Once, a diagnosis of
extensively drug-resistant TB meant quick death. A three-drug regimen cures
most patients in just months.
By Donald G. McNeil Jr. Aug. 14, 2019
TSAKANE, South Africa
— When she joined a trial of new tuberculosis drugs, the dying young
woman weighed just 57 pounds.
Stricken with a
deadly strain of the disease, she was mortally terrified. Local nurses told her
the Johannesburg hospital to which she must be transferred was very far away —
and infested with vervet monkeys.
“I cried the whole
way in the ambulance,” Tsholofelo Msimango recalled recently. “They said I
would live with monkeys and the sisters there were not nice and the food was
bad and there was no way I would come back. They told my parents to fix the
insurance because I would die.”
Five years later, Ms.
Msimango, 25, is now tuberculosis-free. She is healthy at 103 pounds, and has a
young son.
The trial she joined
was small — it enrolled only 109 patients — but experts are calling the
preliminary results groundbreaking. The drug regimen tested on Ms. Msimango has
shown a 90 percent success rate against a deadly plague, extensively
drug-resistant tuberculosis.
On Wednesday, the
Food and Drug Administration effectively endorsed the approach, approving the
newest of the three drugs used in the regimen. Usually, the World Health
Organization adopts approvals made by the F.D.A. or its European counterpart,
meaning the treatment could soon come into use worldwide.
Tuberculosis has
now surpassed AIDS as the
world’s leading infectious cause of death, and the so-called XDR
strain is the ultimate in lethality. It is resistant to all four
families of antibiotics typically used to fight the disease.
Only a tiny fraction
of the 10 million people infected by TB each year get this type, but very few
of them survive it.
There are about 30,000 cases in
over 100 countries. Three-quarters of those patients die before they even
receive a diagnosis, experts believe, and among those who get typical
treatment, the cure rate is only 34 percent.
The treatment itself
is extraordinarily difficult. A typical regimen in South Africa requires up to
40 daily pills, taken for up to two years.
Other countries rely
on even older regimens that include daily injections of antibiotics that can
have devastating side effects, including deafness, kidney failure and
psychosis.
But in the trial Ms.
Msimango joined, nicknamed Nix-TB, patients took only five pills a day for six
months.
The pills contain
just three drugs: pretomanid, bedaquiline and linezolid. (Someday, the whole
regimen might come in just one pill, as H.I.V. drugs do, one expert said.)
Until recently, some
advocacy groups opposed pretomanid’s approval, saying the drug needed further
testing. But other TB experts argued that the situation is so desperate that
risks had to be taken.
Dr. Gerald Friedland,
one of the discoverers of XDR-TB and now an emeritus professor at Yale’s
medical school, called Nix “a wonderful trial” that could revolutionize
treatment: “If this works as well as it seems to, we need to do this now.”
A killer appears
News that
tuberculosis had evolved a terrifying new strain first broke in 2006, when doctors at a global AIDS
conference learned of a doomed group of tuberculosis patients in Tugela Ferry,
a rural South African town.
Of the 53 patients in
whom the strain had been detected, 52 were dead — most within a month of
diagnosis. They were relatively young: The median age was 35.
Many of them had
never been treated for TB before, meaning they had caught the drug-resistant
strain from others who had been infected and had not developed it by failing to
take their drugs. Several were health workers who were assumed to have caught
it from patients.
Within months, South
Africa realized it had cases of the deadly infection in 40 hospitals. Alarmed,
W.H.O. officials called for worldwide testing.
The results showed
that 28 countries, including the United States, had the deadly strain, XDR-TB,
and that two-thirds of the cases were in China, India and Russia. It took far
longer to determine how widespread it was in Africa, because most countries
there could not do the sophisticated testing.
H.I.V., the virus
that causes AIDS, helped drive the epidemic. Anyone infected with it is 25
times as likely to get TB, according to the W.H.O. But many victims, including
Ms. Msimango, catch this type of TB without ever having H.I.V.
In the early years,
XDR-TB was a death sentence. Doctors tried every drug they
could think of, from those used to treat leprosy to those for urinary tract
infections.
