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 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-TB

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

© Rowan Sybus

The face of MDR-TB

www.mariellafurrer.com

Definitions

• 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 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 # diagnosed with MDR-TB

16000 14000 12000 10000 8000 6000 4000 2000 0 8198 9070 7386 10085 14161 2008 2009 2010 2011 2012 1800 1600 1400 1200 1000 800 600 400 200 0 488

# diagnosed with XDR-TB

1574 594 741 1545 2008 2009 2010 2011 2012

10000 8000 6000 4000 2000 0

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

18000 16000 14000 12000 11659 15706 8686 9664 8127 2008 2009 2010 2011 2012

The 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 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 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 -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-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 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 -1 High burden of undetected disease • • • •

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

18000 16000 14000 12000 10000 8000 6000 4000 2000 0

Addressing MDR-TB:-Challenges-2

Low levels of treatment initiation 15706

Treatment initiation gap

11659 9664 8686 8127 5928 6252 7195 4574 4422 2008 2009 #diagnosed M/XDR TB 2010 2011 # started on treatment M/XDR TB 2012

Addressing 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-4 • • • •

Human resources

Quantity   Quality  Inadequate care to patients  Nurses, doctors, counsellors, social workers, laboratory staff, audiologists/ assistants Heavy workload with neglect of MDR TB 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-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 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

Conclusion • 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

Acknowledgements

• • • 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- XDR TB 2007-2012

1600 1400 1200 1000 800

# Diagnosed # started on treatment

600 400 200 0 2008 2009 2010 2011 2012