South Africa is actively monitoring a new Covid-19 variant known as Nimbus, says Health Minister
New Covid variant
South Africa is actively monitoring the emergence of a new Covid-19 variant known as Nimbus or NB.1.8.1, Health Mimister Aaron Motsoaledi told the G20 Health Working Group, which he addressed on Tuesday
The variant is a descendant of the Omicron lineage, meaning that current recommendations for SARS-CoV-2 vaccines are still effective and no new public health actions are required.
'I wish to reassure this esteemed gathering that South Africa has robust surveillance systems in place. Our National Institute for Communicable Diseases manages a comprehensive sentinel surveillance programme that systematically tests for key respiratory viruses, including SARS-CoV-2, influenza and RSV [respiratory syncytial virus],' he said.
'Currently, our data shows very low SARS-CoV-2 activity. While we are observing a seasonal increase in influenza, we are well prepared to manage this.'
Motsoaledi said the Health Department would continue to monitor the situation and would report any significant changes.
Motsoaledi called for the assembled member states to support 'critical' steps in reaching implementation of the recently adopted World Health Organization (WHO) Pandemic Agreement.
'As an active participant and representative member for the African region, I can say with certainty that we see this agreement as a crucial step towards rectifying the deep-seated imbalances in access to life-saving pandemic products that were so painfully exposed during the recent [Covid-19] crisis,' said Motsoaledi.
'We now call upon the elevated political will of all G20 members and our global partners to overcome the entrenched commercial interests and diplomatic hurdles that stand in our way.'
The 78th World Health Assembly in Geneva, Switzerland, formally adopted the Pandemic Agreement in May – a move Motsoaledi described as a 'landmark achievement for global health governance'. However, he noted that the work required to transform the agreement from a document of principles to a 'life-saving tool for justice and our shared global health security' was far from over.
Tuesday's meeting was the fourth time the Health Working Group has convened since South Africa's G20 presidency activities kicked off. The group's mandate is to improve global health by addressing challenges, building resilient systems and promoting equitable access to services.
WHO Pandemic Agreement
The adoption of the Pandemic Agreement came after more than three years of intensive negotiations launched by governments in response to the impacts of the Covid-19 pandemic. Precious Matsoso, the former director-general of the South African Department of Health, co-chaired the Intergovernmental Negotiating Body that coordinated the process to draft and negotiate the agreement.
The agreement sets out principles, approaches and tools for better international coordination towards pandemic prevention and responsiveness across a range of areas, including through the 'equitable and timely access to vaccines, therapeutics and diagnostics', according to the WHO.
Motsoaledi explained that the agreement was built on several key pillars aimed at fundamentally reshaping the approach to global health emergencies. These included:
A firm commitment to equitable, timely and affordable access to pandemic-related health products, particularly for countries in need;
The establishment of a global supply chain and logistics network to enhance the distribution of critical resources;
The creation of a dedicated coordinating financial mechanism to support countries in building their pandemic prevention, preparedness and response capacities; and
A 'holistic 'One Health' approach' which recognises the interconnectedness of human, animal and environmental health.
'The centrepiece of this agreement, and the key to unlocking its full potential for equity, is the Pathogen Access and Benefit-Sharing (PABS) system. This innovative mechanism will require pharmaceutical manufacturers to contribute 20% of their production during pandemic emergencies in return for access to pathogen data,' said Motsoaledi.
'We are now entering a critical new phase. The detailed negotiations on the PABS system annexure will commence immediately through an intergovernmental working group. The first meeting to elect the bureau for this group must take place before 15 July, and it is rightly anticipated that the leadership will reflect a balance between the Global North and the Global South.'
Motsoaledi called the negotiations to finalise the PABS system a political test that would demonstrate member states' collective will to move 'beyond rhetoric' towards delivering tangible results.
'Let us seize this moment. Let us work together with renewed urgency and unwavering resolve to complete the remaining vital task,' he said.
The Pandemic Agreement has been adopted at a time when global health financing has been thrown into crisis by the decision of the US administration under President Donald Trump to withdraw foreign aid spending from a range of health programmes, including the President's Emergency Plan for Aids Relief (Pepfar). The US also announced its withdrawal from the WHO in January.
The US has been absent from many G20-related engagements, though President Cyril Ramaphosa announced in May that Trump had agreed that the US would participate in the forthcoming G20 summit, according to a Business Day report.
Daily Maverick has asked the Department of Health whether the US was represented at the fourth meeting of the Health Working Group, and its response will be added when it becomes available.
