Brief Introduction of Tuberculosis
Tuberculosis (TB) is a disease caused by the bacteria Mycobacterium tuberculosis. It can affect the brain, kidneys or spine, but most commonly affects the lungs. It is an airborne disease, meaning that it is spread through the air from an infected person to another person.
Before the introduction of antibiotics, TB was treated with the sanatorium method, which was simply containing TB-infected patients in a medical facility for a long time.
With the introduction of antibiotics, patients were being cured much more successfully. However, the history of TB took an unexpected turn with incorrect use of antibiotics, causing new strains of the TB bacteria to emerge.
Tuberculosis and South Africa
South Africa’s TB crisis is severe, and in 2013 it was considered the country with the second-highest number of MDR-TB cases globally according to the World Health Organisation (WHO) (Padayatchi, et al., 16 September 2014). It is not clear as to when exactly TB was discovered in South Africa, but it was recognised as a significant medical condition in 1919. (Kanabus, 2016). Ever since, it has become a huge epidemic in South Africa, and its urgency is still present today.
Drug Resistance
The hereditary information in bacteria (ribose nucleic acid (RNA)) can mutate, which may result in allowing the bacterium to form new characteristics of survival. As a result, when a TB bacterium is not efficiently treated with the antibiotic (Tomlinson, 2011), it can form a mutation in its DNA/RNA when reproducing which can enable the mutated TB bacterium to withstand the otherwise fatal effects of the antibiotic, and further reproduce. In this way, drug-resistant strains of TB are formed.
TB and HIV/AIDS
TB and HIV/AIDS (Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome) are completely different infections. However, when a person who has HIV/AIDS contracts TB, the chances of death become higher as each infection quickens the adverse effects of one another (Kanabus, 2016). TB is, in fact, the leading cause of mortality for patients infected by HIV (in 2015, 35% of the global HIV deaths were because of TB (WHO, 2017).
When an individual with a co-infection of TB and HIV dies, that person’s cause of death is listed underneath HIV/AIDS. Therefore, it is important to keep an eye on the mortality rate of HIV-patients as well as many of them are infected by TB – this will enable additional data that may affect the findings of how TB affects the mortality rate of South Africa further on. South Africa itself is the third country with the most co-infected TB and HIV patients.
Outline
Scope:
My research falls under the category of a secondary research, as I am working from data collected from various accessible sources. I am conducting this investigation as TB is an urgent issue in South Africa today, and by examining the trend of drug-resistant TB, it can be a way to determine if the introduction of more anti-TB drugs to treat TB is indeed the best method to decrease the mortality rate caused by TB in South Africa. It can also be a way to predict how long a new anti-TB drug will be effective for until the TB bacteria will become resistant to that drug. These are the reasons why I am conducting my research.
Method:
Research the number of Drug-Resistant Tuberculosis (DR-TB) occurrences in specific years, starting from when Tuberculosis (TB) drugs were first introduced in South Africa.
Research the dates (years) in which specific anti-TB drugs were therapeutically used in South Africa.
*The results of this would indicate if there is a strong correlation between the number of DR-TB cases and the use of new anti-TB drugs in South Africa. These results could further be used to pose a question if the introduction of new anti-TB drugs is truly effective in combating drug-resistant strains of TB, and also to predict how soon resistance in new drugs would occur.
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Review of Literature
Source 1
Summary
South Africa is faced with the serious epidemic of tuberculosis (TB), with a heavy influence of the human immunodeficiency virus (HIV) worsening TB’s fatal effects. The number of TB cases is continually increasing in South Africa, and so South Africa has taken the initiative to control TB by finding, treating and preventing it. To find TB, South Africa has developed technologies to identify the bacteria, but difficulties of using the technologies due to its complexities continue to be a problem. TB is being treated with antibiotics, but the use of certain antibiotics is limited as they do not have an effect on recurring cases of TB, with the increase of drug-resistant not considered for retreatment of recurring TB cases, as South Africa is aware of drug-resistant TB. Prevention-wise, South Africa is not as focused on preventing TB as to treat it, but there are strategies planned. Worryingly, MDR-TB and XDR-TB cases have grown in number, with a not-too-successful treatment rate of 42% (MDR -TB) and 18% (XDR-TB) (2010).
Usefulness
This source is useful for my research as it provides a clear, scientific explanation of the situation of TB in South Africa in the present day. This enables me to extract data that I can use to better understand the effects of TB in South Africa specifically.
Validity
This journal was published in 2014, which is relatively recent. This can be seen in how the oldest data that was collected to be used is only from 2009, which is not too old. Most of the sources referenced to create this source are from 2012 onwards, which enables this source to be valid for my research.
