TB Patients Chafe Under Lockdown in South Africa

TB Patients Chafe Under Lockdown in South Africa

The New York Times

March 25, 2008
TB Patients Chafe Under Lockdown in South Africa

By CELIA W. DUGGER

PORT ELIZABETH, South Africa — The Jose Pearson TB Hospital here is like a prison for the sick. It is encircled by three fences topped with coils of razor wire to keep patients infected with lethal strains of tuberculosis from escaping.

But at Christmastime and again around Easter, dozens of them cut holes in the fences, slipped through electrified wires or pushed through the gates in a desperate bid to spend the holidays with their families. Patients have been tracked down and forced to return; the hospital has quadrupled the number of guards. Many patients fear they will get out of here only in a coffin.

“We’re being held here like prisoners, but we didn’t commit a crime,” Siyasanga Lukas, 20, who has been here since 2006, said before escaping last week. “I’ve seen people die and die and die. The only discharge you get from this place is to the mortuary.”

Struggling to contain a dangerous epidemic of extensively drug-resistant tuberculosis, known as XDR-TB, the South African government is requiring that those unlucky enough to have the disease be hospitalized until they are no longer infectious. Hospitals in two of the three provinces with the most cases — here in the Eastern Cape, as well as in the Western Cape — have sought court orders to compel the return of runaways.

The public health threat is grave. The disease spreads through the air when patients cough and sneeze. It is resistant to the most effective drugs. And in South Africa, where these resistant strains of tuberculosis have reached every province and prey on those whose immune systems are weakened by AIDS, it will kill many, if not most, of those who get it.

As extensively drug-resistant TB rapidly emerges as a global threat to public health — one found in 45 countries — South Africa is grappling with a sticky ethical problem: how to balance the liberty of individual patients against the need to protect society.

It is a quandary that has recurred over the past century, not least in New York City, where uncooperative TB patients were confined to North Brother Island in the East River in the early 1900s and to Rikers Island in the 1950s.

In the early 1990s, when New York faced its own outbreak of drug-resistant TB, the city treated people as outpatients and locked them up in hospitals only as a last resort.

Most other countries are now treating drug-resistant TB on a voluntary basis, public health experts say. But health officials here contend that the best way to protect society is to isolate patients in TB hospitals. Infected people cannot be relied on to avoid public places, they say. And treating people in their homes has serious risks: Patients from rural areas often live in windowless shacks where families sleep jammed in a single room — ideal conditions for spreading the disease.

“XDR is like biological warfare,” said Dr. Bongani Lujabe, the chief medical officer at Jose Pearson hospital. “If you let it loose, you decimate a population, especially in poor communities with a high prevalence of H.I.V./AIDS.”

But other public health experts say overcrowded, poorly ventilated hospitals have themselves been a driving force in spreading the disease in South Africa. The public would be safer if patients were treated at home, they say, with regular monitoring by health workers and contagion-control measures for the family. Locking up the sick until death will also discourage those with undiagnosed cases from coming forward, most likely driving the epidemic underground.

“It’s much better to know where the patients are and treat them where they’re happy,” said Dr. Tony Moll, chief medical officer at Church of Scotland Hospital in Tugela Ferry. It is running a pilot project to care for patients at home.

Some 563 people were confirmed with extensively drug-resistant TB last year in South Africa and started on treatment, compared with only 20 cases in the United States from 2000 through 2006. A third of those patients in South Africa have died. More than 300 remained in hospitals.

Further complicating matters, South Africa’s provinces have taken different approaches to deciding how long to hospitalize people with XDR-TB. In KwaZulu-Natal, the other province with the most cases, the main hospital is discharging patients after six months of treatment, even if they remain infectious, to make room for new patients who have a better chance of being cured. The province is rapidly adding beds, part of a national expansion of hospital capacity for XDR-TB.

“We know we’re putting out patients who are a risk to the public, but we don’t have an alternative,” said Dr. Iqbal Master, chief medical officer of the King George V Hospital in Durban.

Two days of interviews with patients cloistered here at Jose Pearson hospital offered a rare glimpse of what all sides agree are the wrenching human costs of the patients’ confinement, as well as their rebellious feelings about being cut off from their loved ones.

