CHAMBER OF MINES OF SOUTH AFRICA 2011/12 REVIEW OF THE TUBERCULOSIS PROGRAMME in the GOLD-PRODUCING MINING COMPANIES registered with the CHAMBER OF MINES OF SOUTH AFRICA. 18 May 2012 by Dr K Baloyi Chamber of Mines of South Africa CHAMBER OF MINES OF SOUTH AFRICA Putting South Africa First

Putting South Africa First Outline Introduction Background Problem statement Aims and objectives Methodology 1 2 TB Audit Findings 3 Proposed way forward Putting South Africa First

Putting South Africa First Introduction In 2009 HPC agreed to have TB programmes, for all member companies, assessed. HPC approved the MOHAC TB Review Tool for implementation. Annual Internal reviews and external reviews every 5 years. 1 2 In 2010 all COM ‘s HPC member companies conducted internal reviews. 2011 External Reviews for the Gold commodity Report approved by COM’s TB Task Team Report is ready for the next Council meeting 3 Putting South Africa First

Putting South Africa First Background TB incidence rates in the gold mines have historically been higher (on average 3 times) than those of the SA TB national average. Contributing Factors: HIV and AIDS epidemic (ten folds) higher rates of silicosis, (up to 3 times), silica dust exposure and the generally poor living conditions of mine workers. In addition, being middle-aged is identified as a risk factor for TB (TB rates are 2.2 times higher in men over 40 years). Note: The mining sector has a large population of middle-aged men Putting South Africa First

Putting South Africa First TB Rates in mining SA rates vs. mining rates Putting South Africa First

Putting South Africa First Statement “If TB and HIV are a snake in the SADC Region, the head of the snake is here in South Africa in the mines. People come from all over the SADC Region to work in our mines and export TB and HIV, along with their earnings. If we want to kill a snake, we need to hit it on its head”. by Dr Aaron Motsoaledi, South African Health Minister, June 2010 Putting South Africa First

Putting South Africa First Political Response Dr Aaron Motsoaledi, South Africa’s Health Minister, June 2010, TB Conference. “If TB and HIV are a snake in the SADC Region, the head of the snake is here in South Africa in the mines. People come from all over the SADC Region to work in our mines and export TB and HIV, along with their earnings. If we want to kill a snake, we need to hit it on its head”. by Dr Aaron Motsoaledi, South African Health Minister, June 2010 The Deputy President, in his World TB Day speech made the following recommendations to the mining industry: Screen and test all employees annually for TB and HIV. Extend hospital services to immediate mining communities. Implement the Gene Xpert diagnostic equipment to improve our diagnostic. Make available facilities for conversion into MDR units. Putting South Africa First

Putting South Africa First Problem Statement Diverse health delivery models across the sector(ranges from companies with no services on site, those that provide only the statutory occupational health services to those that provide occupational as well as PHC and hospital services 1 There is a paucity of data on the performance of TB programmes. (there is no central repository of TB data for the sector). The sector relies on TB incidence data submitted annually to the DMR, while data on TB outcomes is submitted to the DOH via the districts. The DOH has in the past not been able to disaggregate industry data on TB programme performance. 2 Putting South Africa First

Putting South Africa First Therefore It is essential that more objective assessments of these Programmes are done, and the External TB Program Review sought to support the independent evaluation of TB programmes on the mines. Putting South Africa First

Putting South Africa First Purpose and objectives The purpose of the External TB Program Review was to establish a baseline on the state of TB programmes in the Gold Commodity. The objectives are: Review each commodity on a 5 years cycle. Identify gaps and potential leading practices. Establish an Interest group to drive the adoption process of leading practices. Establish a system for assisting companies with addressing gaps. Putting South Africa First

Putting South Africa First Methodology COM lead the establishment of a team led by an independent consultant (Mr. Xoli Mahlalela) and comprising of staff from the COM, companies, DoH (Provincial TB Coordinators), DMR (Provincial Medical Inspectors), Union representatives, 2. Visited seven gold mining companies over a period of three months (between November 2011 and January 2012). 3. In one review, DoH was not represented. 4. A standardized TB Review Tool was utilized. 5. Documents and reports were reviewed for verification. 6. Audits were conducted at health facilities - hospitals, TB Clinics, PHC Clinics, and Occupational Health Clinics – in selected mines 6. Relevant sections within the health facilities were visited and key staff members were interviewed with further review of documents and records . Putting South Africa First

Putting South Africa First Limitations Even though some approved adjustments had been made to improve the audit tool, there were still sections that needed further review and improvement. There were no accompanying Standard Operating Procedure (SOP) and guidance to ensure a common understanding and interpretation by the reviewers. It is important to state that the results and data presented in this report represent the findings on the actual dates that the reviews were conducted. Putting South Africa First

Putting South Africa First Findings Area of review Finding Recommendation Documents (policies, training) Improvements observed (since 2010) Company TB policies available at all facilities 86% of policies commit to treating contractors. Very limited involvement of employee representatives in policy development. Poor review systems for the policies. The NTBCP and DMR guidelines were not fully adhered to. Poor relationship between mine health services and local DoH offices.(Meetings and Training workshops) None had signed MOUs with the DoH. Strengthening of: Policy development Relationship with DoH Include contractors in policies. Putting South Africa First

Putting South Africa First Findings Area of review Finding Recommendation 2.TB Case finding 3.DOTS 4.TB clinic Less than 50% of companies implemented cough questionnaires. Not all patients with chest-x-rays showing abnormalities were investigated for TB. Very few patients were lost to follow-up. Some centers were without dedicated sputum collection areas. Improvement Implementation of the cough questionnaire Case finding referral and follow-up of contract workers Usage of standardized DOT register. Putting South Africa First

Putting South Africa First Findings Area of review Finding Recommendation 5. Laboratory 6. Radiology 7. Pharmacy 8.Deceased patients 5,6&7 Generally of high standard, fully compliant and accredited, and had good quality control measures in place. Very High numbers of missed opportunities to detect TB amongst patients whose lungs were sent to NIOH after death, Only one company held Mortality meetings Implement a system for mortality meetings Putting South Africa First

Putting South Africa First TB Task Team Recommendations TB task Team approved the report with the following recommendations: The TB Task team should prioritize the report recommendations for implementation: Training of TB staff should: be relevant to TB and HIV management emphasize adherence to NDOH & DMR programme guidelines aim to improve proper maintenance of TB Registers emphasize the importance of an appropriate referral system. encourage professionals to have a high index of suspicion To strengthen active case finding by: Implementing cough questionnaire at both PHC and OHC. investigating abnormal X-rays. Implement a system that promotes TB screening on all patients at all points of interface or consultations with health professional). Putting South Africa First

Putting South Africa First TB Task Team Recommendations Establish and maintain a TB Interest Group Policies (employees reps involvement, contractors etc) Maintenance of TB registers. Mortality Meeting Intensive case finding strategy Referral system HPC to lead the following: MOUs with the NDoH Access to Electronic TB Register Putting South Africa First

CHAMBER OF MINES OF SOUTH AFRICA t h a n k y o u CHAMBER OF MINES OF SOUTH AFRICA Putting South Africa First