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Despite many research efforts to find another vaccine, and a promising candidate being studied in a phase 3 trial, BCG remains the only TB vaccine in use for now. A brief history of TB treatment Though TB has been making humans sick for many centuries, the bug that causes the illness was identified only in 1882, by the German physician and microbiologist Robert Koch. It would be roughly another 60 years before the first effective treatments would become available. Until the 1940s, TB treatment mainly involved staying in a sanatorium. The first drugs to treat TB with any success were the antibiotics streptomycin and para-aminosalicylic acid. These two drugs had significant side effects, and using only two drugs often led to TB becoming resistant to the treatment. As described in this excellent overview, what followed was a 'great flurry of drug discovery research' that lasted from the 1940s to the 1960s. The four drugs used to treat most cases of TB today – isoniazid, rifampicin, pyrazinamide, and ethambutol – were all first used to treat TB in this period. After the 1960s, there was a lull in investment in TB research for several decades, probably because TB rates in wealthy countries had declined, and what cases there were could generally be cured with the new treatments. 'The Global North was very much of the perspective that it's [TB] a disease that's waning and 'it's no longer our problem',' Meintjes says. 'It was seen as a disease of poverty; a disease of other countries, and money was put into diseases that are common in the Global North.' This all changed around the turn of the century with the HIV epidemic and a resurgence of TB, particularly drug-resistant TB (DR-TB) in Europe and North America, says Meintjes. By definition, DR-TB means that some of the standard drugs used to treat TB no longer work. The renewed interest in TB resulted in a new flurry of TB drug discovery. Maybe most notably, in the 2010s, a drug called bedaquiline replaced older DR-TB drugs that were associated with hearing loss. A slightly older antibiotic called linezolid also became a cornerstone of DR-TB treatment. Today, in South Africa, 'normal' drug-susceptible TB (DS-TB) in adults is treated with a six-month treatment course – consisting of four drugs for two months and then two drugs for the next four months. A four-month treatment course has been shown to work in a clinical trial, but is not yet routinely provided in the country. Kids are typically treated for four or six months. DR-TB is treated with anything from three to six drugs, for any time from six to 24 months. How someone's TB is classified is largely determined by which drugs their particular strain of TB is resistant to. Lindsay McKenna, co-director of the TB Project at the Treatment Action Group, suggests thinking of it as a ladder. If the standard four drugs all work for your TB, then you don't have to climb any rungs. If rifampicin doesn't work for you, you have rifampicin-resistant TB (RR-TB) and must climb to the first rung to find drugs that work. If both rifampicin and isoniazid no longer work, you have multi-drug-resistant TB (MDR-TB) and must climb another rung. If you have resistance to even more drugs and you have pre-extensively drug-resistant TB and after that, extensively drug-resistant TB. (In practice, TB programmes often classify RR-TB and MDR-TB together since the same medicines are used to treat them.) All of the above treatments are for people who are ill with TB disease. There is also so-called TB preventive therapy, which aims to kill the TB bacteria in the lungs of someone who is infected, but who hasn't yet become ill with TB disease. These preventive treatments typically involve taking one or two medicines for one to six months, depending on the specific treatment regimen. It is possible that new long-acting formulations could allow for an entire course of preventive therapy to be administered as a single injection, though that research is still at an early stage. How the treatments work One reason for the complexity of TB treatment is the bacterium's large and complex genome. Meintjes says that HIV has nine genes, while TB has around 4,000. Having so many genes means the bug has lots of potential to bypass the effect of drugs targeting certain molecules or pathways and still survive. On the other hand, the many genes, at least in theory, provide many potential targets for antibiotics to attack. As noted, to cure TB, one typically has to attack the bug with at least three or four drugs. Meintjes says it is like a group of lions taking down a large buffalo – each one targeting a different part of the buffalo. Along these lines, TB drugs can broadly fit into different categories based on which part of the bacterium they target. Some drugs attack the way the bacterium builds its cell wall, others disrupt how the bug makes its protein, yet others interfere with how the bacterium produces or gets energy, and finally, some sabotage the way TB replicates. As Meintjes explains, isoniazid targets the cell wall of the bacterium by affecting the formation of molecules within the wall, ultimately causing it to leak and die. Rifampicin targets the genetic mechanisms of the TB bacterium, which prevents it from replicating. Bedaquiline works by targeting the mechanisms that allow the bug to metabolise energy, essentially starving it of fuel. A class of antibiotics called fluoroquinolones, specifically levofloxacin and moxifloxacin, target the TB bacteria's DNA while it's trying to copy itself and stops that process, explains Furin. Another drug, linezolid, interferes with how the bacterium makes proteins, which it needs to survive. It is not entirely clear how some other drugs, like clofazimine and pyrazinamide, work, says Furin. Even when attacking TB with several drugs and from multiple angles like this, it can still take months for all the bacteria in someone's body to be killed and for them to be cured. This is because, according to Furin, sometimes the protective wall formed by the immune system to contain the TB becomes too thick for the drugs to get through. And the environment inside the wall is often very acidic and deactivates some of the drugs that do manage to get in. How treatment could improve Novelist George Orwell, who was diagnosed with TB in 1947, was one of the first people to be treated with streptomycin. 