Good Shepherd Hospital blog

Review March 2008

Background

The Lubombo Regional Epilepsy programme was established in 2002. It is one of a number of chronic disease management programmes operating from Good Shepherd Hospital across the Lubombo region of Swaziland. The Epilepsy Specialist Nurse (ESN) leads regular clinics at GSH supported by a nursing assistant and provides a specialist outreach service to 17 clinics in the region. Patients attend their local clinic or GSH on a monthly basis. Previously all people with epilepsy in the region attended the Mental Health Unit at GSH. This led to high default rates with patients travelling long distances for monthly review.

The clinic nurses have been trained in regional workshops to manage epilepsy. The diagnosis of epilepsy is usually made by a doctor and treatment is commenced. The patient is then referred to the ESN. The patient is registered on the epilepsy database and given a unique identifying number. The patient is reviewed at GSH and if seizure free is transferred for further follow-up to their local clinic.

Each patient has a chronic disease card which is held at the local clinic. The card includes demographics, seizure description, type of seizure, year of onset, current treatment and seizure activity. At the monthly visit the number of seizures is reviewed. If the patient has continued seizures the drug treatment may be titrated or the patient may be asked to attend for review by the ESN for review of the drug treatment and dose titration or add-on treatment. The aim of treatment is to achieve seizure freedom with monotherapy if possible. The ESN will arrange review at GSH by a doctor if necessary.

At the monthly clinic visit by the ESN all of the chronic disease cards held at the clinic are reviewed. Data is recorded on clinic attendances, defaulters, seizure activity, changes in medication and any moves out of the area or deaths. Patients with difficult to control seizures are reviewed and changes in treatment are made as necessary. Drug supplies are delivered to the clinics including anti-epileptic drugs and drugs for psychiatric conditions.

Aim of review

• To observe delivery of the programme in GSH and an outreach visit.
• To identify current challenges for the programme.
• To review the epilepsy register and analyse recent data.

Findings

Good Shepherd Hospital

The ESN is well-established in his role and has developed increasing competence in the management of epilepsy. He is able to titrate drug treatments and to introduce new drugs appropriately. He counsels patients with a new diagnosis of epilepsy and encourages compliance and emphasises the importance of regular review. He aims for monotherapy and is aware of the increase in side effects with multiple drugs.

He has observed a recent change in practice such that some MOs are introducing two drugs at an early stage without titrating the first drug to an effective dose. No guidelines for drug titration are currently in use in OPD.

He has a nursing assistant based at the GSH unit. There has been some turnover in this role.

The ESN takes part in the hospital on-call rota. This has an impact on the delivery of outreach as the on-call rota is released with short notice leading to the cancellation of outreach clinics.

There has been some difficulty with the supply of sodium valproate in the last year. GSH were unable to supply the clinics and some patients had to be converted to carbamazepine.

Epilepsy Register

Individual patient data has not been entered on to the database since December 2006. Previously the ESN had a print-out of individual data for each clinic visited indicating previous treatment, diagnosis, seizure activity,etc. This was useful for active management but also indicated any missing data which could then be collected at the clinic visit.

In December 2004 535 were registered. The sex was known for 523 people: 282 males (53.9%) and 241 females (46.1%). The mean age was 26 years with a median of 23 years. 33% were attending GSH and 67% were attending rural clinics.

Of the 530 patients where seizure type was recorded 502 (94%) were described as having generalised seizures and 28 (5%) partial seizures.

From the summary data for 2007 total re-attendances on a monthly basis ranged from 237-274, with new cases 1-8 and defaulters 20-42. This suggests a current active population of approx 300 patients. No information on possible aetiology is currently recorded.

Analysis is currently based on group data on a monthly basis with an average of 65% previously reported as seizure-free per month. From the 2007 group data there has been a significant improvement in seizure control with 88-93% reported as seizure free each month. There has been some previous analysis of patients who are seizure free for at least 6 months and this needs to be extended to seizure freedom for at least 12 months and the at least 2 years.

Clinics

Initially 20 clinics were recruited to the Lubombo Epilepsy programme. Sithobela, Mhlume and Simunye now run their own service. The outreach service now supports 17 clinics.

Since the roll-out of ART to clinics the ESN visits have been coordinated with the ART team visits. This has reduced the epilepsy team outreach to certain clinics not included in the ART roll-out e.g. Gilgal, Bholi, Sitsatsaweni, Manyeveni and Mpaka. Gilgal clinic has only been visited on six occasions during the last year. The Epilepsy SN tries to coordinate visits to the other clinics on the way back from the ART clinics if possible.

No data has been collected from Vuvulane clinic for the last year. The ESN reports that the clinic nurses at Vuvulane have not been recording data on the chronic disease cards which were being stored in the dispensary. He has moved the cards into the consulting rooms and has reminded the clinic nurses of the need to record on the card rather than the OPD paper.

Siphofaneni clinic has reported a high defaulter rate for the last 6 months. However the ESN has identified that these are not true defaulters but this is also due to inadequate recording by clinic staff.

Summary of progress

The Lubombo Regional Epilepsy programme delivers specialist outreach epilepsy support to 17 clinics in the Lubombo region. The majority of clinics use the chronic disease cards to monitor patients with epilepsy. The number of patients who are seizure free has increased significantly since 2004. Active management of epilepsy is well-established aiming for monotherapy with low side effects. The ESN has established a good relationship with the clinics and provides advice at regular clinic visits and by telephone between visits.

There have been a number of challenges for the service in the last year. The following recommendations were agreed at this review visit.

