South Africa will increasingly move towards nurse-initiated treatment for multidrug-resistant tuberculosis (MDR-TB) in the next five years, and a programme in KwaZulu-Natal Province, which has a high HIV/TB burden, is already training nurses to manage MDR-TB patients.
Faced with a chronic shortage of doctors, South Africa moved to nurse-initiated antiretroviral treatment (NiMart) in April 2010. Now, government plans to roll out nurse-initiated MDR-TB treatment, and to make it and NiMart available at all primary healthcare, antenatal, TB and mobile outreach clinics by 2016, according to the National Strategic Plan on HIV, STIs [sexually transmitted infections] and TB.
In KwaZulu-Natal province, a programme run by the US-based Johns Hopkins University has already trained at least 70 nurses in MDR-TB treatment initiation and care.
Preliminary research, released at the South African TB Conference, in Durban, showed that outcomes in patients initiated and monitored by these nurses were as good, and sometimes better, than those under a doctor’s care.
The research presented by Dr Jason Farley of Johns Hopkins compared the early outcomes of about 90 MDR-TB patients who had been assigned to one of two groups. Those in poorer health, or who were HIV-positive with low CD4 counts (indicating a weakened immune system) were initiated and monitored by a doctor. Nurses initiated those in better health, or who were HIV-positive but with higher CD4 counts.
Culture conversion rates - the number of patients with two consecutive TB-free sputum cultures - were the same in both groups, but nurse-initiated and -managed patients tended to reach culture conversion about two weeks sooner than those under a doctor’s care, and were also more likely to be routinely checked for adverse reactions to their drugs.
About a third of all MDR-TB patients diagnosed in 2011 never received treatment, according to figures presented by Dr Norbert Ndjeka, director of Drug-resistant TB, TB and HIV at the South African National Department of Health.
Before the publication of new guidelines for drug-resistant TB in August 2011, MDR-TB patients could only be initiated on treatment after being admitted to a TB hospital, but a lack of beds in these facilities contributed to long MDR-TB treatment waiting lists, Ndjeka said.
How they do it
Johns Hopkins has adapted a chronic care model in its training programme for nurses, Farley said. It is centred on five key aspects, including patient self-management strategies, community resources, and treatment delivery. The model has been tested in more than 500 health facilities worldwide.
Nurses receive a one-week intensive, case-based course in the theory of MDR-TB and its treatment before starting three months of clinical mentoring, including training in physical examinations, a one-week refresher course on HIV, and six weeks of in-service training in MDR-TB wards at major hospitals.
According to Farley, who presented information on the programme at the South African TB Conference, the training has exposed gaps in the current training of primary healthcare nurses - for instance, many have not been trained to interpret audiology reports.
Kanamycin, an injected drug that forms part of South Africa’s MDR-TB treatment regimens, must be administered to adults up to three times a week for six months. These injections are not only painful but can cause permanent hearing loss, leaving patients with the horrible choice of being dead or deaf, said Dr. Helen Cox of the international humanitarian medical organization, Médecins Sans Frontières (MSF).
MSF recently installed audiology booths in Khayelitsha, a township outside Cape Town to help monitor potential hearing loss in MDR-TB patients. A lay health worker was trained to do baseline tests to establish hearing capability when the patient starts the treatment, and an audiologist comes in to conduct follow-up testing on designated days each month.
Clinics in KwaZulu-Natal’s rural Udu district, where Farley works, have begun using tele-audiology to send hearing tests electronically to audiologists in larger centres for interpretation.
Johns Hopkins has also added laboratory monitoring and evaluation. “When lab results are obtained, often there are abnormalities. [A nurse’s] initial response is usually, ‘refer’,” Farley said. “Within the MDR-TB programme, we need to be able to triage, or determine what we can manage, and refer as appropriate.”
Ntombasekaya Mlandu was the first nurse in South Africa to begin initiating patients on MDR-TB treatment. She said her NiMart training on how to initiate and monitor ARV patients did not prepare her for MDR-TB.
“The only thing we knew in the NiMart is that when you faced even the slightest problem you would refer the patient to the hospital,” Mlandu told IRIN/PlusNews. “Now, with MDR-TB, most of the blood results I can manage… and if I do have a problem, there is a doctor to assist me.”
Following training, the nurses reported that they felt more confident about managing MDR-TB, but Farley said their confidence levels had probably risen because they gained real-world experience.
Mlandu had never worked in an MDR ward when she was selected for the Johns Hopkins programme. Now, she says, “Even if you wake me up in the middle of the night and say, ‘What is [the MDR-TB drug] ethionamide doing to the client?’ I will tell you that if the thyroid is enlarged, you better take the thyroid-stimulating hormone [levels] right there and then.”