”We were very excited when the antiretroviral [ARV] drugs came at last,”’ said Tony Moll, chief medical officer at the Church of Scotland hospital near Tugela Ferry, KwaZulu-Natal.
”We witnessed dramatic turnarounds in the health of patients with HIV. Then we had a small group who responded magnificently to the ARVs — their immune systems were bouncing back — while they kept on getting sicker.”
Ten of the group died within days. Tests showed they had succumbed to the rare extreme drug-resistant TB known as XDR TB.
That was 18 months ago. Picking up multiple cases, Moll and his colleagues started to wonder how extensive the problem was. ”We began to realise it was no longer a local outbreak; it’s an epidemic across the province. Combined with HIV, it can mutate some more and spread to the rest of the community. Then you have a disaster. There are people who say it is just a matter of time.’’ By then, XDR TB had been detected in at least 28 other hospitals in KwaZulu-Natal.
Moll alerted the province’s health officials to the crisis in e‑mails last year, pleading with them to investigate the scale of the outbreak and to provide better means of diagnosing XDR TB, so that sufferers could be isolated from other patients and were not dead by the time test results came back. He got little response.
In May he drafted a letter sent by the hospital to KwaZulu-Natal Health Minister Peggy Nkonyeni.
”We asked for an intense epidemioÂÂlogical study, for improved ventilation in the TB wards and adequate isolation of the TB patients so they didn’t infect the other patients. The research has not been done, the ventilation has not been done. Isolation sites have been identified,’’ he said.
The letter may have offended some officials by suggesting that America’s Centres for Disease Control (CDC) help with the research. ”That would have needed a government-to-government initiation. That wasn’t done,’’ said Moll.
Ironically, it was last week’s visit to South Africa by the CDC and the World Health Organisation (WHO) — and their warning of the need for immediate action — that appears to have prompted an official response to the cries of Moll and his colleagues.
Their demands also form some of the steps the WHO and CDC now say are necessary to contain the spread of XDR TB, along with additional test laboratories and more money for drug development.
The health department says it is working around the clock to contain the outbreak by setting up systems to monitor its spread and investigating whether two previously unavailable drugs might provide effective treatment.
But frontline staff in KwaZulu-Natal say the response falls far short of what needs to be done. Still reeling from the long battle over Aids drugs, they say they want to avoid a confrontation with the government, but that they will not stand silent if it is slow to act and ignores WHO advice.
Regular TB is already the single largest killer of people with Aids in South Africa, where one in 10 of the population is HIV-positive. The Church of Scotland hospital, which serves about 250 000 people, has dealt with 63 patients known to have XDR TB — about one in six of the cases worldwide.
About 60 have died in an average of 16 days of being diagnosed. ”That’s a 98% mortality rate,’’ said Moll. ”We really don’t want this to spread to the general population.”
TB patients at the hospital occupy two isolation wards where men and women, already so weakened by Aids that they cannot haul themselves to the toilet, struggle to contain their coughing.
Medical researchers believe the outbreak has also crept undetected into Mozambique and Lesotho, and spread to other areas of South Africa, partly due to the movement of migrant labourers.
”It frightens me,” said Umesh Lalloo, of Durban’s Nelson Mandela School of Medicine and head of the research team investigating the Tugela Ferry outbreak. ”I hope and pray it dies out. If we do nothing about it and it spreads, it could make bird flu look like a picnic.
”Bird flu was tackled before it became a problem. A lot of money was spent to contain it. We’re saying use the same resources here and no one will know how bad it could have been.”
Some of those in the frontline fear they are about to revisit the bruising battles over Aids with President Thabo Mbeki. Reportedly angry that the latest TB crisis was made public, Health Minister Manto Tshabalala-Msimang snubbed a meeting of the WHO, CDC and South Africa’s TB experts last week to discuss how to combat the outbreak.
The origins of XDR TB are uncertain, but the WHO says the misuse of anti-TB drugs is the most likely cause. This has already resulted in the growing spread in South Africa of a multi-drug resistant form of the disease — MDR TB — that does not respond to standard drug treatments, but can be contained by the prolonged use of more expensive medicines.
Ordinary TB costs about R200 to treat. MDR TB costs nearly a hundred times more and treatment takes 18 months, a further burden on a health service already grappling with Aids.
”The reason to raise the alarm is to get action,” said Lalloo. ”The warning signals are there. We hope the government will take rapid action. If this does not happen, we will face a serious crisis.” — Â