Multidrug- and higher degrees of drug resistant Mycobacterium tuberculosis have become a global public health issue of high priority. According to the World Health Organization (WHO) 2008 estimates, there were 440.000 cases and 150.000 deaths of multidrug-resistant tuberculosis (MDR-TB) globally and only about 1% of these cases were on treatment regimens based on WHO recommended standards
. In 2010, extensively drug-resistant (XDR)-TB was reported in 58 countries throughout all regions of the world. Due to the emergence of MDR-TB, the WHO developed a directly observed therapy short-course (DOTS) Plus strategy in 2000
. This strategy aims at ensuring correct identification and proper management of MDR-TB patients. DOTS-Plus treatment of MDR-TB cases has been proven to be highly cost effective in certain areas
Treatment delays have been attributed to various factors, such as living far from the health care facility, feeling a high degree of stigma, seeking initial care at a non-professional health care facility and having more than one health care encounter before diagnosis. However, health providers’ and health systems’ inherent delays have been found to account for the major part of the total delay
[5, 6]. The delay in the diagnosis and treatment of MDR-TB can result in patients developing persistent disease, progressive parenchymal destruction, higher bacillary loads, continuing transmission and increased mortality. In most public health settings there is lack of adequate and appropriate infection-control measures and, together with high human immune-deficiency virus (HIV) co-infection rates in certain settings
, this represents a public health emergency, calling for earlier detection and treatment of drug resistant TB
South Africa currently ranks fourth amongst countries with a high absolute number of MDR-TB cases, with an estimated number of 13.000 (6.7% of retreatment and 1.8% of new TB cases)
[1, 5, 6], and with a high rate of HIV co-infection
. Comprehensive programmatic management of patients with MDR-TB became national South African policy in 2000 and was implemented through provincial MDR-TB referral centres
. The most advantageous strategy for MDR-TB patients capitalizes on early diagnosis of MDR-TB
Gauteng Province with only 1.4% of South Africa’s land surface is highly urbanized and has an estimated population of between 8.8 and 9.5 million people. As South Africa’s economic hub, Gauteng attracts people from all across the country as well as the Southern African region who come in search of employment opportunities. The province is divided into six health care districts with a number of hospitals and PHCs. Within the larger hospitals, TB Focal Points were established in most of the major hospitals. TB Focal Points are centres dedicated to effective diagnosis, investigation, and treatment of TB and simultaneous investigation for HIV co-infection. Usually jointly staffed by doctors and PHC nurses, they assist in the diagnosis and referral of drug resistant TB. If patients are diagnosed with MDR- or XDR-TB, they are transferred for treatment to Sizwe Tropical Diseases Hospital (SH), a 268-bed specialized treatment centre for MDR- and XDR-TB patients.
According to the 2008 South African guidelines on management of MDR-TB, MDR-TB patients were admitted for at least the first six months or until they had produced two consecutive monthly culture-negative sputa
Prior to this study, SH estimated that 30-40% of culture-confirmed patients were unaccounted for in terms of treatment in Gauteng province.
The objectives of the study were to determine the number of culture and DST confirmed MDR- and XDR-TB cases in Gauteng that were not referred for specialist treatment at SH during the study period, and to identify reasons for this, with a focus on the functioning of health care facility follow up systems.