Indira Govender

Mobile health (mHealth) technologies are increasingly used to support community-based healthcare. However, their real-world impact often remains unclear. Understanding implementation factors is essential for advancing their use and achieving meaningful health outcomes. We evaluated an mHealth tool (AitaHealth) after customising its modules and workflows for household Tuberculosis (TB) contact tracing and other community-based data collection by community health workers (CHWs). We describe the acceptability, feasibility, and implementation fidelity of this approach. We conducted a mixed-methods evaluation in two South African districts: uMkhanyakude and Ekurhuleni. We collected qualitative data through focus group discussions (FGDs) and in-depth interviews (IDIs) with CHWs, team leaders, and key stakeholders. We used deductive thematic analysis grounded in the Technology Acceptance Model (TAM) to assess the acceptability and implementation feasibility of the mHealth tool. We used quantitative data from the AitaHealth metadata to assess implementation fidelity. CHWs appreciated AitaHealth’s efficiency, data security, and credibility. Across the two districts, 103 CHWs recorded data for 2,452 households and 10,649 household members. However, they reported challenges in ease of use, with unreliable devices, weak support, and safety concerns hindering data collection. These issues led to inconsistent engagement, with 48.5% of CHWs logging in fewer than 15 times during implementation. Despite these challenges, when used, AitaHealth ensured high-quality data collection and household coverage, with TB-related fields completed in over 94% of households, demonstrating its potential under better conditions. AitaHealth`s limitations stemmed from system constraints rather than user resistance. To achieve full impact, mHealth tools require reliable infrastructure and supportive environments for both the tools and their implementers.

Objectives: Several novel tuberculosis vaccines (NTVs) are being evaluated in clinical trials. Understanding the perception of acceptability and confidence in NTVs will inform implementation strategies. Methods: We conducted a cross-sectional survey to assess acceptability in and confidence of NTVs among adult persons with HIV (PWH) at two clinics in KwaZulu-Natal province, South Africa. We evaluated associations between acceptability and sociodemographic factors. Results: Among 225 PWH, 112 (50%) responded “Definitely yes, as soon as available”, 86 (38%) “Definitely yes, but wait ≥6 months to receive it” and 27 (12%) “Unsure, leaning yes, any timeline” to an NTV. Acceptability was associated with perception of tuberculosis’s (TB’s) importance in the community, perceived risk of contracting TB, personal history of TB, not currently living with someone with TB, incompatibility of vaccines with religion, and unemployment. Most participants were confident in the vaccine’s potential safety (110, 93%) and effectiveness (221, 98%). Participants preferred to receive information from government, community, and health entities, or internet, and vaccination at community settings over public health facilities. Conclusions: NTV acceptability was high amongst these PWH, and they preferred community-based delivery models. Our findings may inform strategies to increase implementation of NTVs among PWH in South Africa.

Background: There is growing interest in tuberculosis (TB) community screening and detection of asymptomatic TB (aTB). We explored how setting and screening approach influence the relationship between reported symptoms and underlying disease severity and infectiousness. Methods: We compared markers of TB severity and infectiousness (computer-aided detection [CAD, CAD4TBv5] scores derived from chest radiographs and trace vs exceeding trace Xpert MTB/RIF Ultra results) among people diagnosed with aTB or symptomatic TB (sTB) through a community survey, and those diagnosed with aTB or sTB in clinics in the same South African community. We evaluated how variation in screening algorithms influence the relative severity of community-diagnosed aTB vs sTB, and estimated the TB prevalence and severity among people not eligible for testing in the survey (CAD score <25 and no reported symptoms). Results: People with clinic-diagnosed sTB had higher CAD scores and a greater proportion of Xpert results exceeding trace than those with community-diagnosed sTB, whereas differences between community-diagnosed aTB and sTB were minimal. Under a hypothetical community universal Xpert testing strategy, people detected with sTB may have more severe disease on average than people detected with aTB. In contrast, restricting testing to people with CAD scores ≥50 and/or reported symptoms would have resulted in higher CAD scores among those diagnosed with aTB than sTB. Conclusions: Screening algorithm design and context influence the spectrum of TB disease detected. Community screening approaches where testing is based on symptoms and/or a threshold CAD score may identify aTB that is on average more severe than sTB. Summary: Our findings suggest reported symptoms are not a reliable indicator of TB disease severity, and that the context in which someone is investigated for TB – self-presentation to a clinic vs active community screening – may be more informative.

The South Africa National Department of Health have set ambitious targets to scale up TB testing, focusing primarily on clinic attendees. In the context of declining funding for TB care and prevention, the most cost-effective approaches for targeting testing should be identified. We developed a mathematical model of TB in South Africa, explicitly incorporating clinic attendance by sex and HIV/ART status. We simulated six screening approaches over 2026–2035 (individually and in combination): three clinic-based (symptom screening, intensified targeted universal TB testing [TUTT, symptom-agnostic sputum testing of clinic attendees in key risk groups], and intensified TUTT allowing saliva samples) and three targeted community-based (community radiographic screening, symptom screening, and universal Xpert Ultra testing), each implemented at a range of coverage levels. Model outputs were combined with a mechanistic cost function to estimate potential impact and cost-effectiveness from a societal perspective. The most cost-effective standalone approach was community radiographic screening at 10% annual population coverage, with an incremental cost-effectiveness ratio (ICER) of $421 per disability-adjusted life year (DALY) averted. 10/11 scenarios along the expansion path included community radiographic screening at progressively higher coverage, combined with a clinic-based approach. Combining complementary approaches to reach both groups at increased risk of TB (e.g. clinic-based screening) and groups with lower screening coverage (e.g. community-based screening) may increase cost-effectiveness of TB screening, compared to standalone approaches. When designing TB screening strategies, both population risk and existing screening coverage should be considered.

