TB EPIDEMIOLOGY IN SOUTH

AFRICA

Dr. Norbert Ndjeka MD, DHSM (Wits), MMed(Fam Med) (MED), Dip HIV Man (SA)

Director Drug-Resistant TB, TB and HIV

National Department of Health

1 Dr Norbert Ndjeka

Content of the presentation

Background: definitions, risk factors and history of TB

The Global situation The African and SADC situation

South African status

Conclusion

BACKGROUND

DEFINITIONS

What is tuberculosis?

Tuberculosis is an infection caused by Mycobacterium Tuberculosis

It is commonly known as TB

7000 BC TB was found in pre-historian human remains in the Eastern Mediterranean

3000 – 4000 BC TB found in spines of mummies

Other names for TB through the

times

Consumption was another name for Tuberculosis(consuming people from the inside)

White plague (palor in people)

Wasting disease

Koch’s disease

1839 term Tuberculosis was introduced by J. L. Schoenlein

Types of TB

Drug-susceptible TB, commonly called TB

Drug-Resistant TB (DR-TB) which is disease caused by Mycobacterium Tuberculosis strains resistant

to one or more anti - TB drugs.

Types of DR-TB

Mono-resistance

• TB strains that are resistant to at least one anti-TB first-line drug (R or H or Z or E)

Poly-resistance

• TB strains that are resistant to at least one anti-TB first-line drug (R or H or Z or E)

MDR-TB

• TB strains resistant to rifampicin and isoniazid with or without resistance to other first-line TB drugs

XDR-TB

• TB strains resistant to rifampicin, isoniazid, any second line injectables (Am, Km or Cm) and to any fluoroquinolone

7/19/2012 Dr. Norbert Ndjeka 7

BACKGROUND

RISK FACTORS

Risk Factors enhancing TB

infection

Medical history: diabetes, HIV, vitamin D deficiency, any

medical or genetic factor that decreases immunity temporarily or permanently

Prolonged steroid therapy, cancer chemotherapy Social habit: smoking, alcoholism, drug addiction Socio-economic factors: overcrowded housing, poverty Environmental factors: exposure to asbestos, silica or solid

fuel

BACKGROUND

HISTORICAL

BACKGROUND

Milestones in TB History

Hermann Brehmer (1826 -1889)– born in Kurztsch in Silesia, Prussia. He suffered from TB as a botany student and was sent to the Himalayas by his father, also a physician. On his return he started studying medicines and presented his thesis in 1854 on the subject : “TB is a curable disease.”

Hermann

Brehmer -

In 1854 he built the first sanatorium for patients afflicted by pulmonary tuberculosis in Goerbersdorf,Germany (now Sokolowsko, Poland) and is referred to as the founder of the sanatoria.

Jean-Antoine villemin (1827-1892)

Born in Prey, Vosges. He studied medicines at the Military Medical school in Strasbourg and graduated in 1853 as an army doctor. Villemin proved that TB is an infectious disease by inoculating lab rabbits with material from infected humans and cattle. He published his results in the treatise “Etudes sur la Tuberculosis”. He found that some bacteria could attack other bacteria and created the term “antibiotic”.

Dr Edward trudeau (1848 – 1915)

Dr Trudeau was born in New York and completed his medical training in 1871 at Columbia College.

He was diagnosed with tuberculosis in 1873 and cured in 1876 after a stay in the Adirondack Mountains.

In 1882 he read about H. Brehmer and founded the Adirondack Cottage Sanatorium. He founded the first laboratory, Saranac Laboratory for the Study of Tuberculosis in the US renamed “TheTrudeau Institute” (ref. Wikipedia Encyclopedia)

Discovering the tubercle bacillus

24th

of March 1882 by Robert koch

Robert koch (1843-1910)

R. Koch was born in Klausthal, Germany and qualified as a physician in 1866 at the University of Gottingen.

Robert Koch announced his discovery of the tubercle bacillus on 24.03.1882. He was named the founder of the medical bacteriology and also made the first photomicrographs of bacteria.

He discovered the phenomenon of “tuberculin

sensitivity”, foundation of cellular immunology. (ref. R.Koch – A life in Medicine and Bacteriology – Thomas D. Brock)

Carlo Forlanini (1847-1918)

Born in Milan, Italy. Forlanini received his medical degree from the University of Pavia, in 1870.