Zelda Hansen, 37, the wife of a welder and mother of sons ages 4, 12 and 14, has lived at the hospital for more than a year. She was among the 31 extensively drug-resistant patients who escaped from the 350-bed hospital before Christmas, along with 57 patients with less severe strains of drug resistance. Her eldest son had started to seem like a stranger to her, she said, while her youngest, her “flower pot,” was growing up without her guidance.

Once home, she said: “I just sat and watched them. And I was very happy.”

Soon the news media trumpeted news of the infectious runaways. A provincial health department spokesman vowed they would be “hunted down.” On Dec. 23, a Sunday morning, Mrs. Hansen said, police officers wearing infection-control masks came to her door. A crowd of neighbors gathered for the spectacle.

Mrs. Hansen refused to go. She begged for a few more days — just through Christmas.

Her middle son, Trevino, 12, fearing she had done something wrong, offered his barefoot mother his sneakers, called tekkies here.

“ ‘Here, Mommy, take my tekkies, go with the police,’ ” she said he had pleaded with her. “ ‘Please, Mommy, go.’ ”

Back at the hospital, on the outskirts of Port Elizabeth, Mrs. Hansen descended into despair. “I felt like going to the trees and just hanging myself I was so humiliated,” she said.

When news of South Africa’s outbreak of extensively drug-resistant TB was announced in Toronto in 2006 at an international AIDS meeting, it sent shudders through the ranks of infectious-disease specialists. These virulent strains had rapidly killed 52 of 53 patients.

Drug resistance emerges in large part because health care systems too often have failed to ensure that patients successfully completed treatments with first- and second-line drugs, according to international health officials.

The medicines to cure ordinary TB here cost about $36 and take six to eight months to cure the patient. The drugs for XDR-TB cost about $7,000, and treatment lasts two years. At the start, patients endure four to six months of painful daily injections in the buttocks or thigh, a morning ritual at Jose Pearson hospital that leaves faces scrunched up in agony. A 10-year-old boy whose mother recently died here of the disease rubbed cream into his backside to relieve the ache. He now lives on the XDR-TB ward as its solitary child, with no family around.

“I do think about my mother,” he said. “But I don’t cry because I’ll never get her back again.”

The provinces began diagnosing and treating XDR-TB on a large scale more than a year ago, but the question of where to care for South Africans who remain infected after two years or more of treatment is unsettled.

“We expect they will die at some stage, but what do we do with them in the meantime?” asked Dr. Lindiwe Mvusi, who manages the government’s tuberculosis program. “Do we send them home or keep them in a sanatorium for life?”

At Jose Pearson, patients who have different degrees of drug resistance — with XDR-TB being more deadly than multidrug-resistant TB — live in different quarters, but they mix on the grounds. Infectious disease experts say some of the multidrug-resistant patients are likely to catch the more severe XDR strains of tuberculosis directly from their fellow patients.

Peter Jantjes, the chief professional nurse on Jose Pearson’s XDR-TB unit, said multidrug-resistant patients were turning into XDR-TB patients at an “intense rate.”

Vuyokazi Gqawe, 30, a saloon keeper, was admitted to the hospital more than two years ago with the lesser form of drug-resistant TB, then was found to have the far more dangerous kind in June. “They don’t have the answers,” she said.

Mrs. Gqawe was pregnant when she was admitted and gave birth here, but she sent her newborn to live with family. She has since seen her daughter, now 2, only in photographs, except when she once waved to her through the hospital gate. “She didn’t even know who I was,” Ms. Gqawe said.

The hospital itself is a caldron of discontent. The staff members and the patients share a pervasive sense of dread.

“It’s going to burst,” warned Louise Bruiners, the sole social worker for the more than 300 patients. “Something really bad is going to happen.”

Angry patients bully and threaten the staff and have even brandished knives at security guards to get out of the hospital, hospital managers say. Crowds of patients have blockaded the entry gate, demanding weekend passes to go home.

On a recent Saturday, as workmen tried to erect a second buffer gate at the entrance, patients pulled it down, jumped up and down on it and repeatedly heaved a chunk of concrete on it.