Household case-contact studies are an established method to estimate the relative infectiousness of people with pulmonary tuberculosis. Testing of child household contacts with a QuantiFERON TB Gold plus (QFT) assay provides a proxy measure of M. tuberculosis infection in exposed household members. This study aims to generate data about the effect of antiretroviral treatment (ART) and of tuberculosis symptoms on risk of intra-household M. tuberculosis transmission to children and investigate the conditions under which symptom-agnostic screening should be considered, which could provide evidence to support a paradigm shift in tuberculosis screening strategy. Index people diagnosed with bacteriologically-confirmed pulmonary tuberculosis who have been identified by routine health services and starting tuberculosis treatment at one of the 12 health facilities serving the population of the Africa Health Research Institute health and demographic surveillance area will be eligible for recruitment. For each consenting index participant, we will enroll all household members aged 2-14 years who will undergo a symptom screen and provide a blood sample for a QFT and HIV test. We will compare the proportion of child contacts who are QFT-positive in households of (i) index adults who are living with HIV and taking ART vs not taking ART and (ii) index adults engaged in ART care who report no symptoms vs those who report symptoms. We will use a novel mathematical model, incorporating new insights into TB natural history and transmission, to determine the circumstances under which screening for TB, regardless of reported symptoms, would have most impact on tuberculosis incidence and mortality, and explore comparative cost-effectiveness of interventions along the diagnostic pathway at different levels of the health system. Estimates of relative risk of intra-household M. tuberculosis transmission, combined with healthcare utilisation and cost data, will allow us to generate mathematical model estimates of the potential epidemiological impact and relative cost-effectiveness of different approaches to tuberculosis case-finding including symptom-agnostic tuberculosis screening at different levels of the health system.

The Journal of the Colleges of Medicine of South Africa seeks to facilitate interdisciplinary and multidisciplinary dialogue and collaboration among healthcare professionals and researchers across different specialities and fields. The journal prioritises contributions, particularly emphasising the Southern African and African context while welcoming contributions from other regions. The Journal of the Colleges of Medicine of South Africa promotes human rights, social justice, and non-discrimination in medicine, dentistry, and healthcare.

In clinical settings where airborne pathogens, such as Mycobacterium tuberculosis, are prevalent, they constitute an important threat to health workers and people accessing healthcare. We report key insights from a 3-year project conducted in primary healthcare clinics in South Africa, alongside other recent tuberculosis infection prevention and control (TB-IPC) research. We discuss the fragmentation of TB-IPC policies and budgets; the characteristics of individuals attending clinics with prevalent pulmonary tuberculosis; clinic congestion and patient flow; clinic design and natural ventilation; and the facility-level determinants of the implementation (or not) of TB-IPC interventions. We present modeling studies that describe the contribution of M. tuberculosis transmission in clinics to the community tuberculosis burden and economic evaluations showing that TB-IPC interventions are highly cost-effective. We argue for a set of changes to TB-IPC, including better coordination of policymaking, clinic decongestion, changes to clinic design and building regulations, and budgeting for enablers to sustain implementation of TB-IPC interventions. Additional research is needed to find the most effective means of improving the implementation of TB-IPC interventions; to develop approaches to screening for prevalent pulmonary tuberculosis that do not rely on symptoms; and to identify groups of patients that can be seen in clinic less frequently.

Healthcare facilities are important sites for the transmission of pathogens spread via bioaerosols, such as Mycobacterium tuberculosis. Natural ventilation can play an important role in reducing this transmission. We aimed to measure rates of natural ventilation in clinics in KwaZulu-Natal and Western Cape provinces, South Africa, then use these measurements to estimate Mycobacterium tuberculosis transmission risk. We measured ventilation in clinic spaces using a tracer-gas release method. In spaces where this was not possible, we estimated ventilation using data on indoor and outdoor carbon dioxide levels. Ventilation was measured i) under usual conditions and ii) with all windows and doors fully open. Under various assumptions about infectiousness and duration of exposure, measured absolute ventilation rates were related to risk of Mycobacterium tuberculosis transmission using the Wells-Riley Equation. In 2019, we obtained ventilation measurements in 33 clinical spaces in 10 clinics: 13 consultation rooms, 16 waiting areas and 4 other clinical spaces. Under usual conditions, the absolute ventilation rate was much higher in waiting rooms (median 1769 m³/hr, range 338–4815 m³/hr) than in consultation rooms (median 197 m³/hr, range 0–1451 m³/hr). When compared with usual conditions, fully opening existing doors and windows resulted in a median two-fold increase in ventilation. Using standard assumptions about infectiousness, we estimated that a health worker would have a 24.8% annual risk of becoming infected with Mycobacterium tuberculosis, and that a patient would have an 0.1% risk of becoming infected per visit. Opening existing doors and windows and rearranging patient pathways to preferentially use better ventilated clinic spaces result in important reductions in Mycobacterium tuberculosis transmission risk. However, unless combined with other tuberculosis infection prevention and control interventions, these changes are insufficient to reduce risk to health workers, and other highly exposed individuals, to acceptable levels.

An error appeared in the corrected proof publication of this article [Govender I, Karat AS, Olivier S, et al. Prevalence of Mycobacterium tuberculosis in Sputum and Reported Symptoms Among Clinic Attendees Compared With a Community Survey in Rural South Africa. Clin Infect Dis https://doi.org/10.1093/cid/ciab970]. The last line of the Financial support section currently states “The community survey was supported by the Wellcome Trust via a strategic award to AHRI (grant number 201433/Z/16/Z)”. The sentence should state “The community survey was supported by the Wellcome Trust via a strategic award to AHRI (grant number 201433/Z/16/A)”.