Tuberculosis (TB) treatment gains worldwide are threatened in SA by the increasing trend in drug resistant-TB, says the National Institute for Communicable Diseases (NICD).
Tuberculosis (TB) is the number one cause of death amongst infectious diseases in South Africa and the gains worldwide in controlling TB are threatened by the increase in DR-TB, notably multidrug-resistant (MDR) and extensively drug-resistant (XDR) TB.
Speaking ahead of World TB Day on 24 March 2018, Dr JM Thandi Dlamini-Miti, DR-TB technical advisor at Right to Care says, “We are seeing a growing number of patients who have never been treated for drug-susceptible-TB presenting with drug-resistant TB. This means they are infected by drug-resistant TB.”
“DR-TB requires a patient to take more drugs and for longer periods, from 9 to 24 months, which places a serious burden on patients, families and the state. Side-effects are more common and severe.”
This year’s theme for World TB Day is “Unite to End TB”. Says Dlamini-Miti: “We endorse this theme because a multi-sectoral and multi-disciplinary approach is required to deal with TB.”
Right to care is working with the Department of Health to increase the early diagnosis of TB, detect resistance, address treatment barriers, improve patient adherence and enhance infection control. “This involves simple actions like sneezing or coughing into the elbow or a tissue and ensuring windows are open – at home, on public transport and in health facilities,” she says.
Early diagnosis and treatment of DR-TB is vital to preventing its spread.
“The National Department of Health’s decentralisation policy to expand MDR-TB treatment from specialised DR-TB hospitals to regional and district hospitals and primary healthcare facilities has been an important intervention. It allows treatment to start sooner, improves adherence and supports patients closer to their homes. USAID funds our activities in certain districts where we support the decentralisation programme,” says Dlamini-Miti.
There are ongoing advances in TB treatment. Says Dlamini-Miti, “The roll out in South Afroca of the DR-TB drug bedaquiline, which was the first new TB drug in nearly 50 years, is being followed by a newer drug, delamanid. We are supporting the National TB Programme with Medicines Control Council (MCC) registration of sites and clinicians, training, data management, drug distribution and monitoring.” Delamanid has been donated to South Africa by the Japanese drug maker Otsuka Pharmaceuticals.
Adherence is a critical factor because poor adherence can lead to further drug resistance and even death. Some MDR-TB regimens require a patient to take 17 pills a day and patients may experience side-effects which include hearing problems. “Monitoring by a multi-disciplinary team is therefore vital. Social workers, dieticians, audiologists, counsellors, pharmacists, nurses and doctors should all be involved in a patient’s progress,” says Dlamini-Miti.
“In South Africa, TB also contributes to approximately 25% of HIV related deaths. It is estimated that around 70% of new adult cases of tuberculosis are co-infected with HIV. The risk of TB in people living with HIV can be significantly reduced by anti-retroviral therapy and isoniazid preventive therapy, but adherence remains the key challenge” she says.
South Africa has the sixth highest tuberculosis prevalence in the world, and in trying to find ways to overcome this statistic, Deputy President David Mabuza, Health Minister Aaron Motsoaledi, KwaZulu-Natal premier Willies Mchunu and KwaZulu-Natal MEC for health Dr Sbongiseni Dhlomo, have engaged with traditional leaders, who the Department of Health sees as influencers. According to a City Press report, Dhlomo expressed the need to unite towards one achievable goal which is to see the end of TB and HIV.
“Leaders (traditional leaders) are big influencers, when they call upon the nation to act, the nation rises in response. These leaders are expected to unite to end TB and HIV by taking action … This year’s theme is meant to put leadership at all levels in the forefront of influencing decision making at all levels to promote prevention, screening and treatment for TB,” said Dhlomo.
New evidence by the South African Aids council has also shown a link between TB and diabetes.
“The sooner you get to the clinic the better, in order to get properly cured and curb the spread,” added Dhlomo.
The KwaZulu-Natal Health MEC also stressed the importance of those diagnosed with the disease to finish their six-month treatment course. “If one does not finish the course, the disease will come back in your system and in most cases it comes back even worse,” he explained.
Inkosi Phathisizwe Chiliza, chair of the KwaZulu-Natal house of traditional leaders, pledged that as traditional leaders they would commit themselves in the fight to stop TB and HIV.
Every minute, three people die of tuberculosis, even though the scourge is treatable and curable. And usually on World TB Day, the global health community rallies around that point. Then another year goes by. But, says a Huffington Post report, this year, advocates agree, the energy is different. “I’ve been at this a long time and seen issues like HIV be a focal point and a rallying point, and there’s a point where an issue reaches a critical mass,” Dr Eric Goosby, the UN special envoy on tuberculosis who previously served as the US Global Aids coordinator, said. “I think we’re at that moment.”
