Health-e (Cape Town)

24 March 2014

South Africa: Nurses to Lead Charge Against DR-TB

Today is World TB Day and there's good news and some sobering news to report that there are new drugs, new tests and a promising vaccine being ... ( Resource: New Tools to Fight Tuberculosis, but Drug Resistance Looms

In a country of more than 50 million people, it is hard to be a "first" but Ntombasekaya Mlandu is. She is the first nurse trained to initiate and manage multi-drug resistant tuberculosis (MDR-TB) patients.

The KwaZulu-Natal woman became the first South African nurse trained to initiate patients on MDR-TB treatment in 2012. Her training is part of government's moves to take MDR-TB treatment out of scarce specialised hospitals and closer to patients.

MDR-TB is resistant to both of the most commonly used anti-TB drugs and only about half of MDR-TB patients survive, according to medical humanitarian organisation, Médecins Sans Frontières.

Doctors used to assume that MDR-TB only developed in patients who had been unable to adhere to regular TB treatment. Not so anymore, according to Dr Francesca Conradie, president of the HIV Clinicians Society and clinical advisor at Edenvale's Sizwe Tropical Diseases Hospital outside Johannesburg.

"We always thought that you got MDR-TB because you weren't adherent to TB treatment," said Conradie speaking at a recent MSF briefing. "That is not true in South Africa in 2014."

According to Conradie, about 60 percent of MDR-TB patients in Gauteng have never had TB before, which means they were infected with the drug-resistant strain. She says colleagues in other provinces report similar figures.

Monitoring and mobiles

About 60 percent of Gauteng MDR-TB patients have never had TB before, which means they were infected with the drug-resistant strain

Mlandu knew the frightening high mortality associated with MDR-TB before she underwent training through the US-based Johns Hopkins University, which is partnering with the Department of Health to train at least 180 nurses like Mlandu by 2016. Armed with guideline-laden smart phone tablets, these nurses will initiate, monitor and eventually prescribe MDR-TB treatment in clinics.

"I still had that fear of contracting MDR-TB, (which) to me was even more than the fear of contracting HIV," she said during an interview shortly after completing the Johns Hopkins course. "I had the understanding that once you contracted MDR-TB, you wouldn't survive."

Although she had never worked with MDR-TB patients, her experience in nurse-initiated antiretroviral treatment, made her a prime candidate for the five-month training during which she learned about MDR-TB treatment and side-effects as well as how to refer tough cases - like diabetic MDR-TB patients - to a doctor for treatment.

Now, Mlandu says her patients have become like family.

"I tell them, 'if you face any problem with MDR-TB treatment, please contact me because I am your sister ... don't rely to the next person to tell you other things that will confuse you," said Mlandu, adding that she uses sms, What's App and Blackberry Messenger to stay in touch with them. "I have to have my phone with me wherever I go because if they don't find me they feel like I've deserted them."

TB numbers just don't add up

Do the maths of MDR-TB in South Africa and you can understand why nurses like Mlandu and moving care out of hospitals is so important.

In 2012, South Africa diagnosed about 14,000 MDR-TB cases but only half were ever treated. The country has enough hospital beds to accommodate less than half of those diagnosed.

Only 63 0f the country's more than 4,000 health facilities are equipped to treat the disease, according to the Department of Health's Dr Norbert Ndjeka, who heads the department's division on HIV, TB and drug resistant TB.

"People travel hours to collect treatment and then when they fail to show up, we label them 'defaulters' - that's stigmatising and not right," he said. "That's why it's important to enable patients to get treatment closer to home - this will reduce transmission and make more beds available."

"A hospital is hospital," he added. "Nothing can beat your home even if it's a five-star hotel."

To deal with the shortage of beds and doctors, the Department of Health introduced a policy to decentralise treatment and move care closer to patients in August 2011. More than two years later however, progress is slow, Ndjeka admits.

Decentralisation without a dedicated budget

Decentralising MDR-TB care and treatment would mean providing, for instance, adherence counselling, psychological support and regular hearing screenings to monitor drug side effects at the primary healthcare level. While the National Department of Health is encouraging provinces to integrate services like these, they have not been allocated additional budget to do this.

Instead, the National Department of Health hopes that provinces will prioritise MDR-TB as they continue to strengthen primary health care, and integrate HIV and TB services.

Provinces are able to use part of their HIV conditional grants to decentralise treatment as people living with HIV make up the majority of TB patients in the country.

To improve access to drug resistant TB medications, the Department of Health also plans to fast-track Medicines Control Council (MCC) approval of the generic drug resistant treatment linezolid manufactured by Indian pharmaceutical Hetero Drugs, according to Ndjeka.

While the last TB tender included the drug, the only MCC-approved version of the drug - manufactured by Pfizer - would have cost government R676 per pill. Linezolid is available in India for about R25 per pill.

- Health-e News Service

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