South Africa: XDR TB

[AlaskaDenise]

http://www.alertnet.org/thenews/newsdesk/L22742855.htm

By Sarah McGregor


JOHANNESBURG, Jan 23 (Reuters) - South Africa should forcibly isolate patients infected with a highly drug-resistant strain of tuberculosis to stop the disease from spreading on the AIDS-hit continent, researchers said on Monday.


South Africa's outbreak of extreme drug resistant tuberculosis (XDR-TB), which has killed at least 74 people in the last several months, may force authorities to override patients' personal rights in favour of the greater public's health, the study in the journal PLoS Medicine said.


"XDR-TB represents a major threat to public health. If the only way to manage it is to forcibly confine then it needs to be done," said Jerome Singh, study co-author and lawyer at Durban's Centre for the AIDS Programme of Research in South Africa.


"Ultimately in such crises, the interests of public health must prevail over the rights of the individual."


TB, an airborne bacillus spread through coughing or sneezing, can usually be cured through treatment. However, the XDR-TB strain may have mutated when patients skipped treatment or were dispensed inadequate antibiotic cocktails.


South Africa has logged almost 400 cases of XDR-TB, which is virtually impervious to treatment by most common TB drugs, and an unprecedented 30 new cases are diagnosed every month, according to the study.


The outbreak has alarmed medical experts who say XDR-TB poses a particular danger to HIV-positive people whose immune systems are already severely compromised by the AIDS virus.


South Africa has one of the planet's highest HIV/AIDS caseloads with about 5.5 million people infected in a population of 45 million. Most of those who died of XDR-TB have tested positive for HIV.


South Africa's highly mobile workforce, rising overseas tourism, and the prevalence of XDR-TB in Johannesburg, the main transportation hub, increases the chance of XDR-TB spreading past national borders and into other African countries struggling with high HIV/AIDS infection rates, Singh said.


PERSONAL CHOICES


South Africa's post-apartheid constitution contains some of the world's strongest safeguards of individual liberties and the government has thus far been silent on whether it may isolate XDR-TB patients. Singh said it is the public's duty to press the government into opening the debate.


In South Africa, XDR-TB patients may visit hospitals as out-patients and then go home, which means they can easily pass the disease in their community, the paper said.


XDR-TB patients at the rural hospital in the eastern province of KwaZulu-Natal, where the super bug was first detected, sleep in a special room but are free to move around the TB ward and even allowed to leave on a day pass.


However, the challenge to control XDR-TB requires not just policy changes but also more state spending, the paper said.


Long-term hospital stays increase the national health-care tab and burden overstretched clinics particularly in rural areas with heavy patient loads, said Singh, adding hospitalized XDR-TB patients should automatically qualify for a social grant.


The World Health Organization has called for the world to prioritise XDR-TB on par with bird flu and recommended governments in impoverished sub-Saharan Africa develop one strategy to deal with the twin challenges of HIV and TB.


Further complicating the XDR-TB problem is that diagnosis and treatment of the disease is time-consuming and costly, surveillance often inadequate and no new drugs have been developed in 40 years.

.

[ruthbeme]

Re: S.Africa urged to isolate "killer" TB patients

South Africa Urged To Isolate Patients With New Deadly TB Strain To Avoid Pandemic

Article Date: 24 Jan 2007 - 1:00 PST

http://www.medicalnewstoday.com/healthnews.php?newsid=61487&nfid=mnf

A panel of HIV and bioethics experts are urging South Africa to enforce isolation of patients infected with a new deadly strain of TB to avoid a pandemic in the country where HIV is widespread. They say that the point where the rights of the individual must give way to the interests of public health has been reached and the country must act now to stop a pandemic that could spread to the rest of the world.

The experts have made this policy recommendation in an article published in the online journal Public Library of Science (PLoS) Medicine.

The lead author of the report is Jerome Singh, a lawyer at the Centre for the Aids Programme of Research in Durban in South Africa. Mr Singh and his colleagues, Ross Upshur and Nesri Padayatchi between them represent the Aids Programme and the University of Toronto's Joint Centre for Bioethics.

It is thought that the new deadly TB strain may have developed because patients were treated with insufficient medication or because they missed some of their treatments.

Mr Singh and his colleagues consider the threat to be global because South Africa has a fast growing throughput of tourists and is home to millions of migrant workers from surrounding countries. It has a thriving ship and road transport system connecting with many other African nations.

Combined with the high rate of HIV infection in the region, the threat of spread of the new deadly TB strain is high, the authors say. This is emphasized by the fact that XDR-TB is now considered to be endemic in the province of KwaZulu-Natal where the strain was first detected. 39 hospitals in the province and other parts of South Africa have now admitted patients with XDR-TB. The authors say that at least 30 new cases of the deadly strain are being reported in the province every month.