David Bryden, a TB advocate for the non-profit Results, also stressed the importance of the groundswell in attention and the resulting political will surrounding TB, the report says. “The shift is real. This is real momentum that we’re seeing.”
The report says top world leaders have begun to rally around the fight to end TB in the past year, kicked off in November by Russian President Vladimir Putin. Russia faces some of the highest rates of multidrug-resistant TB – a deadlier form of the disease. Putin spoke of the need to address TB not only at home but also globally, saying, “I am convinced that only together by closing the ranks will we be able to counter the threat which has acquired truly global character.”
Then in March, the report says, Indian Prime Minister Narendra Modi announced the country’s plan to eradicate tuberculosis by 2025 – a bold move that global health experts hailed as a game-changer in the fight against the disease that is one of the top five causes of death.
Putin and Modi’s commitments will hopefully spur other world leaders to do the same, Dr Tedros Adhanom Ghebreyesus, director general of the World Health Organisation (WHO), said. “We hope this produces a snowball effect and that other world leaders step up and commit to an ambitious plan of action to rapidly drive down TB deaths and suffering.”
All of this is part of the build-up to 26 September, the first UN high-level meeting on tuberculosis, which global health experts consider to be the pivotal moment the movement has been working toward.
The report says only four other such meetings have been held: one for HIV/Aids in 2001, one for non-communicable diseases in 2011, one for Ebola in 2014 and one for antimicrobial resistance in 2015. “We have no more time anymore to wait,” Dr Tereza Kasaeva, the new director of the WHO’s Global TB Programme, said in the report. ”If we do not succeed in this period, we will have failed.”
And the language itself around the fight against TB has begun to shift, according to Irene Koek, the senior deputy assistant administrator in the US Agency for International Development’s Global Health Bureau, who has worked on TB for decades. She pointed to USAID head Mark Green’s repeated public insistence that this is “a fight we can win.”
USAID also received an added $20m to fight TB globally in the federal omnibus signed last week by President Donald Trump. The spending package also includes language from Congress asking the Department of Health and Human Services to prioritise the 2016 national action plan for combating multidrug-resistant TB.
Goosby also highlighted the change in attitude toward the fight against TB, saying it was pivotal in attracting top political leaders to the fight. “It’s an opportunity for political leadership to see this as their personal legacy in each country, as ending TB is doable,” Goosby said. “We are within the point where you can see progress in two to three years, which is well within a politician’s tenure.”
And those kinds of promises from world leaders lead to a trail of accountability that leads to progress, according to Goosby – a sentiment that Kaseava echoed. “The idea is that we should not only be active on World TB Day,” Kasaeva said. “A day should become a week, a week should become month, a month should become a year.”
The WHO has called on African countries to work towards eliminating TB in the region by increasing funding to the sector. WHO regional director for Africa, Dr Matshidiso Moeti, is quoted in a New Telegraph report as saying in Abuja, Nigeria, that despite concerted efforts, the African region is still accountable for the world’s highest levels of TB infections and deaths. He said this is due to the culture of poor funding by African governments and poor attitude towards taking responsibility for essential TB treatment in the areas of medicines and laboratory supplies.
Moeti said: “On 24 March every year, the global community rallies together on World TB Day to focus on how best to defeat TB, an old disease that can be prevented and treated, but continues to afflict and kill many people. Although the African region has made good progress in controlling TB, we still have the world’s highest levels of the disease, and only half of existing TB cases are being detected by our health systems.
“We have the most patients infected with both HIV and TB and are seeing alarming increases in the forms of TB that resist treatment with common medicines. Finally, governments are contributing only a quarter of the resources needed to provide adequate TB services, and 40% of needs remain unfunded. I strongly urge governments to scale up domestic funding for TB control and take responsibility for essential medicines and laboratory supplies. Furthermore, governments should push for universal coverage with proven high-quality services.”
The report says while pledging commitment of the WHO and AU Commission towards ending the TB epidemic by 2030 in line with the Sustainable Development Goals and End TB Strategy, he said that there was need for concerted efforts by African governments, community and opinion leaders, health workers and organisations to create more awareness on issues around TB to enable improved access to its treatment at all levels.
“A TB-free world will only be achieved through leaders who champion efforts to end TB at local level. At the first Ministerial Conference on Ending TB in Moscow in November 2017, 75 ministers from the African region committed to end TB. Member states of the AU finalised a Common African Position on TB (CAP-TB) on the side-lines of that historic conference. Leaders have tremendous influence to build strong partnerships and commitment to end the TB epidemic at every level. I therefore call on governments, parliamentarians and policy-makers to drive ambitious plans that will accelerate TB control at national level.”
