Virulent TB in South Africa May Imperil Millions

MICHAEL WINES

NTY, 28 January

JOHANNESBURG, Jan. 27 — More than a year after a virulent strain of tuberculosis killed 52 of 53 infected patients in a rural South African hospital, experts here and abroad say the disease has most likely spread to neighboring countries, and some say urgent action is essential to halt its advance.

Several expressed concern at what they called South Africa’s sluggish response to a health emergency that, left unchecked, could prove hugely expensive to contain and could threaten millions across sub-Saharan Africa.

The director of the government’s tuberculosis programs called those concerns unfounded and said officials were doing everything reasonable to combat the outbreak.

The form of TB, known as XDR for extensively drug-resistant, cannot be effectively treated with most first- and second-line tuberculosis drugs, and some doctors consider it incurable.

Since it was first detected last year in KwaZulu-Natal Province, bordering the Indian Ocean, additional cases have been found at 39 hospitals in South Africa’s other eight provinces. In interviews on Friday, several epidemiologists and TB experts said the disease had probably moved into Lesotho, Swaziland and Mozambique — countries that share borders and migrant work forces with South Africa — and perhaps to Zimbabwe, which sends hundreds of thousands of destitute refugees to and from South Africa each year.

But no one can say with certainty, because none of those countries have the laboratories and clinical experts necessary to diagnose and track the disease. Ominously, none have the money and skills that would be needed to contain it should it begin to spread.

Even in South Africa, where nearly 330 cases have been officially documented, evidence of the disease’s spread is mostly anecdotal, and epidemiological work needed to trace its progress is only now beginning.

“We don’t understand the extent of it, and whether it’s more widespread than anyone thinks,” Mario C. Raviglione, the director of the Stop TB Department of the World Health Organization in Geneva, said in a telephone interview. “And if we don’t know what has caused it, then we don’t know how to stop it.”

Cases of XDR TB exist elsewhere, in countries like Russia and China where inadequate treatment programs have allowed drug-resistant strains of the disease to emerge. The South African outbreak is considered far more alarming than those elsewhere, however, because it is not only far larger, but has surfaced at the center of the world’s H.I.V. pandemic.

Although one third of the world’s people, by W.H.O. estimates, are infected with dormant tuberculosis germs, the disease thrives when immune systems are weakened by H.I.V. At least two in three South African TB sufferers are H.I.V. positive. Should XDR TB gain a foothold in the H.I.V.-positive population, it could wreak havoc not only among the five million South Africans who carry the virus, but the tens of millions more throughout sub-Saharan Africa.

People without H.I.V. have a far smaller chance of contracting tuberculosis, even if they are infected with the bacillus that causes TB. But because tuberculosis is spread through the air, anyone in close contact with an active TB sufferer is at some risk of falling ill.

Most if not all of the 52 people who died in the initial outbreak of XDR TB, at the Church of Scotland Hospital in a KwaZulu-Natal hamlet called Tugela Ferry in 2005 and early 2006, had AIDS. Most died within weeks of being tested for drug-resistant tuberculosis, a mortality rate scientists called unprecedented.

Since then, South African health officials say, they have confirmed a total of 328 cases of XDR TB, all but 43 in KwaZulu-Natal. Slightly more than half the patients have died.

Those numbers are deceptive, however. The Tugela Ferry outbreak was reported in part because the hospital there was part of a Yale University research project involving H.I.V.-positive patients with tuberculosis. Because South Africa’s treatment and reporting programs for tuberculosis are notoriously poor — barely half of TB patients are cured — virtually all experts contend the true rate of infection is greater.

“We’re really concerned that there may be similar outbreaks to the one in Tugela Ferry that are currently going undetected because the patients die very quickly,” said Dr. Karin Weyer, who directs tuberculosis programs for South Africa’s Medical Research Council, a semiofficial research arm of the government.

Some other researchers and experts say they share Dr. Weyer’s concern. They say South African health officials have lagged badly in assembling the epidemiological studies, treatment programs and skilled clinicians needed to combat the outbreak, and say the government has responded slowly to international offers of help.

Dr. Weyer said the council “shares the concern that not enough is being done, quickly enough, to get on top of the problem.” In particular, she said, officials have yet to carry out epidemiological studies or address a “shocking” lack of infection controls in hospitals that could allow TB and other infections to spread freely among H.I.V.-positive patients
“It’s an emergency, and we’re not reacting as if it were an emergency,” said Dr. Nesri Padayatchi, an epidemiologist and expert on drug-resistant TB for Caprisa, a Durban-based consortium of South African and American AIDS researchers. “I think we have the financial resources to address the issue, and we’ve been told the Department of Health has allocated these resources.”

Although the government was first told of the outbreak 20 months ago, in May 2005, “to date, on the ground in clinics and hospitals, we are not seeing the effect,” she said.

In KwaZulu-Natal’s major city, Durban, the sole hospital capable of treating XDR TB patients has a waiting list of 70 such cases, she said.

Dr. Weyer said the waiting list indicates that “capacity is becoming a problem” in KwaZulu-Natal, the outbreak’s center. “I’m quite sure we may find a similar situation in other provinces,” she added.

A spokesman at the hospital said it could not easily determine how many patients were awaiting treatment.

But the manager of South Africa’s national tuberculosis program, Dr. Lindiwe Mvusi, said such complaints were misplaced. The Durban hospital in question, she said, is under renovation, and officials are “looking for accommodations in other hospitals” while construction proceeds.

Hospitals in other provinces have enough beds now for XDR TB patients, and some are expanding isolation wards to handle any spread of the disease, she said.

She said other responses to the outbreak were under way, including a rough assessment of TB cases in hospitals nationwide. A more comprehensive national survey of TB cases may be conducted late this year, she added, and health officials in KwaZulu-Natal have begun surveillance programs to detect new cases of drug-resistant TB in the province.

Dr. Mvusi also rejected the notion that the tuberculosis had moved beyond South Africa’s borders. But in interviews, a number of TB experts and epidemiologists raised that concern, including Mr. Raviglione at the world health organization, Dr. Padayatchi, Dr. Weyer and Dr. Gerald Friedland, director of the AIDS program at the Yale University School of Medicine.

Dr. Raviglione of W.H.O. said that South African health officials were cooperating on responses to the outbreak, and that an official of his organization would arrive in Pretoria within days to discuss placing a team of global TB experts in the country.

“W.H.O. is ready to come to South Africa and to help in any place, for anything, whether surveillance, or detection, or infection control,” he said. However, those arrangements have not been completed.

Dr. Mvusi, the government’s TB program head, said global health experts were welcome, but “in an advisory role, because we want the capacity locally.”