The hospital’s management has been trying to make Jose Pearson more tolerable. It has brought in a pool table, flat-panel televisions, soccer balls and sewing machines. Hospital managers hope to bring patients’ families to the hospital for more regular visits. The hospital had suspended all weekend passes to patients for months, but recently reinstated them for the handful of XDR-TB patients showing signs of becoming noninfectious.

“It’s good, the things they’re doing, and we thank them for it,” said Mrs. Hansen, the patient who briefly escaped, “but nothing can replace your freedom.”

Copyright 2008 The New York Times Company









allAfrica.com



Tuberculosis Infections Up 20 Percent

Rwanda News Agency/Agence Rwandaise d'Information (Kigali)

NEWS
24 March 2008
Posted to the web 24 March 2008
Kigali

Prevalence rates for tuberculosis in Rwanda have shot up instead of going down, figures from the Health Ministry to coincide with World TB Day indicate.

Between 2004 and 2008, the number of those carrying the TB virus rose from 6367 to 8014, the Health Minister Dr. Ntawukuriryayo Jean-Damascene said yesterday night in his TB Day commemoration message for March 24.



The rise means there was a 20% shoot up blamed, according to the Minister, on the HIV/AIDS virus that he said destroys the body immunity systems leaving victims with very minimal protection against viruses such as TB.

According to the World Health Organisation, as testing and detection rates for TB have reduced dramatically globally, Kenya and Rwanda have seen the highest HIV testing rates in Africa for the tuberculosis (TB) care programmes.

The Global Tuberculosis Control report for 2008 released March 17 said the two East African countries share the record with Malawi as the foremost African countries progressing well in the fight against an upsurge of TB.

Between 2001 to 2005, the average rate at which new TB cases were detected was increasing by 6% per year; but between 2005 and 2006 that rate of increase was cut in half, to 3%, the WHO said.

The reason for this slowing of progress, according to the report, is that some national programmes that were making rapid strides during the previous five years have been unable to continue at the same pace in 2006.

There were 9.2 million new cases of TB in 2006, including 700 000 cases among people living with HIV, and 500 000 cases of multi-drug resistant TB (MDR-TB).

An estimated 1.5 million people died from TB in 2006. In addition, another 200 000 people with HIV died from HIV-associated TB.

The report highlights point to two aspects of the epidemic that could further slow progress on TB. The first is multidrug-resistant tuberculosis (MDR-TB), reported by WHO last month to have reached the highest levels ever recorded.

The second threat to continued progress is the lethal combination of TB and HIV, which is fuelling the TB epidemic in many parts of the world, especially Africa, the report said.

Rwanda recorded the highest rate of 76 per cent, Malawi 64 per cent while Kenya had 60 per cent to show for domestic strides in the fight against TB.

Integrated care

Rwanda, Kenya and Malawi, among other countries, have established integrated HIV/TB services, offering HIV testing and counseling, TB diagnosis, and treatment for co-infected individuals.

Dr. Michel Gasana, Director of the Rwanda's TB Control Program, says the country's "one stop service" approach centered on patients is a key feature of the program, according a news posting on the World Bank website.

Rwanda has revamped the way services are organized and financed, the Bank says.

An opt-out policy (whereby TB patients are routinely tested unless they refuse) resulted in more than 76 percent of TB patients being tested for HIV in 2006.

Under a performance-based contracting approach for HIV/TB services in the Rwanda HIV/AIDS Project, bonus payments are made to teams of providers based on results attained. This scheme has stimulated such innovative strategies as TB case-finding by community workers and home visits to co-infected patients.

Providers are encouraged to take a holistic approach to care, including promotion of institutional deliveries for pregnant women, and family planning. Systematic supervision by district officials, which is also remunerated, provides an opportunity to give feedback to staff.

Dr. Agnes Binagwaho, Executive Secretary of the Rwanda HIV/AIDS commission, notes the tremendous potential of people living with HIV/AIDS to raise awareness and promote behavior change at the community level.

She also points out that the country has given a major impetus to integration across the three major diseases (TB, HIV/AIDS and malaria).

Attacking these diseases in a joint effort is part of the World Bank's plan.

"In countries across Africa that are struggling with the co-epidemic, one cannot mention HIV without mentioning TB and vice versa," said Joel Spicer, senior health specialist in the World Bank's Africa region. Spicer emphasizes the importance of scaling up TB/HIV collaborative activities.

