Multi-drug resistant tuberculosis: Progress and challenges in South

Africa

Multi-drug resistant tuberculosis: Progress and challenges in South

Africa

Dr S. Moyo HIV/AIDS, Sexually Transmitted Infections and TB

research (HAST)Programme Human Sciences Research Council

02 June 2014

Presentation OverviewPresentation Overview

• Definitions

• Burden of multi-drug resistant TB (MDR-TB) in South Africa

• Significance of MDR-TB in South Africa

• Successes and challenges in addressing the MDR-TB burden

• Recommended key actions

• Conclusion

The face of MDR-TBThe face of MDR-TB

Photos: courtesy of Médecins San Frontières, Khayelitsha DR-TB project

The face of MDR-TB The face of MDR-TB

© Rowan Sybus

www.mariellafurrer.com

DefinitionsDefinitions

• Multi-drug resistant TB (MDR-TB) caused by mycobacteria with resistance to first-line anti TB drugs rifampicin and isoniazid

• Extensively drug resistant TB (XDR-TB)- MDR plus resistance to second-line drugs:-second-line injectable agent and a fluoroquinolone

• Pre-XDR TB MDR plus resistance to a second line injectable agent or a fluoroquinolone

The Burden of MDR-TB in South AfricaThe Burden of MDR-TB in South Africa

• One of the 27 high MDR-TB burden countries

• Second largest number of MDR-TB cases in 2012

• ~10% of MDR-TB cases have XDR-TB

• Reports highest number of XDR-TB cases globally

• 1.8% of new TB cases and 6.7% of previously treated TB cases have MDR-TB

• ~ 4% of all TB is MDR across all provinces

• Most cases reported in KZN (46%), EC (19%) WC(15%) and GP(8%)- MDR-TB 2012

Number of laboratory diagnosed cases MDR & XDR-TB 2008-2012

Number of laboratory diagnosed cases MDR & XDR-TB 2008-2012

Number of laboratory diagnosed cases MDR & XDR-TB 2008-2012

Number of laboratory diagnosed cases MDR & XDR-TB 2008-2012

The significance of MDR-TBThe significance of MDR-TB• Growing problem globally and threatens global TB

control

• Now driven by community transmission

• More difficult to treat than drug sensitive TB

• More expensive to treat than drug sensitive TB

The significance of MDR-TB: More difficult to treatThe significance of MDR-TB: More difficult to treat

• Longer duration of treatment:- at least 18 months of treatment

• Treatment regimens have significant side effects, and include a painful injectable agent

• Patient outcomes are poor• < 50% treatment success rate• high mortality and failure of

treatment• more than 12 months median

survival among treatment failures

The significance of MDR-TB: More expensive to treatThe significance of MDR-TB: More expensive to treat

• MDR TB comprising 2.2% of total TB burden but consumed 48% of total estimated National TB budget in SA in 2011. Pooran et al, PLoS One 2013

• Cost of diagnostics

• & monitoring

• Cost of drugs • Hospitalisation

Addressing MDR-TB: Progress -1Addressing MDR-TB: Progress -1

• TB control is one of the key national health priorities In the NSP specific goals for MDR-TB are

• Initiation of appropriate therapy with 5 days

suspicion of resistance• 95% pts on appropriate therapy• 60% treatment success

• Framework for management of MDR-TB • Premised on decentralised/deinstitutionalised management

(hospitalisation available where necessary)

• Nurse initiated MDR-TB treatment

Addressing MDR-TB: Progress-2Addressing MDR-TB: Progress-2

• Use of modern diagnostics Molecular methods for rapid diagnosis Hain assay- Line probe assay XpertMTB/Rif as replacement for smear microscopy

• Review and evaluation of treatment regimens

• Monitoring of resistance patterns National drug resistance surveys

Addressing MDR-TB: Progress summaryAddressing MDR-TB: Progress summary

National Department of health: Report on Think Tank meeting on the management of multidrug resistant Tb in South Africa- 26-28 March, 2014

Addressing MDR-TB:-Challenges -1Addressing MDR-TB:-Challenges -1

• Poor case detection• Patients do not present for

care• Patients receive inadequate/

inappropriate care • Contact tracing and

assessment of contacts is not always conducted

• Inadequate testing • Drug susceptibility testing • Second line drug

susceptibility testing

High burden of undetected disease

Addressing MDR-TB:-Challenges-2Addressing MDR-TB:-Challenges-2

Treatment initiation gap

Low levels of treatment initiation

Addressing MDR-TB:-Challenges-3Addressing MDR-TB:-Challenges-3

• Limited treatment regimen options• Limited options for constructing effective regimens• Available drugs have limited efficacy and many significant

side effects• Poor outcomes, High default rates

• Recording and reporting• Poor in many areas, definitions are not always well

understood• Paper registers not entirely compatible with the electronic

database (EDR.Web)- ?diagnosed/started on treatment reported

• Limited access EDR.Web

Addressing MDR-TB:-Challenges-4Addressing MDR-TB:-Challenges-4

• Human resources • Quantity

Nurses, doctors, counsellors, social workers, laboratory staff, audiologists/ assistants

Heavy workload with neglect of MDR TB• Quality

Inadequate care to patients Infection control measures

• Poor implementation of decentralisation• Poor local level leadership• Inadequate staff• * No real buy-in on the experience of established models

with possibility of scale up

Addressing MDR-TB:-Challenges-5Addressing MDR-TB:-Challenges-5

• Management of patients who have failed treatment• Palliative care options• Balancing patients’ rights and protection of the public• Community education

• Inadequate focus on some vulnerable groups• Young children• Adolescents• Healthcare workers*

Key actions neededKey actions needed

• Increased awareness of MDR-TB to increase testing and case detection (communities and health care facilities)

• Strengthening of the health system for MDR-TB testing and appropriate care (accelerate rollout of nurse initiated MDR-TB treatment)

• Urgent review and updating of treatment regimens

• Increased financing

• Examination of successful decentralisation models for urgent scale up of access to diagnosis and care

ConclusionConclusion

• MDR-TB poses a real threat to TB control

• Urgent and bold steps are urgently needed to address MDR-TB

• Find TB, treat TB and cure TB

AcknowledgementsAcknowledgements

• Médecins Sans Frontières – Khayelitsha Project• Mariella Furrer photography- www.mariellafurrer.com• National Department of Health

• Extra slides

Number of laboratory diagnosed cases and number started on treatment- MDR TB

2007-2012

Number of laboratory diagnosed cases and number started on treatment- MDR TB

2007-2012

Number of laboratory diagnosed cases and number started on treatment- XDR TB

2007-2012

Number of laboratory diagnosed cases and number started on treatment- XDR TB

2007-2012