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
The face of MDR-TB
© Rowan Sybus
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
14161
14000
12000
10000
8198
8000
10085
9070
7386
6000
4000
2000
0
2008
1800
1600
1400
1200
1000
800
600
400
200
0
2009
2010
# diagnosed with XDR-TB
2011
1574
2012
1545
741
488
2008
594
2009
2010
2011
2012
Number of laboratory diagnosed cases MDR &
XDR-TB 2008-2012
18000
16000
15706
Number of cases
14000
12000
11659
10000
8000
9664
8686
8127
6000
4000
2000
0
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
Addressing MDR-TB:-Challenges-2
Low levels of treatment initiation
18000
16000
15706
14000
12000
11659
10000
8000
Treatment
initiation gap
9664
8686
8127
7195
6000
4000
5928
4422
6252
4574
2000
0
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
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-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
Number of cases
1200
1000
# Diagnosed
800
# started on treatment
600
400
200
0
2008
2009
2010
2011
2012