Business outside the box to combat MDR-TB

Catherine Mwauyakufa, CNS Correspondent, Zimbabwe
The approach of business as usual has to end, as tackling MDR-TB is an emergency that calls for unusual approaches if we are to meet the target of  ending TB by 2030, as envisaged in one of the sustainable development goals (SDGs). The world has to combat multi drug resistant TB (MDR-TB) on a war footing to make the dream of ending TB by 2030 a reality.

Some points to ponder

Firstly how does drug resistance build-up? Most of it comes from inadequate and incomplete treatment regimens, and poor quality or counterfeit medicines. Proper storage under optimal conditions also plays a role as drugs stored incorrectly can degenerate even before expiry date and giving these drugs to patients would be futile. Secondly, health personnel ought to be adequately trained to handle TB cases. They in turn have to educate the patient on the need to complete treatment. TB cannot be treated like a headache where one stops taking pain killers when feeling better. If a doctor prescribes treatment for 6 months or even a year then that has to be completed even if one starts feeling okay after 3 months. MDR-TB does not respond to isoniazid and rifampicin which are two key TB drugs used in standard first line treatment.

What do the experts say

Statistics given by Dr Mario Raviglione, Director of WHO Global TB Programme, during a webinar organised by CNS and the International Union against Tuberculosis and Lung Disease (The Union) paints a grim picture of the ever increasing burden of MDR-TB. “MDR-TB accounted for 480,000 cases in 2014 and this was 3% of the new TB cases globally. A total of 190,000 deaths were recorded,” said Dr Raviglione. An estimated 9.7% of these MDR-TB cases are of extensively drug resistant TB (XDR-TB), which has been reported in 105 countries so far. My neighbouring country South Africa reported XDR-TB in as far back as 2011. With unemployment high in Zimbabwe, 80% of its working class has trekked to South Africa in search of employment.

In Zimbabwe, 120 cases of MDR-TB were reported in 2015—up from 5 cases reported in 2011. This tremendous 24 times increase may be attributed to the non availability of modern diagnostic tools like the GeneXpert machine, due to which detection of MDR-TB was limited at that time. But the machine is now available in ten provincial hospitals, whereas in 2011 it was available only at Murambinda Mission Hospital run by catholic nuns in conjunction with Medecins Sans Frontiere (MSF). TB knowing no borders and Zimbabwe has to treat MDR-TB cases with the serious concern it deserves.

The Director for HIV/AIDS and TB in Zimbabwe’s Ministry of Health and Child Care, Dr Owen Mugurungi said that decentralisation of TB treatment would decongest the main centres. “Decentralisation of MDR-TB treatment in the country will decongest the burden at Wilkins Infectious Diseases, Nazareth and Thorngrove hospitals. What we need to do is to equip the existing nursing staff with skills and knowledge on how to treat MDR-TB”, said Dr Mugurungi. Mission hospitals like Murambinda in Buhera, Howard Hospital in Chiweshe and Karanda Hospital in Mt Darwin are fully equipped to handle MDR-TB cases. Health personnel in district hospitals do not seem to be prepared and equipped to handle MDR-TB patients. A case in point is the Karoi District Hospital where MDR-TB patients are housed in a wooden hostel and have to use outside amenities for ablution. The nurses are afraid to handle the patients and neglect was noted by a health monitoring team that visited the hospital in 2013.

“On our visit to Karoi District Hospital, we sadly noted three patients who were housed in a wooden house and had to use outside toilets and bathrooms. The nursing staff showed fear of contracting MDR-TB, hence they did not handle the patients correctly,” said Mr Stanley Takaona who headed the team. However Mr Takaona was very appreciative of hospitals run by MSF. “We have been to Tsholotsho district and I am pleased to say MSF has built a half way hospital for MDR-TB patients. The patients receive proper treatment and care and hence pose no threat of further resistance,” he said. Most hospitals in Zimbabwe refer MDR-TB patients to access treatment from home and for some patients the distance they have to travel on foot, from home to hospital could be 10 km or more, hence they fail to adhere to treatment. Accessing treatment from home also poses the threat of directly infecting other family members with MDR-TB in the absence of proper infection control methods.

New developments

World experts are not sleeping on their laurels as far as MDR-TB is concerned. The Union, US Agency for International Development, Janssen Research & Development, and UK Medical Research are collaborating on an on-going clinical study called STREAM, to test the effectiveness of shortened treatment regimens for MDR-TB. The first stage of STREAM is testing whether a 9-month regimen used with notable success in Bangladesh, can be used in different settings with comparable results. While speaking at the webinar, Jamhoih Tonsing, Director South East Asia office of The Union, was happy to share that, “One arm of the second phase of the STREAM study would test an all-oral 9 months treatment regimen where Bedaquiline will replace Kanamycin injections. The second arm would look at 6 months regimen with two months of Kanamycin”. If successful, the new regimens would prove to be more patient friendly  and shorten treatment time from 2 years to 9 or 6 months.

MSF and other humanitarian organisations are calling for affordable medicines to treat MDR/XDR-TB. This is especially true of the two new drugs Delanamid and Bedaquiline that could prove to be game changers in the treatment of the more resistant forms of TB. However, as of now, both these drugs are out of reach for most of the people in need of them due to their ridiculously high prices. What is needed at this juncture is the political will to wholeheartedly support the untiring efforts of the scientific community by rolling out the new proven drugs and regimens for treatment of all forms of TB, and by controlling new infections with the help of community.

Catherine Mwauyakufa, Citizen News Service - CNS
April 1, 2016

1 comment:

  1. Some of these guidelines are actually pretty straightforward which should already be known to patients of this chronic illness. Nevertheless, without proper education and constant reminders, people will still forget along the way. Hence, it is the due responsibility of both patients and healthcare practitioners to do their part accordingly to ensure a healthy environment for all.

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