The emergence and spread of MDR and XDR TB is judged to be particularly problematic in populations where there is high HIV prevalence. People living with HIV are more likely to develop TB, more likely to cluster together in health care facilities and more likely to experience rapid progression to disease once they become infected with a drug-resistant variant of TB, and much more likely to die from it before the diagnosis can be confirmed.
The example of Tugela Ferry in South Africa demonstrates just how dangerous MDR TB can become in a setting of high HIV prevalence. MDR TB had been present in the province of KwaZulu-Natal since the mid-1990s, but the transformation of a strain resistant to isoniazid and rifampcin into one that was extensively drug resistant led to an outbreak of XDR TB among HIV-positive patients at the Church of Scotland Hospital in Tugela Ferry. Patients who acquired XDR TB through nosocomial transmission often died before they could be diagnosed with drug-resistant TB. Fifty of the 51 patients first identified with XDR TB died within a median of 16 days of sputum collection at the hospital.
In South Africa at least, current policy in some provinces – but not all - is to hospitalise all patients diagnosed with MDR TB until intensive treatment is completed and the patient has a negative smear and TB culture – a period of at least six months.
This policy is intended to limit the number of contacts that an infected person has prior to conversion to smear-negative TB, and to ensure that the treatment regimen is adhered to.
However, lengthy hospitalisation is neither practical nor humane, in the view of doctors speaking at a satellite meeting during November’s World Lung Health meeting organised by the Treatment Action Campaign, Médecins sans Frontières, Partners in Health, AIDS Rights Alliance of southern Africa and the Open Society Institute.
Indeed, enforced hospitalisation is so resented by patients that they recently mounted a demonstration at Sizwe isolation hospital near Johannesburg. One patient was shot when police panicked.
"These were not activists, these were people demanding to be treated like human beings," said Dr Eric Goemaere, MSF head of mission in South Africa.
And just before Christmas 2007, 49 patients with MDR and XDR TB at an isolation unit in the Eastern Cape began to slip away after having cut through barbed wire fences surrounding the facility in Port Elizabeth, anxious not to be separated from their families during the holiday period.
In any case, says Dr Francois Venter of the Reproductive Health and HIV Research group at the University of the Witwatersrand, Johannesburg, this policy is not enforced in practice everywhere, particularly in the private sector in South Africa.
The policy is also unscientific, he pointed out in an article written with Mark Heywood of the AIDS Law Project in November 2007. “Generally, patients with TB are ill and infectious for many months before they are sick enough to be diagnosed. Once they start treatment, it usually takes months to diagnose MDR TB…A huge proportion of people with MDR TB die long before being identified, meaning those who actually end up on MDR TB treatment are only the tip of the iceberg.”
“Isolating someone for a brief period when they have been infectious for a long time is locking the door long after the horse has bolted.”
But hospitalisation may be necessary in some circumstances, for example if the patient is so sick they cannot walk, if infection control in the community is very difficult or if masks are unavailable. MDR TB treatment regimens also contain daily injectable drugs and administration may be difficult to arrange on an out-patient basis.
Referral to a specialist facility is also advisable, notes Dr Riitta Dlodlo, HIV programme director of the International Union Against TB and Lung Disease, because MDR TB drug regimens are complex and the treatment of patients should be supervised by centres of excellence – or at least centres with some experience in its management – and in centres with the necessary infrastructure, in order to ensure the best outcomes for patients.
But hospital facilities for MDR TB in South Africa are inadequate. Patients are referred to designated hospitals, often hundreds of miles from home, and must leave their families and livelihoods for six to eight months.
Yet the burden of MDR TB cases is now so high, these hospitals cannot cope. Khayelitsha township in the Western Cape province identified 109 cases in 2006, for example.
“The reality is that there are not enough beds in MDR facilities in South Africa to admit all those currently diagnosed with MDR TB, let alone the increased numbers that we will diagnose if we improve the coverage of drug sensitivity testing,” Dr Graeme Meintjes of GF Jooste Hospital in Western Cape province told HATIP.
“The current policy of initial inpatient treatment for all MDR TB cases results in patients with MDR waiting for a bed in an MDR facility while being treated in a general inpatient or outpatient facility. In most of these facilities infection control is currently poor and fellow patients, including those with HIV infection, are thus potentially exposed to MDR TB”.
Dr Jim Kim of Partners in Health told a press conference during the World Lung Health meeting: “We believe that this treatment does not require hospitals. In fact, you want to stay away from hospitals as much as possible and provide treatment on a community-based level [in order to reduce transmission within clinical facilities]”
In practice, some hospitals are having to treat MDR TB in the community. Dr Tony Moll of the Church of Scotland Hospital, Tugela Ferry, said that his clinic was managing MDR patients at local primary health clinics or at home unless they are very ill. A mobile injection team is visiting patients; as well as administering injectable TB drugs, the teams are also carrying out training in TB treatment literacy and infection control, side-effect monitoring and contact screening.
“Instead of…more hospital beds, money should be directed towards building MDR-TB community programmes inspired by existing antiretroviral ones…This has ceased to be a medical specialist issue; it has become a large-scale community problem,” Francois Venter and Mark Heywood wrote in the November 11 2007 edition of South Africa’s Sunday Times.