Strategic overview of MDR and XDR TB in South Africa

Multi-Drug Resistant Tuberculosis

STRATEGIC OVERVIEW ON MDR-TB CARE IN SOUTH AFRICA

Dr. Norbert Ndjeka Director, Drug-Resistant TB, TB and HIV

Outline

1. National Strategic Plan for HIV and TB (NSP)

2. TB and DR-TB Epidemiology 3. Background on MDR-TB Care 4. Possible solutions 5. The Response of Umzinyathi district 6. Conclusion

3/5/2014 2 Dr. Norbert Ndjeka

NSP

3/5/2014 Dr. Norbert Ndjeka 3

INTRODUCTION

The NSP sets 5 year targets to direct the country’s response to TB & HIV epidemic

The underlying vision look far further into future

The 20-year goal has 4 priorities as inspired by the UNAIDS “Getting to Zero Strategy”

“Getting to Zero Strategy”

The 20-year vision: Zero new HIV & TB infections Zero new infections due to vertical transmission Zero preventable deaths associated with HIV and TB Zero discrimination associated with HIV and TB

NSP: GOALS

The NSP (2012 to 2016) has the following broad goals: Fifty percent (50 %) reduction in new HIV

infections Initiate at least 80% of eligible patients on ART

with 70% alive and on treatment five years after initiation

Reduce the number of TB infections and deaths by 50%

Reduce self-reported stigma relating to HIV and TB by at least 50%

WHAT DOES THIS MEAN?

Early initiation of ART (within 2 weeks) in all TB, DR-TB co-infected

All MDR-TB started on treatment within 5 days after confirmation

All PHC to provide ART and MDR-TB treatment by 2016

Improve MDR-TB success rate to 60%

EPIDEMIOLOGY


Dr. Norbert Ndjeka 9

HEALTH SERVICES IN SOUTH AFRICA

• Population: 50, 586 757

• Provinces – 9

• Districts - 53

• Sub districts - 253

• Health facilities – 4790

• MDR-TB beds: 2,500

• DR-TB sites: 63

NC 2.2%

WC 10.5%

EC 13.5%

KZN 21.4% FS 5.5%

NW 6.4%

LP 11%

MP 7.2%

GP 22.4%

3/5/2014

Decreasing number of TB cases: Increasing MDR-TB cases


353 610 388 882 405 982 396 554 389 974

344 748

7 350 8 026 9 070 7 386 10 085 14161 0

50 000

100 000

150 000

200 000

250 000

300 000

350 000

400 000

450 000

2007 2008 2009 2010 2011 2012

Notified TB Notified MDR-TB

RSA: Treatment Outcomes-New Smear +ve PTB (2005-2011)

0

10

20

30

40

50

60

70

80

90

2005 2006 2007 2008 2009 2010 2011

Rx Success rate Cure rate Defaulter rate

• Treatment cure rate has improved from a mere 55 % to 75 % between 2005 and 2011

• Treatment success rate has increased from 70 % to almost 80 %

• Defaulter rate has decreased from 10 % to 6 %


Laboratory diagnosed MDR-TB Province 2004 2005 2006 2007 2008 2009 2010 2011 2012 Totals (%) EC 379 545 836 1092 1501 1858 1782 2178 2205 12377 18

FS 116 151 198 179 381 253 267 412 390 2347 3

GP 537 676 732 986 1028 1307 934 1643 1198 9001 13

KZN 583 1024 2200 2208 1573 1773 2032 1825 6630 19888 29

LP 59 40 77 91 185 204 126 290 266 1353 2

MP 162 134 139 506 657 446 312 824 760 3940 6

NC 168 155 188 199 290 631 353 427 373 2784 4

NW 130 203 225 397 363 520 158 473 267 2736 4

WC 1085 1192 1179 1771 2220 2078 1422 2013 2072 15034 22

Total 3219 4120 5774 7429 8198 9070 7386 10085 14161 69460 100


MDR-TB Started on Treatment

PROVINCE

2007 2008 2009 2010 2011 2012

Eastern Cape 932 772 847 927 1207 1062

Free State 158 233 148 167 214 201

Gauteng 497 414 512 607 572 417

KwaZulu-Natal 788 1039 927 1788 1733 2571

Limpopo 71 104 88 119 152 135

Mpumalanga 148 272 198 298 313 591

Northern Cape 145 148 253 230 264 243

North West 156 159 175 143 188 268

Western Cape 439 890 995 1034 1000 1006

South Africa

3334 4031 4143 5313 5643 6494


MDR-TB Treatment outcomes (24 months), 2007-2010


0

10

20

30

40

50

60

Treatment Success Rate Defaulter Rate Mortality Rate Treatment failure rate

Perc

enta

ge (%

)

