[e-drug] XDR-TB strain in South Africa

["Wilbert Bannenberg" <wjb@wxs.nl>]

E-DRUG: XDR-TB strain in South Africa
------------------------------

[Below a few frightening newsstories from South Africa about the new XDR-TB strain which killed nearly all infected people, especially the HIV+ ones. All anti-TB drugs are ineffective, except cycloserine, ethionamide and PAS. To quote CDC: "The emergence of XDR-TB in the world poses a threat everywhere in the world." Thanks to Andy/DRUGINFO; copied as fair use. WB]

http://www.mg.co.za/articlePage.aspx?articleid=283446&area=/breaking_news/breaking_news__national/
New TB strain in SA: 'No time to wait' 
Louise Flanagan | Johannesburg, South Africa  
07 September 2006 03:52 
 
The extreme drug-resistant tuberculosis (XDR-TB) in KwaZulu-Natal must be dealt with urgently, international health experts said in Johannesburg on Thursday.

"There is no time to wait before we embark on decisive action," said the World Health Organisation's Dr Ernesto Jaramillo, explaining that an epidemic could have a deadly impact.

"It's imperative that we don't allow this to go unmitigated," said Dr Ken Castro, of the United States's Centres for Disease Control and Prevention. "The emergence of XDR-TB in the world poses a threat everywhere in the world."

They were part of a group of more than 100 medical experts and policymakers from around the world meeting to discuss the XDR-TB, which emerged in KwaZulu-Natal recently. Fifty-three cases of XDR-TB were identified in the province, and 52 of the patients died within 25 days.

The experts are putting together a seven-point plan to combat the spread of XDR-TB. Top priority is establishing the extent of infection.

"Among the actions required are urgent and rapid surveys in high-risk countries to assess the full extent of XDR-TB globally, matched by increased laboratory capability to carry out vital culture and drug resistance testing," said the South African Medical Research Council (SAMRC).

Rapid diagnostic tests are crucial, as current tests to confirm the XDR-TB diagnosis take too long due to the speed of fatality of the disease.

New drugs
The plan calls for new drugs to fight the disease.

The surviving KwaZulu-Natal patient "is the only one that is at the moment alive and we now have nothing to offer", said Dr Willem Sturm, the dean of the faculty of medicine at the Nelson Mandela medical school in Durban. 

He said KwaZulu-Natal urgently needs two existing anti-TB drugs, which South Africa does not have, in the hope that they will be effective against XDR-TB.

Cases of XDR-TB were found mainly at Tugela Ferry in KwaZulu-Natal, but also at another 28 places in the province, said Sturm.

The plan also calls for infection-control precautions, research support and universal access to antiretrovirals under joint TB/HIV programmes.

Jaramillo said it is imperative for programmes backing HIV infection and TB to be linked, as there is a "deadly synergy" between the two. "Both have to receive the same priority, otherwise no impact would be obtained."

He said XDR-TB exists elsewhere in the world, but South Africa is the first place where its emergence with HIV infection has been identified as a "major threat".

"HIV has the potential to fast-track XDR-TB into an uncontrollable epidemic," said Dr Karin Weyer, TB research director for the SAMRC.

Some of the KwaZulu-Natal victims were on antiretrovirals, but succumbed rapidly to XDR-TB, which the experts said was an ominous sign.

Emergency
TB kills 1,7-million people a year, and a year ago African ministers declared TB an emergency. The SAMRC said combating XDR-TB must now be added to the TB emergency plans, together with promoting access to antiretrovirals under joint TB/HIV activities.

XDR-TB is resistant to the two most potent anti-TB drugs, as well as at least three of the six classes of reserve second-line drugs.

Globally, there have been just 347 identified cases of XDR-TB, mainly in the former Soviet Union and Asia.

In KwaZulu-Natal, a recent survey found that of 554 patients, 221 had multi-drug-resistant TB (MDR-TB). Of these, 53 had XDR-TB. Of the XDR-TB patients, all 44 of those tested for HIV were HIV-positive.

MDR-TB arises when patients do not complete their medication from an earlier bout of TB. However, not all the XDR-TB patients had previously been treated for TB. -- Sapa 
 
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Hi all

News of the XDR-TB strain in KZN has hit the local and international media. here's BDay's coverage, as "fair use". Apart from the issues of registration of new (and old) TB drugs, this problem raises significant ethical questions. Should known XDR-TB cases be isolated? How could this be accomplished? Should hospitalization and isolation be mandatory? How should health workers be protected in such units?

