The mortality rate for patients using a tuberculosis (TB) treatment programme in the Northern Province of South Africa is relatively high (12 percent). Is this related to the distance that patients have to travel for treatment? Researchers from the University of the North and Jane Furse Memorial Hospital, South Africa, and King's College Hospital, UK, address this question.

DOTS (directly-observed treatment, short-course) is the WHO-recommended strategy for TB treatment. There is a consensus that TB care should be integrated into general health services. But there is debate about how far diagnosis and treatment should be decentralised into primary healthcare. In this DOTS-based TB programme in a resource-poor setting, diagnosis and intensive phase treatment take place in the district hospital. Treatment then continues through directly observed therapy supervised by community volunteers.

The study involved four general hospitals in three health districts. Patients were classified into four groups depending on how far they lived from the hospital: up to 20 km, 20 - 40 km, 40 - 60 km and more than 60 km. The study found that:

• Of 1187 patients who started TB treatment in the hospitals, 74 percent were known to be alive at the end of treatment, whereas 13 percent had died.
• 91 percent of patients live within 60 km of the hospital they attend for treatment. The estimated median distance travelled is 28 km.
• There is an increased risk of dying only for those patients living more than 60 km from the hospital.
• Many patients who travel more than 60 km bypass hospitals nearer their home. The reasons for this are unclear.

Important features of the DOTS strategy for treatment of TB include:

• diagnosis and management based on the results of sputum smear microscopy
• use of standardised drug treatments that depend on the clinical setting and sputum results
• systems for recording and reporting the outcome of treatment.

It is particularly difficult to follow these guidelines in primary healthcare settings where there are no microscopes, poor transport systems and no doctors, and where nurses have many other responsibilities.

TB mortality is high in this population, even amongst those living closest to the hospital. These results suggest that moving the diagnosis of TB from the hospitals to primary healthcare clinics may not reduce the numbers of deaths from TB in rural South Africa.

Source(s):
'Is the distance a patient lives from the hospital a risk factor for death from tuberculosis in rural South Africa?', International Journal of Tuberculosis and Lung Disease 6 (2): 1-6, by R. Barker, M. Nthangeni and F. Millard, 2002

Funded by: TB Alert

id21 Research Highlight: 25 July 2002

Further Information:
Jack Barker
King's College Hospital
Bessemer Road
Camberwell
London
UK

Tel: +44 (0)20 7346 3165
Fax: +44 (0)20 7346 3589
Contact the contributor: jack.barker@kingshc.nhs.uk

King's College Hospital, London

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