Drugs are not enough for extreme TB - doctors

By, The Star, March 6, 2007

Multi-drug-resistant tuberculosis (MDR-TB) needs a proactive networked response, particularly when it appears together with HIV infection, an international discussion on MDR-TB heard in Johannesburg on Monday.

"It is one disease where there are more questions than answers," said Dr Norbert Ndjeka from Limpopo - part of a group of South African doctors who travelled to Latvia for training in MDR-TB management.

MDR-TB is TB which does not respond to standard TB treatment, and extreme drug resistant TB (XDR-TB) is even more resistant to treatment. The combination of XDR-TB and HIV infection in South Africa has been proving deadly.

The Johannesburg meeting, organised by the international Lilly MDR-TB Partnership brought South Africans together with Lilly affiliates from Europe.

This partnership is underwritten by international pharmaceutical company Lilly to the tune of $70-million and brings together public and private partners, health professionals, business and communities to address MDR-TB around the world. It was the partnership's first global study tour.

"Drugs are not enough," said partnership project head, Dr Patrizia Carlevaro.

The partnership aims to combat the growing MDR-TB pandemic and support the World Health Organisation's goal of treating 800 000 patients by 2015.

Ndjeka said 13 medical professionals from eight provinces - excluding the Eastern Cape - attended the Latvia training, which included monitoring and management, MDR-TB and HIV co-infection, infection control and drug management.

Ndjeka told the Johannesburg meeting that the training they received was "superb" and said South Africa could learn a lot from Latvia's management of MDR-TB.

"Their cure rate is above 66 percent... Ours is below 50 percent."

Ndjeka said Latvia had good methods of networking on patient difficulties.

"We do not have all the information around resistance patterns in the South African population."

He said South Africa also did not have all the drugs - XDR-TB treatment required six or seven drugs.

Latvia has policies on infection control in place, runs effective isolation of XDR-TB patients, has masks and special lights to kill TB germs through radiation, and screens health care workers annually for infection.

The South African team trained in Latvia recommended to the health department that the national MDR-TB protocol be updated and encouraged research and networking on the MDR-TB problem, including HIV and TB collaboration.

"As government alone we cannot make it.

"Involvement of all stakeholders is essential to achieve better outcomes for our national TB control programme," said Ndjeka.

"The growing incidence of extreme drug resistant TB in South Africa is highlighting the urgent need for more effective measures for preventing, detecting, diagnosing and managing TB," said Dr Kgosi Letlape, chairman of the South African Medical Association (Sama).

Letlape said South Africa ranked seventh in the world in reported TB cases and was among the 22 high-burden countries targeted as part of the WHO's Stop TB campaign.

He said Sama aimed to help develop the capacity of health professionals to deal with TB. He said TB and HIV care should be integrated and commented that HIV-positive patients were generally better informed than those with TB, which impacted on their treatment.

"You have got much higher compliance among HIV patients than among TB patients."

Sama is developing an online training course for physicians on MDR-TB which will include the WHO guidelines on combating the disease.

The course aims to provide doctors with the skills to diagnose, prevent, detect and manage TB, including promoting education and self-care, promoting therapy compliance and controlling associated disorders.

Letlape said 2554 health professionals had been trained in TB management since 2003, and Sama hoped to increase this to 5000 in 2007.

General secretary for the Democratic Nurses' Association of South Africa (Denosa), Thembeka Gwagwa, said Denosa aimed to empower nurses to deal with TB.

As part of this, Denosa trained a core group of 20 nurses from seven provinces in TB management, who in turn trained another 500 nationally.

Northern Cape nurses reported that during the last quarter of 2006, after their 186 nurses were trained, the TB cure rate increased from 18.7 percent to 20.1 percent, while the treatment interruption rate dropped from 21.3 percent to 14.8 percent.

Eastern Cape trained 60 nurses, and reported that the TB treatment compliance improved by 30 percent.

Mpumalanga and KwaZulu-Natal nurses reported a "sharp decrease" in the treatment interruption rate after training.

Gwagwa pointed out that some provinces had no budget for training, which "doesn't augur well".

She said poverty was a huge challenge in battling MDR-TB, as it stopped patients from getting to clinics and meant they took medication on empty stomachs.

"MDR-TB is a man-made problem," said nurse and educator Kathy Dennill, who heads the nursing leadership programme at the Foundation for Professional Development (FPD).

"It stems from bad management. And we need to look at that management."

Dennill's foundation runs training for nurses.

FPD's Dr Anton Stoltz said the links between HIV and TB were crucial.

"It is very important that we know how people with TB present with HIV."

In support of the battle against MDR-TB, Lilly has passed on the skills and technology needed to manufacture TB drugs.

"We have given away our trademark," said Carlevaro.

"Twenty years ago people were saying MDR-TB is a lost cause. Now we say it's cost-effective to treat."

