Hospital not coping with MDR TB increase
Brooklyn Chest Clinic is unable to cope with the increase in patients with multi-drug resistant (MDR) and extreme drug resistant (XDR) tuberculosis, and Western Cape health workers are calling for patients to be treated in the community.
For now, the Western Cape is sticking to its plan to hospitalize MDR TB patients, despite the fact that it only has beds for 135 patients and expectations are that the need is going to rise to over 1 000 beds.
Already 18 XDR TB patients are being treated at Brooklyn’s male and female isolation wards, the province’s main TB hospital. Another four XDR TB patients have been identified at three prisons but there are only 22 XDR TB beds at the hospital.
‘We need to now as a department and as a society come up with the best and most humane manner to care for untreatable infectious patients. Maybe put infection control measures in place at community level and do lots of health education so that patients can be with their families and loved ones,’ says Dr Marlene Poolman, Deputy Director for TB Control in the province.
Patients suspected of having MDR TB are currently subjected to a lengthy process, including waiting eight weeks for results of drug susceptibility tests and waiting between four and six weeks for a bed at Brooklyn Chest Hospital.
‘This means that by the time you reach the patients they have easily been living, fully infectious in the community for between five and six months,’ says Dr Eric Goemaere, head of Medecins Sans Frontieres in South Africa.
Goemaere, who has been central in establishing several HIV treatment sites in Khayelitsha, was one of the only healthworkers prepared to speak on the record about the crisis facing TB care and treatment, which he cautioned was not isolated to the Western Cape.
Since the spotlight turned to XDR TB, the Western Cape has been conducting routine drug susceptibility tests on TB patients who have not been responding to treatment, and this has resulted in a steep increase in the number of identified MDR and XDR TB cases.
Six men, 11 women and a baby are currently being treated in two renovated isolation wards at Brooklyn Chest Hospital.
The isolation wards are situated at the far end of the sprawling grounds housing the TB hospital and were opened in the middle of March. Five nursing staff, wearing respirators, cover day and night duties in the bare, sparsely furnished wards.
In a recent interview Dr Simon Moeti, Senior Medical Superintendent at Brooklyn, denied that there was a long waiting list for MDR TB patients, stating unequivocally that MDR TB patients have ‘never faced a waiting list of longer than two weeks.’
Poolman said however that the turn-over for beds was slow and pressure for beds high, especially now for XDR-TB cases.
Several doctors working in Khayelitsha who spoke on condition of anonymity refuted Moeti’s claim, saying the waiting list has been closer to between four and six weeks, sometimes longer.
‘The waiting list goes up and down as patients die, leave the hospital or disappear, but we have at times been told there will be no beds for between two and three months,’ said one doctor.
‘We need a plan B. T here is no way that all these patients can be treated in a hospital. They simply don’t have the capacity,’ he added.
Another Khayelitsha doctor said patients often agreed to be admitted to Brooklyn ‘after intensive counseling’ only to be told there was no bed. ‘By the time a bed becomes available they no longer want to go.
‘Two doctors working for the City of Cape Town called the system a ‘mess’, saying it was almost impossible to get clinic patients who were not responding to treatment admitted to Brooklyn.
A number of doctors said in the past patients who were not getting better at Brooklyn were sent home.
Poolman confirmed that it took around two months to get a diagnosis for MDR TB and four months for XDR TB. Diagnostic tests for TB are outdated with very little money pumped into developing modern drugs and diagnostics for a disease that mainly affects poor people.
Poolman said the province was in the process of testing a rapid diagnostic tool that would be able to identify one of the drugs many MDR TB patients are resistant to. Diagnosis could be available in a ‘few days’, she said.
Goemaere said it was difficult to understand why antiretroviral treatment for HIV positive patients could decentralized to community level where nurses are responsible for patients, but that it could not be done for MDR TB treatment.
‘As it is, patients spend a long time in the community before being referred. It is ironic that when we devised the ARV model for Khayelitsha we learnt from the decentralized TB treatment model,’ said Goemaere.
Goemaere said he felt the same principle may need to apply to XDR TB.
‘These patients are also infectious in the community for a long time before they hit the headlines. As it is, the reputation of Brooklyn Chest Hospital is such that people see it as a one-way institution, a place where you don’t walk out alive.
‘So, people are trying to escape from being referred. We need to make people accept that we will have to treat people in the community and make sure we have the right infection control measures at home to do so,’ said Goemaere.
Meanwhile, Poolman said that the province would have to look at a way to make more beds available for both MDR and XDR TB.
‘We also need to look at a palliative care facility for these patients. It is expensive to care for people who are untreatable,’ she said.
Poolman added that it was critical to turn off the tap that was creating MDR and XDR TB ‘by strengthening the general TB programme so that all patients receive appropriate treatment for the correct time period and finish the whole course of treatment’.