The World Health Organization (WHO) has called for XDR-TB to be given the same global priority as avian flu. It has asked the governments in the sub-Saharan part of Africa to unite their HIV and TB fighting strategies.

Health Officials in South Africa are grappling with the conflict between the rights of the individual and the public health importance of this new situation. They have consulted with the WHO but have not yet released any information on their decision.

The WHO reported in September last year that the town Tugela Ferry, in KwaZulu-Natal was harbouring a new and deadly strain of extensively drug-resistant tuberculosis, XDR-TB. Tugela Ferry is also said to be the "epicentre of South Africa's HIV/AIDS epidemic".

Of the 544 patients observed in the region in 2005, 221 had developed the multi-drug-resistant form of tuberculosis, MDR-TB, and from these 53 of them had the extensively drug-resistant strain, XDR-TB. Also, 44 of the 53 XDR-TB patients were infected with HIV. 52 of the 53 patients died.

The median survival term after diagnosis for the 52 XDR-TB patients who died was 16 days, showing a fatality rate and speed of development for TB that is unprecedented anywhere in the world. Six of the patients who died, were health workers, and the dead also included those on antiretroviral treatment.

MDR-TB stands for multi-drug-resistant tuberculosis, i.e. Mycobacterium tuberculosis that has developed resistance to the antibiotic rifampicin and prodrug isoniazid, and most likely other drugs as well.

XDR-TB is a more resistant version of MDR-TB with additional resistance to at least three of the six classes of second-line anti-TB drugs. A second-line drug is a drug that is either less effective than a first-line drug such as rifampicin, or it could have toxic side-effects.

"XDR-TB in South Africa: No Time for Denial or Complacency."
Jerome Amir Singh, Ross Upshur, Nesri Padayatchi.
PLoS Med 4(1): e50 doi:10.1371/journal.pmed.0040050


Written by: Catharine Paddock
Writer: Medical News Today

[Gert van der Hoek]

Re: S.Africa urged to isolate "killer" TB patients

South Africa: WHO to Help Country Fight Deadly New TB Strain

Business Day (Johannesburg)

April 5, 2007
Posted to the web April 5, 2007

Tamar Kahn
Johannesburg

The World Health Organisation (WHO) planned to help SA improve its measures for controlling tuberculosis (TB) and gain a deeper understanding of the deadly new drug-resistant strains of the disease that first emerged in KwaZulu-Natal last year, a senior WHO TB expert said yesterday.

The health department has recorded 352 patients with extremely drug-resistant (XDR) TB, 257 of whom have died. Most XDR-TB patients were in Kwa- Zulu-Natal, where the mortality rate was much higher -- only 26 of the 247 patients known there to be infected with the disease were still alive, according to the department's latest figures.


"So far we've had reports of XDR-TB from KwaZulu-Natal and other provinces, but we don't know the full extent of the epidemic," said the WHO's Dr Fabio Scano, who is responsible for research and policy development in the STOP TB Directorate.

"We think KwaZulu-Natal is the epicentre, but we're not sure," he said from Pretoria.

Scano arrived in SA two weeks ago, following the health department's appeal for help from the WHO. He spent the first week of his visit in KwaZulu-Natal, where he visited the Church of Scotland Hospital in Tugela Ferry, which has seen the majority of XDR-TB patients diagnosed to date.

Scano said a TB survey launched this week was expected to shed fresh light on the extent of multi-drug resistant (MDR) TB and XDR-TB. The study, conducted by the Medical Research Council (MRC), the National Health Laboratory Service and the Foundation for Innovative New Diagnostics, will also assess the efficacy of two new rapid tests for drug resistant strains of TB. About 40000 patients will be tested. The two new technologies are Biotec's FASTPlaque- Response test and Hain Lifescience's MTBDRplus assay.

Scano declined to be drawn on his views regarding incarcerating patients infected with XDR-TB, referring questions to the position statements issued by the WHO and MRC. The MRC website says "enforced hospitalisation or quarantine of patients with XDR-TB is only justifiable as a last resort after all reasonable voluntary measures to isolate individual patients have failed".

The issue grabbed headlines recently after Gauteng health authorities obtained a court order compelling a group of patients infected with XDR-TB to remain in hospital. The patients tried to escape the facility and return to their families.

Strains of MDR-TB are resistant to the two most potent first-line anti-TB drugs isoniazid and rifampicin, which usually are taken for just six months. Once these fail to work, doctors have to use more expensive second-line anti-TB drugs which must be taken for about 18 months. These include fluoroquinolones, kanamycin, amikacin and capreomycin. XDR-TB strains are resistant to first-line and some second-line drugs, and are potentially untreatable.

http://allafrica.com/stories/200704050158.html

[Gert van der Hoek]

Re: S.Africa urged to isolate "killer" TB patients

New TB strain in South Africa a concern

JOHANNESBURG, South Africa (AP) - The extent of the deadly new strain of tuberculosis in South Africa and the region is not known and is cause for concern, an international health expert said Wednesday.

