Mine Health and Safety Act, 1996 (Act No. 29 of 1996)

Notices

Guidance Note for a Management and Control Programme for Tuberculosis in the South African Mining Industry

Part B : Author's Guide

10. Treatment follow-up
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10.1Where a patient is separated from work while on treatment the employer should make reasonable efforts to ensure continuous treatment and determine the final outcome. The employer should, as far as reasonably practicable, try to arrange for the patient to return for assessment (at the end of treatment). If this is not possible, alternative arrangements should be put in place to determine the outcome.

 

10.2For those patients who interrupt treatment for less than two months refer to the protocol below (NTBMG).

 

TIMING OF SPUTUM EXAMINATION

AIM

ACTION

COMMENTS

END OF INTENSIVE PHASE

One week before the end of the two months’ intensive phase of treatment (at seven weeks)

To determine smear conversion a sign of good

clinical progress
(1)If negative, change to the continuation phase of treatment at the end of the 8th week of intensive phase treatment.

This means the patient is responding well to treatment. Educate and counsel patient about importance of treatment compliance.
(2) Register the patient as "negative".

To guide the health worker on whether to change the patient to continuation phase of treatment or extend the intensive phase.
(3)If positive, check for treatment compliance, re-assess patient clinically:
(a)Conduct LPA (or culture and DST, if LPA is not available).
(b)Continue with the intensive phase treatment for one month.
(c)Register the patient as "positive".
(d)Review the drug susceptibility results when available.

This indicates the following:

•That the initial phase of therapy was poorly supervised and that patient’s compliance to treatment was poor.
•That there is a slow rate of progress with smear conversion, which is common in patients with extensive cavitations and a high bacillary load at diagnosis.
•That the patient may have resistance to the other TB drugs i.e. Isoniazid (since only Rifampicin resistance was excluded upfront) or may have been reinfected with a drug resistant strain.
•The patient could have non-tuberculous mycobacterial infection.
•The patient may have another condition or taking other medication that affects the absorption or effectiveness of the TB drugs.
•Patient may have been infected with mixed strains with amplification of resistant strains due to treatment.

Address treatment compliance by counselling the patient and identifying a treatment supporter where necessary.

FOR THOSE REMAINING POSITIVE AT 2 MONTHS

Repeat smear one

week before the

end of the third

month (11 weeks)
(4) If negative and drug susceptible, change to continuation phase of treatment at the end of the 12th week. Register the patient as "negative".
(5)If negative and Isoniazid mono resistant TB is confirmed, continue intensive phase treatment and refer patient to MDRTB for assessment and registration in DR-TB register. Register the patient as "Isoniazid mono-resistant TB" in the TB register.
(6)If still positive and RRTB or MDR-TB is confirmed, stop treatment and refer patient to the MDR-TB treatment initiation site for assessment and treatment initiation. Register the patient as "RR-TB or MDR-TB" in TB register.

The intensive phase treatment is not extended beyond three months in patients with drug susceptible TB.

END OF CONTINUATION PHASE

One week before the end of the four months’ continuation phase (at 23 weeks)

To determine the final outcome of treatment for the patient.
(1)If negative, stop treatment at the end of the 24th week of treatment. Register the patient as "cured".

Educate the patient about TB prevention and healthy lifestyle.
(2)If positive, stop TB treatment. Register patient as "treatment failure".
(a)Conduct LPA and DST for pyrazinamide and ethambutol.
(b)Review the results when available.

This indicates the following:

•That the patient was reinfected with a sensitive or resistant strain.
•The treatment during the continuation phase was unsupervised and patient compliance was poor.

FOR THOSE REMAINING POSITIVE AT 6 MONTHS

To determine further management of the patient.
(1)If drug susceptible, restart TB treatment, counsel the patient and provide treatment support.


(2)If DR-TB RR-TB, Isoniazid Mono resistant, MDR-TB, Other resistance), refer to the MDR-TB treatment initiation site hospital for assessment and treatment.

 

10.3Referral to another facility for TB care beyond employment

 

10.3.1Where a patient’s employment is terminated while on TB treatment, the patient should be referred to an appropriate TB care facility where the patient can continue with treatment.

 

10.3.2The TB care facility concerned should be contacted and alerted of the patient referred to it. The TB care facility should also be provided with contact details of the patient. If the TB care facility concerned is in another country, the National TB Manager of that country should be contacted.

 

10.3.3The patient should be provided with a letter or form detailing the diagnosis, bacteriological investigations conducted (including dates), treatment regimen dosages and other chronic medication or ancillary medication that the patient is taking. The letter should also indicate the expected date for follow up at the mine health centre/one stop services during and post treatment (12 months after treatment completion). The referral letter should be accompanied by:
(a)GW 20/14 Referral Form prescribed by the NDOH;
(b)The patient's health record (green card); and
(c)MBOD guideline/COIDA (first, progress and final report) for benefit examination and compensation.

 

10.3.4The patient should be provided with a counselling package which includes:
(a)the available information on the receiving facility; and
(b)Importance of presenting to the receiving facility to his home and continuation and when they should present to the clinic/ hospital .

 

NOTE: A copy of the GW 20/14 Form should be forwarded to the province/ country where the patient resides to ensure continuum of treatment and care. The acknowledgement slip on the form must be completed by the receiving facility and returned to the referring mine health facility.

 

10.4Provision of TB services where employer does not have a health care facility

 

Where the employer does not provide access to health services, it should refer employees to the nearest local health care facility for diagnosis and treatment.

 

10.5Infection control

 

The TB management control programme should include appropriate infection control measures, covering at least:

10.5.1 Workplace and administrative controls;
10.5.2Environmental control measures;
10.5.3Measures to protect health workers and staff; and
10.5.4An implemented written infection control plan for each facility.