Tackling Tuberculosis through Community Contact Tracing in Mozambique

Getting to see how our projects are being implemented in the countries where were work is always rewarding. The ability to work directly with local country staff helps us get a much better idea of the specific challenges and the strengths of each facility we visit, and how we (at the Elizabeth Glaser Pediatric AIDS Foundation’s headquarters in Washington, DC) can improve efficiencies overall. I recently had the opportunity to visit Mozambique with colleagues to discuss challenges and solutions, and assess progress on a study the EGPAF-Mozambique team is implementing.

Mozambique is among the 22 high tuberculosis (TB)-burden countries, and among the top ten countries with highest burden of TB/HIV co-infection.

In Mozambique:

• 52% of persons with TB are also infected with HIV.
• the TB mortality rate is 67 per 100,000 among people without HIV and 134 per 100,000 among people living with HIV (WHO, 2014).
• Of 58,270 total TB cases reported in Mozambique in 2014, 10% occurred among children (MISAU, 2014).

Through EGPAF’s Centers for Disease Control-funded DELTA project, EGPAF-Mozambique is implementing a TB community contact tracing study at four health facilities in Gaza Province: Macia, Chissano, Licilo, and Praia de Bilene.

The study is hoping to improve TB and HIV case detection and linkage to appropriate care services by implementing active contact tracing (the process by which activists go out to the community to find all people who have been in contact with the TB case, screen them, and refer those who are have signs and symptoms to the health facility for diagnosis and treatment).

EGPAF staff look over TB register at Bilene health facility

One of the key aspects of the study is the use of local activists. Community health workers focus on contact tracing, finding patients who are lost, community awareness, HIV counselling and testing, and TB screening in the community. They travel into the communities to locate and screen the household contacts of the TB index case.

The local activists also play a crucial role in community sensitization, which is helping reduce the local stigma and myths around TB.

We met with them to discuss the progress being made. They said that so far, the communities seemed accepting of their work, yet there were still some challenges surrounding patient transport back to the facilities. Some of the other issues in the community are the local myths and stigma surrounding TB, which have traditionally created service uptake issues particularly in Gaza. The local communities in Gaza associate TB with mystical powers, which offers traditional healer’s treatments as the cure.

Sample transport bikes

In Gaza, there are two common local explanations or myths of why TB occurs, one is  “tsanka “and the other is “nderi”. Tsanka says that TB is acquired when a woman has an abortion or miscarriage, or when a woman’s husband dies, and she doesn’t go through with the purification ceremonies.  One of the ceremonies occurs when a woman’s husband dies, she is thought to be impure and to be purified she has to have sexual relations with the husband’s brother. The next morning, after the “purification” the wife is supposed to serve food to the whole family. However if she forgets someone, they believe that that person will get a form of TB called Kudsinga.

Nderi says that TB is acquired when a man has had sexual relations with a woman who has had a miscarriage or abortion.

To help change these perceptions of TB, health workers explain the real cause of disease, and link the community members to diagnostics and treatment at the health facilities.

Sample transport bikes

In community settings, activists and community health workers aim to deconstruct the notion of these local myths and spread awareness about possible forms of getting infected with TB, how to treat it, and safe practices when living with a person with TB.

With the initial successes the activists are having within the local communities coupled with the advocacy done by health workers at the facilities, we are hopeful that these norms will begin to change.

The study also combines the use of both new lab methodologies and technologies (including the use of on-site GeneXpert machines to detect the presence of DNA material of the TB bacteria in sputum – a mixture of saliva and mucus from the lungs) and community interventions to help reduce the high rates of TB in Mozambique. This project will provide information on the feasibility and yield of household-based contact screening for TB and HIV testing and linkage to appropriate care for TB, HIV, and TB/HIV in Mozambique. Information on feasibility of use of the novel pediatric specimens collected through the research components will provide information on whether use of these specimens is feasible under programmatic conditions. In addition, the project hopes to improve the implementation of currently recommended contact tracing strategies by prioritizing household contacts of patients newly enrolled on TB treatment for home visits. The study pilot has just concluded at the end of February 2018, and the final results are expected in March 2019.

It was inspiring to see both patients and health care providers so excited about and eager to participate in this new project. I think that the pairing of the facility and community-level activities brings together the patients and providers in a way that fosters both trust and, hopefully, change.

References:

1. Tuberculosis Profile – Mozambique. Geneva, Switzerland: World Health Organization; 2014.
2. Ministry of Health NPHD, National Program for Tuberculosis Control. Report of Activities, 2014. Maputo, Mozambique: Republic of Mozambique; 2014.