In South Africa, Fears of a Deadly TB Epidemic

The nurses wear masks on the crowded tuberculosis ward at the Church of Scotland Hospital in this small town ringed by rocky hills. The windows stay open, even when it’s chilly, to improve the flow of fresh air.

And every patient who arrives at this government hospital with a cough that has lingered at least two weeks is tested for a frightening strain of tuberculosis that has defied all known drug regimens, with deadly results.

Of 63 people known to have developed this mutant TB here in rural KwaZulu-Natal province, 60 have died -- most within a month of going to the hospital. With new tests indicating the strain has cropped up at 27 other hospitals in the province, health experts here and abroad are scrambling to figure out whether this could spin into a far-reaching epidemic.

“It could be we have the same problem everywhere. If that’s the case, we have a big problem,” said medical microbiologist Willem Sturm, dean of the University of KwaZulu-Natal’s Nelson R. Mandela Medical School in Durban.

Without major action, including stricter infection control, “we will have that worst-case scenario of the numbers just getting bigger and bigger and more and more deaths,” said Dr. Tony Moll, chief physician at the missionary-founded Church of Scotland Hospital. “Who knows how fast it can grow and spread?”

Although this type of TB -- called extensive drug-resistant TB, or XDR -- has been found in most regions of the world, including the United States, the numbers have been relatively small. Just 347 cases worldwide were identified by late 2004, and no other place has recorded Tugela Ferry’s concentration.

The outbreak has raised such concern that officials of the World Health Organization and U.S. Centers for Disease Control and Prevention converged on Johannesburg in September for two days of urgent meetings.

“TB is a disease without borders,” said Dr. Kenneth G. Castro, director of the CDC’s Division of Tuberculosis Elimination. The outbreak should reinforce the need for vigilance in the public health sector, he said. “XDR-TB anywhere in the world poses a threat to everywhere in the world, including the U.S.”

Medicine’s seeming inability to treat XDR stems partly from the fact that the world has largely ignored tuberculosis for years, experts say. Once the No. 1 killer in the United States, TB was brought under control starting in the 1940s by the development of drugs. No new TB drugs have been developed in more than 40 years.

Meanwhile, across sub-Saharan Africa the HIV epidemic continues to fuel a parallel TB epidemic because tuberculosis poses great risk to those with weak immune systems. South Africa has more people with HIV -- 5.5 million -- than any country but India. Globally, the WHO estimates TB kills 1.7 million people a year, including 590,000 in Africa. Everyone who developed XDR-TB here tested positive for HIV or was suspected of having the virus, which causes AIDS.

Since the mid-1980s, the number of active TB cases at Church of Scotland Hospital has skyrocketed tenfold, from 200 a year to more than 2,000. Nationwide, more than 270,000 people had TB in 2004, the government says.

Even ordinary tuberculosis kills thousands here. Moll said that every year 8,000 people die of treatable TB across the province of 9.3 million. Perhaps they don’t or can’t seek treatment, or are so ravaged by it and HIV that they cannot be saved. Without treatment, normal TB will kill otherwise healthy people half the time, Sturm said.

On top of that, multi-drug-resistant TB, which resists some drug combinations, is a growing worry that claims 1,500 lives a year in the province, Moll said. It costs $3,250 to treat, compared with $50 for normal TB.

And now there is essentially untreatable XDR, which may have mutated from multi-drug-resistant TB. Resistant strains can emerge when patients do not finish the standard four-drug six-month treatment, a problem compounded by lack of healthcare workers to monitor adherence.

Experts have tried to tamp growing alarm by informing the public that healthy people are not at great risk of having a latent TB infection turn into active TB of any sort. Yet news of XDR’s emergence in town and the lack of hard information are raising fears.

“I’m afraid. I want to know a lot about that kind of TB,” said Mthunzi Makhunga, a store clerk. “Maybe one day it will affect me.”

Tuberculosis is caused by bacteria that usually attack the lungs. It is spread when a person with active TB coughs or sneezes and someone nearby breathes in the bacteria. Poverty worsens it because the poor often live in cramped, unhealthful conditions.

The WHO estimates a third of the world’s population is infected with latent TB. Most people do not develop active TB. The disease arises when weak immune systems are unable to keep the bacteria from multiplying. Symptoms often include a bad cough, phlegm in the lungs, fatigue, weight loss and lack of appetite.

The virulent strain’s emergence in Tugela Ferry comes at a cruel time: just as progress is being made on HIV, as a result of antiretroviral drugs rolled out by the national government in March 2004.

In late 2004, Moll and a Yale University researcher were studying patients with both HIV and TB. They saw “amazing turnarounds” because of antiretrovirals. “But we noticed a small group of people who were not getting better,” Moll said. “Their TB was rapidly progressing in spite of being on TB drugs” and, often, on antiretrovirals.

In spring 2005, they sent sputum samples from 45 patients to a Durban lab. Ten of the samples indicated XDR infection, meaning the TB was resistant to all so-called first-line drugs and all tested second-line drugs.

“That was a big red flashing light that there was something wrong,” he said.

Moll alerted the provincial Department of Health. The Church of Scotland Hospital stepped up surveillance, taking samples of everyone with lingering coughs. The province added hospital staff, including two teams to track down everyone who came in contact with a multi-drug-resistant patient.

A presentation in Toronto helped spread the word and led to the Johannesburg meetings with the WHO, CDC and South Africa’s Medical Research Council. Experts renewed calls for drug development and faster identification of XDR-TB than the current six-week period.

XDR’s toll may yet grow. Two of the three survivors from the group of 63 are not out of the woods, nor is a Johannesburg woman who is No. 64.

But the third survivor in Tugela Ferry is home and doing “amazingly well,” Moll said. He cannot explain it, except that the man had been on antiretrovirals for a couple of months.

“He’s not coughing XDR germs out anymore, and he’s gaining weight and looking strong. Here’s one guy who has gone against the grain and doing well and giving us some hope.”