Mycobacterium tuberculosis (MTB) is an airborne pathogen that is easily transmitted from person to person. An intact immune system prevents the organism from causing disease in most individuals. In South Africa, the prevalence of human immunodeficiency virus (HIV) has reached astronomical levels and is now fuelling the tuberculosis (TB) epidemic. Drug resistant MTB strains combined with a weakened host immune system is a lethal combination. Multi-drug resistant (MDR) including extensively drug resistant (XDR) tuberculosis is on the increase, with Tugela Ferry in KwaZulu-Natal South Africa, reporting the largest cluster of XDR cases in the world. It is unknown whether a single clone of the drug resistant strain is circulating in this area or whether there are multiple strains at play. Using 2 complementary genotyping methods, we showed that the MDR strains present are the result of clonal spread associated with the F28 family, as well as de novo resistance which manifests as unique patterns. The XDR epidemic in Tugela Ferry is the result of clonal spread of a strain belonging to the F15/LAM4/KZN family. / Thesis (M.Med.)-University of KwaZulu-Natal, Durban, 2011.

Introduction Sputum smears stained by the Ziehl-Neelsen method are the least expensive tool for diagnosing patients with infectious tuberculosis. However, false positive and false negative results have serious implications for treatment of patients. Therefore, controlling the quality of sputum microscopy services is important to ensure that the laboratory produce results that are accurate, reliable and reproducible. Aim The aim of the study was to determine the quality of tuberculosis smear microscopy in public health laboratories in KwaZulu-Natal between the years 2001 and 2006, and to assess the current knowledge and attitude of laboratory workers and laboratory managers to proficiency testing as a quality assurance technique. Methods A secondary analysis of laboratory proficiency testing results, from the KwaZulu-Natal reference laboratory (2001 to 2004) and from the National Health Laboratory Services reference laboratory (2006), was performed. Key informant interviews were conducted to determine the role proficiency testing played as a quality assurance technique. Results Overall laboratory performance was 93% from 2001 to 2004 and 98% in 2006. High false negative results were the predominant error. Sensitivity and specificity improved from 91% (for both) in 2001 to 2004 to 97% (for both) in 2006. Overall performance of primary, district and tertiary health care levels were 92%, 93% and 73% respectively in the period 2001 to 2004 and 98%, 98% and 94% respectively in 2006.There was significant (p<0.01) improvement in both urban (97%) and rural (98%) laboratory performance in 2006. The overall scores by year ranged from 89% (2002) to 98% (2006), but the annual overall scores (2001 to 2006) only achieved the acceptable level twice. Key informants indicated that proficiency testing was an essential exercise, however, they reported challenges such as inconsistent feedback, high workload and need for training. Discussion Overall performance improved from an unacceptable level of 93% (2001-2004) to a satisfactory level of 98% (2006). Likely reasons include improvement in technical skills of microscopists and improvement in preparation of proficiency testing slides. Proficiency testing is considered an essential exercise to improve laboratory performance, however, participants know that they are being tested and may give 'special attention' to proficiency testing slides resulting in a social desirability bias. Recommendations A blinded rechecking programme should be established in conjunction with the use of a standardised checklist during support visits. Feedback, communication and staff training should be improved while the workload should be evaluated. / Thesis (MMed.)-Univerity of KwaZulu-Natal, Durban, 2009.