Reliability
Academics who are an expert in the particular field of study (in this case of TB) have produced this journal, which would only be published if it were reliable and true. It compiles a succinct summary of a huge topic from many sources, allowing for a brief yet informative overview of TB. This source with its highly educated authors, professional editors and reliable analysis of the topic proves to be efficient in representing information.
Limitations
Some information mentioned in the journal is not related to my area of research, as the journal targets a specific audience whose interests may differ from mine (medical doctors and nurses). Therefore there is some information that is irrelevant to my research.
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Source 2
Summary
These guidelines are for healthcare professionals dealing specifically with treating the different strains of drug-resistant TB in South Africa. In particular, multiple-drug resistant TB (MDR-TB) is discussed in detail. The specific drugs used for each type of drug resistant TB (DRTB) is shown, with factors that contribute to the development of MDR-TB such as poorly continued medication regimen, and the spreading of MDR-TB through the air with insufficient preventive measures. The number of cases of DRTB throughout several years in South Africa is also shown in the means of a table, showing an increase in the number of reported cases.
Usefulness
The identification, treatment and prevention of drug-resistant TB in South Africa are explicitly examined. However, these guidelines are for healthcare workers specifica
lly, making some of the numerous and tedious data presented irrelevant for the use of my research. Therefore although it provides quality data, it provides too many unnecessary data for my research.
Validity
This source is valid as it is a compilation of the policy guidelines for doctors and nurses in the treatment of drug-resistant TB, published in 2013. It is recent publication of formal information that has been put together by numerous researchers, and therefore is valid. However, there could have been changes made if new data was found after the publication.
Reliability
These guidelines were put together by many qualified researchers, which were then formally published by the Department of Health of South Africa. This proves its reliability, accuracy and legitimacy. The given information is also relevant to the context of TB in South Africa, by exploring the factors characteristic to South Africa with TB.
Limitations
Limitations in this source include jargon used by doctors and nurses that may be difficult to understand without prior knowledge. Therefore, the language and diction used limits people other than medical practitioners in understanding the source.
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Source 3
Summary
The different categories of TB drugs are explored, with specific examples of drugs with their names. First line drugs have a significant effect on patients who have not been exposed to TB before, and can fight TB efficiently. When treating TB patients, several drugs should be taken at the same time, as drug resistance will be obtained more quickly if only one drug is used at a time. Second line drugs (injectable agents), fluoroquinolones, other core second line agents, and add-on agents are then used in different combinations for drug-resistant TB patients, according to what strain of drug resistant TB they may have contracted (MDR / XDR – TB).
Usefulness
A clear, simple layout of the information about TB drugs allows for quick understanding, and proves to be very useful for my research as I am able to collect the necessary data in a simple and straightforward way, without wasting time reading unnecessary information.
Validity
In this source’s instance, it is regularly updated to ensure that the information provided is valid. Furthermore, the information provided by this source draws on data from other sources mainly from 2010, which is still quite recent and therefore valid.
Reliability
The reliability of the source is not quite clear, as the qualifications of the author are not disclosed to us. This disables us from knowing if the author is a legitimate source that we can trust, as he/she could be an unqualified person drawing assumptions from other people’s work, and representing it in their own way. Therefore it is not a very reliable a source.
Limitations
Further insight into learning about the TB drugs is limited, as this source is for the understanding of the general public. Therefore, this source has limitations in knowing the drugs on a deeper level, such as how they work and what effect they have on the TB bacterium.
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Source 4
Summary
Anti-tuberculosis antibiotic-resistant strains of TB were first recorded in the late 1940s. The World Health Organization (WHO) set up a project – namely the Global Tuberculosis Program – to collect data from reports and surveys relating to TB and keep an eye on the drug-resistant strains of TB. In 2006, the TB epidemic proved to be more threatening as extensively drug resistant TB (XDR TB) was identified.
A particular trend in 2014 showed that about 40% of reported pulmonary TB patients that year also showed to have MDR-TB. Although they were treated more successfully than previous years, there was a definite increase in the amount of MDR TB patients who started using second-line drugs for treatment. New drugs such as bedaquiline (2013) and delamanid (2014) were also accepted for the treatment of TB – they are already being used by many institutions.
Usefulness
This source explores the trends of TB drug-resistance throughout the past, the present and predictions for the future, allowing a deep insight into the topic. This is valuable for my investigation as it falls under the area of study that I will closely be examining.
