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Responding to SARS-CoV-2 in South Africa: What can we learn from drug-resistant tuberculosis?

Norbert Ndjeka, Francesca Conradie, Graeme Meintjes, Anja Reuter, Jennifer Hughes, Xavier Padanilam, Nazir Ismail, Yulene Kock, Iqbal Master, Rodolfo Romero, Julian te Riele, Martin Enwerem, Hannetjie Ferreira, Gary Maartens
European Respiratory Journal 2020; DOI: 10.1183/13993003.01369-2020
Norbert Ndjeka
1National department of health, drug resistant TB directorate, Pretoria, South Africa
13Joint first author: NN and FC contributed equally
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Francesca Conradie
2University of Witwatersrand, Faculty of Health Sciences, Department of Clinical Medicine, Johannesburg, South Africa
13Joint first author: NN and FC contributed equally
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Graeme Meintjes
3Department of Medicine and Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Rondebosch, South Africa
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Anja Reuter
4Medicines Sans Frontieres, Khayelitsha, South Africa
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Jennifer Hughes
5Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
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Xavier Padanilam
6Sizwe Tropical Disease Hospital, Department of Health, Gauteng, South Africa
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Nazir Ismail
7Centre for Tuberculosis, National Institute for Communicable Diseases, Johannesburg, South Africa
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Yulene Kock
1National department of health, drug resistant TB directorate, Pretoria, South Africa
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Iqbal Master
8King Dinuzulu Hospital, Kwazulu Natal Provincial Department of Health, Durban, South Africa
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Rodolfo Romero
9Clinical head, District Clinical Specialist Team, Namakwa, Northern Cape, South Africa
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Julian te Riele
10Metro TB Hospital Centre, Brooklyn Chest Hospital, Cape Town, Western Cape, South Africa
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Martin Enwerem
11Witbank TB Specialized Hospital, Witbank, Mpumalanga, South Africa
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Hannetjie Ferreira
12Klerksdorp-Tshepong Hospital, Klerksdorp, North West, South Africa
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Gary Maartens
3Department of Medicine and Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Rondebosch, South Africa
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Abstract

Rapid adoption of new diagnostic tools, parallel process of research and implementation, decentralization of services, the use of personal protective equipment as well as strong partnership and collaboration could strengthen the fight against COVID-19.

Introduction

The novel coronavirus strain, SARS-CoV-2, was first reported from China in December 2019 [1]. As of the 14th May 2020, more than 4.4 million individuals have tested positive for SARS-COV-2 globally [2]. More than 300,000 individuals have died globally due to SARS-COV-2 [2]. In South Africa (SA), cumulatively at the same time point, 12739 individuals were infected and 238 deaths reported [2]. Tuberculosis is the leading infectious disease cause of death with 1.4 million deaths in 2018 [3]. Drug-resistant tuberculosis (DR-TB) is a threat to tuberculosis control globally. Over the last decade, several interventions have improved the outcomes of DR-TB patients and reduced the burden of disease. We discuss lessons from DR-TB interventions in South Africa that could be helpful in the fight against SARS-COV-2.

Lessons from DR-TB

  1. Rapid adoption of new diagnostics.

  2. Early awareness, testing and diagnosis are important factors in successful management. The use of GeneXpert MTB/RIF brought about a revolution in diagnosing DR-TB reducing time to detection from weeks to days. The recommended primary diagnostic for SARS-COV-2 detection is molecular using polymerase chain reaction method. Several rapid molecular diagnostic methods are available and should be rapidly evaluated and implemented. South Africa has adopted several and recently also introduced the GeneXpert Xpress SARS-CoV-2 cartridge diagnosing COVID-19 within 45minutes, leveraging the GeneXpert platform that is decentralised and extensively used for TB diagnosis.