Forlanini developed the

pneumothorax in 1882

Carlo Forlanini developed the artificial pneumothorax in 1882 and induced the first artificial pneumothorax procedure in 1888. He reported the first results of the method six years later at the 11th Medical Congress in Rome.

1900: The

sanatorium

movement begins:

Support systems for patients were

developed

Spinal brace on a patient with spinal TB so that disabling deformities

of the spine might not occur (Valley Echo, June 1939)

BCG was established in 1920

Bacillus Calmette-Guerin strain (BCG) was established

TB drugs become available

on the market

1944: streptomycin was discovered for the use of TB treatment 1952: Isionazid theurapeutic efficacy confirmed/Pyrazinamide made available 1956: Madras experiment (outpatient chemotherapy) 1962: Clinical use of Ethambutol in US 1967: Clinical use of Rifampicin in US

TB EPIDEMIOLOGY

GLOBAL SITUATION

TB Epidemiology

Estimated TB incidence in 2009

World Africa South Africa

9.4 million Accounts for 1/3rd 3rd highest in numbers 2nd highest in incidence rate

Estimated proportion of HIV positives in incident TB cases in 2009

World Africa South Africa

1.1 million (12%) Accounts for 80% co-infected cases

Accounts for 31%, 60% TB patients are HIV pos

Estimated MDR-TB incidence

World Africa South Africa

650,000 5th highest in the world (13000); 2nd highest in

reported cases in the world Dr. Norbert Ndjeka 7/19/2012 24

Ref: Multidrug and extensively drug-resistant TB

(M/XDR-TB): 2010 global report on surveillance and

response. WHO/HTM/TB/2010.3

Ref: Multidrug and extensively drug-resistant TB

(M/XDR-TB): 2010 global report on surveillance and

response. WHO/HTM/TB/2010.3

Current View Notified MDR-TB (absolute) - 2010

The boundaries and names shown and the designations used on this map do not imply the expression of any

opinion whatsoever on the part of the World Health Organization concerning the legal status of any country,

territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted

lines on maps represent approximate border lines for which there may not yet be full agreement.

Copyright - WHO 2011. All rights reserved.

Indicators of diagnosis, notification and treatment of multidrug-resistant TB, by country

Generated Source: www.who.int/tb/data 13-Jun-2012 10:21

Current View Notified MDR-TB (population rate per 100,000) - 2010

The boundaries and names shown and the designations used on this map do not imply the expression of any

opinion whatsoever on the part of the World Health Organization concerning the legal status of any country,

territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted

lines on maps represent approximate border lines for which there may not yet be full agreement.

Copyright - WHO 2011. All rights reserved.

Indicators of diagnosis, notification and treatment of multidrug-resistant TB, by country

Generated Source: www.who.int/tb/data 13-Jun-2012 10:24

Global situation

Globally, every year, an estimated 650,000 MDR-TB patients are diagnosed

Only 46,000 (7%) globally are initiated on treatment • WHO Report 2011, Global TB Control WHO/htm/tb/2011.16

7/19/2012 29 Dr. Norbert Ndjeka

TB EPIDEMIOLOGY

AFRICAN & SADC

SITUATION

Epidemiology of TB in Africa

Africa has 11 % of the world population with 1/3rd of notified TB cases

SADC Region in Africa has 25 % of the African population but 50 % of all notified TB cases

Mortality rate of TB is 2 to 3 times higher in the SADC region then in the rest of the African continent.

Ref: Multidrug and extensively drug-resistant TB (M/XDR-TB): 2010 global report on surveillance and response.

WHO/HTM/TB/2010.3

TB EPIDEMIOLOGY

SOUTH AFRICAN STATUS

Current View

* % TB cases with 1st line DST exceeding 100% shown as 100%; this may happen if TB notification is incomplete especially in systems where

reporting of TB and DST are not linked.

