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At the Wallacedene clinic, a short drive from Cape Town’s bustling waterfront full of tourists and richer citizens, dozens of South Africans with tuberculosis sit patiently waiting for advice and support from nurses and doctors.
They are at the centre of an epidemic of one of the world’s biggest infectious disease killers and many struggle to find medicines that will improve their health. The risks they face highlight the broader need for affordable, reliable, accessible and rapid diagnostics to tackle a growing global threat of antimicrobial resistance (AMR).
Most weeks, staff identify fresh cases of multidrug resistant TB. These require complex and lengthy therapy with multiple medicines that bring side effects still worse than the painful standard six-month treatment.
Even bedaquiline, one of the newest “salvage therapies”, used when other drugs have failed, is not always effective. Doctors say local people who were never previously infected are starting to contract directly strains of TB that are already resistant to the drug, leaving them with no further options.
One of the biggest problems is a low rate of detection, with existing diagnostics relatively slow, unavailable and expensive. That leaves people untreated and enables the disease to spread more widely. Existing tests that require hospital referrals and several days to process can often lead to patients dropping out of the system altogether.
Doctors are now experimenting with new approaches to active case finding, the systematic screening of people suspected of having TB, and taking diagnostics into local communities and seeking out cases rather than waiting for patients to approach the medical profession.
of healthcare decisions are influenced by diagnostics. Only 1% of spending goes on them
There is an urgent need to develop more effective tools for diagnosing illness. TB provides one of the more striking illustrations of this need, but more generally drug resistance is growing, undermining the power of the already limited range of antibiotics available to treat patients.
“Rapid diagnostics could transform the way we use antimicrobials in humans and animals: reducing unnecessary use, slowing AMR and so making existing drugs last longer,” wrote Jim O’Neill, the economist, in his 2016 report on antimicrobial resistance for the British government. “I find it incredible that doctors must still prescribe antibiotics based only on their immediate assessment of a patient’s symptoms, just like they used to when antibiotics first entered common use in the 1950s.”
Without good diagnostics, doctors cannot reliably identify treatments or generate data to help track the spread of infection. Often they provide inappropriate older medicines or else over-use innovative newer drugs, failing to cure patients while worsening resistance.
Yet diagnostics remains the poor cousin of medicine, suffering from under-investment in research and insufficient support to ensure that treatments that are already available are widely disseminated and used where doctors and patients need them.
“About 80 per cent of healthcare decisions are influenced by diagnostics, but only 1 per cent of spending goes on them,” says Catharina Boehme, chief executive of Geneva-based non-profit Foundation for Innovative New Diagnostics (Find), which works with researchers and companies with a focus on patients in poorer countries.
Find has helped support the development and application in South Africa of GeneXpert, a test that confirms TB and the presence of the strain resistant to the drug rifampicin. It is working on newer and more portable techniques to help more effectively identify resistant TB.
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Like many other diagnostics experts, Find say there is an urgent need to develop a simple “triage” test that can allow doctors to distinguish viral from bacterial infections in their patients.One of the biggest concerns of the medical community is that viruses are treated with antibiotics — with no positive effect on the patient, while also worsening resistance in the wider community.
Ms Boehme believes that with sufficient support, efforts now under way to develop triage tests could lead to promising results over the coming few years. Yet the tests themselves will be of limited impact unless they can reach patients in poorer countries.
For now, there is no global body that would help purchase and distribute AMR tests outside the industrialised world. Coming years will call for fresh financial as well as scientific progress to tackle antibiotic resistance.