Hope on the horizon for people living with MDR-TB

Catherine Mwauyakufa, CNS Correspondent, Zimbabwe
More efficacious medications are needed in the successful treatment of multi-drug resistant TB (MDR-TB) if we are to realise the goal of ending  TB by 2030, as envisaged in the sustainable development goals (SDGs). World Health Organisation (WHO) estimates that 480,000 new MDR-TB cases were noted in 2014. Also treatment success rate stands at 50% globally. Something urgent needs to be done to save lives of people with MDR-TB.

In Zimbabwe, like elsewhere, the treatment schedule for MDR-TB is lengthy and costly. Even though available free of cost in the public health system, it is costly as one has to travel long distances to a health centre on a daily basis for the injections which is part of the treatment. Few hospitals in Zimbabwe have admission units specifically for MDR-TB, leaving the bulk of patients commuting from home. The majority of the 14.8 million population of Zimbabwe lives in the rural areas where infrastructure, road networks and general standard of living is lower as compared to urban settings. The distance between one health facility to the other can be 20 km or more; and with no reliable transport, distance becomes a barrier for most rural people in accessing treatment. Rural areas with mission hospitals are spared the burden as these facilities have admission wards.

Rutendo Mazi, an adolescent being treated for MDR-TB said she has defaulted on several occasions after failing to travel to the hospital—“I need USD 1 to travel to hospital and another dollar to come back home. There are times I have failed to travel for medication when my mother has no money,” said Mazi who risks passing the MDR-TB to her parents and siblings. With no bus fare to travel to and from hospital and the current drought weighing heavily on the already hard lives, MDR-TB patients have to endure the many months of treatment required. Hence when one hears the locals saying that MDR-TB is ‘not treatable’, one needs to understand their predicament, as they have witnessed many of their loved ones succumb to it. Moreover, the medications used are often difficult to tolerate, more so on an empty stomach. The International Union Against Tuberculosis and Lung Disease (The Union) firmly believes that a more accessible and tolerable treatment for MDR-TB is urgently needed. Good news is coming from the Damien Foundation pilot programme in Bangladesh and elsewhere, which shows that with regimens that are effective, MDR-TB can be treated in a shorter period.

Dr I.D. Rusen, Senior Vice President, Research and Development at The Union, who led the Treat TB initiative and co-ordinated the STREAM clinical studies for shorter regimen for MDR-TB, said that the regimen has given promising results in pilot studies. “The proposed regimen takes between 9 to 12 months to complete as compared to 24 months for the current regimen and the cost is also lower at $1000 per patient as compared to the current regimen. Data for 515 patients in Bangladesh on the 9-month regimen shows a cure rate of 82.1%,” said Dr Rusen. The main drugs used in TB treatment in Zimbabwe are rifampicin and isoniazid, and when treatment fails patients then develop resistance.  Resistance may be as a result of non treatment adherence too. Health personnel in district hospitals seem to be not prepared and equipped to handle MDR-TB cases. A case in point is that at Karoi District Hospital, where such patients are housed in a wooden hostel and have to use outside amenities for ablutions. The nurses are afraid to handle them and neglect was noted by a health monitoring team that visited the hospital in 2013.

Mr Stanley Takaona
who headed the team noted the lack of support for MDR-TB patients at this particular hospital. “On our visit to Karoi District Hospital, we sadly noted three patients who were housed in a wooden shack 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 Takaona. Praising the work of MSF, Mr Takaona shared that, “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 are on full treatment and hence pose no threat of further resistance. They have decent facilities and the health personnel handle patients with care. They are discharged only when full cured”. 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 can be 10km and above hence they fail to adhere. Accessing treatment for MDR-TB patients from home poses the further risk of transmission to family members. Most cases of MDR-TB have been traced to family members and the infected got the TB during care-giving. Gogo Lucia Muramba is one such case. She has had MDR-TB and has been on treatment for the past three years. She cared for her son who succumbed to MDR-TB 5 years ago.

On hearing that there is light at the end of the tunnel for the burden of MDR-TB, Gogo Muramba welcomed the news. “I have been on treatment for MDR-TB for 3 years. After 2 years the results showed that I was not cured so the doctors said I should continue with treatment. The news you are telling me of effective medication having been found is good news, otherwise I was now giving up,” said the 73-year-old grandmother from Zimunya. The rise of MDR-TB cases is Zimbabwe is a cause for concern. TB and HIV co-infection is a factor that cannot be ignored in Zimbabwe as 70% of TB patients also test HIV positive. Dr Owen Mugurungi, Director of the AIDS and TB Unit in the Ministry of Health and Child Care in Zimbabwe said during a workshop for journalists in Kadoma in 2014 that, “We are seeing a rise in the number of MDR-TB cases in Zimbabwe and this is mainly due to patients not adhering to treatment. These patients pose the risk of passing that strain so the TB burden in the country keeps growing,” said Dr Mugurungi. “The treatment course for MDR-TB is long, taking 24 months and in some cases even more. The tablets are many and some patients can develop intolerance. Patients often have to travel long distances to the clinics. Hence non adherence can be a result of fatigue and burnout. It is a complex issue,” he said. 

I spoke to Martin Choke, a patient who was now on MDR-TB treatment as he had left first line TB treatment in between. “I was feeling fine and healthy and did not see the reason to continue coming to the clinic. The nurses said I had two more months of treatment left and I thought they did not know what they were saying. I stopped coming for treatment. However, a year and a half later I got very ill and was diagnosed with MDR-TB, This time around the treatment is longer and I have injections too which I did not have during the first time. I will have to do what the doctors say if I am to live and see my children graduate from high school,” said Choke. Dr Fuad Mirzayev, speaking on WHO Treatment guidelines for MDR-TB 2016 update during a webinar for writers by CNS, said a shorter regimen is recommended with clofazimine/linezolid as core second line medicines and PAS as an add on. This could be used for patients with rifampicin resistance. It can also be used in children, adults and people living with HIV affected by pulmonary MDR-TB. This however, is not recommended for patients with extra pulmonary TB and in pregnant women. The new regimen will go a long way in improving treatment adherence and reducing loss-to-follow up, thereby potentially saving more lives. I am for ending MDR-TB by 2030 and will advocate for my government to walk the talk.

Catherine Mwauyakufa, Citizen News Service - CNS
July 25, 2016