Tag: tuberculosis screening

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Testing More People with TB Symptoms is Critical to Reducing New Infections, Study Finds

On By ModernMedia
Tuberculosis bacteria. Credit: CDC

By Marcus Low for Spotlight

Many people who report with TB symptoms at South Africa’s public sector clinics do not receive TB tests. Testing more of these people is one of the most effective things we can do to reduce rates of TB disease and death, according to a major new modelling study.

While South Africa has made substantial progress against tuberculosis (TB), we are not on track to meet key targets set for 2030. This is according to a new modelling paper published in the journal Global Health Action.

TB incidence in South Africa was projected to decline by 46% by 2030, relative to a 2015 baseline. The World Health Organization (WHO) End TB target adopted by South Africa aimed at an 80% reduction in incidence. TB mortality was projected to decline by 54%, against the End TB target of 90%.

The researchers also published uncertainty intervals around these estimates. Even though these intervals are relatively wide, their upper limits are below the End TB targets, suggesting that it is unlikely that South Africa will reach the targets by 2030. The modelling however also identified interventions that could help South Africa get closer to the targets.

The new research is an extension of Thembisa, an existing mathematical model of HIV and TB in South Africa. University of Cape Town epidemiologist Dr Leigh Johnson, who is the lead author of the new study, is also the key driving force behind Thembisa.

Identifying what works

The researchers estimated which of a long list of interventions would have the greatest impact against TB. In technical terms, they looked at how varying 27 different parameters linked to TB interventions impacted projected TB incidence and mortality from 2025 to 2040 by calculating correlation coefficients (see the paper for a more nuanced explanation).

They found that the greatest reductions in TB would be achieved if a high percentage (89%) of people reporting with TB symptoms were tested using new point-of-care TB tests. This would result in a 49% reduction in average TB incidence and a 67% reduction in average TB mortality, relative to a scenario in which there are no changes to current programmes. TB symptoms include persistent cough, chest pain, night sweats, fever, and unexplained weight loss. There is good evidence that many people who report with these symptoms at clinics are not offered molecular TB tests.

The World Health Organization earlier this year recommended the use of such new point-of-care TB tests. These tests aren’t yet in general use in South Africa, although they are being evaluated in pilot projects. The new tests can be run on both sputum and tongue swabs. For now, most molecular TB tests in South Africa still involve someone producing a sputum sample – which some people struggle with – and the sample being transported to a lab for testing.

The researchers also found that high rates of door-to-door testing with the new point-of-care tests could reduce TB incidence and mortality by 38% and 49% respectively, while combining high rates of door-to-door testing and digital chest X-ray screening in asymptomatic individuals could reduce TB incidence and mortality by 17% and 21%.

Even without the new tests, there are substantial gains to be had if testing was stepped up in people with symptoms. TB incidence could be reduced by as much as 29% if the level of sputum testing in individuals seeking care for TB symptoms were increased to the upper bound considered by the researchers.

Once people have been diagnosed with TB and start taking TB treatment, they typically become non-infectious within around two weeks. Diagnosing people more quickly thus results in people remaining infectious for shorter periods, thus slowing TB transmission.

Other influential parameters identified by the researchers include the extent to which COVID-19-related behaviour changes are sustained, the rate at which people living with HIV start taking antiretroviral treatment (untreated HIV is a major driver of TB), and the combined uptake and efficacy of 3HP, a relatively new form of TB preventive therapy.

Testing is the key

“We found that the rate of testing in people seeking treatment for TB symptoms is the most important driver of future TB incidence and mortality,” wrote the authors.“This finding is not surprising given the historically low rates of TB testing. In studies of patients seeking treatment for TB symptoms in South African health facilities, the proportion who received a TB test has been highly variable, ranging from 3% to 84%, with a median of only 30%. Similarly low rates have been reported in other countries with high TB burdens.”

The study authors write that these low rates of testing reflect the non-specificity of TB symptoms and healthcare workers’ concerns about the cost and time required to collect sputum specimens and to send them to a central laboratory for molecular testing. In one South African study, they point out that 36% of all people attending clinics had symptoms suggestive of TB.

