Drug-re­sis­tant tu­ber­cu­lo­sis is on the rise and it’s spread­ing, writes

CityPress - - News -

South Africa is fac­ing a health disas­ter that ex­perts are de­scrib­ing as a “tick­ing time bomb”. State hos­pi­tals have been dis­charg­ing pa­tients with a highly in­fec­tious strain of tu­ber­cu­lo­sis (TB) from spe­cialised hos­pi­tals – far worse than the ex­ten­sive drug-re­sis­tant (XDR) TB we al­ready know about.

This strain is in­cur­able, mean­ing it does not re­spond to any an­tibi­otics used to date to treat XDR TB. The dis­charg­ing of pa­tients with in­cur­able TB or “to­tally drug-re­sis­tant TB” to the care of their fam­i­lies has been tak­ing place for the past few years.

Now there are fears that this has led to the strain spread­ing and an in­crease in the num­ber of peo­ple di­ag­nosed with in­cur­able TB. Some pa­tients di­ag­nosed with this strain of TB have never had TB be­fore, mean­ing they could have been in­fected by the dis­charged pa­tients.

Keer­tan Dheda, pro­fes­sor of medicine at the Univer­sity of Cape Town, told City Press this week that the health risk posed by dis­charg­ing pa­tients with in­cur­able XDR TB was a ma­jor con­cern among doc­tors.

“We are sit­ting on a tick­ing time bomb and if we con­tinue in this way, we will have a disas­ter on our hands,” he said.

“Mil­lions of peo­ple in South Africa are im­munecom­pro­mised ow­ing to HIV or di­a­betes [which weaken one’s im­mune sys­tem]. TB thrives in such sit­u­a­tions. You could be in the taxi or wait­ing in a queue and a per­son with in­cur­able TB coughs with­out cov­er­ing their mouth. Then the germs spread, lead­ing to a pos­si­ble in­fec­tion,” he ex­plained.

“Nor­mal TB is out of con­trol in this coun­try. With the in­creas­ing cases of in­cur­able TB and HIV col­lid­ing, it can only lead to disas­ter,” he said.

It is not yet known how many peo­ple have in­cur­able TB in South Africa, but in 2015, there were an es­ti­mated 1 024 cases of XDR TB.

David Mametja, chief di­rec­tor for TB con­trol and man­age­ment at the na­tional de­part­ment of health, said Dheda was speak­ing the “hard truth”.

“We re­alise the risks of re­leas­ing a per­son who has in­cur­able TB into the com­mu­nity, but we have to con­sider the per­sonal needs of the pa­tient. Peo­ple with XDR TB stay in hos­pi­tals for long pe­ri­ods. Of­ten, the spe­cialised fa­cil­i­ties where they are treated are re­mote, mean­ing they are re­moved from their fam­i­lies, which then af­fects them psy­cho­log­i­cally, lead­ing to some ab­scond­ing or de­vel­op­ing poor treat­ment out­comes,” Mametja said.

“Stud­ies have shown that de­cen­tral­is­ing pa­tients who have been treated in hos­pi­tals for longer pe­ri­ods yields bet­ter re­sults than keep­ing them in hospi­tal against their will.”

Dheda and his col­leagues pub­lished a study about this im­mi­nent disas­ter in the pres­ti­gious jour­nal The Lancet last month. The study – which fol­lowed 273 pa­tients with XDR and in­cur­able TB from Brook­lyn Chest Hospi­tal, Western Cape, and Dr Harry Surtie Hospi­tal, North­ern Cape, for more than six years – showed that some pa­tients who were still highly in­fec­tious were dis­charged and sent home. Un­for­tu­nately, they spread bac­te­ria, in­fect­ing those they came into con­tact with.

Re­searchers found that out of 172 pa­tients, 17 who were dis­charged from hos­pi­tals spread the dis­ease to 20 other in­di­vid­u­als.

“This fig­ure could be an un­der­es­ti­mate be­cause it in­cludes only se­condary cases with ac­tive XDR TB or in­cur­able TB iden­ti­fied dur­ing the study pe­riod,” Dheda said.

“For us to know the real im­pact, we would need to do ex­tended re­search to as­sess la­tently in­fected peo­ple who might progress to dis­ease at a later stage.”

The study also found that half of the peo­ple newly in­fected (se­condary cases) with XRD TB or in­cur­able TB had died. Dheda said this high mor­tal­ity rate made it even more ur­gent to come up with “com­mu­ni­ty­based con­tain­ment strate­gies”.

“These strate­gies should in­clude vol­un­tary, longterm, com­mu­nity-stay fa­cil­i­ties and pal­lia­tive care, and more modern-day sana­to­rium fa­cil­i­ties where pa­tients can die with dig­nity. At present, few such fa­cil­i­ties ex­ist in our com­mu­ni­ties,” he said.

Mametja also ac­knowl­edged that more of the sana­to­rium-like fa­cil­i­ties were needed to ad­dress the sit­u­a­tion. He said govern­ment was al­ready send­ing some pa­tients with XRD TB and in­cur­able TB to hospices around the coun­try.

He also ex­plained that, be­fore a per­son is dis­charged into the care of his or her loved ones, both the fam­ily and home where pa­tients would be cared for are as­sessed.

“We look at whether there is a re­spon­si­ble per­son who can look af­ter the pa­tient, if there is enough space to al­low for iso­la­tion of the pa­tient and if there is good ven­ti­la­tion where the pa­tient is. We also ed­u­cate all of them and give them ba­sic masks that should al­ways be worn when the pa­tient is in close con­tact with fam­ily mem­bers to avoid cross-in­fec­tion,” Mametja said.

Dheda said he ap­pre­ci­ated the ef­forts be­ing made by govern­ment to con­tain the spread of in­cur­able TB, such as rolling out new-gen­er­a­tion di­ag­nos­tic tech­nol­ogy (GenXpert that di­ag­noses mul­tidru­gre­sis­tant TB in min­utes), but more needed to be done.

“We need a wider avail­abil­ity of bet­ter TB drugs. We need peo­ple to be ed­u­cated to pre­vent TB in­fec­tion in the first place. This would re­quire more peo­ple to be em­ployed so that over­crowd­ing, lack of good nu­tri­tion and poverty would be re­duced,” Dheda said.

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