When it comes to the treatment of multidrug-resistant tuberculosis (MDR-TB), wide consensus exists that South Africa is the world leader in this field. But this wasn’t always the case. In 2011 there were only 17 MDR-TB treatment initiation sites in our country. Over the past ten years, following the appointment of Dr Norbert Ndjeka as Chief Director, TB Control and Management at SA’s National Department of Health, the number of MDR-TB treatment initiation sites has grown to 658. So, where does portable audiometry – and the Kuduwave portable audiometer – come into play in this remarkable success story?
Previously, South African MDR-TB patients were treated with the injectable medication kanamycin. Regrettably, it was established that this medication not only caused ototoxicity (irreversible hearing loss resulting from medication), it also increased the death rate among patients.
Under the guidance of Dr Ndjeka (who also serves as temporary Multidrug-Resistant TB advisor for the World Health Organisation), SA’s MDR-TB programme began implementing a highly effective decentralisation strategy. This strategy included testing the hearing of all patients on the programme – including those who lived in remote areas without access to hospitals and audiologists who make use of traditional audiometric sound booths.
To reach these patients and prevent further ototoxic hearing loss, the programme required clinically validated, location-independent, diagnostic audiometers. Telemedicine-enabled portable audiometry devices that could conduct hearing tests in any location.
Enter eMoyo’s Kuduwave portable audiometer.
We caught up with Dr Ndjeka, who was recently honoured for his visionary work and activism with an Honorary Doctorate of Science in the field of medicine by the University of Cape Town.
Read on to learn more about this remarkable healthcare professional’s transformative impact on South Africa’s national MDR-TB programme, his impressions of the Kuduwave portable audiometer, and his thoughts on telehealth as the medicine of the future.
Since your appointment, the death rate amongst SA’s XDR TB patients has decreased from 58% to 20%, while our country’s MDR-TB death rate has come down from 20% to approximately 15%. These statistics are staggering. Could you tell us more about how this came about?
In 2011, treatment of MultiDrug-Resistant Tuberculosis (MDR-TB) in South Africa was highly centralised, with only 17 initiation treatment sites nationally. Treatment success rate was poor, with less than 40% of MDR-TB patients on the programme successfully treated, and only 10% of XDR-TB (the most severe type of tuberculosis) patients successfully treated. Patients had to travel long distances to access treatment, which was a big problem. So, our policy on decentralisation made a big difference, and things started to improve.
However, in order to treat patients effectively, you also need the tools of the trade. Access to quality laboratories, quality medicines. And, very importantly, access to quality equipment.
This included portable audiometry equipment for reliably testing patients’ hearing. This was crucial because, at the time, we were administering an injectable medication which sadly caused hearing problems or ototoxicity in many of our patients on the MDR-TB programme.
Can you tell us more about how SA’s national MDR-TB programme came to employ portable audiometry for testing patients’ hearing?
We started making use of portable audiometry around 2011, just after we launched our decentralisation programme. We decided to acquire a few Kuduwave portable audiometers because fixed audiometric sound booths were not accessible to most of our patients. In fact, our MDR-TB patients were often discriminated against and denied access to testing because it meant they’d be sharing equipment with patients who were not infected with TB.
Once we got our Kuduwave portable audiometers, the idea was to distribute them to all the clinical environments where our MDR-TB patients were being treated, including the smaller sites. But we also wanted to be able to travel with our audiometers, to reach and test patients who lived in remote areas. So that was our vision for the programme, and we started to implement this in 2011.
Additionally, there was also a huge need to scale up. We required the capacity to test more people’s hearing in more places, and test patients’ hearing before starting them on a treatment regimen. We also needed to test patients’ hearing every month, or even more regularly, especially if the patient was being treated with an injectable agent.
This all became possible in 2011 when we started making use of portable audiometry in our decentralisation efforts.
Can you tell us more about bedaquiline, the oral medication you are now using to treat MDR-TB patients on your programme?
We replaced kanamycin with bedaquiline. We realised it is a better and safer treatment for MDR-TB patients because it does not cause ototoxicity. So yes, the question remains, now that we are treating the vast majority of our patients with bedaquiline, which does not cause ototoxicity, where does the Kuduwave fit into our treatment programme?
Firstly, remember that we are now leading the world in the introduction of new medications for treating this disease. The rest of the world, which is still using injectables for MDR-TB, should absolutely be testing the hearing of all patients on their respective programmes.
That said, even on our programme, sometimes you will find patients who cannot tolerate bedaquiline. Such patients will then be treated with an injectable agent called amikacin. Amikacin is the only injectable medication that may be used in a very small number of patients on our programme. For such patients, regular hearing tests are essential.
If bedaquiline eliminates the risk of ototoxic hearing loss, are you now testing patients’ hearing as a precautionary measure, or for detecting ototoxic harm from previous MDR-TB medication, before starting them on a new treatment regimen?
We continue testing patients’ hearing on our programme, because a lot of patients who received injectables for TB in the past, be it streptomycin, kanamycin or amikacin, now suffer from hearing impairments.
Such patients often return to our treatment facilities because their hearing problems persist. This is why we decided also to have Kuduwave portable audiometers available for conducting hearing tests at our bigger sites. At least one site per province, preferably two, should have the capability to test patients’ hearing and therefore require Kuduwave portable audiometers.
If we establish that oral tablets are not working for a patient, and we have to start treating them with injectables, it is crucial that we monitor their hearing through regular testing. That’s the reason why the Kuduwave portable audiometer still plays such an essential role in our MDR-TB programme.
