South Africa has insufficient infrastructure to cope with the ongoing tuberculosis (TB) epidemic, with extensively drug-resistant TB (XDR-TB) emerging on top of the rise in multi-drug resistant TB (MDR-TB).
Geoff Abbott (right) of the CSIR on the construction site of one of the dedicated TB wards
Infrastructure constraints in existing hospital buildings for TB patients remain an obstacle to safe health service delivery. "The spatial layout in many buildings impedes the implementation of airborne infection control of diseases such as TB. In South Africa, very few facilities exist that are able to manage suspected or confirmed TB patients adequately," notes Geoff Abbott of the CSIR.
The CSIR is assisting seven provincial Departments of Health with the roll-out of special accommodation for M(X)DR-TB TB patients at existing hospitals. More than R92 million of international donor funding was sourced by the national Department of Health from The Global Fund for this project as part of its drive to strengthen national and provincial capacity in South Africa for the prevention, care and treatment of drug resistant TB patients. The provinces where such facilities are being constructed have committed to contributing an additional R115 million towards the project.
In discussions with the national Department of Health, facilities were identified where the establishment of new patient accommodation for M(X)DR-TB was crucial. Construction at the first hospital site started in 2009, with most of the other projects getting off the ground from April 2010.
"The whole drive is aimed at providing additional 'beds' for TB patients, usually at existing drug-resistant TB hospitals. In total, 460 beds will be added at nine hospitals in seven provinces. The lack of appropriate hospital infrastructure for treating drug-resistant TB is a key constraint against the effective and safe treatment and rehabilitation of patients. Unfortunately, many cases have occurred where both patients and staff have been infected with drug-resistant TB in existing facilities because the buildings are not appropriately designed or have not been remodelled to reduce the risk of cross infection," explains Abbott.
The CSIR is using the research on The Global Fund and other drug-resistant TB projects to review existing international guidelines for the planning, design and operation of drug-resistant TB facilities and to develop and adapt these to local requirements in South Africa. Key local issues include the sheer numbers involved in the epidemic - South Africa has the highest incidence rate for the disease in the world, this links to HIV where over 70% of TB cases are co-infected with HIV, funding and staffing constraints and a wide range of climatic zones.
A focus of the CSIR research is on providing low-cost yet fully-functional units. "The use of natural ventilation is key to providing low-cost, low-maintenance facilities. However, one still needs to ensure that the required number of air changes and effective dilution of the air are achieved. Various window, fixed opening and roof configurations were developed and tested in the CSIR's building performance laboratory. We used primarily computational fluid dynamics software to model building options and to adjust and refine designs. By careful management of airflow, even in very light wind conditions, acceptable air change rates can be achieved. After construction, we will evaluate the buildings in use to validate our research results," says Abbott.
As drug-resistant TB patients have to stay in health facilities for up to a year, health authorities involved in this new roll-out are trying to make their stay as comfortable as possible. New CSIR designs generally provide for patients to be accommodated in single rooms, which not only reduces the opportunity for cross infection, but also provides for greater patient dignity. Research has shown that patients in multi-bed units are often cross-infected with different strains of TB, increasing treatment costs and a considerable increase in the length of stay. New national policies also consider the spread of facilities, looking to accommodate patients as close to their families as possible.
"The different phases in TB treatment require differing types of accommodation. Acute patients need a high level of nursing care and need to be located close to the nursing support base and a higher level of technological support. Post-acute patients spend most of their rehabilitation time outside the building. Here, one has to provide recreational spaces for supporting activities such as sports, visitor areas, physiotherapy facilities, as well as a business hub for people to continue with running their businesses from the unit. Even classrooms for schooling of the younger patients are taken into account. These extra facilities are generally funded from the provincial budgets," explains Abbott.
Construction of the new 40-bed MDR-TB unit at Manguzi Hospital in KwaZulu-Natal has been completed. "In this instance, a new comprehensive service unit for MDR-TB has been built at the community hospital. It comprises male and female wards, along with an administration and out-patient service block." In Welkom in the Free State, the decommissioned maternity unit at Kopano Hospital has been completely remodelled to provide a similar 45-bed comprehensive service unit for MDR-TB, with construction due to be finished within the next three months.
Other locations for new or improved TB wards include:
- Catherine Booth Hospital in KwaZulu-Natal
- Modimolle Hospital in Limpopo
- Bongani Hospital in Mpumalanga
- West End Hospital in the Northern Cape
- Tshepong Hospital in North West
- Jose Pearson Hospital in the Eastern Cape.
A ninth project, the conversion of existing wards into an MDR-TB unit, was added late in the process at Nkqubela Hospital in the Eastern Cape. "This project will be run as part of a skills capacity-building programme involving staff from the provincial health and works departments and local architects and engineers. It is intended to provide a model for other similar conversions elsewhere in the province."
"We anticipate that seven of the nine sub-projects will be completed and ready for occupation by the end of 2010, with the remaining two scheduled for completion early in the new year."
The two provinces that currently do not form part of the project are Gauteng and the Western Cape, based on earlier funding from the Global Fund. "Due to the work undertaken so far in other provinces, the Western Cape has approached us for assistance in a major new XDR-TB project at its main provincial TB centre in Cape Town. The intention is to draw on this project for developing guidelines for use in other provincial projects," Abbott concludes.