Updated 17 January 2014

Patients with drug-resistant TB discharged

A study has found that substantial numbers of patients with extensively-drug resistant TB and totally resistant TB are being discharged from hospital, potentially exposing the wider community to infection.

Conducted by the University of Cape Town (UCT) in collaboration with the University of Stellenbosch and the Department of Health, the study found that substantial numbers of patients with extensively-drug resistant XDR-TB and totally resistant TB are being discharged from hospital, potentially exposing the wider community to infection. 

“These patients can survive for months or even years, and are contributing to the community-based spread of XDR-TB,” explains study leader Professor Keertan Dheda from the Department of Medicine, University of Cape Town and Groote Schuur Hospital.

“The study has shown for the first time that, in contrast to sporadic and isolated cases of treatment failure and near-total or totally drug-resistant cases that have been reported in several countries, treatment failure (and discharge of such patients into the wider community) is occurring on a country-wide level in South Africa.”

Most common cause of death

Tuberculosis (TB) remains one of the foremost public health problems in South Africa. Almost half a million cases of tuberculosis are treated annually, it has substantial impact on the national GDP, and is officially the most common cause of death in South Africa. TB is easily treated with antibiotics but strains of TB have emerged that are multi-drug resistant (MDR), extensively drug-resistant (XDR) or totally drug-resistant to antibiotics.

Annually between 500 and 1000 patients with XDR-TB are diagnosed or treated in South Africa.  There’s little information about the prognosis and natural history in patients with XDR-TB. This is required for rational design of plans to fight the disease and for appropriate resource allocation.

“We realise that the problem here is similar to that experienced in many other parts of the world,” Dr Yogan Pillay from the Department of Health, told delegates at a press conference in Cape Town on Friday, 17 January. “But we have a big problem.”

Read: XDR-TB genes decoded

Resistant to eight or more drugs

UCT researchers, in collaboration with others at Gordonia Hospital in the Northern Cape, the University of Stellenbosch, and co-workers at Sizwe Hospital in Johannesburg, followed a group of 107 XDR-TB patients from three provinces in South Africa, who were put on treatment between August 2002 and February 2008, for a period of several years until 2012.

More than 60% of the TB strains tested in these patients were resistant to eight or more drugs.  Despite these patients being treated with an average of eight drugs (between six and ten drugs), the prognosis and treatment outcomes of these patients were, unfortunately, dismal:

After five years of follow-up, only 11% had a favourable outcome. The rest had died or treatment failed.

Out of 107 patients, 45 patients were eventually discharged from hospital. Just under half of these patients   (19 out of 45) were treatment failures (they were alive, but still had culturable TB bugs in their sputum). 

These treatment failures, because of limited bed space in hospitals and lack of appropriate facilities that could house them, were discharged back to their homes in the community.

In the community setting, these patients survived for an average of approximately 20 months with some patients continuing to survive for more than four years.

Worryingly, a third of these treatment failures who were discharged back into the community had smear-positive disease – in other words, they had a very high concentration of bugs in the sputum. This made them at high risk of transmitting the disease. 

Read: Rapid test for resistant TB?

Key implications

There are several key implications of the findings:

i) Patients with failed XDR-TB and resistance beyond XDR-TB are being discharged on a country-wide level back into the community, where they’re transmitting the disease. A co-ordinated national strategy is urgently required that combines a home-care package, long community stay facilities, and palliative-care facilities so that these patients can be appropriately accommodated, thus preventing spread of disease within the community.

ii) The poor prognosis of patients with XDR-TB and the growing problem implies that newer TB drugs such as bedaquiline, linezolid and delamanid, which are already available in Europe and the United States, need to be urgently trialled and made available to TB programmes in Africa.  In this way, newly diagnosed patients can be rapidly treated, rendered non-infectious, and cured.

iii) This is a serious reminder for healthcare workers, planners and policy makers that prevention of TB and drug-resistant TB is paramount. Preventing and treating HIV, alleviating poverty and over-crowding, and addressing factors that will strengthen and improve the functioning of the national TB programme is critical if further cases of drug-resistant TB are to be prevented.

“It’s critical that solutions are found to preventing and containing drug-resistant TB, as the associated costs are unsustainable,” Dedha says. “For example, in South Africa, we’ve shown that, despite drug-resistant TB forming less than 3% of the total TB burden in South Africa, it currently consumes almost 40% of the total national TB management budget (in the region of R1.5 billion).”

How can tuberculosis be prevented?

Government committed to change

Pillay reiterated the Department of Health’s commitment to the prevention and treatment of all forms of TB – including MDR-TB, XDR-TB and “super” XDR-TB. Diagnosing and treating drug-susceptible TB will remain the mainstay of South Africa’s TB programme, Pilay says. However, in coming years, more attention will be paid to controlling drug-resistant forms of TB as well.

A grant of $52 million now makes it possible to further decentralise the treatment of drug-resistant TB, making diagnostic tools, treatment and appropriative care more accessible countrywide. The South African Government also plans to heavily invest in the training of nurses in the next few years in an effort to decrease the time between diagnosis and treatment.

Prisons and mining communities across South Africa will also be targeted in terms of diagnosis and treatment of both TB and HIV. “Upon becoming a prisoner, every one of our inmates – across South Africa’s 242 correctional facilities – will be screened for TB and tested for HIV,” Pillay said. The families of TB-positive inmates will also be screened and, if necessary, treated.

Read more:

Therapy for XDR-TB
New XDR-TB test for SA
XDR-TB patient beats the odds


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