SA is facing an incurable TB ‘ticking time bomb’

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The health risk posed by state hospitals discharging patients with totally drug resistant TB was a ‘ticking time bomb’, says Professor Keertan Dheeda of the University of Cape Town.

City Press reports that 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.

The report says 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.

The report quotes Keertan Dheda, professor of medicine at the University of Cape Town, as saying 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 immune-compromised 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.

The report says 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 de-centralising 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 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 is quoted in the report as saying. “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 “community-based containment strategies”. “These strategies should include voluntary, long-term, 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.

According to the report, 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 multidrug-resistant 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.

Background: Inadequate case detection results in high levels of undiagnosed tuberculosis in sub-Saharan Africa. Data for the effect of new diagnostic tools when used for community-based intensified case finding are not available, so we investigated whether the use of sputum Xpert-MTB/RIF and the Determine TB LAM urine test in two African communities could be effective.
Methods: In a pragmatic, randomised, parallel-group trial with individual randomisation stratified by country, we compared sputum Xpert-MTB/RIF, and if HIV-infected, the Determine TB LAM urine test (novel diagnostic group), with laboratory-based sputum smear microscopy (routine diagnostic group) for intensified case finding in communities with high tuberculosis and HIV prevalence in Cape Town, South Africa, and Harare, Zimbabwe. Participants were randomly assigned (1:1) to these groups with computer-generated allocation lists, using culture as the reference standard. In Cape Town, participants were randomised and tested at an Xpert-equipped mobile van, while in Harare, participants were driven to a local clinic where the same diagnostic tests were done. The primary endpoint was the proportion of culture-positive tuberculosis cases initiating tuberculosis treatment in each study group at 60 days. This trial is registered at ClinicalTrials.gov, number NCT01990274.
Findings: Between Oct 18, 2013, and March 31, 2015, 2261 individuals were screened and 875 (39%) of these met the criteria for diagnostic testing. 439 participants were randomly assigned to the novel group and 436 to the routine group. 74 (9%) of 875 participants had confirmed tuberculosis. If late culture-based treatment initiation was excluded, more patients with culture-positive tuberculosis were initiated on treatment in the novel group at 60 days (36 [86%] of 42 in the novel group vs 18 [56%] of 32 in the routine group). Thus the difference in the proportion initiating treatment between groups was 29% (95% CI 9–50, p=0·0047) and 53% more patients initiated therapy in the novel diagnostic group than in the routine diagnostic group. One culture-positive patient was treated based only on a positive LAM test.
Interpretation: Compared with traditional tools, Xpert-MTB/RIF for community-based intensified case finding in HIV and tuberculosis-endemic settings increased the proportion of patients initiating treatment. By contrast, urine LAM testing was not found to be useful for intensive case finding in this setting.

Gregory L Calligaro, Lynn S Zijenah, Jonathan G Peter, Grant Theron, Virginia Buser, Ruth McNerney, Wilbert Bara, Tsitsi Bandason, Ureshnie Govender, Michele Tomasicchio, Liezel Smith, Bongani M Mayosi, Keertan Dheda

City Press report
Infectious Diseases article summary

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