Dr Fabio Scano, a TB expert from the World Health Organization in Geneva, has been sent to South Africa at the request of the government to assist with the outbreak of the extensively drug-resistant tuberculosis strain, or XDR-TB.

''We don't know the extent of multiple drug resistant and extreme drug resistant TB in sub-Saharan Africa and the southern African region. There is not yet the capacity to test in these countries,'' Scano said at a news conference.

South Africa has reported 352 cases of the virulent strain since it was discovered last year in the eastern KwaZulu-Natal province. There have been 221 deaths and concerns have been raised about the strain spreading across the region.

Scano said an epidemiological investigation was under way to determine the full extent of the disease.

''I don't think the situation in KwaZulu-Natal is unique,'' said Professor Ronnie Green-Thompson, special adviser to the health minister. ''If we test in other provinces we may well find a similar prevalence.''

Multiple drug resistant TB, known as MDR-TB, does not respond to a ''first line'' of drugs while the extreme strain does not respond to a ''second line'' of drugs.

Africa is the only continent where TB rates are increasing and the disease is complicated by high rates of HIV infection, which lowers a person's immune system.

''MDR-TB and XDR-TB and the way they are magnified by HIV infection is the biggest public health challenge both nationally and internationally,'' Scano said.

He said that without the drug resistant strain, 12-14 percent of TB patients who have HIV die because of the ''lethal combination'' of the two diseases.

Scano said WHO was committed to working with South Africa to address the challenge presented by the disease.

''There are a lot of interventions under way but we have yet to see the results ... the fight against TB is a marathon, not a sprint. But there is a need for action now,'' he said.

Drug resistance grows when people do not complete a grueling six month regime of medication, and South Africa has a low adherence rate.

Part of the two-year collaboration between WHO and South Africa is to ensure greater adherence of patients to the treatment programs.

The health department has had to force a number of XDR-TB patients back to hospital after they tried to return to their homes and in the United States, a 27-year-old man suffering from the extreme strain has been locked up indefinitely as a danger to the public.

Nthari Matsau, Deputy Director-General of the health department, stressed that while it was important to separate TB patients, issues of discrimination and human rights had to be considered.

''Incarceration is not an ideal way of separating TB patients. There are much more acceptable and humane ways,'' she said.

Scano said new drugs to treat XDR-TB were now available in South Africa but he said there was a huge need for new medicines to be developed to combat the disease.

''Unless there is massive investment in new drugs, we won't make headway in the fight against TB. We have to do the best we can with what we have,'' he said.

http://www.komotv.com/news/health/6936042.html

[Gert van der Hoek]

Re: S.Africa: new TB strain a concern

South Africa: Killer TB Toll at 3 as Isolation Unit Fills Up


Cape Argus (Cape Town)

April 23, 2007
Posted to the web April 23, 2007

Di Caelers Cape Town

Extremely drug-resistant tuberculosis, a deadly strain of the disease that is very difficult to treat, has killed two more people in the Western Cape in the past month.

These deaths raise the toll from from XDR-TB this year to three, with the number of confirmed cases having doubled since the end of last month.


Two women died in the isolation unit at Brooklyn Chest Hospital in the past three weeks, according to provincial Health Depart- ment spokeswoman Faiza Steyn.

The 24-bed isolation unit at the hospital, specially designed to address the XDR-TB threat, is near full capacity, with 17 patients.

A further four patients with confirmed XDR-TB are being treated in isolation in prisons around the Western Cape.

The latest statistics were re-vealed by Health MEC Pierre Uys during his address to the provincial government's standing committee on social development before the weekend. Further de-tails were not available.

In February, the Cape Argus reported the first XDR-TB death in the province, and late last month reported that four new cases had brought the total to 12.

Uys also revealed that Brooklyn Chest Hospital, destined to become a centre of excellence for the treatment of multi-drug-resistant TB, which is slightly less dangerous than XDR-TB, is set for a complete upgrade and will finally have more than 700 beds.

"It is planned to rebuild a large 721-bed hospital for TB in the met-ro that will incorporate the D P Marais and Brooklyn Chest hospitals," Uys said.

A business case had been submitted to the Health Department for financial support under the Hospital Revitalisation Fund.

Uys told the committee that the plan had been approved, but no funding had yet been forthcoming.

Professor Craig Househam, head of health in the Western Cape, explained the dichotomy between the law and the constitution over enforcing treatment for affected patients.

"We can legally ensure people are institutionalised (for this treatment), but in terms of the constitution we cannot enforce treatment," he said.