In South Africa, Lilly has passed on technology, skills and capital funding to pharmaceutical company Aspen Pharmacare, to enable it to produce low-cost drugs to fight MDR-TB, including XDR-TB.

Aspen currently manufactures the oral TB drug cycloserine and within about 15 months will be able to manufacture capreomycin, thanks to Lilly's assistance, said Aspen executive director Stavros Nicolaou.

He said Aspen was developing the capacity to manufacture a dried injectable powder in a vial which required only water to be added to it, a method which kept the medicine stable. This would be used for capreomycin.

He urged support for the battle against both TB and HIV - "a potentially devastating cocktail".

Nicolaou said that thanks to Lilly's help, Aspen could sell the MDR-TB drugs "largely on a cost-recovery basis" instead of a profit-making basis. - Sapa


Source: http://www.thestar.co.za/?fSectionId=&fArticleId=nw20070305225920738C736233

Malawi: Rescuing Infants From Tuberculosis

By, Moses Kaufa, The Chronicle Newspaper (Lilongwe), September 4, 2007

The call to action in Prevention of Mother to Child Transmission (PMTCT) aims to reduce the risk of mother to child transmission of HIV through integrated HIV/Aids education, routine counselling and testing as well as administration of a prophylaxis single dose Nevirapine therapy to mother and infant.

It goes without saying then, that the need to protect infants or the unborn from the possibility of contracting Tuberculosis, including the Multi-Drug Resistant (MDR) and Extremely Drug Resistant (XDR) TB, which is closely linked to the HIV epidemic, becomes of paramount importance.

During the last decade, there has been an increase of TB infections as an opportunistic infection in people with HIV because of their weakened immune systems. This is causing concern in the light of MDR and XDR-TB surfacing because interventions such as the prevention of mother to child transmission of HIV may be challenged where the mother is living with HIV and found with Tuberculosis.

Communications Officer of National TB Control Programme, Henry Chimbali, told Health Check that most healthy people do not get TB unless they are in very close contact with people infected with Tuberculosis as it is spread through droplets in the air.

"The infection of XDR-TB is transmitted the same as the standard TB and could be prevented the same way ordinary Tuberculosis is prevented," Chimbali said.

The international medical humanitarian organisation, Medicines Sans Frontieres (MSF) is quoted by Health Check calling for approaches and new tools to treat multi-drug resistant (MDR) Tuberculosis in Southern Africa.

"MDR, and now XDR-TB, are the tip of an iceberg of failing strategies to control TB," said Dr.. Eric Goemaere of MSF "We desperately need new tools and new approaches and we need them now - we cannot just sit and wait. Despite all the international fanfare created by XDR, efforts to treat drug resistant TB in high HIV prevalence settings are moving at a snail's pace and investments to develop new drugs and diagnostics to improve management of all forms of TB are terribly inadequate. This situation is unacceptable." He said

The World Health Organisation says it is important to avoid prolonged and close contact with a person who has been infected by TB, MDR-TB or XDR-TB in a place that does not have good ventilation and fresh air as one way of protecting oneself from becoming infected with the Tuberculosis.

According to the National TB Control Programme, XDR-TB patients need experts to handle their cases while they are quarantined.

Chimbali told Health Check, however, that any development of TB could be averted if regular TB is treated effectively and if Malawi succeeded in controlling the XDR-TB transmission, then the risk of infection would not be there.

Country Director for UNC Project at Kamuzu Central Hospital, Dr.. Francis Martinson, says there is need for a prophylaxis regimen to protect mother/infant pairs from tuberculosis just as there is a Nevirapine dose to facilitate the prevention of mother to child transmission of HIV.

In this regard, University of Northern Carolina (UNC) Project has embarked on a randomized, placebo-controlled trial to determine the efficacy of Isoniazid (INH), a component drug in the combination of TB treatment in preventing Tuberculosis disease and latent TB infection among South African infants with peri-natal exposure to HIV.

Dr. Martinson told Health Check that the trial would have an initial sample size of 1,300 study participants consisting of 500 infected and 800 uninfected exposed study participants.

"The objective of the trial aims to determine whether INH prophylaxis increases TB disease survival for HIV infected participants; to determine whether INH prophylaxis increases TB infection-free survival for peri-natal-exposed HIV uninfected study participants," said Dr.. Martinson.

"Among both peri-natal-exposed HIV infected and HIV uninfected study participants we are also trying to assess the toxicity and safety of INH prophylaxis."

The fact that once one is HIV positive and having Tuberculosis, one is automatically placed on antiretroviral therapy, puts the mother/infant pair at risk of not accessing medical care if they infect one another and do not get diagnosed in time.

This uncertainty surrounding lives of infants makes it clear that it is imperative for stakeholders to ensure that such cases are identified and assisted adequately in time to save mother/infant pairs' lives and to prevent the spread of both TB and HIV.

Source: http://allafrica.com/stories/200709040470.html