Nursing union Hospersa has, meanwhile, criticised the South African government for the little focus given to the high prevalance of TB cases amongst health care workers. Polity reports that the union has previously written to various government departments demanding action in addressing the alarming occupation health and safety (OHS) contraventions that are endangering health care workers lives and putting them at risk in contracting TB at work. The union has now vowed to seek legal advice to force government to address the dismal working conditions subjected to their members where TB infections are rising at a frightening rate.
The report says that is alarming for South Africa is that the country has the second-highest TB incidence amongst healthcare workers in the world. It is estimated that healthcare workers are at a four to eight times’ higher risk of contracting TB than the general public. The WHO statistics revealed that South Africa accounted for 21% of the reported incidents and there are still fears that the situation could be worse as many cases do not get reported. Hospersa is calling for a robust approach towards addressing this alarming rate in health workers.
“We are concerned by the lack of intervention from the National Department of Health (NDoH) in addressing TB amongst health workers,” says spokesperson, Fazeela Fayers. “South African healthcare workers are neglected when it comes to prevention of TB exposure at work. They are also the forgotten heroes in the fight for a TB-free world whereby those that do contract it at work are battling to claim workplace compensation,” said Fayers.
The report says last year, the National Strategic Plan (NSP) 2017-2022 on HIV, TB and Sexually Transmitted Infections (STI’s) was unveiled by the South African National Aids Council (SANAC). The NSP 2017-2022 serves as a road-map for a future where these three diseases are no longer public health problems.
The five-year plan sets out eight interrelated goals of which the third goal highlights the need to reach all key and vulnerable populations with customised and targeted interventions. This goal also highlights the need for collaboration across sectors to enable the many thousands of organisations and individuals who drive the response to HIV, TB and STIs to act as a concerted force, moving in the same direction.
“However, the lack of attention given to the high prevalence of TB amongst health workers makes this goal a moving target,” argued Fayers. “The healthcare profession is losing qualified professionals at an alarming rate, as many healthcare workers fear the high occupational risks, and those who contract TB, contract Multi Drug-Resistant TB (MDR-TB), and TB outside of the lungs which is currently not compensated” said Fayers.
“One such incident where occupational TB has had devastating results is on a health worker employed at Potchesfstroom Hospital, North West Province,” said Fayers. “The Hospersa member contracted TB of the spine in 2013. MRI results showed that she had collapsed vertebrae five (5), six (6) and seven (7) as a result of the TB,” added Fayers.
“During our visit at Potchesfstroom Hospital late last year, we discovered gross contraventions of occupational health and safety,” said Fayers. “Our members at the hospital confirmed that there are no routine screenings for staff members while some disclosed that the last screening took place in 2003. We also noted that patients admitted in the general wards are not screened for TB as and when they get admitted which leads to staff members coming into contact with TB patients without being aware until it is too late.
The ultraviolet irradiation machines installed at the TB ward for controlling the transmission of TB are also poorly maintained while specialised TB masks are not provided to staff members but are only provided to patients with MDR-TB and extensively drug resistant (XDR)-TB. However, these patients are often seen walking around the wards without wearing their masks,” added Fayers.
“On 3 October 2017, Hospersa met with the director-general for the National Department of Health and addressed some of these concerns,” mentioned Fayers. “The DG acknowledged the department’s lack of an OHS policy and committed to a swift response to our call for an emergency task team to address these issues. However, the DG is yet to act on this commitment,” said Fayers.
“We have also issued a memorandum of demand to the Ministry of Labour to enforce OHS compliance at the DoH after the embattled Health Department was issued with a section 7 notice in 2016 over the many OHS contraventions in public health facilities. Furthermore, we have written numerous letters to the Minister of Health on without receiving any responses to our correspondence. We will now look at the legal options available to us to force government to address our members’ concerns,” added Fayers.
“It is unacceptable for the DoH to turn a blind eye to our members’ genuine concerns. We are losing the fight against TB due to the high incident rate amongst health care workers. Government needs to act swiftly in addressing the escalating occupational TB rate if we are to have a fighting chance against the disease,” concluded Fayers.
And concerns have been raised by City of Johannesburg’s mayoral committee member for health and social development, Dr Mpho Phalatse, about the high default rate of patients who are on the TB treatment programme, reports News24.
Phalatse said of the 14,648 TB cases tracked by the City’s health department in 2016, 12,797 were initiated on treatment. “Of the 12,797, only 9,669 completed treatment, 852 defaulted from treatment, 3,128 were cured, with 740 deaths,” she said.
“I’m concerned about the high default rate in some areas in the City. Though our community health workers are available to track defaulters and provide treatment support, their efforts are often hampered by the provision of wrong addresses when patients open files at the clinic.”
“We believe this is because of a fear of being turned away if they (patients) do not reside within the clinic’s geographic catchment area,” Phalatse is quoted in the report as saying.
She said her department had made it clear, however, that patients were welcome to attend any clinic of their choice and that they should report any incidents of staff refusing to assist them.