Indicators

2007

2008

2009

2010

Eastern Cape Free State Gauteng KwaZulu-Natal Limpopo Mpumalanga North West Northern

Cape Western Cape

Success 27.8% 54.6% 28.0% 62.1% 44.1% 26.1% 63.6% 35.9% 21.5% Failed 13.1% 5.5% 3.7% 1.1% 4.2% 2.0% 5.2% 11.0% 8.6%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

Succ

ess

& F

aile

d

15

Eastern Cape Free State Gauteng KwaZulu-Natal Limpopo Mpumalanga North West Northern Cape Western Cape Died 27.7% 17.2% 20.8% 13.2% 11.9% 20.1% 9.2% 13.3% 13.2% Defaulted 16.2% 16.0% 22.4% 9.2% 31.4% 7.4% 11.6% 33.7% 27.1%

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

35.0%

40.0%

Died

& D

efau

lted

16

Laboratory Diagnosed XDR-TB


Province 2004 2005 2006 2007 2008 2009 2010 2011 2012 Total (%)

EC 3 18 61 108 175 123 320 377 477 1662 27

FS 1 6 3 4 3 3 7 18 31 76 1

GP 5 14 19 33 30 65 37 91 50 344 6

KZN 59 227 336 241 181 254 201 758 754 3011 48

LP - 2 5 2 2 6 6 18 3 44 1

MP - - - 12 14 18 5 24 3 76 1

NC 4 10 3 7 19 40 39 111 72 305 5

NW 1 5 9 4 4 13 14 14 10 74 1

WC 12 16 28 42 60 72 112 163 145 650 10

Total 85 298 464 453 488 594 741 1574 1545 6242 100

XDR-TB cases started on treatment PROVINCE 2007 2008 2009 2010 2011 2012

Eastern Cape

171 135 135 224 208 204 Free State

7 7 6 5 16 9 Gauteng

45 40 25 30 33 26 KwaZulu-Natal 170 163 177 235 211 267 Limpopo

2 0 3 3 11 3 Mpumalanga

0 3 5 6 5 8 Northern Cape 11 8 13 37 51 26 North West

4 1 9 14 6 14 Western Cape

64 34 58 61 68 144 South Africa 474 391 431 615 609 701


XDR-TB Treatment outcome (24 months) 2007-2010


0

10

20

30

40

50

60

Treatment Success Rate Defaulter Rate Mortality Rate Treatment failure rate

Perc

ent (

%)

Indicator

2007

2008

2009

2010

BACKGROUND ON MDR-TB CARE


SERVICES TO BE OFFERED

Adherence counseling Prophylaxis required Social support Nutritional support Psychological support Transport

• Regular clinical evaluation

• Provision of injectable and

oral medications

• Further laboratory monitoring

• HIV test and care offered


BREWELSKLOOF HOSPITAL

Worcester

Harry Comay TB Hospital


Newly renovated ward


MDR-TB Regimen (Adults &Children > 8 years)

6 Km – Mfx – Eto – Trd - Z /18 Z - Mfx - Eto - Trd

INTENSIVE PHASE

CONTINUATION PHASE

MINIMUM NUMBER OF MONTHS OF TREATMENT


Source: RSA MDR-TB Guidelines,2011

MDR-TB Regimen (Children < 8 Years)

6 Am – Lfx – Eto – Trd - Z /18 Z - Lfx - Eto - Trd

INTENSIVE PHASE

CONTINUATION PHASE

MINIMUM NUMBER OF MONTHS OF TREATMENT


Source: RSA MDR-TB Guidelines,2011


Challenges (1)

DR-TB treatment still centralized

Risk of transmission in hospital

Poor outcome of DR-TB cases

Increasing numbers of DR-TB failing treatment

Palliative care

Inadequate Recording and Reporting (R & R)


Challenges (2)

Inadequate access to new drugs such as Linezolid

Inadequate laboratory testing for DST

Availability of quality, strong evidence to support

new interventions

No funds to support new initiates at provincial

level in a context where MDR-TB is mostly the

last priority


POSSIBLE SOLUTIONS


DECENTRALIZED MANAGEMENT OF MDR-TB

Provides guidance for management of MDR-TB

patients closer to their homes, both in health facilities and in community

Enables provinces to start MDR-TB treatment as soon as diagnosis is made, hence decreasing risk of transmission


