Faculty of Health Sciences
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Item Nurses’ knowledge, attitudes and experiences on the implementation of tuberculosis preventive therapy among HIV positive patients in north sub-district, eThekwini(2024) Nomvungu, Xoliswa; Sokhela, Dudu Gloria; Bhengu, T. J.Introduction Tuberculosis (TB) is a common opportunistic infection that occurs more often in people living with human immunodeficiency virus (HIV) because of their weakened immune system, thus increasing their risk of contracting tuberculosis. In the year 2010 isoniazid was introduced by the World Health Organisation for people living with HIV who had no presumptive TB symptoms to prevent TB incidence. The recommended regimen is a daily dose of 5mg/kg 300mg isoniazid for at least six months extended to nine months if there is interruption of treatment. However, tuberculosis continues to affect people living with HIV. Purpose of the study The purpose of the study was to explore knowledge, attitudes and experiences of professional nurses on the implementation of tuberculosis preventive therapy (TPT) among HIV positive patients who are found to have not contracted TB, in selected primary health care facilities. Methodology A descriptive quantitative cross-sectional survey design was used to determine the factors that influence implementation of tuberculosis preventive therapy by professional nurses to HIV positive patients without presumptive TB features. Census sampling of respondents was used to gather a sample of 120 professional nurses. Results of the study The results indicated that the majority of respondents had knowledge about TPT and a positive attitude towards its implementation. Some respondents had no experience of TPT implementation. A few respondents reported not implementing TPT for various reasons, including fear of side effects in patients. Conclusion This study found that knowledge and experience are critical in changing attitudes of professional nurses as well as encouraging them to implement TPT among HIV positive patients to prevent TB incidence.Item A qualitative exploration into the presence of TB stigmatization across three districts in South Africa(Springer Science and Business Media LLC, 2023-03-15) DeSanto, Daniel; Velen, Kavindhran; Lessells, Richard; Makgopa, Sewele; Gumede, Dumile; Fielding, Katherine; Grant, Alison D.; Charalambous, Salome; Chetty-Makkan, Candice M.Tuberculosis (TB) stigma is a barrier to active case finding and delivery of care in fighting the TB epidemic. As part of a project exploring different models for delivery of TB contact tracing, we conducted a qualitative analysis to explore the presence of TB stigma within communities across South Africa.Methods
We conducted 43 in-depth interviews with 31 people with TB and 12 household contacts as well as five focus group discussions with 40 ward-based team members and 11 community stakeholders across three South African districts.Results
TB stigma is driven and facilitated by fear of disease coupled with an understanding of TB/HIV duality and manifests as anticipated and internalized stigma. Individuals are marked with TB stigma verbally through gossip and visually through symptomatic identification or when accessing care in either TB-specific areas in health clinics or though ward-based outreach teams. Individuals' unique understanding of stigma influences how they seek care.Conclusion
TB stigma contributes to suboptimal case finding and care at the community level in South Africa. Interventions to combat stigma, such as community and individual education campaigns on TB treatment and transmission as well as the training of health care workers on stigma and stigmatization are needed to prevent discrimination and protect patient confidentiality.Item Molecular surveillance of tuberculosis-causing mycobacteria in wastewater(Elsevier BV, 2022-02) Mtetwa, Hlengiwe N.; Amoah, Isaac Dennis; Kumari, Sheena; Bux, Faizal; Reddy, PoovendhreeThe surveillance of tuberculosis infections has largely depended on clinical diagnostics and hospitalization data. The advancement in molecular methods creates an opportunity for the adoption of alternative surveillance systems, such as wastewater-based epidemiology. This study presents the use of conventional and advanced polymerase chain reaction techniques (droplet digital PCR) to determine the occurrence and concentration of total mycobacteria and members of the Mycobacterium tuberculosis complex (MTBC) in treated and untreated wastewater. Wastewater samples were taken from three wastewater treatment plants (WWTPs) in the city of Durban, South Africa, known for a high burden of TB/MDR-TB due to HIV infections. All untreated wastewater samples contained total mycobacteria and MTBC at varying percentages per WWTP studied. Other members of the MTBC related to tuberculosis infection in animals, M. bovis and M. caprae were also detected. The highest median concentration detected in untreated wastewater was up to 4.9 (±0.2) Log10 copies/ml for total mycobacteria, 4.0 (±0.85) Log10 copies/ml for MTBC, 3.9 (±0.54) Log10 copies/ml for M. tuberculosis, 2.7 (±0.42) Log10 copies/ml for M. africanum, 4.0 (±0.29) Log10 copies/ml for M. bovis and 4.5 (±0.52) Log10 copies/ml for M. caprae. Lower concentrations were detected in the treated wastewater, with a statistically significant difference (P-value ≤ 0.05) in concentrations observed. The log reduction achieved for these bacteria in the respective WWTPs was not statistically different, indicating that the treatment configuration did not have an impact on their removal. The detection of M. africanum in wastewater from South Africa shows that it is possible that some of the TB infections in the community could be caused by this mycobacterium. This study, therefore, highlights the potential of