“From 2007 to 2014, we threw the kitchen sink
at it,’’ said Dr. Francesca Conradie, a researcher at the University of the
Witwatersrand, Johannesburg, and director of the Nix trial.
The death rate was
about 80 percent. Sometimes the drugs killed patients. In other cases, patients
died of the disease, because they could not tolerate the drugs and stopped
taking them.
Tuberculosis germs
burrow deep into the lungs and barricade themselves inside clumps of dead
cells. Breaking those nodules apart and killing all the bacteria inside
requires taking drugs for months.
Nearly all
antibiotics cause nausea and diarrhea. But some, especially the injections, are
far tougher on patients.
“Some get
hallucinations,” said Dr. Pauline Howell, a tuberculosis researcher who runs
the Nix trial at Sizwe Tropical Diseases Hospital in Johannesburg,
where Ms. Msimango was treated. “I had one patient who tried to cut open his
skin because he thought bugs were crawling under it.”
The drugs may leave
patients in wheelchairs with vertigo, or deaf in just a weekend. Nerves in
their feet and hands may wither until they can no longer walk or cook. One of
Dr. Howell’s patients suffered so much from ringing in the ears that he tried
to commit suicide.
Ms. Msimango, too,
veered close to death because the drugs were too much for her.
When she was 19, she
said, she caught drug-resistant TB from another young woman — the temporarily
homeless daughter of a friend of her mother.
Her mother had
generously taken in the young woman and had told her daughter to share her bed,
a common arrangement in townships like Tsakane. “A few weeks after she left, I
started coughing,” Ms. Msimango said.
“She had not told us
that she had drug-resistant TB and had defaulted,” she added, using a common
term for dropping out of treatment.
At first, Ms.
Msimango got her injections at a hospital and took her pills under her mother’s
watchful eye. But they made her feel so awful that she secretly spat them out,
stuffing them between the sofa cushions when her mother wasn’t looking.
After she defaulted
twice herself, she was transferred to Sizwe, terrified that she would die
alone.
No masks, no doctors
Although it lies in
South Africa’s largest city, Sizwe does host monkeys, along
with feral peacocks and the occasional mongoose. It has long been on the
front lines of South Africa’s protracted battle against tuberculosis.
The hospital sits on
an isolated hilltop 10 miles from downtown. The British built it in 1895
as Rietfontein Hospital to
house victims of contagious diseases like leprosy, smallpox and syphilis.
Gandhi volunteered there during
a 1904 bubonic plague outbreak,
and Archbishop Desmond Tutu was a tuberculosis patient there in his youth.
In 1996, with the
AIDS epidemic raging, the W.H.O. announced that South Africa had the world’s worst tuberculosis epidemic: 350 cases
per 100,000 citizens.
That finding shocked
the government, which had been using outdated approaches against the disease.
Diagnoses were made by X-ray, which are less accurate than sputum tests, and
doctors hospitalized every patient.
I visited shortly
after the 1996 announcement, and the situation inside Rietfontein was unnerving. In the
men’s ward, dozens of TB patients lay on cots only two feet apart; those with
drug-resistant strains slept next to patients with the usual type.
No one wore a mask,
and no doctor was on duty. At night, the patients shut the windows and turned
up the heat, and the room became a deadly incubator.
A return visit this
month showed that far more than the name had changed
(Sizwe means “nation” in Zulu).
The former men’s ward
is now a mostly empty meeting hall. Patients with TB that is not drug-resistant
are treated at home, and even those with partially drug-resistant strains are
usually hospitalized only briefly.
The XDR-TB patients
rest in a ward atop the hill, and golf carts transport those too weak to walk.
Each patient has a separate room and bathroom, hookups for oxygen and lung
suction, a TV and big windows and a door to the lawn outside.
The building has a
sophisticated ventilation system, but it often breaks down, so the policy is to
keep all the doors and windows open as much as possible, said Dr. Rianna Louw,
the hospital’s chief executive.
Patients can work in
the garden, play pool or foosball, and take classes in sewing, beading or other
crafts that might help them earn a living when they get out.
