Tugela Ferry XDR-TB outbreak continues to grow, but treatment in KZN provides hope

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Two hundred and sixty-six people in the South African town of Tugela Ferry have now been diagnosed with XDR-TB in the world’s largest outbreak of extensively drug-resistant TB. A further 205 cases of MDR have also been discovered, and eight staff at the Church of Scotland Hospital, Tugela Ferry, have died of MDR or XDR-TB.

Eight-four per cent of all XDR-TB patients identified at the Church of Scotland Hospital have died, Dr Tony Moll reported on Sunday at the 38th World Lung Health conference in Cape Town, South Africa.

He outlined infection control measures taken at the hospital to reduce the spread of MDR and XDR-TB. Although South Africa recommends referral of all MDR and XDR-TB patients to a provincial MDR treatment centre, lack of beds is forcing the Church of Scotland Hospital to manage XDR patients locally.

Glossary

extensively drug-resistant TB (XDR-TB)

A form of drug-resistant tuberculosis in which bacteria are resistant to isoniazid and rifampicin, the two most powerful anti-TB drugs, plus any fluoroquinolone and at least one injectable second-line drug. 

multidrug-resistant tuberculosis (MDR-TB)

A specific form of drug-resistant TB, due to bacilli resistant to at least isoniazid and rifampicin, the two most powerful anti-TB drugs. MDR-TB usually occurs when treatment is interrupted, thus allowing organisms in which mutations for drug resistance have occurred to proliferate.

infection control

Infection prevention and control (IPC) aims to prevent or stop the spread of infections in healthcare settings. Standard precautions include hand hygiene, using personal protective equipment, safe handling and disposal of sharp objects (relevant for HIV and other blood-borne viruses), safe handling and disposal of waste, and spillage management.

referral

A healthcare professional’s recommendation that a person sees another medical specialist or service.

cure

To eliminate a disease or a condition in an individual, or to fully restore health. A cure for HIV infection is one of the ultimate long-term goals of research today. It refers to a strategy or strategies that would eliminate HIV from a person’s body, or permanently control the virus and render it unable to cause disease. A ‘sterilising’ cure would completely eliminate the virus. A ‘functional’ cure would suppress HIV viral load, keeping it below the level of detection without the use of ART. The virus would not be eliminated from the body but would be effectively controlled and prevented from causing any illness. 

But, said Tony Moll, the hospital wasn’t designed for airborne infection control, it was designed with bloodborne infections in mind, and didn’t even have an airborne infection control policy at the time XDR-TB surfaced in patients.

The most basic measure, the separation of highly infectious TB patients and highly vulnerable HIV patients, has already been instituted, both in wards and in outpatient facilities. For example, HIV-positive TB patients no longer attend the same ARV literacy sessions as other HIV-positive patients prior to starting ARV treatment.

The hospital is also separating XDR-TB and drug susceptible TB patients on the wards – but this has proved more challenging due to the severe lack of space in the hospital.

A more basic precaution, ensuring that the air within the facility is changed regularly for fresh air, also poses difficulties. During the summer windows can be opened wide, but winter nights in Tugela Ferry are very cold, so mechanical ventilation has been installed.

There has been great concern among staff about the risk of MDR and XDR-TB, but when Dr Moll offered staff the opportunity to move to other areas or facilities if they were HIV-positive, he was told by one nurse: “You will have hardly anyone left.”

However, there has been concern among staff that moving to another facility would reveal their HIV status.

“What staff have found a lot more acceptable was to introduce antiretroviral therapy for them at a higher CD4 count – 350 cells.”

Due to the pressure on bed space, the hospital has found that it has already having to treat MDR TB patients in the community, carrying out daily injections either at home or at local primary health clinics. An “injection team on wheels” is assisting with this process of decentralising care.

Home visits to the families of MDR and XDR-TB patients have revealed limited community spread. Only 1.3% of 2240 community contacts followed up have been found to have MDR-TB.

But throughout KZN, said Dr Moll, surveillance and contact tracing need to be given a lot more emphasis.

Throughout KwaZulu-Natal 689 MDR-TB cases were identified during 2006 and 448 so far in 2007, with 67 XDR cases in 2006 and 125 so far in 2007.

Data on treatment outcomes among XDR-TB patients from across KwaZulu Natal were also presented, by Dr Max O’Donnell of Boston University. Gathered from KZN’s MDR-TB referral hospital, which should treat all patients with MDR-TB during the compulsory four month hospitalisation period during intensive MDR-TB treatment, the findings cover 72 patients admitted since the second-line TB drug capreomycin became available in November 2006.

Treated patients came from 26 different hospitals in KZN: one quarter from Tugela Ferry Church of Scotland hospital, where the XDR outbreak was first identified in 2005, 11% from the Durban area, and 8% from Pietermaritzburg.

Three-quarters (76%) were HIV-positive, 56% were already taking antiretroviral therapy, and the mean CD4 count among HIV-positive patients was 193 cells/mm3 (+/- 90 cells).

Twenty-nine patients had received prior TB treatment; in 15 cases for MDR treatment.

King George V Hospital used three regimens during the period under study, all of them containing capreomycin:

  • PZA/PAS/CAP/ETH/EMB/TER
  • PZA/CAP/ETH/TER/CLAR/AMOX/CLAV
  • PZA/PAS/CAP/ETH/TER

Of 62 patients who received treatment (ten patients either died or absconded before treatment could start), 20 died during treatment (32%). Five died from adverse events, chiefly hypokalemia (a severe electrolyte imbalance that leads to kidney failure, caused by capreomycin). Three died from AIDS-related illnesses, seven from respiratory disease and five from unknown causes.

Dr O’Donnell remarked that with greater experience of managing hypokalemia, the rate of severe hypokalemia has come down.

Dr Gerry Friedland of Yale University School of Medicine, one of the team that investigated the original XDR-TB outbreak, pointed out that the treatment outcomes were considerably better than those seen in Tugela Ferry, where 96% had died. However, no confirmed data on conversion from smear-positive to smear-negative are yet available to show whether XDR patients in KZN are on the road to a cure.

References

Moll A et al. Treatment of HIV-associated XDR-TB patients. 38th World Lung Health Conference, Cape Town, 2007.

O’Donnell M et al. Clinical treatment outcomes and epidemiologic risk factors for extensive drug resistant tuberculosis patients on treatment in KwaZulu-Natal, South Africa. 38th World Lung Health Conference, Cape Town, late breaker, 2007.

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