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by Stephen Leahy

Extreme Strain of TB Appears in S Africa

(IPS) -- Enforced quarantines may be needed in South Africa and elsewhere to bring a deadly, contagious and drug-resistant strain of tuberculosis under control, health experts say.

An outbreak of extensively drug-resistant tuberculosis (XDR-TB) in South Africa's KwaZulu-Natal province gained the attention of the World Health Organization last year. Hundreds have been infected and the fatality rate is extremely high.

"The problem is a lot bigger than we know," said Jerome Amir Singh, an HIV/AIDS expert at the Nelson R. Mandela School of Medicine, University of KwaZulu-Natal in Durban.

"The high rates of normal TB and HIV infection in KZN ( KwaZulu-Natal) has created a very explosive disease cocktail," Singh told IPS from Durban.

In a survey of TB patients last year, 51 percent of the XDR patients had no prior TB treatment, suggesting that they had been newly infected by XDR-TB strains. In less than 25 days, 52 of the 53 XDR-TB patients died, a death rate unprecedented anywhere in the world, Singh and colleagues write in a policy paper "XDR-TB in South Africa: No Time for Denialism or Complacency" published Monday in the journal PLoS Medicine.

Given South Africa's international tourism boom and global trade and transport systems, the XDR-TB outbreak represents "a potentially explosive international health crisis," they write.

Millions of migrant workers from neighboring countries like Zimbabwe, Mozambique, Lesotho and Swaziland and from within different regions of South Africa, as well as high rates of HIV infection, create ideal conditions for the spread of XDR-TB.

Indeed, at least 30 new cases of XDR-TB are being detected in KZN each month.

"This could break the South African health care system," said Singh.

While South Africa has just begun to determine the extent of XDR-TB infections, neighboring countries are largely unaware of the problem and don't have the resources to test for the disease, he says. Diagnosis of XDR-TB requires specialized labs and takes several weeks.

"I wouldn't be surprised if it has spread to all the surrounding countries," Singh warned.

About one-third of the world's population carries the TB bacterium in their bodies. Fortunately, the body's normal immune response is enough to keep the bacterium inactive. However when the immune system is compromized by other diseases or malnutrition, the opportunistic TB bacterium comes to life.

Drugs developed in the 1930s became effective tools for fighting the disease and TB was eradicated from many parts of the world. However, global efforts to wipe out the disease completely waned -- and then HIV struck in the 1980s.

"People with HIV infections presented a fertile field for TB to make a major comeback," said David Olsen, an advisor to the international humanitarian group Medecins Sans Fronti¸res (MSF) in New York City.

Strains of drug-resistant TB first arose in the former Soviet bloc countries in the 1990s as a result of incomplete drug treatment regimes and deteriorating health care systems. TB is difficult to treat because the bacterium has sub-populations that can stay dormant for months or even years. Three and four different drugs must be taken on a rotating schedule for many months and treatment can require isolation in hospital for up to 24 months.

Similar conditions arose in South Africa where 15 percent of TB patients fail to complete the first-line six-month treatment and 30 percent don't finish the second six months.

The result was multi-drug-resistant TB (MDR-TB), which in turn spawned XDR-TB.

MSF reports that 450,000 new cases of drug-resistant TB are reported each year worldwide, while the World Health Organization says 1.7 million people die from TB annually. One problem is that no new TB drugs have been developed since the 1960s.

What's especially alarming in South Africa is the presence of XDR-TB amongst large populations with HIV, which means it will spread more quickly and be more lethal, Olsen told IPS.

TB is spread through an infected person's coughing or sneezing in close proximity to other people. Proper treatment for MDR-TB or XDR-TB infections means the use of older, more toxic drugs and complete isolation in a private room with negative pressure ventilation to prevent the spread of the disease for up to 24 months, he said.

"That level of treatment is out of the question in most of Africa and many other parts of the world," Olsen said.

KwaZulu Natal has only one hospital for treating MDR or XDR-TB, and it only has 11 beds, says Singh, even though the South African government has been aware of the problem since 2005.

"Given the South African government's poor track record in dealing with the country's HIV/AIDS epidemic and what is at stake if it adopts a similar lethargic and denialist response to the country's XDR-TB outbreak, the international community must be vigilant in monitoring the government's response to this emerging crisis," says Dr. Nesri Padayatchi, deputy director of the Center for AIDS Program of Research in South Africa (CAPRISA).

Urgent public health action is needed to stop the spread of XDR-TB in South Africa, agrees co-author Dr. Ross Upshur, director of the University of Toronto Joint Center for Bioethics.

The mobility rights of people with suspected infections will need to be restricted until they test negative, Upshur said in an interview in Toronto.

A quarantine of tens of thousands of people was the key in stemming Canada's 2004 SARS outbreak, he noted.

However, quarantines will be doubly difficult in South Africa because up to ten million people receive social grants and payments from the government. Those payments, which often represent the entire income for a family, are suspended on admission into a hospital.

As a result, many infected with TB are treated as outpatients, says Singh.

Not only will South Africa have to consider enforced isolation for infected patients but also the creation of state-sponsored social support networks to help people and their families, he said.

Without urgent action, the only practical and effective method for isolating large numbers of people infected with MDT-TB or XDR-TB for long periods would be something like leper colonies.

"TB patients must not be treated like criminals," stressed Upshur. "The spread of the disease is a failure by all of us."

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Albion Monitor   January 22, 2007   (

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