In S. Africa, a frightening resurgence

Doctors note high death rate as cases of hard-to-treat TB pile up

September 18, 2006|By Scott Calvert | Scott Calvert,SUN FOREIGN REPORTER

TUGELA FERRY, South Africa -- The nurses now wear masks in the crowded tuberculosis ward at the Church of Scotland Hospital in this small town ringed by rocky hills. The windows stay open, even when it's chilly, to improve the flow of fresh air.

And every patient who arrives at this government hospital with a cough that has lasted at least two weeks is tested for a frightening strain of tuberculosis that has defied all known drug regimens, with deadly results.

Of 63 people known to have developed this mutant TB disease here in rural KwaZulu-Natal Province, 60 have died - most within a month of going to the hospital. With new tests indicating the strain has cropped up at 27 other hospitals in the province, health experts here and abroad are scrambling to figure out whether this could spin into a far-reaching epidemic.

"It could be we have the same problem everywhere. If that's the case, we have a big problem," said Willem Sturm, a medical microbiologist and dean of the University of KwaZulu-Natal's Nelson R. Mandela Medical School in Durban.

Without major action, including scaled-up infection control, "we will have that worst-case scenario of the numbers just getting bigger and bigger, and more and more deaths," said Dr. Tony Moll, chief physician at the missionary-founded Church of Scotland Hospital. "Who knows how fast it can grow and spread?"

Although this type of TB - called Extensive (or Extreme) Drug Resistant TB (XDR for short) - has been found in most regions of the world, including the United States, the numbers have been relatively small: Just 347 cases worldwide were identified by late 2004, and no other place has recorded Tugela Ferry's concentration.

The outbreak has raised such concern that officials of the World Health Organization and U.S. Centers for Disease Control and Prevention converged on Johannesburg this month for two days of urgent meetings.

"TB is a disease without borders," said Dr. Kenneth G. Castro, director of the CDC's Division of Tuberculosis Elimination. The outbreak should reinforce the need for vigilance in the public health sector, he said. "XDR TB anywhere in the world poses a threat to everywhere in the world, including the U.S."

The South African government placed an order this month for two TB drugs long ago discontinued in that country, in the hope that they might provide a cure in combination with other drugs. But Moll and others say they are weak drugs and might not work.

Ignored disease

Medicine's seeming inability to treat XDR stems partly from the fact that the world has largely ignored tuberculosis for years, say experts. Once the No. 1 killer in the United States, according to the CDC, TB was brought under control starting in the 1940s by the development of drugs. No new drugs have been developed in more than 40 years.

Meanwhile, across sub-Saharan Africa, the HIV epidemic continues to fuel a parallel TB epidemic because tuberculosis poses great risk to those with weak immune systems. South Africa has more people with HIV, about 5.5 million, than any country but India. Globally, the WHO estimates TB kills 1.7 million people a year, 590,000 in Africa. Everyone who developed XDR TB here tested positive for HIV or was suspected of having the virus, which causes AIDS.

Since the mid-1980s, the number of active TB cases at Moll's hospital has increased tenfold, from 200 a year to more than 2,000. Nationwide, more than 270,000 people had TB in 2004, the government says.

Even ordinary tuberculosis kills thousands here. Moll said 8,000 people die every year of treatable TB across the province of 9.3 million; perhaps they don't or can't seek treatment, or are so ravaged by it and HIV that they cannot be saved. Without treatment, normal TB will kill otherwise healthy people half of the time, Sturm said.

On top of that, drug-resistant TB, which resists some but not all available drug combinations, is a growing worry that claims 1,500 lives a year in the province, Moll said. It costs $3,250 to treat, compared with $50 for normal TB.

And now there is essentially untreatable XDR, which might have mutated from multidrug-resistant TB. Resistant strains can emerge when patients fail to finish the standard four-drug, six-month treatment, a problem compounded by lack of health care workers to monitor adherence.

Experts have tried to allay growing public alarm by saying healthy people are not at great risk of having a latent infection turn into TB of any sort. Yet news of XDR's emergence in town and the lack of hard information are raising fears.

"I'm afraid. I want to know a lot about that kind of TB," said Mthunzi Makhunga, a store clerk walking along Tugela Ferry's main street Thursday. "Maybe one day it will affect me."

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