Drug resistant TB South Africa

Diagnosis of drug resistant TB

In 2015 19,613 individuals were reported to have been diagnosed with the rifampicin resistance (RR-TB) form of drug resistant TB.

Although this appeared to be a significant increase over previous years, this may have been at least partially as a result of improved diagnosis. In 2011 the Xpert MTB/RIF diagnostic test was progressively rolled out nationally in South Africa. This meant that everyone being investigated for TB was automatically tested for rifampicin resistance.

Before 2011 only patients who reported previous treatment or those considered at high risk of DR-TB (such as individuals with close contact to known MDR-TB patients or healthcare workers) were tested for resistance. There is more about the history of drug resistant TB in South Africa.

 

Treatment of drug resistant TB

South Africa provides second-line TB treatment for the third largest number of RR-TB globally. But a significant gap remains between the number of cases reported and those started on second line treatment. Delays in starting treatment are also common.

In 2015 12,527 patients were reported to have started on second line treatment for RR-TB. But this was only 64% of the number reported to have been diagnosed.

2011 2012 2013 2014 2015
Diagnosed (notified) 10,085 14,181 14,581 18,734 19,613
Started on treatment 5,643 6,494 10,663 11,538 12,527

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Factors such as high early mortality, particularly among HIV positive patients, difficulties in accessing laboratory results, lack of access to second line treatment provision in primary care, under reporting, and late updating of records may all have contributed to this gap.

Overall treatment is successful for approximately half the patients starting treatment. This is similar to the global treatment success rate.

Bedaquiline for the treatment of drug resistant TB

Bedaquiline, for the treatment of drug resistant TB

Bedaquiline, for the treatment of drug resistant TB

The South African government has arranged with Janssen, the manufacturer of Bedaquiline, that Bedaquiline is to be made available in South Africa at a lower price of US$400.1“South Africa announces lower price for TB drug bedaquiline”, 2018, The Union, https://www.theunion.org/news-centre/news/south-africa-announces-lower-price-for-tb-drug-bedaquiline

There is more about Bedaquiline.

Drug resistance survey 2012 - 2014

The second national survey of TB drug resistance was conducted in 2012-2014. Overall 4.6% of more than 10,000 pulmonary TB patients were found to have RR-TB, resulting in an estimated RR-TB burden of 20,000 per year. However national estimates of the incidence and prevalence of RR-TB mask significant difference across provinces.2South African Tuberculosis Drug Resistance Survey 2012-14, 2016, National Health Laboratory Service, National Institute for Communicable Diseases

Percentage of TB cases found to have RMR-TB, RR-TB or MDR-TB across provinces in South Africa in the 2012-2014 national survey

EC FS GP KZN LP MP NC NW WC
RMR 1.1 2.2 1.3 1.9 2.2 3.0 2.2 1.3 1.2
MDR-TB 2.2 2.4 3.5 3.0 1.7 5.4 2.7 1.7 3.0
RR-TB 3.3 4.6 4.8 4.9 3.9 8.4 4.9 3.0 4.2

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Key: KZN - KwaZulu-Natal, MP - Mpumalanga, FS - Free State, NW - North West, GP - Gauteng, EC - Eastern Cape, LP - Limpopo, NC - Northern Cape, WC - Western Cape

Definitions for drug resistant TB

  • DR-TB Drug resistant TB (resistance to any TB drug)
  • RMR-TB Rifampicin mono-resistant TB (resistance to rifampicin but not resistant to isoniazid)
  • MDR-TB Multi-drug resistant TB (TB resistant to isoniazid and rifampicin)
  • RR-TB Rifampicin resistant TB (TB resistant to rifampicin regardless of resistance to other drugs)
  • Pre XDR-TB MDR-TB with resistance to either a fluoroquinolone or a second-line injectable drug.
  • XDR-TB Extensively drug resistant TB (MDR TB with resistance to both a fluoroquinolone and a second line injectable drug)

Decentralisation and deinstitutionalisation of drug-resistant TB care

A policy change concerning the treatment and care of people with drug resistant TB, had taken place at national level in 2011. This meant that although some people would still be admitted to hospital many more would be treated in the community.

But by 2013 56% of all RR-TB patients were still admitted to a tertiary-level or specialist TB hospital to start treatment, and only 19% were started on treatment in primary care. By November 2015 all provinces were reported to have decentrialised sites. Although many districts and several hospitals still required mandatory hospital admission in order for patients to start second line treatment.

Ongoing transmission of XDR TB

Cases of XDR-TB have increased significantly since 2002. Many of those people diagnosed with XDR-TB are also co-infected with HIV.

It is believed that the majority of the cases have occurred as a result of transmission of XDR TB, rather than inadequate treatment of MDR TB. As a result it is considered that the control of the epidemic of drug resistant TB will require an increased focus on interrupting transmission.3Shah, N S, Transmission of Extensively Drug-Resistant Tuberculosis in South Africa", 2017, https://www.nejm.org/doi/10.1056/NEJMoa1604544?url_ver=Z39.88-2003&rfr_id=ori%3Arid%3Acrossref.org&rfr_dat=cr_pub%3Dwww.ncbi.nlm.nih.gov

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