The Emergence of Drug Resistant TB
Drug resistant TB (that is TB which is resistant to at least one anti tuberculosis drug) had emerged in South Africa by the 1980s, but was not thought to be a major problem.1Schaaf H, “The 5 year outcome of multi drug resistant tuberculosis patients in the Cape Province of South Africa”, Trop Med Int Health, 1996 www.ncbi.nlm.nih.gov/pubmed/8911459 2Weyer K, “Tuberculosis drug resistance in the Western Cape”, S Afr Med J 1995
www.ncbi.nlm.nih.gov/pubmed/7652628 XDR TB (using the 2006 revised definition) was prevalent in the Western Cape province of South Africa as early as 1992.3Symons, G, “A historical review of XDR tuberculosis in the Western Cape province of South Africa”, S Afr Med J 2011 www.ncbi.nlm.nih.gov/pubmed/21920174
TBFacts.org has more about the different types of drug resistant TB.
Drug Resistant TB Management Programme
The South African National Department of Health implemented its first drug resistant TB management programme in early 2000. The guidelines required that all the drug resistant TB patients should be hospitalised for at least the first six months of their TB treatment.
The South African TB drug resistance survey 2001 - 2002
The first definite figures of drug resistant TB came from a national survey carried out in 2001-2002 which showed that although the absolute numbers were small, in most of the provinces there were some TB patients who were already resistant to the four main TB drugs, isoniazid (INH), Rifampicin (RMP), Ethambutol (EMB) and Streptomycin (SM).
In the worst affected province, the Eastern Cape, more than 10% of strains had resistance to at least 1 drug.4"Anti-tuberculosis drug resistance in the world report no. 3 2004”, WHO, Geneva, 2004
TB drug resistance by South African province 2001-2002 New Treatment Patients
|South African province||Total number of strains tested||No. susceptible to all four drugs||No. resistant to 1 drug||No. resistant to 2 drugs||No. resistant to 3 drugs||No. resistant to 4 drugs||Treatment success (%)||Estimated HIV positive TB cases (%)|
If there is a "plus sign" please click on it for more columns
XDR TB at Tugela Ferry
In 2005 South African and US clinicians and researchers identified a large number of cases of an almost untreatable type of TB at the Church of Scotland hospital in Tugela Ferry, a rural and extremely poor part of KwaZulu-Natal. The XDR TB, as it was called, occurred among HIV infected individuals and it was resistant to almost all the anti TB drugs available in South Africa.5“Tugela Ferry, KwaZulu Natal, South Africa” ysmwebsites.trafficmanager.net/intmed/global/sites/southafrica.aspxThere is more about XDR TB at Tugela Ferry.
Locking up people with drug resistant TB
Many problems had resulted from the compulsory hospitalisation of drug resistant TB patients for six months. The TB patients were forced to give up almost all their work and home responsibilities.6“Multi Drug Resistant Tuberculosis, A policy framework on decentralised and deinstitutionalised management for South Africa” https://www.tbfacts.org/wp-content/uploads/2018/06/S-Africa-Prisons.pdf In 2008 there were a number of breakouts by TB patients who were desperate to be able to go home. The TB patients had to stay as in-patients until they were no longer infectious and patients with XDR TB were being required to spend up to two years in hospital with the very real possibility that they would die before they were released.7“Prison-like hospitals for drug-resistant TB patients” IRIN March 2008 https://www.tbfacts.org/wp-content/uploads/2018/06/S-Africa-Prisons.pdf
“We’re being held here like prisoners, but we didn’t commit a crime. I’ve seen people die and die and die. The only discharge you get from this place is to the mortuary”8“TB patients Chafe under Lockdown in South Africa” New York Times March 2008 www.nytimes.com/2008/03/25/world/africa/25safrica.html?pagewanted=all&_r=0Siyasanga Lukas, a patient at Jose Pearson TB hospital
Drug resistant TB statistics
|2007 MDR TB||2007 XDR TB||2008 MDR TB||2008 XDR TB||2009 MDR TB||2009 XDR TB||2010 MDR TB||2010 XDR TB|
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A review of the TB program
A clinical audit of drug resistant TB services, together with a WHO led review of the TB programme, revealed that the current programme was facing many challenges which included:
- delayed initiation of treatment
- inadequate bed capacity
- poor infection control in hospitals
- and poor adherence to treatment.