Working as part of the Stop TB Partnership, the African region is intensifying and scaling up efforts in TB control through its portfolio of health and HIV/AIDS projects.



Copyright © 2008 Rwanda News Agency/Agence Rwandaise d'Information. All rights reserved. Distributed by AllAfrica Global Media (allAfrica.com).









Daily Times

Daily Times - Site Edition


Tuesday, March 25, 2008

USAID working to control tuberculosis in Pakistan

Staff Report

ISLAMABAD: The United States gave $6.4 million to support Pakistan’s National Tuberculosis (TB) Control Programme through the World Health Organisation (WHO) during the last five years, said USAID Pakistan Mission Director Anne Aarnes while addressing a ceremony to mark World TB Day on Monday.

She said, “Even though a cure has existed for more than half a century, tuberculosis remains one of humankind’s greatest scourges. As we commemorate World TB Day, we are reminded that TB anywhere is TB everywhere.”

Estimated 280,000 Pakistanis contract tuberculosis each year and according to the WHO, TB remains one of the leading causes of death in Pakistan and is responsible for five percent of the country’s total disease burden. Aarnes said, “We must work together to enhance quality TB cure services as well as forming public-private partnerships to detect and treat TB.”

USAID helps to improve and sustain quality service provision of Directly Observed Therapy Short Course (DOTS) – the internationally approved approach for treating TB and reducing the development of drug-resistant strains of the disease.

USAID’s TB programme is part of the $1.5 billion aid that the US government is providing to Pakistan over a five-year period to improve economic growth, education, health, and governance, and to reconstruct areas affected by the October 2005 earthquake.









BANGLADESH

World TB Day Observed

'70,000 die of TB a year'

Staff Correspondent



The country observed World TB Day yesterday as elsewhere across the globe with the slogan 'I am stopping TB'.

Different organisations held workshop, seminar, rally and advocacy meeting to disseminate information regarding tuberculosis (TB) and make people aware of the disease.

At an advocacy meeting at the Bangladesh College of Physicians and Surgeons (BCPS) organised by The Chest and Heart Association of Bangladesh and National Tuberculosis Control Programme the speakers said that tuberculosis is a deadly disease in this country but it can be cured if the patients continue the drugs as per the direction of the physicians.

They added that the government has been providing the drugs free of cost.

Prof Dr Pravat Chandra Barua, line director of TB and Leprosy Control Programme said that every year 70,000 people die of Tuberculosis (TB) and 30 lakh new patients are diagnosed with the disease.

Prof Mirza Mohammad Hiron, president of The Chest and Heart Association, said that under the Tuberculosis Control Programme the case detection has increased to 72 percent and the treatment success rate is more than 93 percent.

While delivering the presidential speech, he also said that the NGOs, medical institutions and the expert physicians shall have to work together to control the disease. The Union Parishad members, teachers and Imams should also be involved with the programme for its success.

Dr Solaiman Siddiqui Bhuiyan, associate professor of National Institute of Diseases of Chest & Hospital (NIDCH), Major Dr Azizur Rahman, pulmonologist of CMH, Dr Golam Sarwar LH Bhuiyan, Dr Shamim Ahmed, Dr SM Mustafa Kamal and Dr AKM Akramul Haque of NIDCH presented scientific papers on the basic facts about TB and the ongoing activities to control the disease and its treatment.

Prof KMHS Sirajul Haque of Bangabandhu Sheikh Mujib Medical University (BSMMU) was present as a special guest while National Professor Dr Nurul Islam was present as the chief guest.

Dr Nurul Islam was presented with AK Khan Memorial Award for his outstanding contribution in the professional arena.

To mark the day, Brac, Ministry of Health and Family Welfare and The National Press Club jointly organised a seminar at the National Press Club in the afternoon while The Daily Star was the media partner.

Director General of DGHS Professor MA Faiz was present as the chief guest while Dr Erwin Cooreman of World Health Organisation (WHO) Bangladesh, Faruque Ahmed, director of Brac Health Programme, Prof Dr Pravat Chandra Barua, line director, National TB Control and Leprosy Elimination Programme, Jamal Abdul Naser Chowdhury, project director, UPHCP-2 and Dr Mohammad Akramul Islam were also present.