“Conducting TB testing in such a large fraction of primary care attendees may be infeasible,” they write.

“Achieving high levels of testing in people with TB symptoms could require levels of laboratory testing beyond current testing capacity. However, new point-of-care tests performed on tongue swabs or sputum present an important opportunity to increase levels of TB testing in symptomatic individuals at reduced cost, without placing additional strain on laboratories.”

In addition to reduced cost, the new point-of-care tests also offer quicker results and have lower operational requirements. The main potential benefit of these tests over existing lab tests is thus that they are likely to be used much more frequently.

Regardless of the testing platform, the study authors argue there is a need to strengthen adherence to existing guidelines for systematic testing of all patients with symptoms suggestive of TB and that we need a larger healthcare workforce dedicated to TB diagnosis, better supply chains, and better monitoring systems to identify where and why symptomatic patients are not being tested.

Disclosure: The study reported on here was supported by the Gates Foundation. Spotlight receives funding from the Gates Foundation, but is editorially independent – an independence that the editors guard jealously. Spotlight is a member of the South African Press Council.

*This article was first published by Spotlight – health journalism in the public interest. Sign up to the Spotlight newsletter.

Categories : Expert Opinion Respiratory DiseasesTags :

To Eliminate TB, We Need to Make Testing More Accessible and Affordable

On By ModernMedia
Tuberculosis bacteria. Credit: CDC

By Yogan Pillay and Gaurang Tanna

New TB tests have massive potential for South Africa’s struggle to get to grips with the age-old disease. Making the most of these new tests will require both ambition and smart implementation, argue Gaurang Tanna and Dr Yogan Pillay.

Every day, more than 140 people die from tuberculosis (TB) in South Africa, yet TB is both preventable and curable. Too many people are tested too late, allowing the disease to spread silently through communities and turning a curable illness into a fatal one.

Unlike most other diseases, anyone can contract TB – the bacteria are airborne and just the act of breathing makes us vulnerable to contracting TB. The risk of TB is higher for people with suppressed immunity, malnutrition, or living with cancer or HIV.

Reducing deaths from TB depends on earlier diagnosis, yet many people are diagnosed late, often after prolonged illness, and only once they reach hospitals with advanced disease. There are some opportunities for improvement. Firstly, we need to address persistent weaknesses in where and how TB tests are offered. Secondly, we need to address delays in care seeking, and missed opportunities for testing within health facilities. Finally, we need to close the operational barriers that impede testing. An added challenge that the TB disease presents is that it is often present without any symptoms.

In recent years, South Africa took important steps to strengthen its TB response and intensified efforts to find people with the TB disease through implementation of Targeted Universal TB Testing (TUTT). TUTT is a strategy that promotes systematic testing among high-TB risk groups, like people living with HIV, household contacts of individuals with TB, and people with previous TB, irrespective of symptoms.

South Africa now conducts approximately 3.6 million TB tests annually, representing a 50% increase compared to pre-COVID pandemic testing. However, we need to scale this up considerably if we are to reach the more than six million people living with HIV currently receiving HIV treatment in South Africa as well as all those with TB symptoms who are often missed at facilities.

The Department of Health has announced a national goal of conducting 5 million TB tests annually. Public-facing dashboards have been implemented to track TB testing and diagnosis, allowing the public to monitor performance across provinces and districts, strengthening transparency and accountability.

Structural barriers to TB testing

Despite strong commitments, TB testing in South Africa continues to face several structural constraints.

First, the cost of molecular diagnostics limits the scale of testing. Current molecular TB tests cost approximately R230 per test.

Second, inefficient clinic workflows reduce testing coverage. In busy primary healthcare facilities, this leads to missed TB testing, contributing to prolonged diagnostic delays during which transmission continues and disease severity worsens.

Third, many patients, especially children and people living with HIV, can’t produce sputum, which current tests require, further reducing testing coverage.

Fourth, people with the highest burden of TB, particularly men, often do not attend government clinics. Men account for a disproportionate share of TB in South Africa but remain underrepresented in testing programmes, contributing to delayed diagnoses and ongoing transmission.

