TB hits health workers

‘Sister Khumalo always says we have to sing so we can forget,” says Thandi Mavuso (not her real name).

The delicate 17-year-old, who passed grade 11 last year, cannot go to school — she has multi-drug-resistant tuberculosis (MDR-TB) and has been undergoing treatment at Durban’s specialist TB hospital, King George V, since February this year.

If she’s lucky, she’ll be discharged and treated as an outpatient by the end of July. There’s not much to do when you live in a hospital ward. Mavuso attends church once a week and looks forward to the weekly arts and crafts class. This week she chose to skip arts and crafts to talk to me instead. She seldom gets visitors.

‘I came to the hospital with my aunt. She used to visit but she’s not working now, so she doesn’t come any more,” she says. TB has been a part of her life for many months. Her mother died of TB in 2007 and her elder brother recently completed treatment for his TB.

She thinks her uncle may also have the illness. ‘He coughs a lot,” she says. She had TB herself in 2008. At the end of last year she became ill again and stopped responding to the drugs. After further tests she was found to have drug-resistant TB and sent to King George V.

Mavuso, like 70% of patients with drug-resistant TB in KwaZulu-Natal, is also HIV positive. When she arrived at King George V, her doctor recommended she begin antiretroviral therapy. ‘That helped me a lot because I’ve gained weight,” she says.

It’s hard to imagine her any thinner than she is now — her tiny frame is lost inside the blue hospital nightgown she wears. ‘I was 26kg when I came here and now I’m 32kg,” she says. She takes 20 pills a day — 13 for her TB, five antiretrovirals and two more to control the side effects of her medication. She hopes to be able to go back to school soon.

But with half the school year gone, there’s little chance she’ll be able to matriculate this year. ‘I want to be a doctor or a lawyer who helps sick people in prison,” she says.

Mavuso is just one of more than a thousand patients treated for drugresistant TB at King George V every year. The prognosis is not good for people with the disease. In KwaZulu-Natal, 20% of patients die after reaching a treatment centre. And of those who have extensively drug-resistant (XDR) TB, which is even more difficult to treat, only half survive.

Treating patients with drug-resistant TB puts strain on hospitals that are already financially stretched. According to Iqbal Master, head of clinical services at King George V, treating drug-susceptible TB costs about R720 a year a person. But the figures skyrocket to R12 000 and R72 000 a patient each year for MDR and XDR TB treatments.

‘We’re treating more patients and the drugs are more expensive, but the budget hasn’t been adjusted,” he says.

Tommie Victor, of Stellenbosch University’s division of molecular biology and human genetics, says that nationally ‘60% of the total budget for TB is spent on control and treatment of drug-resistant TB — so only 40% is left to treat the larger epidemic.”

According to the World Health Organisation, there were 460 000 new TB cases in South Africa in 2007 and 8 000 cases of drug-resistant TB. Although MDR-TB can be transmitted from person to person, the less common XDR-TB is usually a result of drug-resistant TB that has been inadequately managed.

But if the pool of XDR-TB patients continues to grow, it could begin to spread, Victor says. As drug-resistant TB becomes more common, the danger to healthcare workers also increases. Keertan Dheda, a professor of respiratory medicine at the University of Cape Town, says several hundred healthcare workers in KwaZulu-Natal have been treated for drug-resistant TB in the past six years.

‘The incidence in KwaZulu-Natal is six times higher in healthcare workers than in the general population. It’s likely they are picking it up in the workplace. As it is, we have a serious shortage of healthcare workers in the country. If they get drug-resistant TB, it will exacerbate the problem,” he says.

Better formal workplace policies, environmental interventions including installing extraction fans, and the use of personal protection such as special masks could help protect healthcare workers who regularly deal with drug-resistant TB patients, Dheda says.

The persistent stigma of HIV has made it difficult for doctors to treat TB patients. At King George V 10% of patients opt out of having an HIV test, leaving doctors to do the guesswork on how best to treat them.

TB is the most common serious opportunistic infection that HIVpositive South Africans contract. TB patients who are tested for HIV can be put on antiretroviral treatment earlier, which can prevent further opportunistic infections and even death.

‘If you don’t treat the HIV you don’t treat the underlying cause, and the patient could get another episode of TB or another infection later on,” Dheda says. Yet the reluctance to test for HIV extends even to healthcare workers, who are well aware of the importance of knowing their status.

A study of healthcare workers admitted to the hospital for drug-resistant TB treatment between 2003 and 2008 showed that in more than 20% of cases the patient’s HIV status was unknown. Master says it can take years to convince even a healthcare worker who deals with co-infected TB patients daily to take an HIV test.

New cancer law will reveal the big picture
Legislation making it compulsory for healthcare institutions to report on cancer could be passed within months, the health department has said. The department came under fire this week after it was revealed that the National Cancer Registry, a division of the National Health Laboratory Service (NHLS) responsible for maintaining data on cancer, has not been updated since 2001.

‘South Africa is critically in need of up-to-date information on cancer trends,” Mike Waters, the DA’s health spokesperson, said. Relying on decade-old South African data, or even on more recent foreign data, to allocate funding for research was not adequate, he said.

Waters called on Aaron Motsoaledi, the health minister, to explain why the institution had been allowed to stagnate. But Fidel Hadebe, the department’s spokesperson, denied that the department had been unable to set appropriate policy on cancer treatment or research because of it.

‘The fact that the cancer register has not provided detailed information does not mean that there is no information about cancer prevalence or incidence available,” Hadebe said. ‘Various research studies conducted within universities and by the Medical Research Council have shown the prevalence of different cancers. ‘What we do not have is a full and comprehensive picture.”

The department said that it was because of the inability to track cancer trends that draft regulations on cancer registration had been drawn up. But until the legislation is passed, healthcare institutions cannot be forced to share their cancer data with the registry.

Barry Kistnasamy, the executive director of the registry, said health professionals were bound by patient confidentiality and could not release information to a third party except if the condition was notifiable.

Cancer was not one of the 33 notifiable medical conditions — such as cholera and haemorrhagic fever — that had to be reported to the health department.

But the regulations will not be a silver bullet because the decadelong backlog of data will have to be processed. ‘A considerable increase in qualified staff and resources is necessary to address the backlog,” said Kistnasamy.

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