Unease is mounting in South Africa after reports that patients with the deadly strain of extremely drug-resistant tuberculosis (XDR-TB) are not being isolated in hospitals. The public health risk is staggering: anybody coming into contact with patients with XDR-TB is at risk of infection, but people living with the HI virus are even more vulnerable.
Photo: World Lung Foundation
|"Criminalising those unfortunate enough to breathe at the wrong moment"
Dr Paul Nunn, head of the World Health Organisation's (WHO) XDR-TB unit, told PlusNews that a greater sense of urgency was needed with HIV-positive people who became infected, as "chances are they will die". Patients with XDR-TB are resistant to both the first-line antibiotics used to treat TB as well as two classes of second-line drugs, making treatment with existing drugs virtually impossible.
These particularly virulent TB strains have already killed over 200 people, and pose a serious threat to this part of the continent, where HIV prevalence is the highest in the world. Most of the South Africans who have died from XDR-TB were HIV positive.
Multidrug-resistant (MDR) TB is also dangerous to people with the virus, as their ability to fight diseases has been weakened. People with this form of TB have only a 50 percent chance of being cured and South Africa's Medical Research Council (MRC) estimates that there are 6,000 cases of MDR-TB per year.
To quarantine or not to quarantine?
South Africa's XDR-TB outbreak has elicited calls for urgent measures to curb the spread of infections, and there have even been suggestions that patients who refused treatment and hospitalisation should be forcibly treated and confined.
These proposals have caused a furore, particularly among activists, who have warned against "criminalising those unfortunate enough to breathe at the wrong moment".
Healthcare workers and officials have also been also cautious about these calls, raising concerns that the threat of being quarantined without consent would deter patients from seeking treatment.
"The debate about quarantine and coercive treatment is premature. The important thing right now is to diagnose and manage such cases ... without this system in place, you won't know who to quarantine," WHO's Nunn pointed out.
|They are catching minibus-taxis and mixing with others
But Prof Jerome Singh, of the Centre for AIDS Programme of Research in South Africa (CAPRISA), warned that the interests of public health were not being adequately considered.
"I don't want to sound alarmist or cause paranoia, but it is a concern. Hospitals are treating MDR-TB patients as outpatients, XDR-TB patients are not being managed properly, and they are catching minibus-taxis and mixing with others ... this is a huge risk," Singh pointed out.
He is the co-author of an article calling for the involuntary detention of drug resistant TB patients as a last resort, published in the Public Library of Science (PloS) Medicine, a journal that presents peer-reviewed, open-access scientific and medical research.
South African health legislation makes provision for the authorities to confine patients with infectious diseases until the disease no longer poses a public health threat, and WHO guidelines also recommend that forced confinement should be regarded as a last resort.
This week, 13 patients with "highly infectious" MDR-TB forced their way out of a hospital in the capital, Pretoria, and demanded to be treated as outpatients, but were ordered back to their beds by an interim High Court order after provincial health authorities lodged an interdict against them.
According to Singh, many patients with MDR- and XDR-TB choose not to stay isolated in hospitals for fear of losing their jobs or having their welfare benefits suspended, as current government policy dictates that people hospitalised at state expense lose their social welfare grants during this time.
"Of course, there will be stigma, but the government has to deal with this proactively and ensure that people are treated humanely, emphasising that these people are not deliberately infecting others," he commented.
Better infection control, not prisons
Eric Goemaere, head of the international medical relief organisation, Medecins San Frontieres (MSF), in South Africa, acknowledged that while it was important "to avoid panic", the management of MDR- and XDR-TB had to be put into perspective.
When a TB patient in South Africa is suspected of developing resistance their sputum sample is sent to a laboratory for testing, but clinics can expect to wait up to 8 weeks for the results. If resistance is confirmed, the patient has to agree to be admitted to an isolation ward at a designated hospital, but most hospitals are struggling to cope with patient loads.