Househam said that health authorities had so far managed to persuade every XDR-TB patient identified to take the treatment needed.

Since last October, the Western Cape Health Department has been examining all known MDR-TB pa-tients in a bid to determine which actually have XDR-TB.

Last year XDR-TB killed more than 50 people in KwaZulu-Natal and more than 300 cases have been confirmed across the country.

Steyn said last month that patients appeared to accept that their isolation was for the good of their health and for the health of their families and communities.

http://allafrica.com/stories/200704231115.html

[Gert van der Hoek]

Re: S.Africa: new TB strain a concern

TB in KZN is worse than an epidemic: health department

JOHANNESBURG ? KwaZulu-Natal (KZN) government says the incidence of tuberculosis (TB) in that province is now worse than an epidemic, SABC reported on Tuesday.

KZN Health MEC Peggy Nkonyeni said TB had reached a case load of more than 1,000 per 100,000 people in the province.

Any figure above 200 per 100,000 is regarded as an epidemic, she said.
Nkonyeni was delivering her budget in Pietermaritzburg.

She said the province had an advanced plan to deal with the epidemic.

On April 4, the World Health Organisation (WHO) said the extent of multi-and extreme-drug-resistant strains of TB (MDR-TB and XDR-TB) in South Africa was not known.

?We know there are quite a lot of MDR- and XDR-TB cases, although we don?t know the extent,? said WHO TB expert Dr Fabio Scano.

Scano is in SA as part of a two-year collaboration with the government to provide technical support and advice in the fight against the disease.
He said there were a number of TB interventions underway but the results were yet to be seen.

On April 4, the health department?s said 237 of 350 XDR-TB patients identified in SA -- 68 percent -- have died. A total of 112 are on treatment and one patient has defaulted on treatment.

KZN has the country?s largest share of cases, with 221 out of 247 patients -- 89 percent -- having died. The survivors are all on treatment.

?Sapa

Last updated 24/04/2007 19:27:50

http://www.citizen.co.za/index/article.aspx?pDesc=37379,1,22

[Gert van der Hoek]

Re: S.Africa: new TB strain a concern

Cape health authorities release XDR TB patient

May 19, 2007, 18:30

Western Cape health authorities have hastily readmitted a patient suffering from extreme drug-resistant (XDR) TB after sending him home for eight days. The move has endangered the lives of all who have come into contact with the KwaNonqaba man.

The 39-year-old man says doctors told him he was suffering from XDR TB, but then they discharged him from the TB hospital in George about a week ago, saying there was nothing more they could do.

Monde Siyoko, the XDR TB sufferer, says: "They told me at the hospital that my MDR is not curable and that I've now developed XDR and the medication is not effective." Siyoko?s elderly mother says doctors gave them strict instructions to keep her ailing son in isolation.

Medical experts say this strain of TB can easily spread by coughing, sneezing or simply talking. Mxolisi Bobelo, the local Sanco leader told reporters: "The gentleman who's released from hospital stays nearby a school and the transport here is mostly by taxis, this thing can affect a lot of people."

Authorities mum on patient?s release

Provincial health authorities did not respond to SABC reporters' enquiries but an ambulance arrived late last night to take the man back to a Cape Town hospital. It is still a mystery how many people Siyoko came into contact with,since he returned home and just how many lives were put at risk.

TB is a common and deadly infectious disease that is caused by mycobacteria. TB most commonly affects the lungs but can also affect the central nervous system, the lymphatic system, the circulatory system, the genitourinary system, bones, joints and even the skin. Over one-third of the world's population now has the TB bacterium in their bodies and sources say new infections are occurring at a rate of one per second.

Not everyone who is infected develops the disease and asymptomatic latent TB infection is most common. However, one in 10 latent infections will progress to active TB disease which, if left untreated, kills more than half of its victims. In 2004, 14.6 million people had active TB and there were 8.9 million new cases and 1.7 million deaths, mostly in developing countries.

A rising number of people in the developed world contract tuberculosis because their immune systems are compromised by immunosuppressive drugs, substance abuse or HIV/Aids.

http://www.sabcnews.com/south_africa/health/0,2172,149393,00.html

[Gert van der Hoek]

Re: S.Africa: new TB strain a concern

Rapid spread of disease alarms experts

STEPHANIE NOLEN

May 21, 2007

DURBAN, SOUTH AFRICA -- The public-health world has been alarmed since the early 1990s about what's called multidrug-resistant (MDR) tuberculosis.

Drug resistance emerges when people are prescribed the wrong drugs or do not complete a course of treatment, which allows for the natural selection of bacteria that are resistant to the drugs.

MDR is found all over the world, with the fastest growth in cases in China and Russia. It is curable in about half of cases, but patients must take highly toxic drugs for as long as two years to get rid of it. (The other half of people die of the disease within a few years.)

