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The Medical Research Council (MRC) told the Weekend Witness that South Africa is in danger of an uncontrollable tuberculosis epidemic because the government's inadequate control of patients defaulting on treatment is leading to a rapid rise in resistance to TB drug treatment.
A frightening new strain, called extreme drug-resistant TB, has emerged in all provinces in South Africa in the past few years. As there are no drugs to treat it, the only outcome of this form of TB is death, said Dr Karin Weyer, MRC operational and policy research head.
Government held responsible
The government is directly responsible for the rise in these drug-resistant strains of TB as resistance develops when patients fail to complete the treatment course. This is an indication that the management of patients at state health facilities is poor.
In South Africa, about 25% of TB patients currently drop out of treatment or move to another province without transferring to another TB treatment programme, according to the Department of Health's National TB Crisis Management Plan. The WHO called for the government to reduce patient default and transfer-out rates to less than 10%.
This dropout rate is highly problematic. Multi-drug resistant TB (MDR-TB) has developed as a result of people with active TB not completing their medical treatment course. Extreme drug-resistant TB (XDR-TB) has developed from people with multi-drug resistance defaulting on treatment.
Research published by the Medical Research Council in June shows that around 70% of patients with MDR-TB don't complete treatment. Deaths among MDR-TB patients are high.
Poor treatment by nursing staff
Ironically, one of the main reasons why people fail to complete the course is poor treatment by the nursing staff, the MRC's research has shown. TB patients are shouted at and blamed for not arriving for treatment and this attitude needs to change, Weyer said.
"No attention is being given (by the government's health facilities) to patients who default on treatment," she said. Health staff are required to visit defaulters to encourage them to continue the treatment, but staff complain of staff shortages and transport problems. The drop-out rate is compounded by treatment for MDR taking two years and making patients feel ill.
"The government needs to hold health services accountible for (defaulting) and to act on poor performance," she said.
"With the threat of MDR-TB meeting up with HIV/Aids, we may find ourselves in a situation that predates antibiotics. All indications are that we are on that road. After 25 years working in TB treatment, I am extremely concerned. We see very little progress and there seems to be complacency in general about TB," she said.
MDR-TB patients in the community
Meanwhile, researchers investigating TB patients in Tugela Ferry from January 2005 to March this year believe that most were infected with the extreme strain in hospital or in the community, as only a small percentage had been treated previously for TB.
Of 536 TB patients, 41% had MDR-TB and 10% had the XDR strain. All but one with XDR-TB died within 25 days of their saliva being tested, according to the research, which was presented at the 16th International Aids Conference in Toronto this week.
Doctors at King George Hospital in Durban have for some time expressed concern that they are releasing MDR-TB patients who don't respond to treatment back into communities that are vulnerable to the disease – especially those with HIV/Aids. Just over 40% of the hospital's patients with MDR-TB are cured.
A drug-resistance crisis
Last week, the WHO warned of a major TB drug-resistance crisis facing South Africa. The intensifying of this resistance into extreme drug-resistant TB is even more worrying.
"The WHO is not aware of any specific plan yet available to face such an epidemic," the organisation said in a statement.
When asked why the Department of Health had not declared TB an emergency, spokesman Sibani Mngadi said the department has declared it a crisis and has developed the national TB Crisis Management Plan which covers all the areas that the WHO-Afro member states committed themselves to last year.
The department has allocated an extra R36 million to implement the plan in line with these resolutions, he said.
Scaling up of activities
However, this week the WHO called for the scaling up of the government's anti-TB activities.
"South Africa, without the slightest hesitation, should go ahead and declare TB and TB/HIV a national emergency, and put together all measures available now to fight it," said Dr Mario Raviglione, Director of the WHO's Stop TB Department.
"If not, we will continue to see 175 people every day dying from what is a curable disease and a disease that can be treated for less than US$20," he said.
In August last year, TB was declared an emergency across Africa at WHO's regional committee meeting in Maputo by Tshabalala-Msimang and 45 other African health ministers. The declaration called for urgent actions to be put in place in the member countries.
When asked if South Africa had responded twelve months after the call with urgent extraordinary actions, the WHO said it believed "the intensity of the SA response has to increase dramatically" and that the emergency plan "needs to be strengthened urgently" as results are not yet evident.
Low TB cure rate
South Africa has a low TB cure rate of 50%, which falls far short of the WHO's required rate of 85%.
In the Durban metropole the cure rate is only 32%. Three other districts singled out by the Department of Health in its Crisis Management Plan for having the highest number of TB cases and the lowest cure rates are East London (31% cure rate), Port Elizabeth (42%) and Johannesburg (61%).
The Umgungundlovu District, including Pietermaritzburg, reported a 36% cure rate. – (Health-e News, Weekend Witness, August 2006)
