Drug Resistant Tuberculosis in South Africa: Findings from a Nationwide Survey, 2012-2014

Executive summary South Africa is one of the 22 highest tuberculosis (TB) burdened countries globally and the occurrence of laboratory-confirmed multi drug resistant TB (MDR–TB) and extensively drug resistant TB (XDR-TB) has long been recognized in South Africa. A drug resistance survey (2012-2014) to quantify and delineate the extent of drug resistance in new and retreatment TB patients nationally and provincially in South Africa, as well as to compare findings with the previous survey (2001-2002) was undertaken based on WHO guidelines. The prevalence of MDR-TB nationally in the latest survey was measured at 2.1% in new cases and 4.6% in retreatment cases with an overall, MDR-TB estimate of 2.8%. Compared to the previous survey, the MDR-TB prevalence has remained relatively stable over the tenyear period. The highest rate observed was in Mpumalanga province with an overall rate of 5.1%. Contrasted to the MDR-TB prevalence nationally, the rate of any rifampicin-resistance prevalence has increased since the previous survey, primarily seen among new cases, and almost doubling from 1.8% to 3.4%, highlighting the likely role of transmission. Second -line drug resistance prevalence among MDR-TB cases was for the first time evaluated in this survey and the findings are concerning. The prevalence of resistance to ethionamide and pyrazinamide, both used empirically in the treatment of MDR-TB, was found to be high at 44.7%% and 59.1% respectively. Additionally, resistance levels to the key drug classes, fluoroquinolones and injectable agents, were both 13%, highlighting the relatively high frequency of preextensively drug-resistant tuberculosis cases among those with MDR-TB. These findings highlight emerging threats to drug resistant TB control requiring urgent intervention.