'I am a lot better, but I had a bad fortnight with the secondary effects of the streptomycin. I suppose with all these drugs it's rather a case of sinking the ship to get rid of the rats,' he wrote in a letter at the time. More than 75 years later, TB treatments have improved massively, but drug side effects remain a real problem, especially when treating DR-TB. Some older treatments for TB involved injections of toxic drugs and had horrible side effects, including hearing loss and kidney damage. While newer drugs are better, there are still issues. Linezolid, for example, can cause peripheral neuropathy (painful tingling in the hands and feet) and anaemia. McKenna says none of the TB drugs is 'necessarily a walk in the park' and all come with side effects. This is because of the drugs themselves, the dosages required to kill the TB bacterium, and how long the drugs need to be taken. Because of this, much of the focus in TB research has been on finding drug combinations that can reduce the duration of treatment and the severity of side effects. For Furin, an ideal future regimen includes 'fewer pills' – she's hoping for one pill once a day for no more than eight weeks, 'fewer side effects', and doing away with the one-size-fits-all approach. Her reference to the 'one size fits all approach' points to one of the central tensions in TB treatment programmes. People with TB often do not get optimal treatment based on the specific characteristics of their own illness. For example, in countries with limited testing for drug resistance, people might be treated with medicines that their specific strain of TB is resistant to. They might thus suffer the side effects of that medicine without any of its benefits. This is less of an issue in South Africa than elsewhere, since the country's health system provides routine testing for resistance against several of the most important TB drugs. There are also questions about whether everyone really needs to be treated for six months to be cured. A landmark study called Truncate has shown that many people can be cured in two months. The difficulty is that we can't currently predict who will be cured after two months and who will need the full six months, or even longer. Figuring this out, as McKenna points out, would enable more personalised care that would mean fewer people are over- or under-treated. Some in the TB world have argued for the development of a pan-TB regimen – a combination of three or so drugs that nobody is resistant to and that accordingly could be given to everyone with TB, no matter what strain of TB they have. The benefit of such a pan-TB regimen would be that it would dramatically simplify the treatment of TB if it worked. But the experts interviewed by Spotlight agree that resistance is likely to develop against the drugs in such a regimen, and as such, testing people for drug resistance will remain necessary, as will alternative treatment regimens. Furin also points out that pharmaceutical companies have a greater incentive to invest in a pan-TB regimen since its potential market share is bigger than for drugs in a more fragmented treatment model. A hard task, getting harder One of the biggest obstacles in the way of finding new TB treatments is that there really aren't any reliable shortcuts when it comes to doing the research. With HIV, one can get a good idea as to whether a treatment is working by looking at biomarkers such as a person's viral load and CD4 count. TB, by contrast, doesn't have any similarly clear biomarkers that tell us whether a treatment is working or not. Arguably, the most promising biomarker for TB is bacterial load – essentially, how many bacteria are left in someone's sputum a while after treatment has begun. Having a high TB bacterial load is associated with a poor treatment outcome, but the problem is that it is difficult to measure reliably. Without a good biomarker, the only way to measure how well treatment is working is to follow patients for a long time and see if they are cured, and if they are, whether they suffer a relapse. Because of this, TB treatment trials often take several years to complete. Despite these challenges, there has been a good deal of activity in recent years. 'There are about 20 different new drugs in clinical trials at the moment – either early or later phase,' says Meintjes. But much of that momentum might now be lost because of the United States' abrupt slashing of research funding, including much TB research. The US government has until now been the largest funder of TB research by some distance. It spent $476-million or over R8.7-billion through its agencies on TB research in 2023, according to a report by TAG. Many ongoing US-funded TB clinical trials have already been affected, according to McKenna, although there have recently been indications that some research funding might be restored. Where does this leave us? That most people with TB can be cured is something worth celebrating. That treatment for DR-TB has become a lot better and shorter over the past two decades is also something to be grateful for. But as we have shown in this Spotlight special briefing, TB is a tough and ancient adversary and keeps adapting. The treatments at our disposal today are far from as good as we'd like them to be. The treatment side effects are often horrible, and many people find it very hard to take these drugs for month after month. We didn't linger on it, but many people who are cured struggle with post-TB lung disease for the rest of their lives – meaning the bug might be gone, but that person's lungs are never the same again. The scientific search for better TB treatments is not a matter of convenience. It is critical to reducing the suffering that several million people will endure just this year. It is also vital for reducing the number of lives that are still being claimed by this age-old disease. And of course, TB will keep mutating, and we will likely see more and more resistance developing against the drugs that we are depending on today. That is why it is imperative that governments, donors, and pharmaceutical companies all maintain and increase their investment in the search for better TB treatments. After all, TB claims more lives than any other single infectious agent on the planet. If that alone doesn't warrant more investment, what does? But there is also a case to be made that we should change the way we conduct TB research. Ideally, more research should be driven, and informed by, what actually matters to people with TB and to people in the communities where TB is rampant. After all, when given the choice, who wouldn't opt for more personalised and more respectful treatment and care? 'The TB community keeps making the same mistakes over and over and then acts mystified when things do not turn out the way they want,' says Furin. 'All the new drugs and new regimens in the world will never be enough if we do not listen to what impacted communities need, and follow their lead.' DM Additional reporting by Marcus Low.
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