wastewater-based epidemiology for monitoring tuberculosis infections.Item Evaluation of antibiotic-resistant bacteria and genes associated with tuberculosis treatment regimens from wastewater treatment plants in South Africa(2022-05-13) Mtetwa, Hlengiwe Nombuso; Reddy, Poovendhree; Kumari, Sheena K.; Bux, FaizalEssential components of a strong public health system include an efficient surveillance system which helps in early detection and prevention of infectious diseases. This is particularly important for tuberculosis (TB) and multidrug-resistant tuberculosis (MDR-TB), due to increasing globally infections and the associated economic burdens. TB and MDR-TB infections are high in several countries, with South Africa contributing almost 3% of total infections globally. This advocates for improved surveillance systems to help health authorities respond effectively in developing effective policies for managing and controlling diseases. The reliance on clinical case reports, hospital admissions and clinical surveys, as surveillance methods, has proven to be a challenge in developing countries like South Africa, where there are other competing interests for scarce resources. The development and implementation of alternative surveillance tools for identifying disease severity, the emergence of novel strain and resistance patterns is, therefore, a top priority. One such strategy is the use of sewage or wastewater-based analysis, commonly referred to as wastewater-based epidemiology (WBE), which has received attention lately due to its role in developing early warning and surveillance of SARS-CoV-2 (COVID-19) infections. This study evaluates, method development for utilizing WBE approach for monitoring TB and MDR-TB infections via the detection and quantification of tuberculosis-causing mycobacteria and genes (ARGs) associated with resistance to TB treatment in untreated wastewater. Furthermore, the study contributes towards the understanding potential TB transmission through wastewater. To achieve these, conventional and advanced polymerase chain reaction (droplet digital PCR) assays were optimized for the detection and quantification of total mycobacteria, members of the Mycobacterium tuberculosis complex (MTBC) and ARGs associated with resistance to first and second-line TB drugs. The mycobacteria targeted in this study were total mycobacteria, M. tuberculosis complex, M. tuberculosis, M. africanum, M. bovis and M. caprae. The ARGs (and the antibiotic they encode resistance to, in parenthesis) targeted in this study were; katG (isoniazid), rpoB (rifampicin), embB (ethambutol), pncA (pyrazinamide), rrs (streptomycin), gyrA (ofloxacin), gryB (moxifloxacin), atpE (bedaquiline), ethR (ethionamide), eis (kanamycin/amikacin). Untreated and treated (post-chlorination) wastewater samples from three wastewater treatments plants (WWTPs) in the city of Durban, South Africa were used for this study. All wastewater samples (untreated and treated) analyzed in this study contained total mycobacteria and MTBC at varying percentages per WWTP studied. The human and animal MTBC pathogens such as M. tuberculosis, M. bovis and M. caprae showed a similar prevalence, except for M. africanum, which was less common compared to the others. The highest median concentration detected in untreated wastewater was 4.9(±0.2) Log10 copies/ml for total mycobacteria, 4.0(±0.85) Log10 copies/ml for MTBC, 3.9(±0.54) Log10 copies/ml for M. tuberculosis, 2.7(±0.42) Log10 copies/ml for M. africanum, 4.0(±0.29) Log10 copies/ml for M. bovis and 4.5(±0.52) Log10 copies/ml for M. caprae. A statistically significant difference (p-value ≤ 0.05) in concentrations of each organism was observed between the plants. A significant reduction in copy numbers from untreated to treated samples were observed. However, the log reduction in each WWTP did not show any statistically significant differences when compared between the three WWTPs, irrespective of the organism or group of organisms (p-value ≥0.05). Furthermore, all targeted ARGS were detected in all samples analyzed at varying concentrations. The most abundant ARG in the untreated wastewater was rrs, associated with resistance to the aminoglycosides, specifically streptomycin. In contrast, pncA gene associated with resistance to the TB drug pyrazinamide was the least detected. Furthermore, the resistant gene associated with bedaquiline (aptE) was also detected in all samples, albeit at low concentrations. This antibiotic is a new addition to the TB treatment regimen in South Africa and it is concerning that resistance has already been detected. The occurrence and concentration of these ARGs were lower in the treated wastewater in most instances, ranging from 1 log copy/ml to over 4 log copies/ml except for selected genes at few instances. The study makes novel major contributions, firstly, the detection of M. tuberculosis complex members in the untreated wastewater at high concentrations signifies a potentially high prevalence of TB in the study area. Secondly, the detection of M. africanum in South African wastewater also signifies that some of the TB infections in the communities could be caused by this pathogen. M. africanum is the main causative agent of TB in West Africa but is not frequently reported clinically in South Africa. Finally, the presence of diverse ARGs associated with TB drugs also points towards an association between the drug use and resistance profile in the area. These results further support the potential application of WBE to gather data on MDR-TB within communities with limited or no clinical data. The detection of the aptE gene also shows that resistance to the new drug, bedaquiline, could already be developing in the communities. The study also observed that the wastewater treatment plant configuration did not significantly influence the