As some patients were hospitalised for a considerable period of time, long waiting lists developed for patients needing to be admitted to the centralised units. A number of patients died before starting treatment. In addition delays in starting treatment meant that more family and community members were exposed to infectious and untreated patients.
Decentralising and deinstituionalising drug resistant TB services
In 2011 the South African National Department of Health responded to these criticisms by suggesting that the length of time that MDR TB patients were required to stay in centralised hospitals was reduced and also that services were decentralised and deinstitutionalised.9“Multi Drug Resistant Tuberculosis, A policy framework on decentralised and deinstitutionalised management for South Africa” https://www.tbfacts.org/wp-content/uploads/2018/06/SA-MDR-TB-Policy.pdf
What is meant by the decentralisation of services?
Decentralised management of drug resistant TB, refers to the transfer of responsibility for treating MDR TB patients, to a lower level of the health system on condition that they meet certain criteria. It includes the management of drug resistant TB patients in decentralised drug resistant TB units, satellite multi drug resistant TB units, or in the community using mobile teams and community caregivers and households.
Which patients would still be admitted to hospital?
- Patients with MDR TB who have tested smear negative and who were TB culture positive, would no longer need to be admitted.
- Patients with MDR TB without extensive disease, and who have tested smear positive should be admitted until they have two negative smear microscopy results.
- Very sick patients with MDR TB and with extensive disease and XDR TB patients, should be admitted until they have two consecutive TB culture negative results.
It was estimated at the time that this would mean that about 30% of patients would no longer need to be admitted. However, this still leaves 60% of patients being hospitalized. It has been said that:
"People lose so much during the treatment phase. They lose an income, they lose relatives, and sometimes spouses. Taking treatment closer to home is the best option.
Dr Maurice Goodman10Makhubu, Ntando, “SA buckling under strain of deadly TB”,
Drug Resistant TB in South Africa after 2011
After 2011 the number of MDR and XDR cases continued to increase with 15,419 and 1,596 patients respectively diagnosed in 2012.11Churchyard, G., Mametja, L. “Tuberculosis control in South Africa: Successes, challenges and recommendations”, South African Medical Journal, 104(3), 244-248. doi:10.7196/samj.7689 The treatment success rate for adult MDR and XDR TB remained low at 42% and 18% respectively for those diagnosed in 2010.
In 2013 there were 10,691 people on treatment for MDR TB, and in 2014 there were 11,500 on treatment.12Makhubu, Ntando, “SA buckling under strain of deadly TB”, www.iol.co.za/lifestyle/
The MDR TB programme has continued to face many challenges including a high initial loss to follow up of patients; inadequate bed capacity; poor infection control and limited availability of appropriate second-line drugs.
What is the Cost of Diagnosis and Treatment of Drug Resistant TB
Assuming adherence to national drug resistant TB management guidelines, the per patient cost of XDR TB in South Africa has been estimated to be $26,392, four times greater than MDR TB ($6,772) and 103 times greater than drug sensitive TB ($257). Despite drug resistant TB comprising only 2.2% of the case burden, it is estimated to have consumed approximately 32% of the total estimated 2011 national TB budget of US$218. But it is still said to be underfunded.
"It is grossly underfunded. Not enough money is put into research, innovation, implementation. The fight against TB is struggling."
Dr Sanni Babutunde, WHO head of TB programme
It was also said that:
"We are not doing well with TB; we are failing. As much effort as had been put into fighting HIV was needed to combat TB. With HIV, we know how transmission occurs, we understand how it spreads but we have no idea what happens with TB, which has been around for much longer.
Dr Sanni Babutunde, WHO head of TB programm