Validity
This source was published in 2016, proving it to be a very recent source with relevant data that is valid in my research.
Reliability
Many academic scholars with their medical degrees and honours have contributed to this source, proving its reliability. Specialists in different studies have come together to form a solid, relevant and detailed analysis which is indeed soundly reliable.
Limitations
This source explores the global trends of TB, and not a specific country. Since I am exploring the impact of TB on South Africa specifically, this source may present relevant facts but not specific data that I may need for my research. It is also a special report designated for a specific scientific audience, which then may exclude certain people like me not used to the jargon.
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Source 5
Summary
A woman was treated with 26 different antibiotics during her hospitalization, to combat a germ from the carbapenem-resistant Enterobacteriaceae (CRE) group. However, none of the antibiotics had an effect on combating the germ, and she was eventually killed by the germ. The rising concern of the emergence of superbugs that cannot be treated with any of our known antibiotics has escalated, as drug resistance is becoming more prominent even in our everyday illnesses such as food poisoning. As these germs mutate to withstand the effect of antibiotics, doctors prescribe stronger drugs which may harm body tissue and also provide an opportunity for the germ to mutate again to form a more resilient resistance against the even the stronger drugs. Thus, more superbugs are emerging with more patients contracting the already-drug-resistant strain of germs, with more deaths occurring due to superbugs. Although the problems occurring because of drug-resistant germs cannot be solved completely, more precautions and strategies should be employed in the coming future.
Usefulness
Although drug resistance is an important aspect for my research topic, this source does not engage with TB in particular. It is also heavily based on an American background, which may make it irrelevant to the antibiotic-resistance situation in South Africa. Therefore, it only provides useful data to a limited extent.
Validity
This article is a very recent article, proving its relevance and significance in our world today. Therefore it proves to be valid and significant.
Reliability
The article is written by someone whose qualifications are not disclosed to us. Therefore, the reliability of the source is questionable as it may just be a summary of other’s opinions and thoughts organized by someone who is not necessarily an expert in the topic being discussed. However, this is compensated for with the many examples, statistics, quotes and thoughts from various doctors and institutions that the author uses.
Limitations
The article is a rather general overview of the problem
s with antibiotic-resistance occurring today – whereas with my research I need specific analysis focusing on TB. Still, it allows for a succinct summary of the foreboding aspect of antibiotic resistance today.
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Methodology and Presentation of Findings
Mentioned in Introduction:
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Data that will be examined:
Types of drug resistant TB
Brief Summary of some significant anti-TB drugs
TB Mortality rate in South Africa (1997-2015)
HIV-caused Mortality rate in South Africa (1997-2015)
Number of laboratory diagnosed MDR-TB reported incidents in South Africa (2004-2012)
Number of laboratory diagnosed XDR-TB reported incidents in South Africa (2004-2012)
Number of TB cases in comparison to the number of MDR-TB cases
The increase in number of notified MDR-TB cases globally, as well as the dates when certain anti-TB drugs were introduced
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Types of drug-resistant TB
Type of drug-resistant TB Definition
Mono-drug resistant TB The resistance to one first-line defense drug.
Poly-drug resistant TB The resistance to two or more anti-TB drugs which do not include rifampicin and isoniazid.
Multiple drug resistant (MDR) TB The resistance to at least 2 of the first-line defense drugs (rifampicin and isoniazid)
Extensively drug resistant (XDR) TB The resistance to rifampicin, isoniazid, any fluoroquinolone, and at least one of the injectable second-line defense drugs
Totally/Extremely drug-resistant (XXDR) TB The resistance to all first-line and second-line defense drugs
Summarised content, (Department of Health of South Africa, 2014)
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Brief Summary of some significant anti-TB drugs
TB Mortality rate in South Africa (1997-2015)
I have compiled data from the mortality rate reports from statssa.gov.za from the reports of the year 2000 and onwards. (It was not possible to find earlier reliable reports).
Data in table compiled by myself from: (Statistics South Africa, 2000-2016)
A table showing the number of TB-caused deaths, and the percentage from the total number of deaths in the years 1997-2015 in South Africa
Year Number of TB-caused deaths Percentage from total number of deaths (%)
1997 22 071 7.0
1998 28 532 7.8
1999 34 250 9.0
2000 42 246 10.2
2001 50 872 11.3
2002 60 311 12.1
2003 74 622 12.2
2004 70 355 12.3
2005 73 903 12.5
2006 77 009 12.7
2007 76 968 12.8
2008 75 281 12.6
2009 69 791 12.0
2010 62 827 11.6
2011 55 102 10.7
2012 48 409 9.9
2013 41 904 8.8
2014 39 495 8.3
2015 33 063 7.2
HIV-caused Mortality rate in South Africa (1997-2015)
I have compiled data from the mortality rate reports from statssa.gov.za from the reports of the year 2000 and onwards. (It was not possible to find earlier reliable reports).
