Killer breaks free

Incomplete treatment and poor-quality drugs have made bacteria resistant to anti-TB drugs across the globe.

Recently in Cape TownA young patient

THE 24 men and women in ward 2 at Brooklyn Chest Hospital, Cape Town, have lost hope. They have developed a strain of tuberculosis that is so strong that science cannot cure it. So they are locked behind iron gates and fenced in by barbed wire, even though the air they breathe moves freely in the ward and travels through the open windows.

Most of them lie, wasting. A shrunken man back-lit by an open window stares with large doped eyes. The women have a fridge and can make food if they so choose to, but none of them looks up to it.

I dont know what to do about their mental health. They dont know whats what and whats not, says Sister Blackburn. Its so depressing, really depressing, she mutters mantra-like throughout the visit.

TB is curable. But incomplete treatment and poor-quality drugs have led to the emergence of bacteria resistant to anti-TB drugs across the globe. The bacteria has mutated not once, but twice. Roughly 450,000 people develop multi-drug resistant (MDR) TB each year. Unable to cope with the MDR TB drug regimen, 25,000 people go on to develop extensively drug resistant TB (XDR TB). For them, treatment options are next to non-existent.

In South Africa, drug resistance has been found since the late 1990s. XDR TB was first detected in 2001, but it was only in 2006, after doctors in Tugula Ferry, KwaZulu Natal, found HIV patients on antiretrovirals succumbing rapidly to TB, that the alarm was raised. During this time incidence of TB increased by over 50 per cent from 424 to 645 cases per 100,000 people from 2001 to 2005, according to the South African daily Business Day. Last year, South Africa reported 342,000 TB infections, of which 6,716 were multi-drug resistant. Between raising the alarm in October 2006 and this November, 216 South Africans died of XDR TB.

For the 4,951 South Africans diagnosed with MDR TB and the 391 with XDR TB, these figures are irrelevant in their individual fight for life. Decades of neglect by governments, industry and science has left them with long, complicated means of finding out what they are afflicted by and then a toxic treatment regimen with side effects which include severe vomiting, diarrhoea, hepatitis, psychiatric and neurological problems and deafness.

The remedy is truly worse than the disease. I can understand why people want to stop taking the medications, says Paul Thorn, who contracted MDR TB in 1995 and spent two years in isolation in a hospital in London.

Back in Brooklyn Chest, one of the men afflicted with XDR TB, now under guard, refused to undergo treatment because he could not afford not to feed his family. He went back to taxi driving and in the process may have exposed every single passenger to the lethal disease.

His case and that of three others prompted the Health Department in Western Cape to issue a court order against them.

Inside the Gugulethu

We dont want this. It took a long time, because we are violating human rights by detaining them in this manner, says Dr. Simon Moeti, Medical Superintendent at Brooklyn Chest.

But given the failure of science, isolating the patients is the only way public health workers know they can prevent patients from spreading the drug-resistant strain.

Health workers are clearly distressed by the ethical dilemmas drug resistance presents them. Sweetness Siwendu, who also works at Brooklyn Chest, asked: If a patient refuses treatment regularly, do we deny treatment to save the drug? Do we do the same if a patient sticks to the medication but it does not work? When should we warn communities? These, says Moeti, are challenges without answers.

Doctors and health workers are putting themselves at risk day in and day out. In a hospital in Tugula Ferry, eight staff members have died of drug-resistant TB.

The psychological and physical strain is taking its toll on the number of nurses. According to the medical humanitarian organisation Medecins Sans Frontieres (MSF), the number of nurses in South Africa dropped from 120 to 109 per 100,000 people between 2000 and 2005.

In Bumala, Limpopo, where the award-winning nurse Kefilwe Mamagoale Mathlala works, there is one nurse for 40 patients. It is difficult. We are unable to follow the [discharge] protocol because of overcrowding. she told Frontline.

