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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