BENEFITS OF DECENTRALIZATION

Reduce transmission of DR-TB by initiating treatment sooner

Make more beds available Improved adherence to medication Improved cost effectiveness Accommodate patient roles and

responsibilities


LEVELS FOR THE DECENTRALIZED MANAGEMENT OF DR-TB



Flow

of

DR

-TB

Pat

ient

s

Province Number of MDR-TB treatment initiation sites before

Number of MDR-TB treatment initiation sites after

Eastern Cape 2 8

Free State 1 4

Gauteng 1 5

KwaZulu-Natal 5 8

Limpopo 1 1


Province Number of MDR-TB treatment initiation sites

before

Number of MDR-TB treatment initiation sites

after

Mpumalanga 1 3

Northern Cape 2 4

North West 1 2

Western Cape 4 17


OTHER INTERVENTIONS (1)

Improve treatment adherence Reassess difficult cases through provincial

review boards Nurse-initiated MDR-TB programme (NIMDR) Provision of hearing tests among MDR-TB

patients Reflex testing (all MDR-TB to automatically

get DST for injectable and fluoroquinolones)


OTHER INTERVENTIONS (2)

Controlled access to new agents e.g. bedaquiline treatment access programme

Strengthen data collection and analysis Think tank session planned to discuss poor

outcomes, palliative care package, discrepancy between number of MDR-TB diagnosed and those treated and means to fast-track decentralization of MDR-TB services


THE RESPONSE OF UMZINYATHI DISTRICT IN KWAZULU NATAL


Durban

Pietermaritzburg

Demographics

The total population of the District is 520 555 according to (DHIS mid year 2012)

13% Account for children less than five years 7% account for sixty years and above 55% of the population are females 72% of the population is under 35 years of ag 80%rural Unemployment rate: 62% Literacy rate: 39%


MMWR – March 2005

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ACTIONS TAKEN

Development and printing of MDR adherence chart

Development of Drug resistant TB task team

Material resources: Additional TB vehicles

Introduction of TB/MDR literacy classes

Systematic tracing, screening and follow up of contacts (every 6 months for 2 years HH visits and GPS)

Identification and regular support of poor performing facilities Human Resources Recruitment and Development: appointment of TB nurses at facilities, tracer teams Designing and introduction of TB appointment dairy in the district. 3/5/2014 Dr. Norbert Ndjeka 43

2005 2006 2007 2008 2009 2010 2011 2012 number of nurses 13 28 49 49 63 69 69 69

0

10

20

30

40

50

60

70

80

Dedicated TB nurses Umzinyathi




5190

5668

5116

4213

922 802

0

1000

2000

3000

4000

5000

6000

2009 2010 2011 2012 Q1/2013 Q2/2013

UMZINYATHI CASEFINDING 2009-Q2/2013


cured compltd failure died trans out dflted not evaluated

2008 81.5% 0.1% 1.1% 13.9% 1.7% 1.8% 0.0% 2009 81.5% 1.1% 2.2% 10.7% 1.5% 2.7% 0.0% 2010 84.8% 1.0% 2.7% 8.7% 1.1% 1.5% 0.1% 2011 86.2% 1.4% 3.1% 7.6% 0.5% 1.1% 0.1% Q1/2012 86.8% 0.8% 1.6% 7.4% 0.3% 3.0% 0.0% Q2/2012 86.5% 0.7% 0.7% 10.5% 0.3% 1.4% 0.0%

0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0% 80.0% 90.0%

100.0%

UMZINYATHI TREATMENT OUTCOMES-NORM 85%


CURED COMPLTD FAILD DIED DFLTED TRANS/MVD NOT EVAL.

2008 66.0% 13.0% 7.0% 7.0% 3.0% 4.0% 0.0% 2009 67.0% 8.0% 3.0% 14.0% 8.0% 1.0% 0.0% 2010 64.0% 9.3% 1.5% 10.9% 9.3% 4.6% 0.0%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

MDR Rx OUTCOMES


64

12294

5380 80

66

24

114 115134

8260

24 3117

178

237 228

135 140

104 97

41

0

50

100

150

200

250

2005 2006 2007 2008 2009 2010 2011 2012

Msinga MDR and XDR cases 2005-2012

MDR

XDR

total


CONCLUSION


CONCLUSION

Decentralized management of MDR-TB

increases access to care It reduces time to MDR-TB treatment initiation

which may reduce community transmission of MDR-TB (To treat is to prevent)

With the interventions described in this presentation we are hoping to scale up MDR-TB treatment, close the gap between diagnosed and treated individuals and increase our MDR-TB treatment success rate to 60 %


Thank you


Strategic overview of MDR and XDR TB in South Africa

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