  3. Parallel process of research and implementation: The Bedaquiline Clinical Access Programme (BCAP) provided access to a novel drug for DR-TB patients, generated local evidence to support decision-making, led to rapid adoption, bolstering the fight against an infectious disease [4]. We managed to reduce mortality among DR-TB patients after updating our clinical guidelines using local data [5]. Death rate decreased from 45% (2010 cohort) to 21% (2016 cohort) among XDR-TB patients and treatment success rate improved from 9% to 58% during the same period in this group of patients. Importantly outcomes were monitored closely after introduction of novel regimens and ensured that data is put in the public domain timeously. The BCAP model is a good example and we encourage rapid referral to COVID-19 clinical trials being conducted, the Solidarity clinical trial is an example and will evaluate new and repurposed agents to treat COVID-19. Another example of a research project that helped drive development of country-specific policies is the surveillance of adverse events conducted by Borisov et al. [6].

  4. Decentralisation of complex services for easy access for community members. Bringing screening, testing and treatment close to where people live has proved to produce better treatment outcomes for DR-TB patients in South Africa and helped reduce cost of DR-TB care [7]. Such interventions are key to success in the fight against SARS-COV-2. Effective decentralisation facilitates contact tracing important for both conditions and has been well resourced for COVID. It is a missed opportunity however not to test for TB when investigating COVID-19 and vice versa. This is recommended by WHO, local adoption is now planned and should be considered in high burden TB settings.

  5. The use of personal protective equipment (PPE) by health care workers and patients:

  6. The use of PPE especially in clinical environments has been associated with reduction of DR-TB transmission among health care workers (HCWs) in various settings. Administrative and environmental factors are also critically important for DR-TB. The major challenge has been scarcity of PPE in various areas where they are needed to manage unsuspected, undiagnosed infectious patients and this is being adequately addressed.

  7. Strong partnership and collaboration

  8. This is a central to the response and led to improvement of DR-TB treatment outcomes. Government officials, academia, non-governmental organisations, and civil society worked together in coalition driving the successes observed [8].

  9. Management of TB and COVID-19 co-infection: as both conditions affect the respiratory system with overlapping symptoms, clinicians are urged to test for both. This is particularly important to prevent nosocomial spread when hospitalisation is needed for either. A total of 776 beds have been identified out of 3798 beds at 33 DR-TB treatment sites. Although, the first TB-COVID-19 cohorts reported did not show a high death rate in this group [9, 10]; HIV co-infection among TB is 59% in SA and is dual risk. Integrating COVID-19 activities in the TB (and HIV) programmes is important.

Conclusion

The fight against SARS-COV-2 can be won if we continue to make effective use of rapid diagnostic tools, effective contact tracing, decentralise treatment services, and strengthen the use of personal protective devices in areas that need them most. Equally importantly partnership between government and private sector, political commitment and learning implementation may go a long way to defeat SARS-COV-2.

Footnotes

  • Data availability: Not applicable

  • Conflict of interest: Dr. NDJEKA has nothing to disclose.

  • Conflict of interest: Dr. Conradie has nothing to disclose.

  • Conflict of interest: Dr. Meintjes has nothing to disclose.

  • Conflict of interest: Dr. Reuter has nothing to disclose.

  • Conflict of interest: Dr. Hughes has nothing to disclose.

  • Conflict of interest: Dr. Padanilam has nothing to disclose.

  • Conflict of interest: Dr. Ismail has nothing to disclose.

  • Conflict of interest: Dr. Kock has nothing to disclose.

  • Conflict of interest: Dr. Master has nothing to disclose.

  • Conflict of interest: Dr. Romero Leyet has nothing to disclose.

  • Conflict of interest: Dr. te Riele has nothing to disclose.

  • Conflict of interest: Dr. Enwerem has nothing to disclose.

  • Conflict of interest: Dr. FERREIRA has nothing to disclose.

  • Received April 23, 2020.
  • Accepted May 21, 2020.
  • Copyright ©ERS 2020
http://creativecommons.org/licenses/by-nc/4.0/

This article is open access and distributed under the terms of the Creative Commons Attribution Non-Commercial Licence 4.0.

