Chapter 10: Infectious and Communicable Disease Control
White Paper for the Transformation of the Health System in South Africa

1. Background and Introduction

Infectious and Communicable Diseases include tuberculosis (TB), hepatitis, measles, polio, malaria, and other diseases such as cholera and leprosy. Although many of these diseases are preventable, they continue to be major health problems in South Africa. For example, South Africa is facing one of the worst TB epidemics in the world. For this reason, the Department of Health has declared TB as a top national health priority. In addition, the current malaria epidemic and the Expanded Programme of Immunisation (EPI) are also identified as requiring urgent attention. One of the main objectives of the Department is to place greater emphasis on prevention and early detection of infectious and communicable diseases.

2. Guiding principles

The following principles will guide future efforts :

• Communicable Disease Control Services (CDCS) should be accessible and integrated into comprehensive primary health care (PHC)services.
• CDCS should be efficient, cost-effective and of good quality.
• Health care staff should be adequately trained in clinical management and on strategies of disease control.
• Communities and individuals should be adequately informed about communicable diseases. Communities should also be constructively involved in disease control activities.
• Programmes should ensure accountability through the recording and reporting system, by establishing a financial management system, and through regular evaluation and review.
• CDCS should ensure effective interventions, including the control and management of epidemics.

3. Implementation strategies

3.1. CDCS should be accessible and integrated into comprehensive PHC services

The prevention, diagnosis and treatment of communicable diseases are essential components of comprehensive primary health care. In particular, TB and immunisation services should be available in primary care settings. Although the control of malaria cannot yet be totally integrated into PHC, diagnosis and treatment should be included in PHC while other prevention efforts, such as the spraying of structures, could be managed at a regional level.

The health facility level: The following should be available in all PHC facilities:

• TB and malaria diagnosis and treatment. Additionally, TB Co-ordinators at all levels will need to facilitate collaboration between the Department, NGOs and the private sector in order to make TB services more accessible.
• Expanded Programme of Immunisation (EPI) services. It is noted that Hepatitis B has also been included in the EPI schedule.

The district level: Every district should have a coordinator responsible for TB and one for EPI. The coordinators should participate in the district health management team to ensure that CDCS services are fully integrated with other health services.

The provincial level: Each province should appoint Coordinators for the EPI, and the TB and malaria programmes. A co-ordinator should also be appointed to manage the response to disease outbreaks.

The national level: The National TB, EPI and Vector-Borne Diseases Control Programmes will be responsible for strategic planning, policy formulation, producing education materials, developing standardised training materials, monitoring and evaluation. The national team will also need to provide adequate technical support to the provinces.

Establishment of a peripheral microscopy network: Microscopy services for diagnosing TB and malaria should be provided in the context of lab services for primary health care. There should be one microscopy centre per 100,000 population.

3.2. CDCS should be efficient, cost effective and of good quality

The following strategies are proposed to ensure that CDCS are efficient and effective:

• Demonstration and training districts should be established to pilot the full Directly Observed Treatment Strategy (DOTS) for TB control.
• Early identification and treatment of opportunistic infections for TB/HIV.
• Uniform drug management approaches, which will involve the use of standard treatment guidelines and the Essential Drug List.
• The quality, quantities and costs of medicines and vaccines used in CD programmes should be assured by a national tendering and contract system.

3.3. Health care staff should be adequately trained on CDC strategies

Pre-service and in-service training in communicable diseases and control strategies should be provided to all health staff.

3.4 Strategies to involve Communities in CDC activities

To make TB treatment as accessible and convenient as possible, patients should be able to receive their Directly Observed Treatment at clinics, at the workplace or in their communities. Employers and community based organisations (CBOs) should be sensitised to the needs of TB patients. Further, district co-ordinators should encourage community involvement in the DOT through education, and liaison with CBOs. With regard to malaria control, communities are already involved in spraying of houses. This involvement should be further developed.

3.5. Strategies to improve individual’s knowledge of communicable diseases

Health promotion materials should be developed and distributed. These should be available in different media, including posters, pamphlets, comic books and videos. Additionally, it is envisaged that individuals should be informed about the symptoms and prevention of the most important diseases, such as TB, childhood diseases and malaria. World TB Day (March 24) should also be used as an opportunity to inform the general public about DOTS and to reduce the stigma attached to TB.

3.6. Strategies to ensure the accountability of the CDC

• Recording and reporting of communicable diseases should be continued, or established where they is not available. In particular, the TB Register and accompanying documentation should be made available to all health care facilities which diagnose and treat TB. Health workers and TB coordinators at all levels will be trained to provide information and to use it for management purposes.
• A chain of supervision from the district to national level has been devised. It is proposed that reports will be reviewed on a quarterly basis.
• Regular monitoring and evaluation of CD programmes should be done.
• A financial management system should be implemented to account for expenditure on CD programmes.

3.7. Control and Management of Epidemics

An epidemic management system will be developed across the country. The management system will be representative of stakeholders, and include representatives of neighbouring countries. Regional and provincial co-ordinators will be appointed to manage the response to outbreaks of diseases.

4. Indicators of success

The following will be indicators of a successful implementation of the CDCS:

• In respect of TB:
  - DOTS should be expanded to cover the entire country by 1999.
  - Cure 85% of new smear-positive TB patients by the year 2000.
  - The risk of TB infection should be reduced by 5% per year.
  
• For malaria:
  - Reduce the number of reported cases of indigenous malaria by 10% per year.
  - Reduce the mortality rate by 0.3% of noted cases per year.
  
• Immunisation coverage (<1 year olds) against diphteria, pertussis, tetanus, measles, poliomyelitis, hepatitis and TB to be least 80% in all districts, and 90% nationally.
• Eradication of poliomyelitis by 1998.
• Neonatal tetanus should be reduced to less than 1 case per 1000 live births in all district by 1997.

For more information, please contact Jane Mathieson or Bea Abrahams by telephone @ 021 - 6964954 or by fax @ 021 - 6969308 or by e-mail at philaw@wn.apc.org . The PHILA programme is funded by a grant from the Henry J. Kaiser Family Foundation.

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