Data in table compiled by myself from: (Statistics South Africa, 2000-2016)
A table showing the number of HIV-caused deaths, and the percentage from the total number of deaths in the years 1997-2015 in South Africa
Year Number of HIV-caused deaths Hypothetical number of deaths caused by co-infection of HIV and TB Percentage from total number of deaths (%)
1997 6 235 2182.25 2
1998 7 269 2544.15 2
1999 9 935 3477.25 2.6
2000 10 459 3660.65 2.5
2001 9 244 3235.40 2
2002 10 491 3671.85 2.1
2003 11 678 4087.30 2.1
2004 13 440 4704.00 2.3
2005 14 532 5086.20 2.5
2006 14 783 5174.05 2.4
2007 13 561 4746.35 2.2
2008 15 179 5312.65 2.5
2009 17 785 6224.75 3.1
2010 18 325 6413.75 3.4
2011 17 338 6068.30 3.4
2012 19 146 6701.10 3.9
2013 23 825 8338.75 5
2014 22 729 7955.15 4.8
2015 21 926 7674.10 4.8
Number of laboratory diagnosed MDR-TB reported incidents in South Africa (2004-2012)
These tables and line graph are directly from the policy guidelines as found in https://www.health-e.org.za/wp-content/uploads/2014/06/MDR-TB-Clinical-Guidelines-Updated-Jan-2013.pdf by the Department of Health of South Africa
Some line graphs compiled by myself from the above mentioned source
Number of laboratory diagnosed XDR-TB reported incidents in South Africa (2004-2012)
These tables and line graph are directly from the policy guidelines as found in https://www.health-e.org.za/wp-content/uploads/2014/06/MDR-TB-Clinical-Guidelines-Updated-Jan-2013.pdf by the Department of Health of South Africa
Some line graphs compiled by myself from the above mentioned source
Number of TB cases in comparison to the number of MDR-TB cases
This table is directly from the policy guidelines as found in https://www.health-e.org.za/wp-content/uploads/2014/06/MDR-TB-Clinical-Guidelines-Updated-Jan-2013.pdf by the Department of Health of South Africa
The increase in number of notified MDR-TB cases globally, as well as the dates when certain anti-TB drugs were introduced
This table is directly from the policy guidelines as found in http://erj.ersjournals.com/content/45/4/1119 by Ioana Diana Olaru, Florian von Groote-Bidlingmaier, Jan Heyckendorf, Wing Wai Yew, Christoph Lange, Kwok Chiu Chang, European Respiratory journal
Processing of Findings
Analysis of the introduction of anti-TB drugs and drug resistance
Unfortunately, MDR-TB has been present in South Africa but the data tracing back to its first appearance is very limited. Still, I am able to deduct certain conclusions from the research done on th
e individual drugs tabulated on page 17.
Although it was not explicitly stated, drug resistance started surfacing with the singular use of streptomycin when it was used singularly. Streptomycin as found in the 1940s, and therefore drug resistance to that drug also most probably emerged in the late 1940s or early 1950s.
Ethambutol was introduced in 1961, and proved to act against strains of TB that were already resistant to isoniazid and streptomycin.
Pyrazinamide was used to treat MDR-TB classified patients after being introduced in 1952, and was then quite efficient in treating MDR-TB patients when used with other first-line defense drugs.
More recently, moxifloxacin, introduced in 1996, is used by South Africa specifically for drug-resistant TB patients.
It was only in the 2010s that new anti-TB drugs, such as bedaquiline and delamanid were introduced. These drugs seem to be working against MDR-TB and XDR-TB, but they are very recent drugs, and with improper use, may become ineffective if new strains of TB become resistant to it.
The research done on the anti-TB drugs alone show us that certain drugs became ineffective in treating TB, and had to be used in conjunction with other stronger drugs. Even before MDR-TB patients were clearly defined and recorded from the 21st Century, more strains of drug-resistant TB were created with introduction of new anti-TB drugs. New drugs were discovered to treat TB, which became ineffective after time as TB became resistant to it, which urged more new drugs to be found, which then had to be used in conjunction with other previous drugs to be effective. Therefore, it can be stated that with the new introduction of more anti-TB drugs, the TB bacteria itself is being exposed to these drugs and can form mutations that are resistant to it in a relatively short time.
