There has been a massive increase in tuberculosis over the past five years, driven mainly by the failure of provinces to tackle the disease effectively and the HIV epidemic, which makes people vulnerable to infection.
While TB cases have more than doubled since 1996 when a national TB programme was implemented, the country’€™s cure rate remains around 54%. The increase is driven mainly by the HIV epidemic and improved detection rates at clinic level.

Speaking on the eve of World TB Day, Dr Lindiwe Mvusi, the health desprtament’€™s national TB director said: “I think we are only seeing the tip of the iceberg, considering that by the time we detect these cases the TB is far advanced.”

Statistically, she may be right. Government bases its figures on registered TB cases and, by 2003, it put the TB incidence rate at 550 TB cases per 100 000 people.

However, the Medical Research Council’€™s (MRC) TB Research Lead Programme believes actual cases to be much higher. It estimated the incidence rate last year to be closer to 1 084 cases per 100 000 people, with a total of 529 320 cases countrywide. It estimates the national co-infection rate of TB and HIV to be 66.4%.

In comparison, Brazil has an incidence rate of 62 cases per 100 000 people and only 4% of adult TB patients also have HIV. Kenya’€™s rates are closer to ours, with an incidence of 540 and TB/HIV co-infection at around 51%.

Although the national TB programme was adopted nine years ago, some provinces have yet to appoint people to manage provincial and district TB programmes or dedicate funds to TB.

The biggest failure of the TB programme is that patients do not complete their six-month course of drugs.

‘€œPatients start feeling better after about two months of treatment so stop taking their drugs, and I think that often health workers have not explained properly how important it is to finish the six-month course,’€ says TB expert Dr Nesri Padayatchi from the Nelson Mandela Medical School.

Mvusi believes that the problem lies with the shortage of Directly Observed Treatment (DOT) volunteers, community workers who ensure that patients take their daily tablets and complete the course.
The DOTS volunteers do not get paid, said Mvusi, so they tended to move to the HIV home-based care programmes where they were paid a stipend.
“We are now trying to make sure that these home-based care workers are able to take care of the TB patients as well,” she explained.

Laboratory services in rural areas are also not up to scratch. Patients are often asked to return a week later for their TB test results and many fail to do so.

The failure of patients to complete there drugs has led to a sharp increase in multi-drug resistant TB (MDR-TB).

Only Kazakhstan has more cases of multi-drug resistant TB, according to the World Health Organisation, although MDR TB cases only account for 1.7% of registered cases (2002 figures).

Infectious diseases expert Dr David Coetzee from the University of Cape Town says that, given the weaknesses in our national TB programme, the MDR TB rate would have been much higher had South Africa not been using a combination drug.

‘€œFor the past 15 or so years, we have been treating patients with one pill that combines all four TB drugs and this has helped to keep the MDR rate down,’€ he explains.

Limpopo and Mpumalanga have been identified as “hotspots’€ for MDR-TB, something that Mvusi acknowledges is probably related to poor programmes in those provinces.

 While MDR TB makes up about 1.5% of TB cases nationally, over 3% of Mpumalanga’€™s cases and almost 2% of Limpopo’€™s cases are MDR TB.

About 17% of repeat TB cases in Mpumalanga have MDR TB, while around 6% of repeat TB cases nationally are multi-drug resistant.

Meanwhile, a large TB referral clinic in Durban, the Prince Cyril Zulu Clinic, reports that cases of MDR TB have more than doubled in the past three years.

Treatment of MDR TB takes at least 16 months, costs up to 100 times more than ordinary TB and has been associated with extraordinarily high mortality rates in HIV infected patients.

Mvusi added that an improvement in reporting and surveillance systems had also contributed to the overall increase in TB rates, as many more cases were being detected. All 183 health sub-districts offer TB treatment and have electronic TB registers to monitor the progress of TB patients.

The World Health Organisation (WHO) noted in its global TB report last year that South Africa had improved its case detection by 12% in 2002.

However, it also said that despite the high correlation between TB and HIV infection, ‘€œthere was no HIV surveillance for TB patients and no plans to establish one’€.

In addition, said the WHO report, there was TB/HIV collaboration in only 13 sub-districts out of 183 and no plan to involve the national TB programme in anti-retroviral delivery.

KwaZulu-Natal has the most TB cases in the country, and has overtaken the Western Cape as the province with the highest incidence rate. KwaZulu-Natal (KZN) also has the highest HIV rate in the country, according to the annual health department surveillance of pregnant women.

Last year, the MRC estimated that 173 944 KZN residents had active TB, the rate was 1 696 cases per 100 000 people and that a staggering 83.4% of these were also HIV infected.

The Western Cape has the second highest TB incidence rate at 1 333, according to the MRC, but the lowest TB-HIV infection rate at around 50.4%.

The health minister has been careful to not link TB and HIV. At a recent Parliamentary media briefing, Dr Manto Tshabalala-Msimang said it was important to “separate TB from HIV”.
She claimed that people were not “coming forward for (TB) treatment because there is a perception that if you have TB, you have HIV”.
The recent release of the Statistics SA mortality report also sought to downplay the link between TB and HIV. According to the report, TB was responsible for 12% of deaths in 2003.

Mvusi acknowledged that the HIV epidemic has played a role in the “marked increase” in TB cases in some provinces, but added that this could not be generalised throughout the country.

‘€œFor example in the Western Cape they have the lowest incidence of HIV, but the highest incidence of TB and clearly there are other factors driving the TB epidemic in that province.
“We also need to remember that HIV positive people may have TB, but it is the HIV negative people who are spreading the TB,” said. Mvusi.

As Dr Coetzee explains, TB is not common among HIV positive people in countries where the TB incidence rate among the general population is relatively low.

‘€œWe had a TB epidemic before we had an HIV epidemic,’€ said Coetzee.

As with HIV/AIDS, political commitment is the first weapon in a five-point checklist of the DOTS strategy prescribed by the World Health Organisation.

The other essential elements of the strategy are a proper recording and reporting system, an uninterrupted supply of medicine, a functioning laboratory system and the observation of
therapy.
For Mvusi, the priorities this year are to further train healthcare workers on TB care, ensure that patients take their drugs for the entire six months and improve laboratory services.

In addition, she says co-ordinating TB and HIV activities is a challenge.

Patient adherence could be improved if patients were properly educated about the importance of taking their medication, she believes.
She added that a rapid TB test that could ensure patients get their results the same day would help a great deal, while new drugs with fewer side effects would also improve treatment outcomes. No new TB drugs have been developed since the seventies.

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