Recommendations for policy in the Western Cape Province regarding the prevention of Major Infectious Diseases including hiv/AI

Key to Districts
1	Metro	4	Overberg
2	West Coast	5	Eden
3	Cape Winelands	6	Central Karoo

Table 5 above demonstrates the close relationship between the migrant status of a population, the relative age composition of the area and HIV prevalence.

Table 6 below indicates a similar correlation between housing type, access to amenities, education, average level of individual income and HIV prevalence within a sub-district

Table 6: 2004 HIV prevalence and selected

socio-economic indicators

2004 HIV prev (%)	Dist.	Sub- district	Pop.	% with Grade 12 Edu-cation	% individual income < R1600 (weighted)	% dwellings with piped water	% informal settle-ments (weighted)
33.0	1	Khayelitsha	329,008	13	94	20	64
29.1	1	Klipfontein	344,441	15	85	67	20
17.8	3	Stellenbosch	117,706	16	82	72	13
17.4	5	Bitou	29,183	16	85	46	17
17.4	5	Knysna	51,466	17	84	52	25

Tuberculosis


It is estimated that approximately one third of the global population are latently infected with the TB bacillus and that this proportion is even higher in areas of high TB prevalence (Corbett et al, 2003). Cellular immunity helps to maintain the pathogen in the latent state, and in the pre-HIV era only about 5-10% of those infected with the bacillus were expected to progress to active TB.
There were an estimated 8.3 million new TB cases worldwide in 2000 and an esti-mated 1.8 million global deaths from TB. South Africa ranks fifth in the world for TB prevalence (Global Health, 2006). The number of new cases in South Africa is in-creasing annually (Health Systems Trust, 2003, and see Figure 5) with an estimated 339 078 new cases in 2004 (Global Health, 2006). Tuberculosis rates in the Western Cape Province have historically been among the highest in the country (Bell and Yach, 1988; Department of Health, Western Cape, 2006). The high rate of TB stands in sharp contrast to the statistics which show that the province has the lowest HIV prevalence.

Figure 5: Number of TB cases in South Africa, 1996-2002

The Western Cape remains the province with the highest incidence of new TB cases in South Africa. The number of registered TB cases has been increasing by 8-10% annually for the last decade, as demonstrated in Figure 6 below.

Figure 6: Caseload of TB in the

Western Cape Province, 1997-2005

1. TB profile of the Western Cape Province

1.1. Overall caseload and differential distribution of burden

The provincial HIV prevalence has increased by 11-12% annually in the last seven years. Over the same period registered TB case-load has increased by

8-10% annually.

There were approximately 48 000 registered TB cases in the Western Cape Province in 2005 (Department of Health, Western Cape, 2005). Further analysis of the distribution of these cases reveals some noteworthy trends.

Firstly, approximately 68% were new cases, the remainder being re-treatment cases.

Table 7 on page 19 describes the total caseload, organised according to the number of registered cases per clinic. Note that TB hospital data, however, have been dropped from this analysis.

Table 7: Differential caseload distribution of TB in the Western Cape

Category	No. of cases seen per year at the facility	No. of facilities in the category	Total case load of the category	% each category contributes to the provincial case load	Average no. of cases per clinic per year
1	>400	22	15 413	34.2	701
2	200-400	44	12 373	27.5	281
3	100-199	60	8 277	18.3	138
4	50-99	75	5 656	12.6	75
5	<50	194	3 343	7.4	17
TOTALS		395	45 062	100	114

As can be seen above, there are 22 “category 1” clinics (clinics that manage more than 400 registered TB cases per year) and these carry 34% of the provincial caseload. A table of these clinics, ranked by caseload, can be seen in Appendix A on page 99. Of these 22 clinics, eighteen fall into the Metro district and only four beyond it. Of note is that five of Khayelitsha’s eight clinics fall into these “high burden” clinics and that these five clinics together carry approximately 11% of the Provincial burden.
The other Metropole sub-districts that contain high burden clinics are Klipfontein (three high burden clinics), Eastern (three high burden clinics), Northern (three high burden clinics), Mitchells Plain (two high burden clinics) and Western (two high burden clinics).