Background: This paper describes the performance of the Tuberculosis (TB) control programme in the Eastern Cape Province. The aim of the study was to evaluate the tuberculosis treatment outcomes as well as to identify factors that contribute to treatment failures in health districts of the Eastern Cape Province from 2003 to 2005. TB can only be controlled and eventually eliminated in the context of a National Tuberculosis Control Program (NTCP). Such a program must operate within the general health service of each country. Although considerable progress has been made with TB control efforts in South Africa since 2000, there is still little sign that the epidemic is abating in the Eastern Cape Province. Method: The study was a descriptive study and the methodology employed in this evaluative study took cognizance of the main approaches used globally (World Health Organization and the International Union Against Tuberculosis and Lung Disease) to assess the performance and quality of Tuberculosis Control Programs. 152 336 records from the Electronic TB Register for the period 2003 – 2005 were systematically reviewed and a random sample design of 252 primary health care facilities with probability proportional to size was used to collect information on health system related factors that contribute to treatment failures with emphasis to input, process and output indicators for the TB Control programme including proper implementation of DOTS strategy. Results: Overall TB treatment outcomes in Eastern Cape Province did not reach the national targets for the period 2003 – 2005. A cure rate of 39.7% for new smear positive patients in 2005 was reported. Only Chris Hani district reached a national target of 70% for smear conversion rate in 2005. The successful treatment outcomes were below 85% threshold suggested by the World Health Organization. Cure rates never reached 50% for the three-year study period. Defaulting from treatment remained a challenge for the TB control programme in the Eastern Cape Province. There has been an increasing number of patients with treatment outcome not evaluated in 2005 from 20.1% to 24.7% in new smear positive cases and in re-treatment smear positive cases, this increased from 21.2% to 27.3%. Conclusion: The findings of the study reveal that, despite considerable efforts made by the NTCP, little change was noted in treatment outcomes. Efforts to provide effective TB treatment using DOTS at district and facility level in the province are constrained by failure of most districts to reach a 100% DOTS coverage. Patients are accurately diagnosed, recorded into the register, drug supply is regular and uninterrupted but there has been a slow increase in the proportion of patients cured and there are an increase number of defaulter rates and patients with treatment outcomes which are not evaluated. An improved base of information is needed to assess the TB morbidity impact more accurately. Human resources were among the most important resources, which were found lacking and health system managers have the responsibility and challenge of ensuring that maximum benefit is derived from these to maintain and expand health services. / Dissertation (MSc)--University of Pretoria, 2009. / School of Health Systems and Public Health (SHSPH) / Unrestricted

Introduction Schistosomiasis is one of the most important and widespread diseases of rural poverty. Worldwide, approximately 779 million people are at risk of infection, with 207 million already infected. Infections with Ascaris lumbricoides, hookworms and Trichuris trichiura, collectively known as the soil-transmitted helminths (STHs), are also highly endemic throughout the tropics, particularly in resource-poor settings. An estimated 1 billion people worldwide are estimated to be infected with STHs. Schistosomes and STHs often co-exist in the same epidemiological settings and, given the high prevalence of concurrent multiple species infections (multiparasitism), a combined approach to prevention and control could lead to significant improvements, including reducing costs associated with single-species control programmes. In China, rigorous national schistosomiasis control efforts over the past 60 years have decreased the prevalence by over 90%; however, since 2000 the number of infected individuals has been rising, possibly indicative of a re-emergence. Fishermen, migrant communities and poor households in rural areas may be most at risk of single and multiple-species parasitic infections and the associated morbidity. Objectives This Ph.D. thesis is structured according to four main goals and a number of specific objectives: Firstly, to update estimates of S. japonicum prevalence, intensity and associated morbidity levels in Hunan province, China, according to the third national PES carried out in 2004; Secondly, to investigate existing barriers in access to