In 2006, South Africa experienced an tuberculosis epidemic that still leaves traces today. WHO quickly put in place recommendations to eradicate the disease. Dr Anandi Martin, a microbiologist at UCLouvain, was invited by WHO in November to visit the country and take stock of the situation.
Tuberculosis is the world's most frequently occurring life-threatening infectious disease, before HIV. One-third of the world's population is infected with Mycobacterium tuberculosis, the bacterium that causes it. Every year around the world, nearly ten million people develop tuberculosis, and two million die. In particular, India, China and Africa have experienced a very high number of tuberculosis cases in recent years. After many years studying tuberculosis in the field and in the laboratory, Dr Anandi Martin, a microbiologist at UCLouvain’s Institute of Experimental and Clinical Research (IREC), participated in a WHO mission in South Africa.
Alarming figures
In 2006, South Africa experienced an unprecedented tuberculosis epidemic. Between January 2005 and March 2006, in Tugela Ferry Hospital, KwaZulu-Natal, of 53 patients with extensively drug-resistant tuberculosis, 52 died very quickly. And the epidemic continues: every year, 1% of the total population of South Africa develops tuberculosis. These numbers are alarming. This is why WHO has put in place a strategy to fight tuberculosis.
A hard-to-eradicate epidemic
More than ten years later, the epidemic has not been eradicated. In this region of South Africa, access to diagnoses is difficult, prevention information does not reach the entire population, and treatment is not always properly followed. Tuberculosis can be cured with six months of treatment. However, WHO is concerned about multidrug-resistant tuberculosis (MDR-TB) and extensively resistant tuberculosis (XDR-TB) strains. They are almost impossible to treat and force health care staff to resort to second-line anti-tuberculosis treatment, which takes longer and is more toxic, more expensive and less well-tolerated. Multidrug-resistant tuberculosis is one of the most serious threats to tuberculosis control. Every year, about half a million people become infected with MDR-TB worldwide. The other major problem in recent years is tuberculosis co-infection with HIV. Tuberculosis is indeed an indicator disease of HIV. However, anti- tuberculosis drugs may interact with anti-HIV drugs. In HIV-positive people, tuberculosis must be managed by an expert, which is not possible in all countries.
A multidisciplinary team
In November 2018, Dr Martin and other tuberculosis experts visited six hospitals in South Africa (in the Kwazulu Natal Region, Gauteng Province, Johannesburg, Cape Town and Khayelitsha Township) to ensure that WHO’s recommendations were well-established. She was accompanied by Harvard Medical School (Boston, USA) and McGill University (Montreal, Canada) experts who tracked patient treatments. Another team from the Global Drug Facility (GDF-Stop TB Partnership) controlled the supply of medicines. Dr Martin came to observe the laboratories, their management and drug-resistance monitoring, and to make recommendations. At the end of ten days on-site, the goal was to observe improvements made on the ground but also gaps and challenges to face in the future.
Significant improvement and continued efforts
Returning from the mission, Dr Martin is already drawing some conclusions. First of all, according to her observations, South Africa has put a lot of money into laboratories which are now extremely well-equipped. All equipment necessary to working in the safest conditions are available: masks, negative pressure, etc. On the biosecurity side, therefore, there is clear improvement, but efforts still need to be made. For example, the system for transporting samples between laboratories isn’t optimal since the sputum samples are transported in simple crates by car. Another example is the negative pressure system needed for handling samples in the labs, which doesn’t always work. Finally, the staff engaged in these laboratories is not large enough given the great number of samples. At the end of their mission, the various experts communicated all these observations to the authorities of South Africa so that they can improve tuberculosis management.
Promising results
With the decentralisation of care and diagnostic laboratories, patient care has been considerably improved. The first results of these efforts are promising, as today in South Africa nearly 70% of MDR-TB patients don’t die. The means employed by the country to fight the disease have had an impact. South Africa is the first country to achieve this success rate and to show that controlling multidrug-resistant tuberculosis is possible with access to an effective new drug, bedaquiline.
The arrival of bedaquiline has brought real hope to patients with multidrug-resistant tuberculosis. For 40 years, no new drug had been invented to treat tuberculosis. South Africa has decided to deploy this treatment systematically for all patients with a multidrug-resistant form of tuberculosis, giving new hope to fighting resistance. Note also that the price of the drug has been halved; it now stands at $400 (less than €350 euros) for six months of treatment, which allows its use on a larger scale.
A recognised ‘made in UCLouvain’ screening test
Dr Martin contributed to the first victory against this multidrug resistance. In 2011, her rapid diagnostic test for tuberculosis screening was recognised by WHO and worldwide. More recently, she was part of the team that conducted clinical trials in patients with multidrug-resistant tuberculosis treated with bedaquiline. She is currently continuing her research on the drug, which has been approved by WHO for one year. By June 2017, 89 countries had introduced the new molecule to try to improve the efficacy of multidrug-resistant tuberculosis treatments. It will take a few years to see its real impact on the epidemic.
Lauranne Garitte
A glance at Dr Anandi Martin's bio
Dr Anandi Martin is a microbiologist specialising in tuberculosis (TB) research, with more than 20 years of experience in the field. She obtained her bachelor’s degree in biology (zoological sciences) at the University of Liège in 1992. She worked for two years in Bolivia as scientific coordinator of the National Tuberculosis Programme. She also worked for nine months in Siberia with Médecins Sans Frontières (MSF) in the prison TB programme. After her field experience, she joined the Institute of Tropical Medicine (ITM) in Antwerp, where she worked for more than 12 years in TB research, and completed her PhD focusing on the development of a new method for detecting drug resistance.
During this time she continued field missions in Africa, Asia and South America. For more than ten years she has been involved in several research projects funded by the European Commission (FP5-FP7). She was also part of the team that conducted the clinical trials in patients with multidrug-resistant TB treated with the new molecule, bedaquiline.
She then did a post-doctorate and worked as a senior researcher for four years at Ghent University. She has been a lecturer for the American Society of Microbiology (ASM) LabCap Program, a member of the WHO Expert Committee on TB, and a member of the WHO STOP-TB Partnership.
At the end of 2016 she joined UCLouvain, specifically the Medical Microbiology Laboratory (Pôle MBLG) of the Institute of Experimental and Clinical Research (IREC), where she continues her TB research activities. Her research interests include different aspects of TB and mycobacterial diagnosis, drug resistance, and operational and basic research. In 2011, WHO recognised her contribution to the TB field by recommending her new low-cost diagnostic test for detecting TB and resistance in low-income countries.