"We make a call for test cases to be done in the Constitutional Court," said Dr Karin Weyer, the research director for TB at the SA Medical Research Council.

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Weyer said there was a need to balance the rights of people infected with illnesses such as extensive drug resistant tuberculosis (XDR-TB), who may refuse or fail to complete treatment, with the rights of their families and communities who could be infected by them.

XDR-TB emerged in KwaZulu-Natal recently, with 52 of 53 identified patients dying within 25 days.

Weyer said there was a "high rate" of patient failure to finish TB treatment. Multi drug-resistant TB (MDR-TB) develops in such cases. Now XDR-TB has been found among both patients who were previously treated for TB and those who were not.

"Patients who default on treatment, and those whose treatment fails, become chronic MDR-TB carriers and pose a significant threat to public health," said the MRC in January in a policy briefing on the legal implications of managing MDR-TB.

"The inherent contradiction posed by the need to address MDR-TB using conventional public health intervention strategies like confinement, coercion, detention or quarantine, while protecting individual patient rights, needs to be tested for constitutional validity.

"Potential conflict in the legislation is evident, as is the lack of adequate procedural safeguards within current public health legislation."

TB is a good disease to use as an example, primarily in order to generate a public health response by the responsible health authority, said the MRC.

In the briefing, the MRC recommended that, due to the toxicity of MDR-TB treatment, reduced patient life expectancy, lower success rate for treatment and need to respect individual rights, MDR-TB treatment should remain voluntary.

The issue arises now in the context of the more virulent XDR-TB. Dr Muhammad Ali Dhansay, who heads the MRC's nutritional intervention research unit, warned against witch hunts against those suspected of having XDR-TB. He said it was not possible to tell who had XDR-TB without appropriate tests.

Dr Ken Castro of the US Centres for Disease Control and Prevention said that in the US, which emphasises individuals' rights, every state had laws on TB control. Patients who did not adhere to treatment could, as a last resort, legally be confined.

Castro said proactive health services were needed to deal with XDR-TB, offering treatment options. "We need to respond before we can demand that individuals are held against their will."

Dr Willem Sturm of the Nelson Mandela School of Medicine in Durban said most of the KwaZulu-Natal cases had been at Tugela Ferry but there had also been cases identified at 28 other hospitals in the province. "There must be sources out there that are still spreading it."

He said health workers were trying to trace those who had had contact with the XDR-TB patients. "We have no idea how many patients are really infected." Castro warned that the widely-used BCG vaccine could not prevent all strains of TB.

New vaccines are in development, mostly modified versions of the BCG. "There are at least four candidates in phase one trials," said Castro. "We will not be able to rely on the vaccine to confront the problem."

Health experts also urged improved infection control measures be implemented in health facilities, to prevent patients picking up infections there. - (Sapa)

For more information on care and support of tuberculosis visit South African National TB Association (SANTA) or phone them on 011 454 0260.

September 2006

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