South Africa

Health-e News: If we’re going to beat TB, SA needs to wake up first

By Health-e News 20 November 2017

Seven countries including South Africa are responsible for the majority of the world’s tuberculosis (TB) burden. HEALTH-E’s Amy Green speaks to experts to find out what it will take to end TB by 2035 – the target of the World Health Assembly.

Almost two thirds of global TB cases occur in India, Indonesia, China, the Philippines, Pakistan, Nigeria and South Africa, noted the World Health Organisation’s (WHO’s) annual report. TB remains the leading infectious disease killer worldwide, and is the single biggest killer of South Africans.

Tackling TB in South Africa has become a global concern, particularly in the light of our big HIV epidemic, which predisposes people to TB, and increasing rates of drug-resistant TB (DR-TB).

South Africans are at especially high risk of developing TB because most of us are already infected with the latent TB bacteria. Healthy immune systems can contain the TB bacteria, but immune-compromised individuals – such as those with HIV, diabetes or cancer – are at a higher risk.

The ambitious targets, endorsed by the World Health Organisation (WHO) and all member countries, aim to see TB deaths cut by 95%, a 90% drop in new cases and to “ensure that no family is burdened with catastrophic expenses due to TB”.

But Dr Amir Shroufi, Deputy Medical Coordinator for Doctors Without Borders (MSF) in South Africa, says that for “South Africa and the world to reach these targets, something would seriously have to change”.

At present, although all TB treatment is free, poor families have to shoulder high transport costs for frequent trips to health facilities. Very sick TB patients often lose their jobs while being treated in hospitals.

But Dr Norbert Njeka, head of DR-TB at the Department of Health, says that scaling up access to one new drug in particular, bedaquiline, has “saved lives”. The drug, developed by Janssen Pharmaceuticals, is the first new anti-TB drug on the market in over 50 years and has shown the most promise for treating DR-TB patients.

Existing treatment for these patients can take over two years to complete, contains a cocktail of toxic drugs and can lead to debilitating side-effects such as deafness – and even then, have a less than 50% chance of cure.

[Since starting so many patients on bedaquiline] we’ve seen a huge drop in death rates – by about 50 to 60%,” Njeka said.

About two thirds of patients in the world taking bedaquiline are in South Africa. About 7,000 of the approximately 11,000 DR-TB cases started on treatment in the country are now treated with the drug.

Patients are given access to bedaquiline as soon as they show any signs of side-effects from the conventional treatment – particularly hearing loss. But few health facilities have the equipment to test for the early stages of hearing loss.

While access to bedaquiline is higher here than anywhere else, Shroufi said it would be beneficial to expand the criteria to enable further access and significantly increase access to the only other new anti-TB drug on the market, delamanid.

But results on the drug’s efficacy, presented at the recent Union Conference in Mexico, left some disappointed. Just over 83% of patients on delamanid responded to treatment within six months in comparison to 78% of patients on conventional treatment, according to research by Japanese pharmaceutical company Otsuka.

This prompted the WHO to announce that it will conduct a review of its recommendations regarding the use of the drug, the results of which it said can be expected in early 2018.

Delamanid is still regarded as a much-needed addition for TB clinicians who lack options when treating drug-resistant patients. Delamanid is being used to treat DR-TB largely in special research-based programmes but, according to MSF, only slightly more than 600 patients have received the drug worldwide to date.

But there is general agreement that two new drugs are not enough. According to the National Institute for Communicable Disease, resistance to bedaquiline is already thought to have been detected in at least two South African patients.

At the Union Conference, Dr Fareed Abdullah, Director for Aids and TB Research at the Medical Research Council, met with other stakeholders about new drug candidate, sutezolid. The TB Alliance announced last month that they would be moving forward to test the drug in humans.

Abdullah told Health-e News that although the promise of a new drug is “very exciting”, “it won’t be a magic bullet that will solve our TB problem”.

He said new diagnostic tests were urgently needed as many patients were being missed with current tests, especially children and people living with HIV – two of the most vulnerable populations at high risk of developing TB.

Everyone agrees we miss between 100,000 and 150,000 cases a year in South Africa,” said Abdullah. “Globally, we miss four million.”

While there are policies in place to promote “active case finding”, where known TB patients’ household members and other contacts are screened for TB, this is not done routinely and widely enough to catch the missing, according to Adbdullah.

He said South Africa had missed many prevention opportunities, particularly for children. For example, medication is available to prevent TB infection from developing into active illness and this can be taken for between 12 months and three years. Although all children under the age of five who have been exposed to anyone with TB qualify for this treatment in South Africa, regardless if they test positive or not, few actually get it.

But the “big hope” is still for a new TB vaccine: “For the past five or six years, TB vaccine research has been in the doldrums, but I think Mexico was a turning point – we learnt there are 17 new possible vaccine candidates being looked at,” Abdullah said.

While he said it’s possible to reach the world’s goal to end TB by 2035, “we require new tools and investments to do it”.

As Shroufi succinctly put it: to end TB, “a lot more needs to happen and we all need to work a lot harder”. DM

Photo: Hlengewi Mthembu massages the hands of her husband Nkosinathi at their home in Esikhawini township, near Empangani, in South Africa’s Kwa-Zulu Natal province October 13, 2005. REUTERS/Mike Hutchings

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