Evolving and strengthening testing capabilities in line with the ambitions of the next phase of TB control in South Africa requires leveraging emerging diagnostic tools and redesigning how TB testing is delivered.

New diagnostic tools create new opportunities

Just recently, the World Health Organization updated its recommendations on TB diagnostics, endorsing the use of near-point-of-care tests and use of tongue swabs for people who cannot produce sputum to expand access to TB diagnostics and improve diagnostic efficiency. These new tools provide an opportunity to rethink how testing is organised across the health system.

Tongue swabs offer a promising alternative sample type, enabling testing among patients who cannot produce sputum. It has also been demonstrated to be more acceptable for patients and providers and is easier to collect in clinics.

At the same time, near-point-of-care molecular platforms (such as Pluslife, a test that has been approved by the South Africa’s health products regulatory body) offer the potential to diagnose TB closer to the patient. It substantially reduces costs, to about one-third the cost of current molecular tests, while demonstrating comparable diagnostic performance for TB, making large-scale expansion of TB testing more accessible and affordable. By delivering results rapidly, within an hour, this technology could enable a test and treat approach. TB testing, diagnosis, and treatment initiation could all happen during a single primary healthcare visit. This would reduce the time to start treatment and limit the number of patients lost between diagnosis and treatment.

Clinic workflows need to be redesigned

Patients presenting with TB symptoms often move through multiple stages of the clinic process – registration, triage, waiting areas, and clinician consultations – before TB testing is considered. Improving TB testing requires services redesign for patient convenience and accessibility, and to be much more systematic. A few simple changes could be introduced.

Firstly,  introduce a fast-track TB queue, allowing individuals to register digitally and drop off samples without completing a full clinic visit.

Secondly, embed TB symptom screening and sample collection at triage or vital-sign stations. Any patient reporting TB symptoms – cough, fever, night sweats, or weight loss – should have a sample collected while waiting to see a clinician.

Thirdly, for people living with HIV,  introduce twin TB testing with annual viral load test (or CD4 for newly diagnosed patients) to systematically test all people living with HIV.

Lastly, we could equip facilities with a near-point-of-care testing platform, like Pluslife, to deliver results before the clinical consultation, allowing TB to be diagnosed rapidly and at lower cost to the health system. It would enable patients to start treatment on the same day.

These approaches could directly address the most persistent diagnostic and linkage gaps in South Africa’s TB programme.

Extending TB testing beyond clinics

New diagnostic platforms also enable TB testing to move beyond government clinics.

A substantial proportion of individuals with TB, particularly men, do not present to clinics and delay seeking care. Near-point-of-care molecular platforms could enable TB testing through alternative delivery channels, including community settings (such as taxi ranks), community pharmacies, workplace clinics, and households through community health worker programmes.

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Expanding testing beyond clinics will help identify TB earlier among populations that remain underserved by current services.

From policy ambition to implementation

South Africa’s progress over the past four years demonstrates that intensified testing strategies such as TUTT can help increase TB diagnosis. Sustaining this momentum will require redesigning primary health care services to fully use these emerging diagnostic tools. Three priorities should guide this transition.

First, TB sample collection workflows in clinics should be redesigned to ensure that every symptomatic and at-risk person is tested for TB.

Second, new diagnostic tools should be deployed, including the use of tongue swabs for people who cannot produce sputum, as well as low cost near-point-of-care molecular tests to simplify testing and treatment initiation pathways.

Third, TB testing should be expanded through alternative delivery channels to reach people who do not routinely access government clinic services, especially men, who are less likely to seek care in these settings.

By aligning ambition and new technologies with service redesign, South Africa can significantly reduce diagnostic delays, decrease deaths due to TB and accelerate progress towards TB elimination.

*Tanna is a senior programme officer for TB, and Dr Pillay is the director of HIV and TB delivery at the Gates Foundation.

Disclosure: Spotlight receives funding from the Gates Foundation but is editorially independent – an independence that the editors guard jealously. Spotlight is a member of the South African Press Council.

Note: Spotlight aims to deepen public understanding of important health issues by publishing a variety of views on its opinion pages. The views expressed in this article are not necessarily shared by the Spotlight editors.

Republished from Spotlight under a Creative Commons licence.

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