Recommended Actions

• HF to develop guidelines for drug treatment of epilepsy for use in a clinic setting. This has been discussed with Dr Mangezi at the National psychiatric Hospital and he would support the introduction of these guidelines on a national basis.
• Individual patient data from Jan 2007 – March 2008 to be entered on to epilepsy register to allow further analysis. This will require additional funding to bring the register up-to-date.
• Analysis to include numbers of patients seizure free for at least 12 months and then 2 years, 3 years if data available.
• Investigate possible reasons for the reduction in numbers under follow up. This may include reduction in the number of clinics in the programme, the impact of the ART roll-out, seizure-free patients stopping treatment.
• On-call duty of ESN. If this duty is essential then can earlier notice be given to reduce impact on planned clinics? Consideration to be given to trained cover for the Epilepsy SN.
• To be more proactive in withdrawing drug treatment in seizure free patients.
• To include possible aetiology for new cases on chronic disease card and register.
• Drug supply – to secure a regular supply of AEDs through the national psychiatric centre.

Helen Ford

Consultant Neurologist

Introduction

Tuberculosis is also one of the most common causes of morbidity and the leading cause of mortality in people living with HIV/AIDS (PLWHA) and Swaziland has a very high burden of TB/HIV .79.6% of TB patients are co-infected with HIV. It is estimated that up to 50% of the HIV patients are co-infected with TB. Although some collaborative activities have been implemented in a few public facilities and NGOs, these have not been standardized and depend largely on the knowledge and motivation of an individual health care worker. More collaboration between the two programmes is needed to improve diagnostic, treatment, preventive, care, and support services for people living with HIV and TB. This will improve synergies, avoid overlaps and maximize service delivery. TB/HIV co-infection programs are patient centered and aim to decrease the burden of disease in populations.

HIV prevention and care should be a priority concern of the National TB Control Programme (NTCP) and TB prevention and care should be a priority concern of Swaziland National HIV/AIDS Programmes (SNAP). Whereas previously TB programmes and HIV/AIDS programmes have largely pursued separate courses, they need to exploit synergies in supporting health service providers to deliver collaborative interventions. At the service delivery level it can be seen that many potential reciprocal synergies exist between different service providers e.g. HIV-positive clients/patients have a high rate of TB (and therefore benefit from TB screening and treatment) and TB patients have a high rate of HIV (and therefore benefit from HTC and associated services).

There is need to decrease the burden of tuberculosis in people living with HIV/AIDS through conducting intensified TB case finding among patients attending HIV care settings using a minimum set of questions to identify suspected TB cases as soon as possible. eg ART clinics, PMTCT, OPDs etc. To provide TB treatment for PLWHA’s with active TB hence the need to establish a referral system between HIV care settings TB clinics and TB diagnostic laboratory.

Swaziland intends to conduct a pilot of intensified case finding in ART clinics and later roll it out to other HIV care settings.

Objectives

· To screen all PLWHA for TB and provide preventive and curative care for those with latent and active TB respectively.

· To provide TB treatment for PLWHA’s with active TB

Process of TB screening

Establish intensified tuberculosis case-finding

Screen for symptoms and signs of tuberculosis using TB screening tool. Early identification of signs and symptoms of tuberculosis, followed by diagnosis and prompt treatment increase chances of survival, improves quality of life and reduces transmission of tuberculosis in the community.

Who should be screened?

People living with HIV/AIDS, their household contacts, groups at high risk for HIV and those in congregate settings (e.g. prisons, police, military barracks, HIV clinics, inpatient wards, schools, large scale factory settings, mine and plantation workers, slums and others),

TB screening should be conducted:

As soon as possible after HIV testing and receipt of HIV positive results and at the point of first contact with health services eg VCT, ART clinic, OPD etc. Patients should be instructed to cover their mouths and nose when coughing, with hands, cloth such as handkerchief, clean rag, tissues or paper masks. All staff is responsible for safety and should work together to help patients adhere to this practice.

Sputum collection

Ensure safe sputum collection and should be done away from other people.

AFB Smear-negative

The TB suspects who are AFB smear-negative receive additional procedures (e.g. chest x-ray and referral visits) or treatment as quickly as possible

AFB Smear-positive

• If the diagnosis of tuberculosis has been confirmed the patient should be started on treatment as soon as possible and should be given free of charge.
• The basis of treatment of tuberculosis is chemotherapy. It is also one of the most efficient means of preventing the spread of tuberculosis microorganisms. The requirements for adequate chemotherapy include an appropriate combination of anti tuberculosis medications to prevent the development of resistance (MDR/XDR) to those medications, correct dosage, regular intake by the patient and a sufficient period of taking medication to prevent relapse of the disease after completion of treatment.

The components of the minimum package are:

- screening tool( see attachment)

- TB suspects register

- CPT

- Sputum bottles

- Education on cough hygiene

- Use of clinical staging to initiate ART

- referral/Linkages to the lab

- Baseline ART assessment

- Availability of TB treatment

- training of ART staff on the minimum TB screening package and TB management

Referral & Linkages

• laboratory

Sputum specimens are sent for AFB smear and turn around time for sputum AFB smear results should be no more than 24 hours

• TB clinic & ART clinic: referral forms

Monitoring and Evaluation

Recording and Information System:

Placement of TB registers in the ART clinic

TB screening tool

Lab request forms- for sputum examination

Monthly report forms for TB screening

Indicators:

number of patients sent the lab who receive their results, initiate on treatment, are referred