[Ip-health] Rocked by Aids, Zulu kingdom now faces even worse foe: incurable TB

[Ira Glazer]

http://www.guardian.co.uk/print/0,,329575390-111446,00.html

Chris McGreal in Tugela Ferry
Wednesday September 13, 2006

The first clue to the hidden killer stalking villages in the Zulu
kingdom revealed itself at a small rural hospital long besieged by
epidemics.

Doctors at the Church of Scotland hospital in Tugela Ferry were already
grappling with the onslaught of Aids and its partner in death,
tuberculosis. But some relief appeared to be in sight when, after years
of criticism for its Aids policies, the South African government was
shamed into providing life-saving drugs to HIV-positive people.

"We were very excited when the anti-retroviral drugs came at last," said
Dr Tony Moll, chief medical officer at the hospital. "We witnessed
dramatic turnarounds in the health of patients with HIV. Then we had a
small group that responded magnificently to the ARVs [anti-retroviral
drugs] - their immune systems were bouncing back - but they kept on
getting sicker."

Ten of the group died within days. Tests showed they had succumbed to a
rare but virtually untreatable form of TB known as extreme drug
resistant, or XDR-TB.

That was 18 months ago. Dr Moll and his colleagues raised the alarm at
the prospect of an untreatable tuberculosis outbreak in a country where
regular TB is already the single largest killer of people with Aids, and
where one in 10 of the population is HIV-positive. They pleaded with
health authorities to investigate the scale of the outbreak and to
provide better means of diagnosing XDR-TB so those with it could be
isolated from other patients and were not dead by the time test results
came back.

"If we picked up 10 XDR cases in one go, we wondered how extensive the
problem was," said Dr Moll. "We began to realise it was no longer a
local outbreak, it's an epidemic across the province. Combined with HIV,
it can mutate some more and spread to the rest of the community. Then
you have a disaster. There are people who say it is just a matter of time."

But it was only last week, when the World Health Organisation and
America's Centres for Disease Control (CDC) visited South Africa and
warned of the need for immediate action, that the cries of Dr Moll and
his colleagues were heeded.

By then, XDR-TB was detected in at least 28 other hospitals in
KwaZulu-Natal. The Church of Scotland hospital in Tugela Ferry, which
serves about 250,000 people over an area of 650 square miles, alone
accounts for about one in six cases worldwide. TB patients occupy two
isolation wards where men and women already so weakened by Aids that
they cannot haul themselves to the toilet struggle to contain their
coughing.

Mortality rate

The hospital has handled 63 patients known to have XDR-TB, of which 60
have died within an average of 16 days of being diagnosed.

"That's a 98% mortality rate," said Dr Moll. "We really don't want this
to spread to the general population."

Medical researchers believe the outbreak has also crept undetected into
Mozambique and Lesotho, and spread to other areas of South Africa,
partly due to the movement of migrant labour, such as miners.

"It frightens me," said Umesh Lalloo, of Durban's Nelson Mandela School
of Medicine and head of the research team investigating the Tugela Ferry
outbreak. "I hope and pray that it dies out. If we do nothing about it
and it spreads, it could make bird flu look like a picnic.

"Bird flu was tackled before it became a problem. A lot of money was
spent to contain it. We are saying, 'Use the same resources here and no
one will know how bad it could have been.'"

But some of those fighting on the frontline fear they are about to
revisit the bruising battles over Aids with President Thabo Mbeki. His
controversial health minister, Manto Tshabalala-Msimang, snubbed a
meeting of the WHO, CDC and South Africa's TB experts last week to
discuss how to combat the outbreak.

Dr Tshabalala-Msimang, who last month drew stinging criticism from the
medical profession for advocating beetroot and garlic as an effective
HIV treatment, was reportedly angry that the latest TB crisis was made
public.

The origins of XDR-TB are uncertain, but the WHO says the misuse of
anti-tuberculosis drugs is the most likely cause. That has already
resulted in the growing spread in South Africa of a form of the disease
- MDR-TB - that does not respond to the standard drug treatments but can
be contained by the prolonged use of more expensive medicines.

Ordinary TB costs about =A320 to treat. MDR-TB costs about =A318,500 and
takes 18 months, a further burden on a health service already grappling
with Aids. XDR-TB does not respond to any of the drugs currently available.

Dr Moll alerted KwaZulu-Natal's health officials to the crisis in emails
last year but got little response. In May he drafted a letter sent by
the hospital to the provincial health minister, Peggy Nkonyeni.

"We asked for an intense epidemiological study, for improved ventilation
in the TB wards and adequate isolation of the TB patients so they didn't
infect the other patients. The research has not been done, the
ventilation has not been done. Isolation sites have been identified," he
said.

Drug development

The letter may have offended some officials by suggesting that the CDC
help with the research. "But that would have needed a
government-to-government initiation. That wasn't done," the doctor said.

Those demands also form some of the steps the WHO and CDC now say are
necessary to contain the spread of XDR-TB, along with more test
laboratories and more money for drug development.

South Africa's health department says it is working around the clock to
contain the outbreak by setting up systems to monitor its spread and
investigating whether two previously unavailable drugs might provide
effective treatment.

Frontline staff in KwaZulu-Natal say that response falls far short of
what needs to be done. Still reeling from the long battle over Aids
drugs, they say they want to avoid a confrontation with the government
but that they will not stand silent if it is slow to act and ignores WHO
advice.

"The reason to raise the alarm is to get action," said Prof Lalloo. "The
warning signals are there. We hope the government will take rapid
action. If this does not happen we will face a serious crisis."