Earlier in the morning Brac and its partner organisations brought out a procession from Shahbagh intersection that ended at the High Court.









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Tuberculosis at historic low in New York City





NEW YORK, March 24 (Xinhua) -- The health department of New York City announced Monday, the World Tuberculosis Day, that TB reached another all-time low in the world metropolis in 2007.

A total of 914 cases were reported in 2007 -- a 4 percent decrease from 2006 and a 76 percent decrease from the high levels seen in the early 1990s, according to a press release emailed to Xinhua.

Despite this continuing progress, New York City's TB rate is still more than double the national rate (11.4 versus 4.4 cases per 100,000 people).

"We continued to make progress this past year, but many challenges remain -- especially among New York City's immigrant communities," said Dr. Thomas R. Frieden, Health Commissioner of New York City.

"Tuberculosis can be prevented and cured and all care and treatment in our centers is free and given without any questions about immigration status," he said.

Immigrant New Yorkers accounted for 71 percent of new cases in 2007, with a rate of 24 cases per 100,000 people. The rate among New Yorkers born in the United States was 5.7 per 100,000.

Globally, TB remains a devastating problem, affecting more than9 million people each year and killing about 1.5 million.

In New York City, two out of three TB cases occur among people born in countries with a high rate of TB, such as China, Mexico, and Ecuador -- a disparity that is seen throughout the nation. In recent years, TB control services have improved dramatically worldwide, where now more than 30 million people have been diagnosed and treated effectively.

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San Francisco Chronicle

EDITORIAL


Tuberculosis on the rise

Monday, March 24, 2008

A worldwide campaign against tuberculosis that began with money, ambition and plans is falling short. Leaders of the United Nations-directed drive must find a way to revive efforts before the disease spreads and hard-to-treat strains slip out of control.

TB, easily spread by a cough or sneeze, is a scourge in poor countries, where months-long drug regimens are beyond the abilities of rudimentary health care systems. Some 9.2 million new cases were reported in 2006, with Asia and Africa especially hard hit.

For more than a decade, the World Health Organization have focused on TB, and initial efforts showed promise as patients were identified and billions were spent on pills and medical care. The goal was to knock TB from its perch as the No. 2 global killer, right after the AIDS virus.

But the U.N.-affiliated agency turned in a disappointing report last week, showing that the steady pace of identifying more TB-infected patients has dropped by half. This means larger numbers are going unspotted and untreated. One TB carrier has the potential to infect 10 to 15 others, the health agency says.

It gets worse. Because so many patients receive only partial treatment or stop taking a daily dose of eight to 10 pills, the TB bug can transform itself into new strains that are tougher to kill. Stronger, more costly drugs are needed for this subgroup. This drug-resistant population, once too small to draw concern, has jumped in size with the potential to spread a more lethal brand of the disease.

The U.N. will need to push harder. It must persuade hard-hit countries to work faster to diagnose and treat the disease. Doing this will take even more money - up to $1 billion more. It's a large bill, but one that will surely grow if nothing is done.

Don't think it's a problem in faraway places. For years, San Francisco has topped the nation's TB charts, due to its role as an immigrant entry point from Asia, dense housing and a large homeless population. The numbers were on the decline until the last two years, when the caseload rose first to 120 and then 143 patients. The rest of the Bay Area likewise has high TB rates that could easily rise save for vigilant, steady care from public health agencies.

Today marks "World TB Day," an opportunity to examine this old and enduring disease, along with strategies to contain it.

Locally, TB experts will gather at San Francisco International Airport, a location that underscores the speed and ease with which the bug can travel around the globe. Along with raising public awareness, these health authorities may bring up another subject closer to home.

Gov. Arnold Schwarzenegger is making it harder to catch and contain TB because of his across-the-board budget cuts that may imperil essential work by a state public health laboratory that performs TB tests. If the cut is made, the time needed to identify the disease from a doctor's office test will increase from 24 hours to six weeks. It's too long a wait for a worried patient and doctor to begin treatment to stop a killer disease.

http://sfgate.com/cgi-bin/article.cgi?f=/c/a/2008/03/24/EDJSVMRJU.DTL

This article appeared on page B - 4 of the San Francisco Chronicle

© 2008 Hearst Communications Inc.









http://cbs5.com/local/san.francisco.tuberculosis.2.683687.html
TB Cases On The Rise In San Francisco

SAN FRANCISCO (CBS 5 / KCBS) ― Monday is World Tuberculosis Day, and in San Francisco the disease is on the rise. There were 143 cases citywide last year, up 20 percent from 2006, which is the highest rate for all of California.

