treatment of tuberculosis (TB), and especially drug-resistant TB, at the primary care level. Nosocomial transmission of TB within primary health facilities is a growing concern in South Africa, and globally. We explore here how TB infection prevention and control (IPC) policies, historically focused on hospitals, are being implemented within primary care facilities. We spoke to 15 policy actors using in-depth interviews about barriers to effective TB-IPC and opportunities for improving implementation. We identified four drivers of poor policy implementation: fragmentation of institutional responsibility and accountability for TB-IPC; struggles by TB-IPC advocates to frame TB-IPC as an urgent and addressable policy problem; barriers to policy innovation from both a lack of evidence as well as a policy environment dependent on ‘new’ evidence to justify new policy; and the impact of professional medical cultures on the accurate recognition of and response to TB risks. Participants also identified examples of TB-IPC innovation and described conditions necessary for these successes. TB-IPC is a long-standing, complex health systems challenge. As important as downstream practices like mask-wearing and ventilation are, sustained, effective TB-IPC ultimately requires that we better address the upstream barriers to TB-IPC policy formulation and implementation.
Linking Women Who Test HIV-Positive in Pregnancy-Related Services to HIV Care and Treatment Services in Kenya: A Mixed Methods Prospective Cohort Study
(Public Library of Science, 2014-03) Ferguson, Laura; Grant, Alison D.; Lewis, James; Kielmann, Karina; Watson-Jones, Deborah; Vusha, Sophie; Ong'ech, John O.; Ross, David A.
Introduction: There has been insufficient attention to long-term care and treatment for pregnant women diagnosed with HIV. Objective and Methods: This prospective cohort study of 100 HIV-positive women recruited within pregnancy-related services in a district hospital in Kenya employed quantitative methods to assess attrition between women testing HIV-positive in pregnancy-related services and accessing long-term HIV care and treatment services. Qualitative methods were used to explore barriers and facilitators to navigating these services. Structured questionnaires were administered to cohort participants at enrolment and 90+ days later. Participants' medical records were monitored prospectively. Semi-structured qualitative interviews were carried out with a sub-set of 19 participants. Findings: Only 53/100 (53%) women registered at an HIV clinic within 90 days of HIV diagnosis, of whom 27/53 (51%) had a CD4 count result in their file. 11/27 (41%) women were eligible for immediate antiretroviral therapy (ART); only 6/11 (55%) started ART during study follow-up. In multivariable logistic regression analysis, factors associated with registration at the HIV clinic within 90 days of HIV diagnosis were: having cared for someone with HIV (aOR:3.67(95%CI:1.22, 11.09)), not having to pay for transport to the hospital (aOR:2.73(95%CI:1.09, 6.84)), and having received enough information to decide to have an HIV test (aOR:3.61(95%CI:0.83, 15.71)). Qualitative data revealed multiple factors underlying high patient drop-out related to women's social support networks (e.g. partner's attitude to HIV status), interactions with health workers (e.g. being given unclear/incorrect HIV-related information) and health services characteristics (e.g. restricted opening hours, long waiting times). Conclusion: HIV testing within pregnancy-related services is an important entry point to HIV care and treatment services, but few women successfully completed the steps needed for assessment of their treatment needs within three months of diagnosis. Programmatic recommendations include simplified pathways to care, better-tailored counselling, integration of ART into antenatal services, and facilitation of social support. 2014 Ferguson et al.
Measuring mortality due to HIV-associated tuberculosis among adults in South Africa: Comparing verbal autopsy, minimally-invasive autopsy, and research data
(PLOS, 2017-03-23) Karat, Aaron S.; Tlali, Mpho; Fielding, Katherine L.; Charalambous, Salome; Chihota, Violet N.; Churchyard, Gavin J.; Hanifa, Yasmeen; Johnson, Suzanne; McCarthy, Kerrigan; Martinson, Neil A.; Omar, Tanvier; Kahn, Kathleen; Chandramohan, Daniel; Grant, Alison D.; Isaakidis, Petros
Background The World Health Organization (WHO) aims to reduce tuberculosis (TB) deaths by 95% by 2035; tracking progress requires accurate measurement of TB mortality. International Classification of Diseases (ICD) codes do not differentiate between HIV-associated TB and HIV more generally. Verbal autopsy (VA) is used to estimate cause of death (CoD) patterns but has mostly been validated against a suboptimal gold standard for HIV and TB. This study, conducted among HIV-positive adults, aimed to estimate the accuracy of VA in ascertaining TB and HIV CoD when compared to a reference standard derived from a variety of clinical sources including, in some, minimally-invasive autopsy (MIA).
Modelling the effect of infection prevention and control measures on rate of Mycobacterium tuberculosis transmission to clinic attendees in primary health clinics in South Africa
(BMJ, 2021-10-25) McCreesh, Nicky; Karat, Aaron S.; Baisley, Kathy; Diaconu, Karin; Bozzani, Fiammetta; Govender, Indira; Beckwith, Peter; Yates, Tom A.; Deol, Arminder K.; Houben, Rein M. G. J.; Kielmann, Karina; White, Richard G.; Grant, Alison D.
Background Elevated rates of tuberculosis in health care workers demonstrate the high rate of Mycobacterium tuberculosis (Mtb) transmission in health facilities in high burden settings. In the context of a project taking a whole systems approach to tuberculosis infection prevention and control (IPC), we aimed to evaluate the potential impact of conventional and novel IPC measures on Mtb transmission to patients and other clinic attendees.