But the months of
isolation needed for treatment can be tough. “Our children are scattered, they
are falling apart!” a patient who gave her name only as Samantha
shouted at a group-therapy session that turned into an airing of grievances.
“The father of my
kids is in prison,” she said. “My firstborn son is arrested for robbing people
in the street. That would not happen if I was home!”
The counselor interrupted
to say: “We understand your frustration. But if we discharge you, we are taking
a risk. You are not healthy. You can still expose people to your disease.
That’s why you will stay a minimum of four months.”
A rush to approval?
The regimen
successfully tested at Sizwe is called BPaL, shorthand for the three drugs
it comprises: bedaquiline, pretomanid and linezolid.
The BPaL regimen is
“bold, because it’s three killer drugs instead of two killers plus some
supportive ones,” Dr. Howell said.
Most regimens, she
explained, rely on two harsh drugs that can destroy bacterial walls and include
others that have fewer side effects but only stop TB bacteria from multiplying.
But even the new
treatment poses hazards.
Short-term use of
linezolid against severe hospital infections causes few problems, but use for
many weeks against TB can kill nerves in the feet, making it hard to walk, or
can suppress the bone marrow where blood cells are made. (To find the ideal
linezolid dose, the Nix investigators have started a new trial, ZeNix.)
The F.D.A. approved bedaquiline in 2012 for use against multi-drug resistant
TB (the XDR strain is an even deadlier subset), and in 2015 the
W.H.O. followed suit. Until Wednesday, pretomanid was in dispute, although in
June an F.D.A. advisory committee voted 14 to 4 to
approve it.
Some advocacy groups
argued at the time that the drug had been too little tested.
“Pretomanid looks
like a promising drug, but it’s being rushed forward, and we don’t want to see
the F.D.A. lower the bar for approval,” Lindsay McKenna, co-director of the
tuberculosis project at the Treatment Action Group, an advocacy organization,
said in July.
Her organization and
others had asked the F.D.A. to first demand more rigorous testing of the drug.
Pretomanid is not
owned by a drug company but by the TB Alliance, a nonprofit based in New York that is
seeking new treatments.
Dr. Mel Spigelman,
the alliance’s president, had argued that a full clinical trial would be both
impractical and unethical.
“Put yourself in a
patient’s position,” he said. “Offered a choice between three drugs with a 90
percent cure rate, and 20 or more with less chance of cure — who would
consent to randomization?”
Such a trial would
cost $30 million and take five more years, he added: “That’s a very poor use of
scarce resources.”
‘There is no survival here’
Innocent Makamu, 32,
was facing two years in the hospital when he chose to join the Nix trial in
2017.
Like Ms. Msimango, he
also had caught drug-resistant TB from a roommate. A plumber, he had shared a
room at a distant construction site with a carpenter.
“He was too much on
the bottle,” Mr. Makamu said. “He kept defaulting.”
Soon afterward, he
began feeling tired and lost his appetite. Doctors at the hospital near his
home diagnosed tuberculosis, and put him on 29 daily pills and a daily
injection.
“It was deep in my
bum,” he said. “I couldn’t sit properly. It hurt every day.”
At the hospital, he
watched two other inpatients wither and die because they could not stick to the
regimen. “I thought, ‘Oh, there is no survival here.’”
Then further tests
showed that he had full-blown XDR-TB. He was transferred to Sizwe and offered a
spot in the Nix trial.
Some patients there
who were on the standard 40-pill regimens discouraged him. “They said, ‘They
are using you as guinea pigs,’” he said. “Even the nurses thought that.”
But he found the
possibility of taking only five pills for six months very tempting, and so he
volunteered. Within a month, he could tell it was working.
“Then the patients
who called us ‘guinea pigs’ — they wished they had taken the research pills,”
he said.
Donald G. McNeil Jr. is a science reporter covering epidemics
and diseases of the world’s poor. He joined The Times in 1976, and has reported
from 60 countries.
A version of this article appears in print on Aug. 14,
2019, Section A, Page 1 of the New York edition with the
headline: Cure Found for Deadliest Strain of Tuberculosis.
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