regards
Andy
~~~
http://www.businessday.co.za/articles/topstories.aspx?ID=BD4A266702
Deadly TB strain stalks KwaZulu-Natal  
Tamar Kahn
Science and Health Editor

CAPE TOWN * The deadly strain of tuberculosis (TB) discovered in HIV patients in KwaZulu-Natal's Royal Church of Scotland Hospital has also been found in a further 12 public hospitals in the province, suggesting the disease is present throughout the region. 

So-called "extensive drug resistant" TB, or XDR-TB, rose to prominence at last month's international AIDS conference, where scientists reported that it had killed all but one of 53 infected patients in Tugela Ferry. It is untreatable and kills swiftly.

It posed a severe risk to those with HIV, said Prof Willem Sturm, a medical microbiologist at the University of KwaZulu-Natal's Nelson Mandela School of Medicine. Sturm is part of the team investigating the outbreak.

"It is all over the province and we have no idea whether it is in other provinces," he said.

Sturm declined to name the hospitals where patients with XDR-TB had been identified or provide details of the latest cases. 

He said the number of hospital cases ranged from "about a dozen to just one". 

"There are definitely more," Sturm said.

The World Health Organisation (WHO) defines multidrug-resistant TB strains as those that do not respond to the two key treatments, isoniazid and rifampicin. XDR-TB is also resistant to three or more of the six classes of second-line drugs.

The disease is transmitted in droplets of moisture expelled by people with active TB in their lungs when they cough, sneeze, spit or speak. 

Though XDR-TB has been reported in other countries, SA appeared to have an unusually high incidence. The US Centres for Disease Control and Prevention identified only 347 cases worldwide in a report this year. 

Its presence in SA, location of one of the world's worst HIV epidemics, poses serious public health challenges. 

More than 5,5-million South Africans, or 11,6% of the population, are infected with HIV. 

XDR-TB has experts so worried that scientists from SA, the WHO and the US Centres for Disease Control and Prevention are holding a two-day conference in Johannesburg to discuss the issue, starting tomorrow. 

The health department was working "around the clock" to combat XDR-TB, said spokeswoman Charity Bhengu. 

Surveillance systems had been put in place in KwaZulu-Natal to monitor the problem and this would be extended to other provinces, she said.

The department was taking steps to obtain two drugs not available in SA that could be used to treat patients with XDR-TB, she said. These were capreomycin and paramino salicylic acid. 

However, Sturm said tests indicated the current strain of XDR-TB in KwaZulu-Natal was resistant to all but two TB drugs * cycloserine and ethionamide.

Since a minimum of three drugs were needed to treat XDR-TB, this meant that the strain was untreatable, he said.

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http://www.mg.co.za/articlePage.aspx?articleid=282965&area=/breaking_news/breaking_news__national/
Continent braces for deadly new TB strain 
Leon Engelbrecht | Johannesburg, South Africa  
03 September 2006 07:36 
 
Africa is facing the prospect of a sharp increase in new and fatal strains of tuberculosis (TB) as drug-resistant forms of the disease find those living with HIV easy victims, according to medical experts.

Specialists in communicable diseases will gather in Johannesburg this week for a conference on the topic amid fears that a sharp rise in treating TB will add to the burden on already overstretched public health budgets.

Karin Weyer, a TB expert at the Medical Research Council, says an outbreak of an extreme drug-resistant (XDR) form of the disease in the eastern KwaZulu-Natal province of South Africa earlier this year set alarm bells ringing about its devastating consequences.

Fifty-two of the 53 patients who contracted XDR-TB in the Tugela Ferry area of KwaZulu-Natal, one of the provinces with the highest rates of HIV in the country, died from the outbreak, Weyer says.

"They were all HIV-positive. This is the frightening thing, XDR-TB has the potential to spread very rapidly in HIV-positive individuals and there is a very quick, very high mortality among patients. In this particular outbreak, they died in a median of 16 days," Weyer says.

At any given moment, about 330 000 South Africans have TB and about 6 000 have the multiple drug-resistant (MDR) variant.

South Africa has the highest number of people living with HIV in the world after India, with 5,5-million of the country's 47-million-strong population affected by the disease.

Organisers of the two-day conference from Thursday -- which will be attended by representatives of the Medical Research Council, World Health Organisation and United States Centres for Disease Control and Prevention -- say the rise of XDR cases is emerging as a "major threat to successful HIV treatment and care in sub-Saharan Africa".

"Though data is limited, population-based surveillance has demonstrated increasing levels of MDR-TB in Botswana, Mozambique and South Africa," they said in a statement.

Nomfundo Eland, of South Africa's main anti-Aids lobby group, the Treatment Action Campaign, says many TB patients contract the disease as they do not follow their full course of drug treatment. "When they fail to do so, they often develop MDR-TB," she says.

The source of the Tugela Ferry outbreak "was probably an MDR-TB patient who didn't complete his treatment and, as a result, then developed XDR TB and spread this to HIV-positive patients," the Medical Research Council's Weyer adds.

MDR-TB is generally resistant to isoniazid and rifampicin, the two main antibiotics traditionally used to fight TB. "XDR-TB means they are resistant also to other drugs, including those available to treat MDR-TB," Weyer says. "This makes it a very serious thing because we have no drugs to treat it with."

While the prevalence of MDR-TB is still relatively low at 2,9% of TB patients, it is increasing and costs significantly more to treat. Normal strains of TB can be treated at a cost of R400 per person, but MDR variants can cost up to R100 000.

"The threat to the broader community is fortunately much lower, and I'm saying that because when someone is HIV-negative and that person gets infected with TB or MDR-TB or XDR-TB, there is only about a 10% lifetime risk of that infection turning into active disease, so it is a small risk," says Weyer.

"But when the immune system gets under pressure, like what happens with HIV-positive individuals, then that 10% lifetime risk is compounded to a 10% annual risk." -- Sapa-AFP 
 
~~~
http://www.iol.co.za/index.php?set_id=1&click_id=125&art_id=qw1157390284354B243
TB surveillance increased in KZN 
September 04 2006 at 08:13PM  
 
The department of health said on Monday it had put surveillance systems in place to monitor the extent of the extensively drug resistant (XDR) tuberculosis (TB) problem in KwaZulu-Natal.