Organisational culture and mask-wearing practices for tuberculosis infection prevention and control among health care workers in primary care facilities in the Western Cape, South Africa: A qualitative study
(MDPI, 2021-11-19) Kallon, Idriss I.; Swartz, Alison; Colvin, Christopher J.; MacGregor, Hayley; Zwama, Gimenne; Voce, Anna S.; Grant, Alison D.; Kielmann, Karina
Background: Although many healthcare workers (HCWs) are aware of the protective role that mask-wearing has in reducing transmission of tuberculosis (TB) and other airborne diseases, studies on infection prevention and control (IPC) for TB in South Africa indicate that mask-wearing is often poorly implemented. Mask-wearing practices are influenced by aspects of the environment and organisational culture within which HCWs work. Methods: We draw on 23 interviews and four focus group discussions conducted with 44 HCWs in six primary care facilities in the Western Cape Province of South Africa. Three key dimensions of organisational culture were used to guide a thematic analysis of HCWs’ perceptions of masks and mask-wearing practices in the context of TB infection prevention and control. Results: First, HCW accounts address both the physical experience of wearing masks, as well as how mask-wearing is perceived in social interactions, reflecting visual manifestations of organisational culture in clinics. Second, HCWs expressed shared ways of thinking in their normalisation of TB as an inevitable risk that is inherent to their work and their localization of TB risk in specific areas of the clinic. Third, deeper assumptions about mask-wearing as an individual choice rather than a collective responsibility were embedded in power and accountability relationships among HCWs and clinic managers. These features of organisational culture are underpinned by broader systemic shortcomings, including limited availability of masks, poorly enforced protocols, and a general lack of role modelling around mask-wearing. HCW mask-wearing was thus shaped not only by individual knowledge and motivation but also by the embodied social dimensions of mask-wearing, the perceptions that TB risk was normal and localizable, and a shared underlying tendency to assume that mask-wearing, ultimately, was a matter of individual choice and responsibility. Conclusions: Organisational culture has an important, and under-researched, impact on HCW mask-wearing and other PPE and IPC practices. Consistent mask-wearing might become a more routine feature of IPC in health facilities if facility managers more actively promote engagement with TB-IPC guidelines and develop a sense of collective involvement and ownership of TB-IPC in facilities.
Performance of verbal autopsy methods in estimating HIV-associated mortality among adults in South Africa
(BMJ, 2018-07-03) Karat, Aaron S.; Maraba, Noriah; Tlali, Mpho; Charalambous, Salome; Chihota, Violet N.; Churchyard, Gavin J.; Fielding, Katherine L.; Hanifa, Yasmeen; Johnson, Suzanne; McCarthy, Kerrigan M.; Kahn, Kathleen; Chandramohan, Daniel; Grant, Alison D.; Topp, Stephanie M.
Introduction Verbal autopsy (VA) can be integrated into civil registration and vital statistics systems, but its accuracy in determining HIV-associated causes of death (CoD) is uncertain. We assessed the sensitivity and specificity of VA questions in determining HIV status and antiretroviral therapy (ART) initiation and compared HIV-associated mortality fractions assigned by different VA interpretation methods.
Prevalence of Mycobacterium tuberculosis in sputum and reported symptoms among clinic attendees compared to a community survey in rural South Africa
(Oxford University Press, 2022-01-12) Govender, Indira; Karat, Aaron S.; Olivier, Stephen; Baisley, Kathy; Beckwith, Peter; Dayi, Njabulo; Dreyer, Jaco; Gareta, Dickman; Gunda, Resign; Kielmann, Karina; Koole, Olivier; Mhlongo, Ngcebo; Modise, Tshwaraganang; Moodley, Sashen; Mpofana, Xolile; Ndung’u, Thumbi; Pillay, Deenan; Siedner, Mark J.; Smit, Theresa; Surujdeen, Ashmika; Wong, Emily B.; Grant, Alison D.
Background Tuberculosis (TB) case finding efforts typically target symptomatic people attending health facilities. We compared the prevalence of Mycobacterium tuberculosis (Mtb) sputum culture-positivity among adult clinic attendees in rural South Africa with a concurrent, community-based estimate from the surrounding demographic surveillance area (DSA). Methods Clinic: Randomly-selected adults (≥18 years) attending two primary healthcare clinics were interviewed and requested to give sputum for mycobacterial culture. HIV and antiretroviral therapy (ART) status were based on self-report and record review. Community: All adult (≥15 years) DSA residents were invited to a mobile clinic for health screening, including serological HIV testing; those with ≥1 TB symptom (cough, weight loss, night sweats, fever) or abnormal chest radiograph were asked for sputum. Results Clinic: 2,055 patients were enrolled (76.9% female, median age 36 years); 1,479 (72.0%) were classified HIV-positive (98.9% on ART) and 131 (6.4%) reported ≥1 TB symptom. Of 20/2,055 (1.0% [95% CI 0.6–1.5]) with Mtb culture-positive sputum, 14 (70%) reported no symptoms. Community: 10,320 residents were enrolled (68.3% female, median age 38 years); 3,105 (30.3%) tested HIV-positive (87.4% on ART) and 1,091 (10.6%) reported ≥1 TB symptom. Of 58/10,320 (0.6% [95% CI 0.4–0.7]) with Mtb culture-positive sputum, 45 (77.6%) reported no symptoms. In both surveys, sputum culture positivity was associated with male sex and reporting >1 TB symptom. Conclusions In both clinic and community settings, most participants with Mtb culture-positive sputum were asymptomatic. TB screening based only on symptoms will miss many people with active disease in both settings.