References

  1. ↵
    1. World Health Organization (WHO)
    . Rolling updates on Coronavirus disease (COVID-19). Accessible on www.who.int/emergencies/diseases/novel-coronavirus-2019/events-as-they-happen Accessed on 20/04/2020
  2. ↵
    1. Johns Hopkins University
    . Johns Hopkins Coronavirus Dashboard. Track the coronavirus outbreak on Johns Hopkins Live Dashboard. Accessible on www.coronavirus.jhu.edu/map.html. Accessed on 14/05/2020.
  3. ↵
    1. World Health Organization (WHO)
    . Global TB report. Geneva, 2019. Accessible on www.who.int/tb/global-report-2019 Accessed on 04/04/2020.
  4. ↵
    1. Ndjeka N,
    2. Schnippel K,
    3. Master I, et al.
    High treatment success rate for multidrug-resistant and extensively drug-resistant tuberculosis using a bedaquiline-containing treatment regimen. Eur Respir J 2018; 52: 1801528. doi:10.1183/13993003.01528-2018
    OpenUrlAbstract/FREE Full Text
  5. ↵
    1. Schnippel K,
    2. Ndjeka NO,
    3. Maartens G, et al.
    Effect of bedaquiline on mortality in South African patients with drug-resistant tuberculosis: a retrospective cohort study. Lancet Respir Med 2018; 6: 699–706. doi:10.1016/S2213-2600(18)30235-2
    OpenUrl
  6. ↵
    1. Borisov S,
    2. Danila E,
    3. Maryandyshev A, et al.
    Surveillance of adverse events in the treatment events in the treatment of drug-resistant tuberculosis: first global report. Eur Respir J 2019; 54: 1901522. doi:10.1183/13993003.01522-2019
    OpenUrlAbstract/FREE Full Text
  7. ↵
    1. Sinanovic E,
    2. Ramma L,
    3. Vassall A, et al.
    Impact of reduced hospitalisation on the cost of treatment for drug-resistant tuberculosis in South Africa. Int J Tuberc Lung Dis 2015; 19: 172–178. doi:10.5588/ijtld.14.0421
    OpenUrlCrossRefPubMed
  8. ↵
    1. Conradie F,
    2. Meintjes G,
    3. Hughes J, et al.
    Clinical Access Program for Bedaquiline for the treatment of drug-resistant tuberculosis. S Afr Med J 2014; 104: 164–166. doi:10.7196/SAMJ.7263
    OpenUrlCrossRefPubMed
  9. ↵
    1. Tadolini M,
    2. Codecasa LR,
    3. Garcia-Garcia JM, et al.
    Active tuberculosis, sequelae and COVID-19 co-infection: first cohort of 49 cases. Eur Respir J 2020. in press.
  10. ↵
    1. Motta I,
    2. Centis R,
    3. D'Ambrosio L, et al.
    Tuberculosis, COVID-19 and migrants: preliminary analysis of deaths occurring in 69 patients from two cohorts. Pulmonology 2020. doi:10.1016/j.pulmoe.2020.05.002 [published online ahead of print, 2020 May 14]
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Responding to SARS-CoV-2 in South Africa: What can we learn from drug-resistant tuberculosis?
Norbert Ndjeka, Francesca Conradie, Graeme Meintjes, Anja Reuter, Jennifer Hughes, Xavier Padanilam, Nazir Ismail, Yulene Kock, Iqbal Master, Rodolfo Romero, Julian te Riele, Martin Enwerem, Hannetjie Ferreira, Gary Maartens
European Respiratory Journal Jan 2020, 2001369; DOI: 10.1183/13993003.01369-2020

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Responding to SARS-CoV-2 in South Africa: What can we learn from drug-resistant tuberculosis?
Norbert Ndjeka, Francesca Conradie, Graeme Meintjes, Anja Reuter, Jennifer Hughes, Xavier Padanilam, Nazir Ismail, Yulene Kock, Iqbal Master, Rodolfo Romero, Julian te Riele, Martin Enwerem, Hannetjie Ferreira, Gary Maartens
European Respiratory Journal Jan 2020, 2001369; DOI: 10.1183/13993003.01369-2020
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