Analysis of the mortality rate in regards to TB-related deaths and HIV-related deaths
The data I have collected shows that TB-caused deaths are one of the main contributors to mortality rate in South Africa, at least from 1997 to 2016. However, data shows that TB-related deaths are decreasing in the 2010s, and therefore TB-caused deaths may start to decline and not be a further contributor to the main causes of mortality in South Africa. Still, this may just be temporary as just before 2010, TB-caused deaths were increasing. The mortality rate may just be fluctuating.
When viewed in conjunction with the theoretical HIV-TB co-infected deaths, along with the steadily increasing MDR-TB and XDR-TB cases, it can be predicted that TB will continue to be a major cause of mortality in South Africa. This is because the HIV-caused mortality rate continues to increase without signs of decreasing as seen by the line graph on page 23, in which about 1/3 (35%) of the deaths (WHO, 2016) are caused by TB.
Also, the rates of MDR-TB and XDR-TB show that currently, hard-to-treat cases are only increasing, which would then lead to more difficult TB treatments to take place. Although TB cases in general are decreasing, the overall picture of the TB epidemic in South Africa does not look promising with the rapidly increasing MDR-TB and XDR-TB cases. Therefore, I believe that from the data I have collected, the future of the TB epidemic of South Africa is not promising, despite the seemingly positive outlook of the TB-caused mortality rate in the 2010s.
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Conclusion
In short, the research done on the anti-TB drugs shows that new strains of drug-resistant TB started to emerge with the introduction of new drugs.
Also, the rapidly increasing number of MDR-TB and XDR-TB cases, and the increasing number of HIV-caused deaths most probably point to the conclusion that TB in general will continue to be a major cause of mortality in South Africa. This is in despite of the fact that TB-caused deaths, and TB cases seem to be decreasing slowly. The rapid increase in MDR-TB and XDR-TB cases, as well as the steadily increasing HIV-caused deaths nullifies the hopes that TB is decreasing.
I conclude that with the new development of TB drugs, more strains of DRTB bacteria are formed, and that the new development of DRTB bacteria in correlation with the HIV epidemic will continue to be a major cause of mortality in South Africa. Therefore, I accept both my hypothesis 1 and 2,
Limitations
Unfortunately, I could not find reliable data about MDR-TB before 1997, as there were difficulties in identifying it, as well as officially recording this data. The lack of technology and political problems such as Apartheid could have been the reasons for the very limited reliable data on early TB resistance in South Africa. Therefore, I could not appropriately compare the number of MDR-TB cases per year in relation to the years that certain anti-TB drugs were introduced as I had originally planned to do so. Consequently, my conclusion is drawn on the logical assumptions made from the research on the anti-TB drugs only. This does not make my conclusion for my Hypothesis 1 strong, and therefore there were limitations in my research for hypothesis 1 in the lack of reliable data to draw results from.
For my hypothesis 2, I was able to access explicit data on the mortality rate of South Africa in relation to TB-caused deaths and HIV-caused deaths. However, since the co-infection of TB and HIV is considered under HIV-caused deaths, I had to make an academic guess about the number of TB-caused deaths within the HIV-caused death rate (with data provided by the WHO that 35% of HIV-caused deaths are due to the co-infection of TB and HIV). Also, data provided on the number of MDR-TB and XDR-TB cases is also inaccurate because these are only the numbers of the reported cases. Due to the lack of understanding of the new technology, MDR-TB is often misdiagnosed or undetected, and it is even more tedious to detect XDR-TB. Furthermore, there are also many patients who suffer from MDR-TB but are unable to access medical facilities to be treated. Therefore, although the data I have used is data from official, professional publications, it is in fact not an accurate representation of the reality of the TB epidemic of South Africa. This makes my conclusion for hypothesis 2 correct if only looking at the data provided by the statssa.gov.za, but it is inaccurate when referring to the overall TB epidemic of South Africa.
Recommendations
TB is a broad term for the many different types of TB affecting different people in South Africa, let alone the world. For further research of a similar nature to mine, I would suggest that one should focus on more specific and recent phenomena of TB in South Africa, such as the XDR-TB outburst in Kwa-Zulu Natal. There is very limited data about the history of TB and its treatment in South Africa, and therefore it would be more effective to assemble data from recent phenomena to find significant conclusions that can truly help fighting the TB epidemic in South Africa, as TB continues to be a major threat, Also, focusing on the actual treatment of South Africa would be more effective in overcoming the TB epidemic, as drug resistant strains of TB only occur from direct contamination which all starts from maltreatment,