* Outcomes for MDR-TB reported two years after the end of the year of enrolment. Patients may not be necessarily have been treated using

internationally-recommended regimens or norms

Time trend, cases Treatment outcomes of MDR-TB cases,

2005 2006 2007 2008 2009 2010

Notified TB 302,467 341,165 353,619 388,882 405,982 396,554

Notified MDR-TB (absolute) 2000 6716 7350 8026 9070 7386

Notified MDR-TB (population rate per 100,000) 4 14 15 16 18 15

% new TB cases with DST

% retreated TB cases with DST

MDR-TB cases with outcomes 0 0 3815 4383

MDR-TB cases enrolled 4143 5402

Estimated number of MDR-TB cases among notified new pulmonary TB cases 5,100

Estimated number of MDR-TB cases among notified new pulmonary TB cases, low bound 4,000

Estimated number of MDR-TB cases among notified new pulmonary TB cases, high bound 6,500

Estimated number of MDR-TB cases among notified retreated pulmonary TB cases 4,100

Estimated number of MDR-TB cases among notified retreated pulmonary TB cases, low bound 3,300

Estimated number of MDR-TB cases among notified retreated pulmonary TB cases, high bound 5,000

Indicators of diagnosis, notification and treatment of multidrug-resistant TB, by region or country

Generated Source: www.who.int/tb/data 12-Jun-2012 03:25

The indicators on this page are intended to monitor the progress of countries to key drug-resistance targets in the Global Plan to Stop TB 2011-2015 (p

Indicators Target for 2015

% of new bacteriologically positive TB cases reported with drug-susceptibility testing ( ≥20%

% of previously treated TB cases reported with drug-susceptibility testing (DST) result 100%

% of patients with confirmed MDR-TB completing treatment successfully ≥75%

% of confirmed MDR-TB cases for whom outcomes are reported 100%

7/19/2012 Dr. Norbert Ndjeka 35

South Africa has the 3rd highest incidence of TB cases in the world (WHO, 2011)

5th highest number of drug-resistant TB cases in the world (WHO, 2011)

TB leading cause of mortality in South Africa (Statistics South Africa, 2011)

60% – 80% of all TB cases co-infected with HIV. (WHO, 2009; Gandhi et al., 2006)

TB in South Africa

South Africa

South Africa is among the high burden TB and MDR-TB countries worldwide

In 2010 we diagnosed: 7 386 MDR-TB patients (5313 started on treatment) and 741 XDR-TB diagnosed with 615 started on treatment

Success rate of MDR-TB is low 42% (2007 cohort), 48 % (2008 cohort)

Success rate Drug-susceptible TB is 78 % (2010) with a cure rate of 73 %

7/19/2012 36 Dr. Norbert Ndjeka

Laboratory diagnosed MDR-TB

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Laboratory diagnosed XDR-TB

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MDR-TB and XDR-TB initiated

on treatment

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TB IN SOUTH AFRICA

AVAILABLE DR-TB

SERVICES

42

Limpopo

North West Gauteng Mpumalanga

KZN Free State

Northern Cape

Western Cape

Eastern Cape

South Africa: 24 M(X)DR Units

= ~2,500 Beds

EXISTING MDR-TB units

MDR-TB Units before 2009

Decentralized MDR-TB Units after 2009

Patient Load and Bed Availability

(as of April 2011)

7/19/2012 43 Dr. Norbert Ndjeka

Management of DR-TB

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7/19/2012 Dr. Norbert Ndjeka 45

Flow

of D

R-T

B P

atie

nts

BREWELSKLOOF

HOSPITAL

Worcester

Harry Comay TB Hospital

Newly renovated ward

llllllllllllllll

DR-TB PATIENTS’ DINNING HALL

Changed outlook of patients’ dining hall to emulate hotel-like services

DR-TB PATIENTS’

ENTERTAINMEMNT

Procured recreation equipment for patients

28 October 2009 51

28 October 2009 52

TB IN SOUTH AFRICA

CONCLUSION

In conclusion…

South Africa is a high-burden TB and DR-TB country

One percent (1 %) of the South African population gets TB annually

Isoniazid preventive therapy, Intensified Case finding and Infection Control (“triple Is”) are critical in preventing TB

Building of health care facilities needs to consider the TB epidemiology by producing designs that decrease TB transmission

54 Dr Norbert Ndjeka

THANK YOU!

55 Dr Norbert Ndjeka