Health department spokesperson Charity Bhengu said the XDR TB strain was resistant to all first-level drugs (ordinary treatment given to TB patients) and to two of the five categories of the second-level drugs Nto treat multi-drug-resistant (MDR) patients.

"The department is working round-the-clock the clock to address this problem."

She said the department was looking at getting two more drugs to replace the two second-level drugs that the XDR was resistant to.

"The two new drugs have been identified and are in a process of being registered to fast track the process."

According to Bhengu, the government spent R400 for treating every patient with ordinary TB.

"When these patients default treatment and develop a MDR TB, the cost of treatment dramatically increases to R24 000, which includes hospitalisation and more expensive drugs."

To reverse the tide of the TB crisis in the country, the government developed a TB Crisis Management Plan which focused on four districts in KwaZulu-Natal, the Eastern Cape and Gauteng.

Fifty-two of the 53 patients who contracted XDR TB in the Tugela Ferry area of KwaZulu-Natal, one of the provinces with the highest rates of HIV in the country, died from the outbreak, Karin Weyer, a tuberculosis expert at the Medical Research Council told French news agency AFP.

Nomfundo Eland of the Treatment Action Campaign, said many TB patients had contracted the disease as they had not followed their full course of drug treatment.

"When they fail to so, they often develop MDR TB," she told AFP.

Bhengu said the department had committed an extra R36-million to deal with the crisis in the affected areas, and was working closely with Professor Willem Sturm of the Nelson Mandela School of Medicine.

"There will be two-day conference from Thursday - which will be attended by representatives of the Medical Research Council, World Health Organisation and US Centres for Disease Control to deal with the TB problem," Bhengu said. - Sapa 

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http://www.iol.co.za/index.php?set_id=1&click_id=125&art_id=vn20060707012711356C995910
'Drug-resistant TB can be passed on easily' 
Jillian Green 
July 07 2006 at 09:52AM  
 
Johannesburg - A study by the Medical Research Council of South Africa (MRC) has found that multidrug-resistant tuberculosis can be transmitted from infected individuals to others in their environments.

The study has also shown that the lack of TB infection control in South African hospitals and clinics could lead to a high rate of transmission of drug-resistant TB.

The resistance to drugs developed when people with TB failed to complete their treatment.

Using guinea pigs, MRC researchers channelled air from the rooms of patients' rooms infected with the drug-resistant type into the animals' enclosure. 

After observing the guinea pigs for four months and conducting tests on them, it was found that more than 80 percent of them had been infected with multidrug-resistant TB, showing that it was highly infectious, said Karin Weyer, director of the MRC's unit for TB operations and policy research.

According to Weyer, the rate of infection in the guinea pigs is a measure of human infectiousness and of the efficacy of environmental infection control interventions.

"HIV-positive patients and TB patients spend hours together in waiting rooms of hospitals and clinics, and the likelihood of transmission from the TB patient to those infected with HIV is great, given that people with HIV have a compromised immune system," she said.

At the Sizwe hospital in Gauteng, a woman who had multidrug-resistant TB came into contact with six HIV-positive people and infected them all, Weyer said.

"Within 43 days all, including the woman, had died." 

John Heinrich, chief executive officer of the SA National Tuberculosis Association, said the infectiousness of multidrug-resistant TB meant there were fewer treatment options available for people infected with this type.

Also, they would have to be treated for longer periods and had no guarantee of being cured. Cure rates for multidrug-resistant TB were below 50%, Heinrich said. 

Patients infected with multidrug-resistant TB have to be treated for 18 months and often this includes prolonged hospitalisation, compared with the six months' treatment a person with normal TB has to endure. 

Treating multidrug-resistant TB costs R30 000, compared with R400 for common TB.

"This a huge danger hiding in the wings and we are very concerned," Heinrich said.

Multidrug-resistant TB accounts for 6 000 of the 300 000 TB cases a year reported in South Africa. 

But Allistair Reid, of the World Health Organisation, said that even with this "low rate", there was cause for concern because of the high incidence of normal TB. 

Normal TB is one of the commonest opportunistic infections associated with HIV.

If the infected person does not complete the prescribed six-month course of treatment, he or she could develop resistance to drugs. 

If a person is resistant to all the TB drugs available, they may develop extremely resistant TB, for which there is no treatment. 

This article was originally published on page 5 of Cape Times on July 07, 2006