In 1996 the National Department of Health declared Tuberculosis (TB) to be an emergency and implemented the Directly Observed Treatment Short-course strategy as the primary control measure. At that time the number of TB cases diagnosed annually was 110,000. Eighteen years later the number of cases diagnosed has risen to between 400,000 and 600,000, placing South Africa as one the countries with the highest burdens of TB.
TB remains the principal cause of human death in South Africa, together with HIV, these convergent diseases represent a clear and present danger to the future health of all South African! says Professor Bavesh Kana, Chair of the 4thSA TB Conference.
These statistics paint a picture of a TB control programme that is in crisis. The severity of this crisis is further emphasised by the emergence of drug resistant TB. The World Health Organization (WHO) reports that 15,400 cases of Multi Drug Resistant (MDR) TB (resistant to at least two of the best anti-TB drugs: isoniazid and rifampicin) are diagnosed annually in South Africa. This is probably a gross underestimate as the recent implementation of the GeneXpert diagnostic assay shows that approximately 7% of all cases presenting for investigation (translating to 22,000 cases per year) are resistant to rifampicin (an indicator for MDR-TB), and furthermore a substantial burden of MDR-TB remains undiagnosed in the community. Alarmingly, <50% of these MDR cases are treated, yet the cost thereof is crippling the TB control budget by consuming nearly 45% of the total funds available.
Despite this enormous investment, treatment outcomes for MDR-TB are poor with less that 50% of cases being cured. This implies that having MDR TB may be fatal; a form of the disease that anyone can contract.
Traditionally the patient was blamed for having MDR TB because it was thought that resistance was acquired mainly through non-compliance with treatment, rather than being transmitted. However, recent molecular epidemiological information shows that most of these MDR-TB is actively transmitted and anyone who is in contact with an infectious MDR-TB case could become infected and subsequently develop disease. This is exemplified by a recent study of healthcare workers who were shown to be at a significantly higher risk of contracting MDR-TB than the general public.
In South Africa treatment of MDR-TB has been standardized since 2002, implying that most individuals are treated with the same drugs. Although this strategy simplifies treatment of large numbers of people, it poses the risk of amplifying resistance, which will occur if individuals with drug resistant TB are treated with drugs that the bacteria they retain are resistant to. Where undiagnosed resistance exists, a standard regimen may inadvertently contain less than the recommended five effective drugs. This will result in the formation of additional drug resistance thus weakening the treatment even further. In fact, careful analysis of the MDR-TB epidemic has shown that the implementation of standardized MDR treatment indeed resulted in the selection of Extensively Drug Resistant (XDR)-TB (MDR with resistance to a fluoroquinolone as well as one of the injectable drugs). This warns of the consequence of treating MDR-TB without prior knowledge of the resistance profileâ€“ a concept that has been known for 60 years.
By ignoring these warnings we have created untreatable forms of TB. For XDR-TB, mortality is 40% in the first year alone and 70% after 5 years.
These dismal treatment outcomes are a warning of the severity of the drug resistant TB epidemic. Alarmingly, many of those who survive beyond the duration of treatment are discharged back into their communities after treatment failure (still infectious) posing a serious health hazard to community contacts. Our only hope for curbing the emerging untreatable epidemic is the development of new treatment regimens in conjunction with rapid and accurate testing for drug-resistance.
Numerous new drugs are in the pipeline but translation into new regimens may take years. In the interim the National Department of Health has taken the bold step to improve case detection and to rapidly identify rifampicin resistance by implementing the GeneXpert MTB/RIF diagnostic. However, this is not enough, more resistant cases are now being diagnosed than ever before and are being initiated onto MDR treatment without complete knowledge of their resistance profiles potentially fuelling the emergence of resistance.
Drug resistance and the associated consequences will feature prominently at the 4th SA TB Conference, to be held at the ICC in Durban. The consequences and management of drug resistance will be the subject of plenary presentations and oral slots, dedicated specifically for this purpose. Moreover, there will be several round tables and symposia on the diagnosis, management and transmission of drug resistance.
These are as follows:
- TB Drug Resistance, chaired by Professor Keertan Dheda on Thursday, 12 June from 16h00 to 17h30
- New Drugs in TB, chaired by Dr Francesca Conradie on Thursday, 12 June from 16h00 to 17h30, speakers in this session include Prof Graeme Meintjies, Dr Jennifer Hughes and Dr Sweetness Siwendu.
Come and join the dialogue, everyone working in all spheres of TB-HIV drug discovery, clinical management, patient advocacy and government policy as well as the basic sciences are encourage the 4th SA TB Conference which takes place in Durban from 10-13 June 2014.
To register and view the Conference programme please visit the website.
Prof Keertan Dheda
Track Chair: Detection and Prevention of TB
Professor of Respiratory Medicine, Director of the Lung Infection and Immunity Unit and Head of the Division of Pulmonology at UCT.
Prof Rob Warren
Track Co-chair: Detection and Prevention of TB
Associate Professor in the Department of Medical Biochemistry at Stellenbosch University
Notes to Editors:
About The Foundation for Professional Development (FPD)
The Foundation for Professional Development (FPD) is a South African Private Institution of Higher Education dedicated to building a better society through education and capacity development. FPD annually provides management and clinical training to 50 000 healthcare professionals and managers across Africa and has support the initiation on ART of more than 390 000 PLHIV. FPD also organises national and international conferences as a conduit to shape public and policy perspectives. FPDâ€™s involvement in conferences dates back to the International AIDS Conference in Durban in 2000 where it provided the conference secretariat. For more information please visit www.foundation.co.za.
For more information about the 4th TB Conference please contact:
TB Conference Local Secretariat
Mobile : 083 235 4033
TB Conference Local Secretariat
Mobile : 084 957 5527
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