But XDR tuberculosis is something else altogether. The bug is resistant to both the main class of antibiotics used to treat TB, and to at least one of the second class of drugs, which are injectable antibiotics.

This leaves almost no option for treating it. People with HIV have proved utterly defenceless to its spread.

"This is an absolute emergency," Mario Raviglione, director of Stop TB at the World Health Organization, said last month.

"It is the most urgent thing I have seen in my 15 years of working in tuberculosis: a highly resistant strain that is now killing HIV-positive people and is spreading very rapidly.

"Nobody is moving fast enough," Mr. Raviglione added.

XDR has been identified in 35 countries, including one case in Canada and 49 in the United States. It poses a far greater risk than HIV or bird flu because of its transmissibility.

Paul Nunn, an expert on tuberculosis at the WHO, described the possibility of a "nightmare scenario" occurring at next year's International AIDS Conference in Mexico City, at which 20,000 participants are expected, a quarter of them with HIV: "Now imagine someone who doesn't know they have XDR gets on a plane, gets off in Mexico City, 10,000 feet up where everybody is breathing hard ..."

In the past few months, XDR has been identified in every one of South Africa's provinces, in rural villages and in city centres, and TB experts say there is no question that it is also spreading across other countries in southern Africa. However, those countries do not have the infrastructure to diagnose it, and so deaths from XDR are going unrecorded.

Just as AIDS treatment is finally beginning to reach into all corners of South Africa and its neighbours, there is a very real possibility that XDR could spread quickly and cause a massive wave of deaths among people with HIV, by far the most vulnerable group.

New twists on an old illness

Multidrug-resistant tuberculosis is found all over the world, with the fastest growth in cases in China and Russia, and the more serious extensively drug-resistant tuberculosis has been identified in 35 countries, including one case in Canada and 49 in the United States.

http://www.theglobeandmail.com/servlet/story/LAC.20070521.TBSIDE21/TPStory/

[Gert van der Hoek]

Re: S.Africa: new TB strain a concern

JOHANNESBURG

Over 70 killer TB cases in E Cape

Thu, 24 May 2007

The Eastern Cape had 74 patients diagnosed with the drug-resistant strain of tuberculosis (XDR-TB) by 15 May this year, The Herald Online reported on Thursday.

It quoted health MEC Nomsa Jajula as saying the number had been increasing at an average of about nine a month.

She said there were adequate facilities to accommodate and isolate patients at the Jose Pearson TB Hospital, Fort Great and Mthatha General.

Her department was in the process of adding a further nine beds at Fort Grey.

Every effort was being made to prevent infected patients from being discharged from hospitals because the disease "spreads like fire when you add petrol", she said.

Jajula said there were 25 ambulances in operation in the Nelson Mandela Bay metro, all of which were in a "good condition".

They served a population of 1.3 million, a ratio of one ambulance to 130 000 people. The national norm for 2010 was one to 10 000 people, the MEC said.

http://iafrica.com/news/sa/899107.htm

[Gert van der Hoek]

Re: S.Africa: new TB strain a concern

South Africa: 'Time-Bomb' TB Patient Gets Sent Home

Cape Argus (Cape Town)

28 May 2007

Posted to the web 28 May 2007


A woman with infectious multi-drug resistant tuberculosis, effectively a walking time-bomb for spreading the disease, has been sent home after doctors failed to secure her a bed in an isolation ward.

Doctors at Delft community health centre raised the alarm after they were forced to send the 53-year-old woman home last Wednesda, and told they should try again today in case a bed had opened up.


Worse still, her doctors say it is highly probable that she has been infectious for as long as 18 months, raising questions about whether similar cases are pushing up drug-resistant TB incidence in the province.

Delft community service doctor Chris Young said the woman had come for help last Wednesday afternoon, complaining of tiredness and shortness of breath.

Another doctor who examined her file found she had been deemed resistant to three of the four first-line drugs at the end of 2005 and was treated at Brooklyn Chest Hospital.

Since that time, about 18 months ago, although she was started on second-line treatment "she has always had positive sputum stains for TB".

Multi-drug resistance, in its worst form, is classified as extremely drug-resistant TB.

At the last count earlier this month, provincial health au-thorities reported that four people had died of the killer strain and 20 were in isolation at Brooklyn Chest Hospital's 22-bed XDR-TB ward.

The slightly less dangerous multi-drug resistant TB (MDR-TB), in terms of which patients are admitted to hospital for the first four months of their treatment, does not respond to treatment with two of the key first-line drugs.

XDR-TB, according to a national definition, is resistant to all first-line treatments, as well as all the second-line drugs in its most severe form.

Young told the Cape Argus that the Delft patient had been tested most recently last month and was still "highly infectious and definitely MDR".