preventive, diagnostic and treatment services for advanced schistosomiasis; Thirdly, to compare and evaluate direct and proxy methods of measuring household socio-economic position, according to data on income, savings and asset-based estimations of wealth; and Finally, to explore and identify behavioural, demographic, economic, environmental and social risk factors associated with the distribution of S. japonicum, STHs and multiple species infections, in two villages of the Dongting Lake region, Hunan province, China. Methods Firstly, we used data from the third national schistosomiasis periodic epidemiological survey (PES) of 2004. In Hunan province, the PES was carried out in 47 villages of the endemic Dongting lake area. A total of 47144 human serological, 7205 stool, and 3893 clinical examinations were performed. For the reservoir hosts, stools from 874 buffaloes and other domestic animals were examined for schistosomiasis by the miracidial hatching test. Secondly, we conducted an in-depth study involving interviews with 66 schistosomiasis control staff and 79 advanced schistosomiasis patient, and six focus group discussions (FGDs), in the Dongting lake region, between August 2002 and February 2003. Using the Health-Access Livelihood framework we examined availability, accessibility, affordability, adequacy and acceptability of schistosomiasis control in the Dongting lake area. Lastly, we carried out two village-wide parasitological, clinical and questionnaire-based investigations between October and December 2006. Parasitological examinations for the prevalence of S. japonicum and the STHs were performed by the Kato-Katz thick smear method, with repeated sampling of each individual. We took fingerprick blood samples to assess haemoglobin levels, using a B-haemoglobin HemoCue photometer. The household-based questionnaire focused on direct and proxy measurements of household wealth, while the individual-based questionnaire focused on demographic and behavioural factors, treatment history and self-perceived symptoms. Results Human sero-prevalence was 11.9% (range: 1.3-34.9% at village level), and the rate of egg-positive stools was 1.9% (0-10.9%) for the same population. The prevalence of infection among buffaloes was 9.5% (0-66.7%). Extrapolating to the entire population of the Dongting Lake region, an estimated 73225 people and 13973 buffaloes were infected. Most frequently reported symptoms were abdominal pain (6.2%) and bloody stools (2.7%). Accessibility and affordability were major barriers in access to schistosomiasis control. Many of staff interviewed indicated that a majority of patients who develop advanced schistosomiasis resided in mildly-endemic or non-endemic settings. None of the patients interviewed had any form of health insurance, and most of their health expenses were out-of-pocket payments. Exploratory factor analysis generated internally robust proxy wealth indices, however these were not complementary to direct measures of household wealth, as indicated by low correlation co-efficients. We found wide disparities in household ownership of durable assets, utility and sanitation, within both settings. Pooled data from the rural and peri-urban settings highlighted structural differences in socioeconomic position (SEP), more likely a result of localised urbanization and modernization. We found higher infection prevalences in rural settings, than in peri-urban settings, for schistosomiasis (6.3% and 6.7% respectively), ascariasis (8.3% and 2.2%, respectively) and trichuriasis (5.1% and 0.5%, respectively), but lower for hookworms (0.1% and 1.5% respectively). Multiple species infections (2.6% and 0.2%, respectively) were less prevalent than single species infections (14.5% and 10.4%). There were significant disparities in the prevalence of parasitic infections between poorest and least poor quintiles of the cohort population. Anaemia and other symptoms, especially headache, stomach ache and swollen stomach, were common in both rural and peri-urban village settings. Conclusion The studies conducted within the framework of this Ph.D. thesis document the current situation pertaining to schistosomiasis and the STHs in Hunan province, China. Our findings highlight the need for increased surveillance, monitoring and health education, with relation to schistosomiasis and STHs, in non-endemic or post-transmission control settings. Based upon these results, we call for improved diagnostic tools, particularly in the case of low intensity infections and for hookworm, and propose an extension of the use of available infrastructure, human resources, knowledge and technology by integrating prevention and control of schistosomiasis with that of other intestinal helminths, particularly STHs. In the future, our studies may form a base from which to further examine local needs and priorities for parasitic disease control in the area.

