Super-resistant TB strains overburdened hospital

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There has been an outbreak of a multi-multi drug resistant strain of tuberculosis in the Tugela Ferry area of KwaZulu-Natal.

Approximately 80 patients from the area have been referred to King George V Hospital in Durban, the province’s only facility dealing with MDR TB, but their chances of recovery are not good.

‘These patients are resistant to three of the second line drugs we use for treating MDR TB,’ says Dr Aruna Ramjee, a TB doctor who has been at the hospital for almost two decades.

The Church of Scotland Hospital in Tugela Ferry picked up the cases when they found that some of their HIV positive patients who also had TB were dying while on antiretroviral treatment, despite the fact that the ARVs were improving their CD4 counts.

‘This made them look again at their TB, and they found they were multi-drug resistant so they were sent to us,’ said Dr Garth Osburn.

All the patients have the same strain of multi-MDR TB, which probably means that they were infected by someone within their community.

Doctors at King George Hospital have for some time been concerned about the fact that they discharge MDR patients who have failed to respond to treatment into communities that are vulnerable to getting the disease.

So far, about 200 infectious patients who have failed to respond to any medicine have been discharged, going back to families and jobs.

‘We understand that we cannot just incarcerate the treatment failures, but how do we protect the rights of their communities? What we need is a place like a hospice for these patients that is isolated from others,’ says Dr VS Challa, who has been treating TB patients for over 30 years.

People who have not taken their TB treatment properly can develop MDR TB, but once they have MDR TB they can then infect anyone who is exposed to their sneezing and coughing with it.

About 10% of the hospital’s MDR patients have never had TB before.

MDR TB is very expensive and hard to treat, costing approximately R20 000 for an18 month course. However, new drugs that are not yet available in South Africa are needed to improve the chances of those with this super-strain of MDR TB.

Currently, little over 40% of all those admitted to King George with MDR TB are cured, and part of the problem is that about one in 10 patients who are discharged simply vanish, never returning for more medicine or check-ups. Internationally, little more than half MDR patients are cured.

Sibusiso Ngobese was diagnosed with TB in 2004, and was admitted to the hospital in January after failing to respond to normal TB treatment.

‘I was coughing too much. I had lost weight and had the sweats at night. But now I am feeling better,’ says Ngobese.

His MDR TB treatment is strenuous. Every morning, he gets an injection and has to take 12 pills. In the afternoon, he takes another two pills.

While Ngobese is lucky to be responding to treatment, he may soon be forced to vacate his bed for others on the waiting list.

Cases of MDR TB are rising exponentially in the province. In 2000, 280 patients were admitted to King George. Last year, 728 patients were admitted..

Aside from the in-patients, the eight TB doctors deal with about 550 outpatients monthly, who come to the MDR clinic.

Ideally, MDR patients should be admitted for four months while they are getting daily injections, but King George only has 240 beds for TB patients.

‘We cannot admit more patients than we have beds but we are trying to increase patient turnover,’ says Dr Iqbal Master. ‘There is about a two-week waiting list for beds at the moment.’

But problems start once the patients are discharged, as many in rural areas and battle to return each month for medicine and check-ups.

The doctors believe that the HIV epidemic is fuelling to the TB epidemic, as people with weaker immune systems are more susceptible to infection.

‘They two come together, TB and HIV. It is madness to see it any other way,’ says Dr Challa, who estimates that about 70% of the hospital’s patients are infected with both TB and HIV.

In order to better address the twin diseases, the hospital has finally been given permission to start dispensing ARVs and is waiting for an additional doctor to be appointed to run this programme.

King George is also in the process of being upgraded and by 2010, it should have capacity for over 400 patients ‘ enough to meet the current demand.

Staff hope that the improved hospital will mean a safer environment for them. Currently, the wards are poorly ventilated, and some staff have also become infected with TB.

‘It would also be good if staff could get an incentive to work with MDR TB, like the inhospitable allowance,’ says Dr Master. ‘Most of the doctors have been here for many years, but new doctors don’t want to work with MDR TB because they fear for themselves and their families.’