"Basically, she is failing second-line treatment for TB," he said.

Efforts to get comment from the Department of Health at the time of going to press failed, but earlier this month department spokeswoman Fai-za Steyn told the Cape Argus that all XDR-TB patients "must be admitted and isolated", although there was not currently sufficient capacity in Cape Town.

She admitted that there were not enough beds, especially in Cape Town where the burden of disease was biggest.

Steyn said at the time that there were three MDR-TB units in the Western Cape, along with the XDR-TB unit at Brooklyn Chest hospital.

Young said they had tried since last Wednesday afternoon to get the Delft woman admitted and isolated.

"We spoke to our referral secondary hospitals as well as a professor of infectious diseases at Tygerberg Hospital.

"The response was that she had to go to Brooklyn Chest for isolation.

"But that hospital's medical superintendent told us he doesn't have facilities at the mo-ment and when we asked what we should do, he said we should send the patient home and try again on Monday or Tuesday," he said.

Young was shocked at the fact that the woman was coming into the Delft outpatients facility every two or three months, all the while "spewing bacteria freely in the health centre and in her community".

"The reality is that it's highly unlikely that she's the only one either.

"But what could we do? We've sent her back into the community," he said.

http://allafrica.com/stories/200705280676.html

See also post # 7 of this thread

[Gert van der Hoek]

Re: S.Africa: new TB strain a concern

South Africa: Boy, 18, is Fifth Western Cape Victim of Killer TB

Cape Argus (Cape Town)

30 May 2007


Di Caelers


An 18-year-old youth has died of extremely drug resistant tuberculosis, the fifth death from the deadly strain of TB in the Western Cape as Brooklyn Chest Hospital runs out of space in its special isolation ward.

The 22-bed isolation unit, specially set up to address the rising incidence of XDR-TB in the province, is now 100% full, as provincial health authorities move fast to identify further space to address the demand.

The issue of isolation of patients with XDR-TB and the slightly less dangerous multi-drug resistant TB (MDR-TB) is in the spotlight following news on Monday that Delft doctors were forced to send home a highly-infectious female patient because of a shortage of isolation-unit beds.

The 53-year-old woman was diagnosed with MDR-TB, but considering she is still infectious after 18 months on alternative treatment, doctors suggest she could well be another XDR-TB case.

Health Department spokeswoman Faiza Steyn said the woman was to be admitted to Brooklyn Chest Hospital today.

Steyn said there were 37 confirmed XDR-TB patients in the Western Cape.

The 18-year-old boy, the most recent person to die of XDR-TB, died at his home.

Meanwhile, to cope with the shortage of beds, both confirmed and suspected cases were being admitted into a side section of a isolation ward at Brooklyn Chest Hospital used for MDR-TB patients.

Patients with MDR-TB, who do not respond to treatment with two of the key first-line drugs, are admitted to hospital for the first four months of their treatment. XDR-TB, according to a national definition, is resistant to all first-line treatments, as well as all the second-line drugs in its most severe form.


Other than the stop-gap side ward, Steyn said provincial health authorities were making plans to convert an "ordinary" TB ward at Brooklyn Chest Hospital, which has 45 beds, into an XDR-TB ward.

The patients with standard TB would be sent to level one district hospitals with TB beds.

Last month, Health MEC Pierre Uys revealed that Brooklyn Chest Hospital is designed to become a centre of excellence for MDR-TB treatment and is set to house more than 700 beds.

http://allafrica.com/stories/200705301009.html

[Gert van der Hoek]

Re: S.Africa: new TB strain a concern

Worst Fears Realized In S. Africa TB Scare

JOHANNESBURG, South Africa, May 31, 2007

"It was the height of summer in February 2005 and the hospital was filled with patients with both TB and HIV/AIDS," recalled Dr. Tony Moll, the anti-retroviral program manager at the Church of Scotland Hospital in Tugela Ferry.

"I remember there were two patients who just weren't getting better. I don't know why, but I had this terrible feeling that something really sinister was happening," Moll said.

In most instances, HIV/AIDS positive patients being treated with both anti-retrovirals and tuberculosis drugs improved, Dr. Moll explained, but not these two. "They were getting worse by the hour."

With a lack of testing facilities in his rural hospital in South Africa's Kwazulu-Natal province, Dr. Moll asked for special permission to have the sputum samples of 45 patients sent to Durban and tested for resistance to TB drugs.

Nurses collected samples from the two very ill patients, and 43 others being treated with TB and anti-retroviral drugs, and sent them off. By the time the results came back eight weeks later, 10 of the patients were dead, including the two who had been very ill.

