XDR TB ‘€“ a sign of failure

KHOPOTSO: Until recently, the Extensively Drug Resistant strain of tuberculosis was an unknown phenomenon to many South Africans. Scientists and doctors, however, identified the form of TB more than a year ago. Dr Willem Sturm is a TB expert at the University of KwaZulu-Natal’€™s Medical School.

 

Dr WILLEM STURM:

The first case was in the beginning of last year.

 

KHOPOTSO: Over a period of more than a year following the discovery of that first case at the Church of Scotland Hospital, in the Tugela Ferry region of KwaZulu-Natal, an active process to find out if more cases existed followed. At that stage it was found that 52 more people had the highly infectious strain of XDR TB.

 

Dr WILLEM STURM: What we did (was) we started collecting respiratory tract specimens from everybody that came into the hospital and coughed ‘€“ irrespective of whether we thought it might be TB or it might not be TB. And all those specimens were sent to the laboratory where we cultured the organism and did susceptibility tests if they grew’€¦ And there before the end of last year, 25% of patients with TB had this form of tuberculosis’€¦ Now, at the end of last year ‘€“ for a short while ‘€“ we did not see new cases. We thought it was over. All patients died and (there was) no transmission any longer. But that was not to be the case because it came back.

 

KHOPOTSO: When did it resurface?

 

Dr WILLEM STURM: At the beginning of this year.                    

 

KHOPOTSO: So far, XDR TB has been identified in 27 more hospitals outside the Tugela Ferry region. This last week, Sizwe Hospital ‘€“ a specialist centre for tropical diseases situated in Edenvale, east of Johannesburg – confirmed that a woman had tested positive for the same TB strain found in KwaZulu-Natal. The woman was subsequently admitted to hospital to receive treatment. Many are now questioning why, if the problem in KwaZulu-Natal persisted for more than a year, did the authorities not act on it then? A weekly newspaper reports that doctors at the Church of Scotland Hospital, where the outbreak started, informed the provincial health department last year about the discovery of XDR TB and what was needed to contain it, but very little response came through and no action was taken. Health-e News Service also reported on XDR TB on two occasions earlier this year. Meanwhile, the problem exacerbated. Dr Karin Weyer, Director of the South African Medical Research Council’€™s Tuberculosis Research Unit, says the emergence of XDR TB points to a failed TB control programme.                          

 

Dr KARIN WEYER: Unfortunately, both Multi-Drug Resistant TB and XDR TB, represent a failure of TB control. If we look at the outcomes of treatment in this country, only around 50% of TB patients are cured the first time around. This does not compare well with other developing countries where cure rates are in excess of 80%. We also have high rates of default from first-line TB treatment. And all of that creates a fertile environment for the development of Multiple-Drug Resistance and, eventually, Extensively Drug Resistant TB.

 

KHOPOTSO: Dr Kenneth Castro is the United States’€™ Centres for Disease Control and Prevention’€™s TB Elimination Unit. He attributes the outbreak to a number of factors, including weak government programmes and individual failure.

 

Dr KENNETH CASTRO: It’€™s not surprising. History has taught us ‘€“ back in the United States, in Argentina, in Italy, in Spain ‘€“ that if you let the conditions deteriorate so that you lose expertise in the management of tuberculosis, if patients don’€™t adhere to the recommended treatment and they interrupt their treatment that breeds drug resistance’€¦ And that’€™s what we have seen in many other parts of the world. If you let the infrastructure deteriorate, TB comes back with a vengeance. And unfortunately, it is not surprising.

 

KHOPOTSO: According to the WHO, in South Africa, almost 270 000 cases of TB are reported every year. Of these, 6000 are multi-drug resistant. The phenomenon of XDR TB, now poses a major public health challenge. Paul Nunn, co-ordinator of the World Health Organisation’€™s TB programme, says the solution can be found if political commitment can be invested into the campaign against TB.

 

PAUL NUNN: I would say two things about it: Political commitment is required to strengthen basic TB control in order to handle the drug resistance problem and in order to handle TB in general. Too many governments are not providing sufficient resources for basic TB control ‘€“ never mind the drug resistance additional problem. However, the second point I’€™d make is that the outbreak now in KwaZulu-Natal, emphasises, that they really have to look at their drug resistance programme as well as the basic TB control issues. They can’€™t afford to ignore it any longer.      

 

KHOPOTSO: That goes along with recommendations made two weeks ago at a consultative meeting on XDR TB in Johannesburg. The meeting adopted a seven-point action plan. The meeting reckoned that three of those can be acted on immediately. Dr Karin Weyer, again.

 

Dr KARIN WEYER: One of the first key issues that need to be done is we need to cure TB patients the first time around. That will prevent the emergence of drug resistance. Secondly, we need to much more rapidly diagnose existing cases ‘€“ and that calls for intensified surveillance in each of the provinces in South Africa to see whether there are other settings where this is occurring. And thirdly, to then quickly appropriately try to treat the existing cases that are being diagnosed. A very important aspect that is lacking in public health facilities in South Africa is adequate infection control measures to try to contain out-breaks of disease in general.      

 

KHOPOTSO: Dr Matteo Zignol works with the TB Strategy and Operations Unit of the World Health Organisation, in Geneva.

 

Dr MATTEO ZIGNOL: Those three are the most important measures that can be put in place right now immediately to prevent the development of new out-breaks. But there are other areas in which we should embark (on), which is the development of new drugs to be able to treat those cases that are virtually untreatable; and also the development of new diagnostic tools to be able to diagnose XDR TB in time, particularly, among people living with HIV’€¦          

 

KHOPOTSO: All 52 of the 53 people who died of XDR TB in KwaZulu-Natal were on both anti-TB and anti-AIDS treatment. A minimum of three drugs are needed to treat this highly infectious type of TB. South Africa only has two ‘€“ ethionamide and cycloserine. According to Professor Willem Sturm of the University of KwaZulu-Natal’€™s Medical School, the two cannot be used on their own to treat patients with XDR TB.

 

Dr WILLEM STURM: No, because then, you would create resistance with those two drugs’€¦ With one, you definitely get resistance, with two there’€™s a very high chance to get resistance, with three it’€™s unlikely to get resistance.  

 

KHOPOTSO: In a statement released to the media, the Department of Health said it was in the process of sourcing two more drugs ‘€“ Para Amino Salicylic Acid and Capreomycin, to use in XDR TB patients.

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