South Africa has the highest Tuberculosis (TB) incidence in the world. In 2006 it was estimated that in South Africa, with only 0.7% of the world population; some 28% of HIV positive adults had TB. To treat one patient with ordinary TB costs the Health Department approximately R310 and a patient with multi-drug TB (MDR-TB) more than R2000. TB has added to the burden of a country which is struggling to cope with the HIV/AIDS pandemic. TB is one of the national health priorities of the Department of Health (DoH). KwaMsane Clinic is located at Mtubatuba, in the UMkhanyakude district. The uMkhanyakude district has the highest prevalence of HIV and the highest number of cases of TB in South Africa. The UMkhanyakude district stretches from the Umfolozi River, which is south of Mtubatuba, to the Mozambique and Swaziland borders. The clinic is a Primary Health Care centre and is open 24 hours a day. UMkhanyakude has a population estimated at 614,046. According to the DoH National Tuberculosis Management Guidelines (2009), the greatest challenge that the TB programme faces are inadequate financial and human resources for TB control, resulting in poor case detection, increasing numbers of multi-drug resistance TB, extensively dry-resistance TB and poor quality data collection and data analysis. The study set out to identify the challenges that KwaMsane clinic faces in terms of TB management. It was found that the problem facing KwaMsane clinic’s effectiveness was largely due to two factors. The first is the delay in patient diagnosis and the second is the negative nurse/patient ratio which affects the workload and compromises levels of service delivery. The population was sufficiently small, but statistically adequate and all 31 employees were surveyed. Of these, 61% or 19 of the employees agreed that there is a delay in patient diagnosis. The recommendations for KwaMsane clinic include more effective recruiting of staff; attracting and retaining qualified and experienced health personnel; equipment and resources need to be more available; and the clinic management should ensure that they have enough personnel to cope with high number of patients More research is needed on issues such as recruiting attracting and retaining qualified and experienced health personnel; provision of skills training for clinic management and other health personnel to improve service delivery; management of information systems at primary health care clinics for record keeping and data analysis; and integrating TB and HIV/AIDS management. / Thesis (MBA)-University of KwaZulu-Natal, Durban, 2011.

Introduction Tuberculosis (TB) is a major cause of death worldwide. Control of Tuberculosis is a serious challenge to global health. A new and potentially devastating threat to TB control is the emergence of multi-drug resistant TB (MDR-TB). South Africa was ranked fourth among the countries with the highest number of confirmed MDR-TB cases. Aim The aim was to investigate the annual MDR-TB prevalence and associated risk factors for MDR-TB from 2001 to 2007 at the Prince Cyril Zulu Communicable Disease Centre. To investigate previous TB treatment duration, previous TB treatment outcome, and duration of previous TB treatment interruption in a subgroup of patients who were previously treated for TB. To determine the average length of time from diagnosis of TB to diagnosis of MDR-TB and commencement of MDR-TB treatment. Methods An observational analytic nested case-control study design was used. All patients who were diagnosed with pulmonary TB and who had a sputum culture performed between 2001 and 2007 were included in the study. The cases were all MDR-TB cases diagnosed on sputum culture between 2001 and 2007. The controls were drug susceptible TB cases which had a sputum culture done at diagnosis, and were diagnosed in the same month as the MDR-TB case Results There were 10 205 sputum cultures performed from 2001 to 2007. MDR-TB was found in 445 patients. An increase in the prevalence of MDR-TB occurred in 2007, due to a significant increase in prevalence among new TB cases. The MDR-TB prevalence was 11.7% among new TB cases and 4.7% among previously treated TB cases in 2007. There was no significant association between demographic characteristics and MDR-TB. Previous TB treatment failure and a duration of previous TB treatment of greater than 32 weeks was found to be significantly associated with MDR-TB. The median time from TB diagnosis to MDR-TB diagnosis was 98 day and from MDR-TB diagnosis to MDR-TB treatment 10 days. Discussion Delays in the diagnosis of MDR-TB, long waiting times before MDR-TB treatment commencement and lack of isolation have contributed to the spread of primary MDR-TB and was most likely responsible for the increase in prevalence of MDR-TB among new TB cases. Recommendations It was suggested that a sputum specimen should be obtained for culture and sensitivity from all new TB patients in areas which have an MDR-TB prevalence of greater than 3% among new TB patients. Ensure patient education on basic infection control measures. Improve MDR-TB diagnosis and reduce waiting times for MDR-TB treatment. / Thesis (M.Med.Sc.)-University of KwaZulu-Natal, Durban, 2011.