Of the 45 samples, 10 were resistant to all six TB drugs they tested for.
"I got a cold shiver, with such fear in my heart," Moll said. "I thought, 'This is airborne. Could I be infected? Could my staff be infected?' To go into a new realm of XDR-TB, which is basically untreatable, was almost unthinkable," he said, using the acronym for Extremely Drug-Resistant Tuberculosis.

Moll?s worst fears were eventually realized. Four of the hospital nurses died in those first few months. From that point on, the hospital began identifying more and more patients. And in almost all cases the patients with XDR-TB were dead before the lab results were back. Most die within 16 days of being identified as a possible XDR-TB case. The mortality rate of XDR-TB is 84 percent.

Since the first two cases, close to 3 years ago, doctors at the Church of Scotland Hospital have identified 266 people with XDR-TB.

That is just one small hospital. Across South Africa, doctors in all nine provinces have reported XDR-TB cases.

"It seems to be simmering, with increasing numbers each month," says Moll said. "It's not explosive, but it's slow, insidious increasing numbers."

With recent U.S. fears of tuberculosis being stoked by a Georgia man's trans-Atlantic travels while infected with XDR-TB, South Africa's struggles serve as an ominous reminder of how deadly the disease can be.

The South African government has installed extractor fans in all TB wards and hospital staff use surgical face masks, but doctors claim there is a lack of good isolation facilities available. It has been reported that small rural clinics and hospitals can sometimes wait for up to three weeks with an XDR-TB patient in a general ward before a bed is available in one of the few urban hospitals better equipped to deal with XDR-TB.

Experts claim a drug to deal specifically with XDR-TB is more than a decade away, so doctors use a combination of six to eight TB drugs to treat it.

Currently, a small group of XDR patients have been treated for more than five months in a Durban hospital, but their results have fallen short of doctors' expectations.

"Ultimately we need prevention, as the current treatment regime just isn?t the way to go," Moll said. "The bulk of the patients just die so quickly."

http://www.cbsnews.com/stories/2007/05/31/health/main2869685.shtml

[Gert van der Hoek]

Re: S.Africa: new TB strain a concern

Three in four extreme TB patients die, says minister

Wyndham Hartley

CAPE TOWN ? Almost three-quarters of all patients diagnosed with extremely drug-resistant tuberculosis had died, Health Minister Manto Tshabalala-Msimang said yesterday in a written reply to a parliamentary question.

In the latest update on the figures across the country, she said 403 cases had been identified and of these about 265 had died.

There were 135 patients who were still undergoing treatment.

SA has the seventh-largest number of TB patients globally and the government has been accused of being slow to respond to the threat of extremely drug-resistant tuberculosis (XDR-TB) since it was first identified in October .

Tshabalala-Msimang said, in reply to a question from Inkatha Freedom Party MP Ruth Rabinowitz, that the worst hit province remained KwaZulu-Natal, where 247 cases had been diagnosed and 221 of them so far had been fatal. Second-highest was Eastern Cape with 74 patients, of whom 26 had died and 47 were still on treatment, with one patient transferred.

The third-highest caseload was in Western Cape, with 32 cases and five fatalities.

XDR-TB had been identified in all nine provinces, with the lowest incidence being in Mpumalanga, where two people were still undergoing treatment, the minister said.


About 13 patients in Gauteng were being held in hospital against their will.

The minister said that all patients in hospital were on treatment and this varied from patient to patient, depending on the resistance patterns.

http://www.businessday.co.za/articles/national.aspx?ID=BD4A489570

[Gert van der Hoek]

Re: S.Africa: XDR TB

XDR-TB cases in Western Cape shoots up in three months


JOHANNESBURG ? Cases of extreme-drug resistant tuberculosis (XDR-TB) have more than quadrupled in the Western Cape in the past three months, the Cape Times reported on Thursday.

The Cape Times cited provincial health department figures.
Also, the Brooklyn Chest TB Hospital has no room for more patients. It has 22 beds in the isolation wards to treat XDR-TB cases.

This comes as the City of Cape Town has drawn up contingency plans in the event of an XDR-TB outbreak.

Since World TB Day in March, 45 XDR-TB cases have been notified in the province. Eight people have died, according to department figures. In March, there were 10 known XDR-TB cases in the province.

XDR-TB, which withstands first-and second-line antibiotic treatment, is almost impossible to treat. It has killed 290 patients nationwide.
Department spokeswoman Faiza Steyn said most patients with XDR-TB were admitted as quickly as possible to Brooklyn.

?At times, patients do have to wait for a bed at Brooklyn Chest Hospital,? Steyn said.

Some patients were treated in side wards at the hospital, while the rest were in isolation at prisons in the province, she said.

City health director Ivan Toms said the department and clinics had implemented steps to reduce the health risk of TB and XDR-TB.

?These include clinic designs to separate waiting areas for TB clients, ensuring good airflow in TB areas, providing masks to coughing TB patients, and respirators for all staff in the TB area,? he said.