Fewer health workers means less time to find defaulters and more drug resistance in the community. Additionally, says Linda Carrier-Walker, Director, International Council of Nurses: It takes time to train nurses in drug resistance and to train them to train others. Its a huge job for already burdened health care workers.

The TB epidemic in South Africa is fuelled by another disease with epic proportions of its own human immunodeficiency virus and acquired immune deficiency syndrome (HIV/AIDS). While in healthy individuals TB lies dormant, an immune system under attack leaves a person highly susceptible. In South Africa, 60 per cent of TB cases occur in adults living with HIV.

HIV-TB is the devils alliance, says Paul, who is also HIV positive. When I learned I had HIV I never felt alone. But when I got MDR TB my support network disappeared.

Pauls support network comprised the very people who are most at risk. Hospitals have tried to separate people living with HIV from those with TB, because the coinfection rates are so high. But in doing so they inadvertently disclose their HIV status, which, some critics say, opens patients to stigmatisation.

HIV complicates TB diagnosis the immune system is so low that the symptoms are masked or patients are too sick to produce the sputum samples required for TB tests. Treating TB-HIV coinfection is also difficult: some drugs interact negatively, it is difficult to know which drugs produce avoidable side effects, and the number of tablets is high and so difficult to take. According to MSF, the daily pill burden can exceed 20.

Unfortunately, division of human and financial resources between HIV and TB is taking its toll. And patients who already travel miles for drugs have to cover twice the distance to separate centres to be seen by separate doctors.

A demonstration in

With so many obstacles what can be done? At the beginning of November, the South African Department of Health announced a new national plan for TB and an additional 400 million rands for MDR XDR TB.

The plan includes drug sensitivity testing for high-risk groups including those with MDR TB, six-month hospitalisation and psychosocial support for XDR TB patients, and enforced quarantine as a last resort. The plan requires that all TB patients are offered HIV counselling and testing, and directs that HIV care should include routine TB screening, TB treatment and preventive therapy.

However, speaking at the Union World Conference on Lung Health in Cape Town, Thami Mseleku, Director-General, Department of Health, said: There is a need for new TB diagnostics and drugs to bolster the ability of affected nations to succeed in controlling TB.

His call is an echo of the long-held demand by patients, health groups and the World Health Organisation for new drugs, faster diagnostics and better vaccines. The collective resources of government, industry and academics in the Stop TB Partnership have brought seven drugs, two diagnostics and three vaccines to clinical trial.

But new vaccines will not be ready until at least 2015, and new drugs and diagnostics are not expected before 2011. According to MSF, mimicking the approach used for AIDS drugs testing in-patients with drug resistance will accelerate the process. But there is also a $500 million gap in the funds needed to develop these tools.

We cant wait until we have new tools in the market. We have to use what we have now, says Ezio Santos Filho of Brazil, who is HIV positive and has survived two TB attacks.

He stresses that the community has a critical role to play in managing services, raising awareness and ensuring patient compliance. Health groups point to the initiatives in Rwanda, where villagers were trained as community health workers, and in Lesotho, where community treatment literacy campaigns were conducted. These will bolster the efforts of public health services and prepare the ground for using new tools, they say.

It is essential to link HIV and TB programmes even if it may seem problematic initially, Ezio says. Where stigma is taking people out of treatment is where we need to focus, he notes.

TB and HIV are married in sub-Saharan Africa, Marcos Espinal, executive secretary, WHO Stop TB Partnership, told Frontline and stressed the importance of AIDS and TB programmes working together.

However, he added: The only way to prevent MDR XDR TB is by implementing the Stop TB strategy, mainly DOTS [direct observation treatment short course] You have to shut down the generator of the problem Otherwise you are not turning the tide. You have to cure those who are susceptible to prevent MDR.

If ordinary TB is still curable, the question is whether there is enough political will to put resources behind the ongoing efforts. It is not just in South Africas interest. MDR TB has been found in 74 countries. India is one of the worlds top four TB hotpots 2.8 per cent of Indias 1.8 million people with TB, that is, 50.5 lakh people, have multi-drug resistance.