Thesis (MScMedSc)--Stellenbosch University, 2011. / ENGLISH ABSTRACT: Introduction: Tuberculosis (TB) treatment registers and laboratory records are essential recording and reporting tools in TB control programmes. Reliable data are essential for any TB control programme but under-registration of TB cases has been well documented internationally, due to under-reporting of patients on treatment or failure to initiate treatment. The accuracy and completeness of routinely collected data are seldom monitored. Aim: This study used record linking to assess the accuracy and completeness of TB treatment register data and the feasibility of estimating the completeness of bacteriological confirmed pulmonary TB registration in two high incident communities in South Africa with capturerecapture methods. Methods: All cases of bacteriologically confirmed TB defined as 2 smear-positive results and/or at least one culture-positive result were included. Record linking was performed between three data sources: (1) TB treatment registers; and (2) all smear and culture results from (a) the nearest central laboratory, and (b) the referral hospital laboratory. To estimate the completeness of TB treatment recording three-source log-linear capture-recapture models were used, with internal validity analysis. Results: The TB treatment registers had 435 TB cases recorded of which 204 (47%) were bacteriologically confirmed cases. An additional 39 cases that were recorded as nonbacteriological cases in the TB treatment register, were reclassified as bacteriologically confirmed. In addition, there were 63 bacteriologically confirmed cases identified from the laboratory databases which were not recorded in the TB treatment register. The final total number of bacteriologically confirmed TB cases across all 3 databases was 306, an increase of 50% over what had initially been recorded in the TB treatment register. The log-linear capture-recapture model estimated the number of bacteriologically confirmed TB cases not found in any of the data sources at 20, resulting in a total number of bacteriologically confirmed TB cases of 326 (95% CI 314-355). The completeness of registration of bacteriologically confirmed pulmonary TB cases was 79% after record linking and 75% after the capture-recapture estimate. Conclusions: The results presented in this thesis highlighted the concern regarding the accuracy and completeness of routinely collected TB recording and reporting data. A high percentage of bacteriologically confirmed cases from both laboratories were not recorded in the TB treatment registers. Capture-recapture can be useful, but not essential, for evaluation of TB control programmes, also in resource-limited settings, but methodology and results should be carefully assessed. The present study estimated the extent of the problem of underreporting of TB in South Africa and identified challenges in the process. Interventions to reduce underreporting of TB are urgently needed. / AFRIKAANSE OPSOMMING: Inleiding: Registers van tuberkulose (TB) behandeling en laboratoriumrekords is noodsaaklike instrumente in die dokumentering van en verslagdoening oor TB beheerprogramme. Betroubare data is onontbeerlik vir enige TB beheerprogram maar onderregistrasie van TB gevalle is internasionaal goed gedokumenteer. Die akkuraatheid en volledigheid van roetine data word selde gemoniteer. Doel: Hierdie studie het rekordkoppeling gebruik om die akkuraatheid en volledigheid van data in TB behandelingsregisters te ondersoek. Voorts is die uitvoerbaarheid van die vangshervangsmetodes vir die beoordeling van die volledigheid van bakteriologies bevestigde pulmonale TB registrasie in twee hoë-insidensie gemeenskappe ondersoek. Metodes: Alle gevalle van bakteriologies bevestigde TB, gedefinieer as 2 smeer-positiewe resultate en/of ten minste een kultuur-positiewe resultaat, is in die studie ingesluit. Rekordkoppeling is onderneem tussen drie databronne: (1) TB behandelingsregisters; en (2) alle smeer- en kultuurpositiewe resultate van (a) die naaste sentrale laboratorium, en (b) die verwysende hospitaallaboratorium. Om die volledigheid van TB behandelingsrekords te ondersoek is drie-bron log-lineêre vangs-hervangs modelle gebruik met interne geldigheidsontleding. Resultate: Die TB registers het 435 aangetekende TB gevalle bevat waarvan 204 (47%) bakteriologies bevestigde gevalle was. 'n Bykomende 39 gevalle wat as nie-bakteriologies bevestigde gevalle aangeteken was in die TB register is hergeklassifiseer as bakteriologies bevestig. Daar is ook 63 bakteriologies bevestigde gevalle geïdentifiseer vanuit die laboratorium databasisse wat nie in die TB register aangeteken was nie. Die finale totale aantal bakteriologies bevestigede TB gevalle oor al drie databasisse heen was 306, 'n toename van 50% in vergelyking met wat aanvanklik in die TB register aangeteken was. Die log-lineêre vangs-hervangs model het die aantal bakteriologies bevestigde gevalle wat nie in enige van die databronne gevind kon word nie as 20 gevalle geskat, wat gelei het tot 'n totaal van 326 (95% VI 314-355) bakteriologies bevestigde gevalle. Die volledigheid van registrasie van bakteriologies bevestigde TB gevalle was 79% na rekordkoppeling en 75% na die vangs-hervangs skatting. Gevolgtrekkings: Die resultate wat in hierdie tesis voorgelê is beklemtoon die besorgdheid oor die akkuraatheid en volledigheid van die aanmelding en optekening van roetine TB data. 'n Hoë persentasie van bakteriologies bevestigde gevalle van beide laboratoriums is nie in die TB register opgeteken nie. Vangs-hervangs kan nuttig wees, maar nie noodsaaklik nie, in die evaluasie van TB beheerprogramme, ook in hulpbron-arm omgewings, maar die metodologie moet omsigtig beoordeel word. Die huidige studie het die omvang van die probleem van onderrapportering van TB in Suid-Afrika beraam en uitdagings in die proses geïdentifiseer. Intervensies om onderrapportering te verminder word dringend benodig.