He said that in the last quarter, Cape Town achieved its best cure rate of 79 percent for TB.

According to XDR-TB statistics, 437 cases have been reported, with 290 deaths among them. Most were in KwaZulu-Natal, where the strain was first detected. ? Sapa.


Last updated

21/06/2007 10:51:57

http://www.citizen.co.za/index/article.aspx?pDesc=41805,1,22

[Gert van der Hoek]

Re: South Africa: XDR TB

South Africa: Isolating TB Patients - Prevention Better Than Cure

ANALYSIS

4 July 2007

Posted to the web 5 July 2007

Jerome Singh


In September 2006, the World Health Organization announced that Tugela Ferry -- a small town in KwaZulu-Natal, South Africa -- was host to the largest outbreak of extensively drug-resistant tuberculosis (XDR-TB) ever recorded. 53 people were diagnosed with the disease and their median survival time from sputum collection was just 16 days.

Since then, as national surveillance of XDR-TB has increased, more than 400 people have been diagnosed with the disease, and the number is growing.

Yet despite this growing crisis, South African officials have been reluctant to consider mandatory isolation of infected individuals, believing such a measure could lead to stigma and the disease being driven underground.

Such an approach, while politically correct, is unwise and could thwart efforts to prevent the outbreak from becoming a regional -- or even global -- epidemic.

A question of resources?

But mandatory isolation of patients carries with it an inevitable logistical and financial burden that many developing countries could struggle to cope with.

South Africa's health system -- like that of many other countries in sub-Saharan Africa -- is already overwhelmed with patients suffering from HIV/AIDS and related opportunistic infections.

There are simply insufficient resources to cater for everyone infected with XDR-TB. This means that potentially dozens of XDR-TB patients are being treated as outpatients, or at general hospitals where they share wards with people infected with other strains of TB, putting potentially curable patients at risk of acquiring a possibly incurable disease.

Other countries in sub-Saharan Africa, such as Lesotho or Malawi, are even worse off, with little or no resources for XDR-TB diagnosis, surveillance, tracing or treatment.

Given the critical lack of hospital beds, home-based care has been mooted as one option for treating XDR-TB patients. But the disease's airborne nature and its lethality to those with immune systems compromised by HIV/AIDS make this a less than optimal solution.

It would be better to have dedicated community-based isolation units, where XDR-TB patients can be treated without putting other members of the local community at risk. Of course, establishing and maintaining such units will have profound financial and logistic implications and may not be feasible or sustainable in poor countries unless -- or even if -- they are backed by investment from the international community.

In addition, isolated patients and their families deserve financial and social support to cope with the prospect of possible isolation until death. Indeed, such support may incentivise infected people to comply with isolation measures.

The ethical dimension

But, even if community-based isolation measures can be financed and logistically provided for, they could still lead to stigma and discrimination. Such strategies then must be accompanied by proper educational and protective mechanisms such as outreach and social support programmes, teaching clinics, and the provision of and training in the proper use of universal precautions such as masks and respirators to guard against XDR-TB infection.

Restricting the mobility rights of people infected with XDR-TB also has ethical and human rights implications. Ethically, patients are entitled to self-determination. Legally too, patients are given a host of human rights by virtue of domestic and international laws, such as the International Covenant on Civil and Political Rights (ICCPR).

Still, these rights are not absolute. The ICCPR, for example, holds that public health may be invoked as grounds for limiting certain rights so that states can take measures to deal with a serious threat to the population's health.

Seen in this context, isolating XDR-TB patients -- involuntarily if needs be -- is a reasonable and justifiable measure to protect the health interests of the wider population. Governments in the developing and developed world alike should not be reluctant to act on human rights grounds alone.

The need to act promptly

On May 30, 2007, US officials announced that a citizen diagnosed with XDR-TB had undertaken trans-Atlantic flights and, in so doing, may have put dozens of people at risk of infection. If, as the passenger alleges, authorities knew of his travel plans in advance, their failure to prevent him undertaking the journey and his subsequent easy re-entry into the country constitutes gross negligence, notwithstanding his allegedly low state of infectiousness.


Although the infected individual has since been isolated -- under the first such federal order issued in the United States since 1963 -- the incident serves to highlight how XDR-TB could potentially spread beyond individual regions very quickly. It also underlines how prompt and restrictive isolation measures could have prevented the incident.

XDR-TB is a global problem that already affects people across the world, including those in affluent countries. Governments must act decisively and responsibly to implement isolation measures in a sensitive and humane way to manage XDR-TB before it becomes an unmanageable pandemic. Prevention is better than cure.

Jerome Amir Singh is head of Ethics and Health Law at the Centre for the AIDS Programme of Research in South Africa.

http://allafrica.com/stories/200707050839.html