Fighting drug-resistant TB: What India can learn from S Africa's success

If India follows new World Health Organization (WHO) guidelines released in August 2018 and reiterated on December 21, 2018, other drug-resistant TB patients will not have to struggle similarly

In July 2017, 40-year-old Noludwe Mabandlela, a single mother of two, collapsed at home. This ended up saving her life. The ambulance that responded took Mabandlela to the nearest government community health centre, where she was diagnosed with multi-drug resistant tuberculosis (MDR-TB). As the name suggests, first-line drugs such as rifampicin used to treat the more common, drug-sensitive TB don’t work on MDR-TB, from which patients have an increased risk of death and from which they take two years to recover, compared to six months in conventional TB.

Forty-year-old Noludwe Mabandlela, a single mother of two, received new TB drugs bedaquiline and delamanid for multi drug-resistant TB and, a year later, now hopes to make a full recovery. Here, she shows a photo of herself before she contracted MDR-TB.

Until then, an ailing Mabandlela--who lives in Khayelitsha, South Africa’s largest township, or informal settlement, 30 km southeast of Cape Town--had been going to a private hospital, where she was not tested for TB. Government health staff started Mabandlela on MDR-TB treatment, which included taking injectable drugs for six months. She developed side-effects from the drugs, including numbness in her feet, hearing loss and kidney impairment.

Mabandlela was then put on bedaquiline--the first new TB drug developed in nearly 40 years--through the South African department of health’s National TB Control Programme (NTCP). Since 2015, South Africa had started making the drug available in the NTCP for patients with extensively drug-resistant TB (XDR-TB)--the most severe form of MDR-TB--and for patients like Mabandlela who developed severe side-effects from MDR-TB drugs.

Mabandlela also received another new TB drug delamanid from international humanitarian aid organisation Medicins Sans Frontieres (MSF), in November 2017. These new drugs are still not commonly accessible--just over 24,000 of the world’s 558,000 MDR-TB patients have received bedaquiline till August 2018, and only 2,020 have received delamanid.

Mabandlela, HIV-positive and a cancer survivor, had almost given up hope as she lay hospitalised for a month. Now, over a year since her treatment began, she hopes to make a full recovery. Her story is a beacon of hope for MDR-TB patients globally.

Till 2014, almost one in two MDR-TB patients in South Africa were not successfully treated, according to a retrospective study of 19,000 patients published in The Lancet Respiratory Medicine journal in July 2018. Two out of 10 MDR-TB patients in the country died during the 18- to 24-month long treatment, the study found.

This changed as South Africa developed and implemented a number of patient-centric initiatives that eased treatment for drug-resistant TB and made South Africa a leading example of successful drug-resistant TB care.

To understand South Africa’s successes in fighting drug-resistant TB, IndiaSpend interviewed government officials, physicians, drug-resistant TB patients and advocacy groups in South Africa. We found political commitment backed with evidence-based policies helped South Africa reduce deaths among patients and become a role-model for other high drug-resistant TB burden countries like India.
 

In the first part of this series, IndiaSpend reported how no more than 2.2% of India’s drug-resistant TB patients had received bedaquiline till November 2018, although India has the most drug-resistant TB patients in the world. In this second part, we compare South Africa’s policies with India’s.

Patients develop side effects of conventional drug-resistant TB medications

Phumeza Tisile is another MDR-TB patient who, like Mabandlela, developed side effects from injectable drugs. Tisile was a student at the University of Cape Town when she was diagnosed with TB in 2010. Since rapid diagnostics for detecting drug-resistant TB were not available then, she was diagnosed with MDR-TB only after conventional TB treatment didn’t work. She was then put on a regimen of 20 drugs a day, including one injection, for six months.

One night during the treatment, Tisile woke up and realised she could not hear. Side effects of the injectable MDR-TB drug kanamycin had left her deaf in both ears. “Before that, I was never counselled about any side-effects. I didn’t know TB treatment could make you deaf,” she told IndiaSpend. “When I reported my hearing loss, the nurse said she is very sorry but there was nothing that could be done,” said Tisile.

Worse, further tests revealed that Tisile had XDR-TB and was resistant to kanamycin, so she lost her hearing taking a drug that wasn’t helping her.

Student Phumeza Tisile lost her hearing as a side-effect of an injectable drug she took for MDR-TB. After recovering, Tisile has become a TB patients’ advocate, raising awareness about the side-effects of conventional MDR-TB drugs.

At the time, in 2010, XDR-TB treatment in South Africa was available only in hospitals and was aimed at controlling transmission, which entailed patients being sequestered for almost the entire two-year treatment in hospital, away from work and personal life. Tisile spent close to a year in three hospitals, including the Brooklyn Chest Hospital in Cape Town, but her health did not improve.

“Every day I saw patients around me die. There was even a separate exit for taking away the dead bodies.” She was then told the treatment wasn’t working and she was referred to MSF, which provided her with linezolid. This anti-bacterial medicine is used as a drug of last resort for MDR-TB and XDR-TB patients, but was not available in South Africa’s NTCP. While linezolid can have serious side-effects too, including blurred vision, numbness in feet and anaemia, Tisile’s health slowly improved and she was declared cured in 2013.

While her treatment was underway, she began blogging on MSF’s website in 2013, raising awareness about the side-effects of injectable TB drugs, and gained the attention of media and other patients. “I got messages from patients saying they wanted to commit suicide, that there was no hope,” she said, “I told them it will work out and they will get better.” Tisile managed to raise resources to get cochlear implants in both ears, and regained her hearing. She also restarted her studies.

Faced with poor treatment success rates till 2013, South Africa introduces bedaquiline

South Africa has 322,000 TB patients, of whom 14,000 are rifampicin-resistant (RR)/ MDR-TB cases, and 192,000 (59%) also have Human Immunodeficiency Virus (HIV+), according to the World Health Organization’s Global Tuberculosis Report (GTR) 2018. South Africa has 2.5% (14,000) of all drug-resistant TB patients. The success rate of MDR-TB treatment in South Africa was 54% and the death rate was 20%, till 2015, according to the Lancet study. For XDR-TB patients, the success rate was 15% and death rate was 42%.

While the absolute numbers of patients isn’t that high, South Africa’s incidence rate of 567 per 100,000 for TB cases is the highest among Brazil, Russia, India, China and South Africa--the five partnering emerging economies collectively known by the acronym BRICS--according to GTR 2018. South Africa is second only to Russia in incidence of RR/MDR-TB, at 25 per 100,000. The incidence rate for HIV+TB patients is 345 per 100,000 in South Africa.