removal of these mycobacteria. Furthermore, selective conditions in the WWTPs may contribute to increased concentrations of ARGs during the treatment processes as indicated by increased concentrations for certain ARGs detected in the treated wastewater. This warrants further studies to determine whether the genes detected in the effluent are extracellular or carried in viable microorganisms, to assess the viability and infectivity of the microorganisms carrying these genes in the effluent samples and therefore the potential public health risks associated with the exposure to wastewater. In conclusion, this study establishes the potential of molecular surveillance of wastewater for monitoring TB and MDR-TB infections in communities and supports the use of WBE as a public health strategy to combat infectious diseases.Item Molecular epidemiology of multi-drug resistant Mycobacterium tuberculosis strains in Swaziland(2021-05-27) Dlamini, Talent Colani; Mkhize, Brenda Thabisile; Sydney, Clive; Malinga, LesibanaBackground: The tuberculosis (TB) epidemic remains a major global health problem, noting that the Swaziland government had declared the disease a national emergency. Hence the study was aimed to determine the prevalence of TB in Swaziland and further to ascertain whether the circulating susceptible M. tuberculosis strain later develops to MDR-TB on the same patient or whether patients acquire a completely new multi-drug resistant strain. Methods: Participants were recruited from four TB testing facilities (n=560), which are regional TB referral facilities in Swaziland. Willing participants who had been selected using a systematic random sampling method, and who met the inclusion criteria, were included in this quantitative descriptive cohort study upon signing an informed consent form (n=103). Sputum samples collected from these participants (at baseline and at follow-up) were tested for the presence of Mycobacterium tuberculosis using the GeneXpert® MTB/RIF assay (Cephied, USA). When found to be positive, the samples were then cultured on the BACTEC™ MGIT™ 960 Mycobacteria Culture System (Becton Dickinson, USA), which was also utilised for drug sensitivity testing and thereafter DNA was extracted for spoligotyping, using a GenoLyse (Hain Life Science, Germany). The study results were analysed using the Statistical Package for the Social Sciences (SSPS) version 25, Epi Info (version 3.5.1, 2008) and STATA 13.0 software packages. Frequencies of multiple-drug resistant-TB (MDR-TB) amongst all the genotype families’ categories based on spoligotyping were compared among the participants from the four regions using a Fisher Exact and Chi-square statistical methods, where associations with a pvalue of < 0.05 were considered statistically significant. The spoligotyping findings were entered into an MS Excel spreadsheet as a binary code signifying either a positive or negative hybridization outcome. The spoligotyping results were then entered into SITVIT2 database (Pasteur Institute of Guadeloupe) to generate spoligotype families. Results: The prevalence of TB infection in this study population was 26.41% (n=103/390) and MDR-TB prevalence was 33.01% (n=34/103). Notably, the TB infection was high among males (64%; n=103) and among the young adults of both genders (18-35 years, with a mean age of 34.4 years). Most of the strains at both baseline and follow-up (58.74%) were susceptible to all of these anti-TB drugs, followed by those strains classified as MDR-TB, with 28.64% and polyresistant and RIF mono-resistant strains being 8.25% and 2.91%% respectively, although with no statistical significance (p=0.786). The Beijing sub-lineage (lineage 2) was the predominant sub-lineage in 28.82% isolates (n=49/170), followed by lineage 4 (Euro American) the S and T1 sub-lineages (of lineage 4) in 20.0% and 11.76% isolates, respectively. The emerging U sublineage was isolated as well with n=1 (2.2%) p=0.001. We then compared sub-lineage changes of baseline and follow-up specimens, together with DST patterns. A total of 33 (53.23%) participants with a pattern of ‘changed sub-lineage and the same DST pattern’ followed by n=16 (25.81%) participants showing ‘changed sub-lineage with changed DST pattern’. The least represented categories were of seven (11.29%) participants with ‘same sub-lineage with the same DST pattern’ category as well as the ‘same sub-lineage with changed drug sensitivity pattern’ category with n=6 (9.68%). The Beijing genotype was significantly detected in the group with the ‘changed sub-lineage and the same DST pattern’ (p ≤0.001). Conclusion: Since high prevalence of TB infection was observed in this current study, mainly among men and young adults, hence mass TB screening and testing campaigns in all health centres and workplace wellness centres are recommended, to reduce the high TB prevalence. A key finding of this study was n=24/103 (23.30%) participants who were susceptible to all first line anti-TB drugs at baseline developed MDR-TB at follow-up. A significant proportion of those developed MDR-TB were infected with the Beijing sub-lineage, which is linked with MDR-TB outbreaks in many regions. Notably, Swaziland has a high M. tuberculosis lineage diversity, with eighteen sub-lineages noted. A significant proportion of the TB infected participants had the Beijing sub-lineage, which is linked with MDR-TB outbreaks in many regions. In addition, the emerging U sub-lineage, also linked to MDR-TB, was noted. Since different strains are reported to uniquely respond to treatment, therefore, it is hence recommended that the various genotypes of M. tuberculosis strains circulating in Swaziland be investigated and monitored, so as to improve on the TB treatment outcomes, control and prevention programs and detect timeously the drug resistant TB strains in Swaziland