"TB is a disease of minorities and the under-served," said Dr. Masae Kawamura with the city's public heath department.

She says the rise is in part due to migration from TB-endemic countries, including Africa.

"Health care workers, inmates and staff of correctional facilities, nursing homes and other long-term care facilities such as residential substance abuse sites should be considered at risk," said Kawamura.

TB is not only on the rise in most Bay Area counties, but is becoming resistant to multiple drugs.

(© MMVIII, CBS Broadcasting Inc. All Rights Reserved.)









telegraph.co.uk

Fear over drug-resistant meningitis

By Rebecca Smith, Medical Editor

Last Updated: 1:30am GMT 24/03/2008



A serious form of meningitis and pneumonia that is resistant to drugs has emerged in children.

Twelve cases have been identified over six years and five children died.

Most had been treated with antibiotics for a drug-resistant form of tuberculosis and it is thought this led to the emergence of the resistant form of pneumoccocal disease, which includes meningitis, pneumonia and septicaemia.

The cases were identified in South Africa and are reported in The Lancet medical journal today, which is World TB Day.

Drug resistance is a major problem and the Department of Health is seeking to reduce the unnecessary use of antibiotics for minor ailments in an attempt to slow down the development of diseases that are resistant to medications.

There is an outbreak of drug-resistant TB in north London but it is not thought that any cases of drug-resistant pneumoccocal disease have been identified.









allAfrica.com



Continent Has Highest Cases of Tuberculosis, Says Report

The East African Standard (Nairobi)


NEWS
24 March 2008
Posted to the web 24 March 2008

By Edith Fortunate
Nairobi

Africa has the highest incidence of Tuberculosis rate per capita (363 per 100 000 population).

According to a new report by the World Health Organisation (WHO), there were about 14.4 million cases of TB in 2006 and an estimated 0.5 million cases of multi drug-resistant TB (MDR-TB) in 2006.

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Targets for global TB control have been set within the framework of the Millennium Development Goals (MDGs).

The MDG Six target is to halt and reverse TB incidence by 2015. The Stop TB Partnership has set two additional impact targets: To halve prevalence and death rates by 2015 compared with their level in 1990.

Among 11 African countries with more than 50 per cent of the world's HIV-positive TB cases for 2002-2006, the percentage of notified cases that were tested increased from 8 per cent to 35 per cent. Rwanda (76 per cent), Malawi (64 per cent) and Kenya (60 per cent) achieved the highest testing rates, which are also higher than the 51per cent target set for African in the Global Plan.

The number of HIV-positive TB patients treated with Cotrimoxazole Preventive Therapy (CPT) reached 147 000 in 2006, equivalent to 78 per cent of the HIV-positive TB patients that were identified through testing and 2.5 times higher than the 58, 000 patients treated with CPT in 2005.

The number started on CPT is less than the 0.5 million specified in the Global Plan for 2006; numbers could be increased if more countries emulated the high testing rates of Rwanda, Malawi and Kenya.

The number of HIV-positive TB patients enrolled on anti-retroviral therapy (ART) was 67, 000 in 2006, more than double the 29, 000 reported for 2005 and seven times the 9, 800 reported in 2004, but less than the 220, 000 target for 2006 in the Global Plan.

The proportion of diagnosed HIV-positive TB patients enrolled on ART was 41 per cent compared with the 44 per cent target for 2006 in the Global Plan.

The outcome targets first set by the World Health Assembly (WHA) in 1991 were to detect at least 70 per cent of new smear-positive cases in directly observed treatment short course programmes and to successfully treat at least 85 per cent of detected cases. All five targets were adopted by the Stop TB Partnership and were recognised in a WHA resolution in 2007.

The Stop TB Strategy was designed to achieve the 2015 impact targets as well as those for case detection and treatment success.



Copyright © 2008 The East African Standard. All rights reserved. Distributed by AllAfrica Global Media (allAfrica.com).