Was there any form of hearing testing done on the MDR-TB programme before you started making use of portable audiometry?
Prior to 2011, before we started using the Kuduwave, there was very little hearing testing in the programme, because it was just so difficult logistically. Patients in big centres had access to audiologists, but only to ones who were actually willing to treat them. Even so, there were so many precautions and arrangements to take care of beforehand. Less-fortunate patients living in remote places didn't have access to audiometric testing at all.
That’s what motivated us to bring in the Kuduwave. We needed to test our patients’ hearing regardless of where they lived. Our bigger treatment sites that were conducting hearing tests mentioned ototoxicity a lot. So we knew it was occurring, but we could only pick it up at the few sites where we were in fact able to test patients’ hearing.
At the other, smaller sites, we would often pick up hearing loss in our patients too late, simply because we did not have the capability at the time to pick up hearing loss at its onset or in the early stages.
And that is one of the biggest advantages of having portable audiometry and the Kuduwave audiometer in our programme. We can now pick up early onset hearing loss, where patients can still hear, but their sense of hearing is diminishing. At this stage, you can take the necessary steps to prevent further hearing loss and preserve patients’ hearing. This is so crucial because once a patient’s hearing is lost, it’s irreversible in most cases.
It appears that the Kuduwave’s simplicity of use is a big bonus in your programme, as nurses and administrators can use it too. Users don’t have to be audiologists to test patients’ hearing. Would you agree with this statement?
I fully agree. The Kuduwave’s simplicity of use has made our job so much easier. Various healthcare professionals with diverse backgrounds are using it to test patients’ hearing, and yes, the fact that it’s so easy to use is a big plus for us and our programme – and for the device itself.
Under your directorship, South Africa’s MDR-TB treatment programme has been completely transformed, with so many lives saved as a result. What, in your opinion, was the single most critical measure implemented in your programme?
I think our most significant achievement would be doing away with the injectable agent, kanamycin. Removing injectables and starting to treat all our patients with oral medication only, for me, is our biggest accomplishment. We still treat patients for a nine-month period, and I’m not fully satisfied with this pill burden. But we’re in a much better place than we were before. It’s a work in progress.
Coming from a medical family, how did you end up working in the field of MDR and XDR TB? Was it a conscious decision, or did life simply take you in this direction?
I worked in Limpopo from 1991 until 2007. I primarily treated HIV patients, so initially this became my main area of interest. In 2005, my province asked me to set up an MDR-TB treatment site for Limpopo because we were the only province without such treatment sites at the time.
Then, while working as an MDR-TB and Infection Control Advisor at URC (University Research Corporation) from 2007 to 2009, I started treating TB and MDR-TB patients, and ultimately MDR-TB became my main practice. It was during this time that I came to realise there were many challenges within our national TB and MDR-TB programme.
From there, in May 2009, I went on to join the National Department of Health. And that’s how my involvement in our country’s national MDR-TB treatment programme began.
When I was a child, there was a cousin I was close to who was a medical doctor. I think our relationship sparked my interest in the medical profession. My parents also told me that, when I was born, my grandmother said I would grow up to become a healer. So, who knows how things end up coming about. But words are powerful, you know.
What, in your opinion, is the potential of the telemedicine-enabled Kuduwave (and other such med-tech devices) to transform healthcare not just in South Africa but across the globe?
Telemedicine, or rather, telehealth, is crucial. I see it as the medicine of the future.
I think Covid has taught us all a big lesson. It made us take note of the importance of telemedicine and working remotely. We are dealing with the Covid-19 pandemic now, but what is next? We just don’t know. Covid has shown us what is possible in terms of working and treating patients remotely. Now we know it is possible and that it can work very effectively.
One of the biggest challenges in our programme is that patients interrupt their treatment. Somehow we lose them, and it’s a big challenge to track them again, in order to follow up and resume their treatment.
If we had a way of keeping in touch with our patients through some form of telemedicine, so many of them would hopefully not abandon their treatment. Employing telemedicine could help us to prevent this from happening.
So I think it is crucial that we continue to innovate and use and develop telemedicine.
“If I had the chance to start my life again, I’d still be a medical doctor. The passion to improve life for humankind is something that I like. Being a doctor puts me in a better position to assist and improve humankind.”
We read a quote of yours in an online article and were struck by the similarity between you and eMoyo’s Dr Dirk Koekemoer. Your sincere motivation to be of service to humankind and improving people’s lives through access to quality healthcare.
I've known Dr Koekemoer for a while. We met through an eMoyo representative who introduced me to the Kuduwave audiometer. I was interested in acquiring this med-tech device for our programme. When I met Dr Koekemoer soon after, we clicked and started working closely together. It was easy to work with him because I too sensed that we have a lot in common.
Even though I find myself working in administration, I refuse to become a bureaucrat. I continue to be a medical doctor, and I continue to cherish the values that led me to choose the medical profession. These values drive me to assist my fellow human beings as best I can.
When I met Dirk Koekemoer, I got the sense that he is truly a doctor. He might run a business, but essentially he remains a doctor, someone who wants to improve the lives of as many people as possible through his work.
So, even though our interactions were more centred around the Kuduwave as a portable audiometry device, and its benefits to our programme, what we have in common to this day is our motivation to improve the health and the lives of people in need.
To find out more about eMoyo’s Kuduwave range of portable audiometers and to book a free demo, please feel free to get in touch.