Goemaere noted that isolation wards in all nine provinces of the country were currently fully booked. "If you have to wait for a [hospital] bed to be available, this can easily take another four to six weeks." The patient often stayed in the community for as long as three months, and by the time healthcare workers sought to isolate them, many more people had been infected.
He pointed out that treatment success rates for multidrug-resistant TB were low, and even lower for XDR-TB, so there was little benefit in enforcing treatment and hospitalisation at this stage.
The Medical Research Council echoed Goemaere's sentiments in a statement: "Given the toxicity of XDR-TB treatment, potentially severe drug side effects, a low success rate of treatment, and the reduced life expectancy of XDR-TB patients, there is no sufficiently strong legal justification for coerced treatment."
"It's not effective and it is unacceptable for patients," Goemaere said. "If you knew that they were going to lock you up and put you in a place where you were most probably going to die, and you would not be able to see your family, what would you do? Escape?"
He related the account of a single mother in Cape Town, who had multidrug-resistant TB and was isolated in hospital despite her objection that there was no-one looking after her four children. By the time she left the hospital, having failed to complete the treatment, all her children were found to be infected with MDR-TB.
"Instead of focusing on pushing and locking away people, we should see if we can leave them in their home environment, or provide isolation close to where they live, and tackle infection control and adherence issues," Goemaere suggested.
MSF has proposed a "paradigm shift" in the country's TB programme, calling for decentralised patient management "while enforcing clinic and community protective measures". Such an approach would also benefit from the community-based support measures in decentralised HIV programmes and decrease the high defaulter rates.
WHO's Nunn admitted that the emergence of XDR-TB was a "wake-up call for managing TB properly", and provided an opportunity to reinforce simple infection control measures to prevent more people from becoming infected.
"We need to do a lot to improve and institute appropriate infection control in most of our public health settings - we've seen it plays a role in the transmission of drug-resistant TB," Dr Karin Weyer, MRC director for TB research told IRIN PlusNews.
The cheapest way of doing this would be to plan the patient flow through a facility to avoid exposing a mother with a baby to a patient with undiagnosed TB, who was coughing in the same overcrowded, poorly ventilated room. At MSF's TB clinic in the Cape Town township of Khayelitsha, for example, the waiting room has been deliberately built without a roof to allow for maximum ventilation.
According to Weyer, other measures should include environmental controls like extraction fans, and protective respiratory devices for healthcare workers. "Our experience is that there's a shocking lack of basic knowledge of airborne infection control, and there's an absence of appropriate plans to deal with it."
In most health facilities, patients sit for hours in congested waiting rooms waiting for their files, with no procedures in place to reduce the risk of airborne infections by fast-tracking someone actively coughing.
"Our most dangerous settings these days are ARV clinics, where patients may inadvertently be exposed to MDR- or XDR-TB ... an ideal situation for outbreaks like the one that happened in Tugela Ferry [which started in an ARV clinic in KwaZulu-Natal Province]," Weyer noted.
About 85 percent of HIV-positive South Africans co-infected with XDR-TB have died
Goemaere recommended that healthcare workers in TB facilities be "systematically tested for TB", while those who were HIV positive should not be encouraged to work in these areas.
Although the national health department has listed these and other infection control measures in its guidelines, it remains unclear as to what extent they have been implemented in a healthcare system already overstretched and struggling to cope with the burden of AIDS.
According to Singh and his co-authors, this is the root of the problem: the emergence of XDR-TB is evidence of the "systematic failure of the global community to tackle a curable disease".
"All this hype surrounding forced isolation ... people are getting carried away talking about incarcerations and being locked up, but they've lost sight of the core issue: the poor implementation of the TB programme," Singh commented.
Nunn, of the WHO's XDR-TB unit, agreed: "Quarantine or not, this is not the most important debate to be having right now. The basics need to be done. There's no point in wringing our hands over [past failures]. We need to work out what we can do now."
This report is part of a PlusNews In-depth: 'The New face of TB: Drug Resistance and HIV'