It is official: KwaZulu-Natal is the epicentre of tuberculosis/HIV infections in South Africa, with the country as a whole having the third highest burden of TB in the world. This province’s combined TB/HIV positive rate is 78.0%.

According to the World Health Organization, 1.7 million people died from TB in 2009, including 380 000 people with HIV, which equates to 4 700 deaths a day globally.

The KwaZulu-Natal MEC for Health Dr Sibongiseni Dlomo said his province, which has been commended for its effective control of malaria, was adopting the same approach to combat TB.

He reiterated that KZN was the worst affected by health maladies in South Africa, such as bearing the ignominy of having the highest rates of maternal mortality, TB and HIV infections.

“If you plucked this province from the rest of the country, the health of the nation would be in a much better state. In other words, South Africa would be healthier without KZN,” he told journalists and health practitioners at Riverside Hotel in Durban on the eve of TB Day (24 March 2011).

TB – and its offshoots of multi-drug resistant (MDR) TB and extensively drug-resistant (XDR) TB – are the bane of the KZN Health Department. Both MDR and XDR are a consequence of patients not adhering to their treatment regime.

But Dr Dlomo indicated that the term defaulter was inappropriate as a reference to patients who failed to complete their TB course. “I prefer the phrase ‘interruption of treatment’ because reasons for this situation could be twofold – either as a result of system failure or the patient may be to blame,” he explained.

He added that part of the new strategy for combating TB/HIV was to treat both diseases under one roof in patients’ homes. Significantly, as a result of such concerted efforts, there has been a drop in TB deaths in KZN from 12% to 10%.

Patient education was singled out as one of the most important buffers against TB infection.

Dedicated TB wards

Insufficient infrastructure to cope with the growing TB epidemic, with XDR-TB compounding the problem of MDR-TB, jolted authorities into action.

The government has partnered with the Council for Scientific and Industrial Research (CSIR) to remedy the situation, through provision of dedicated TB wards at nine provincial hospitals. This is one mechanism identified in preventing cross-infection.

Catherine Booth TB Wards

One of the facilities Black Business Quarterly visited recently is nearing completion at Catherine Booth Hospital, in the foothills of northern KZN at Amatikulu in the Uthungulu District.

The new state-of-the-art TB wing, complete with a mini gym, could easily pass for a three-star hotel. It comprises 34 en-suite rooms, made to strict specifications by the CSIR, which is a specialist in health infrastructure.

Drug-resistant patients will be accommodated one to a room, to reduce risk and prevent opportunities for airborne transmission from occurring.

Employing CSIR technology, the rooms will enjoy 16 air changes hourly. These innovations will add to lessening patient-to-patient and patient-to-staff infection, which is risky.

The different window configuration will comprise horizontal, pivot, hopper and top hung sections.

There will be dedicated MDR wards at decentralised sites in every district of the country.

“The CSIR is assisting seven provincial departments of Health with the rollout of special accommodation for MDR/XDR-TB patients at existing hospitals. More than R92 million of donor funding was sourced by the national Department of Health from the Global Fund for its drive to strengthen national and provincial capacity in South Africa for prevention, care and treatment of drug-resistant TB patients.

The provinces where such facilities are being constructed have committed an additional R115 million toward the project,” said Geoff Abbott of the CSIR.

“The lack of appropriate hospital infrastructure for treating drug-resistant TB is a key constraint against effective and safe treatment and rehabilitation of patients. Unfortunately, many cases have occurred where both patients and staff have been infected with drug-resistant TB in existing facilities because the buildings are not appropriately designed or have not been remodelled to reduce the risk of cross-infection.”

Mechanical ventilation will be utilised in KZN on account of its cost-effectiveness there.

The Catherine Booth TB complex has an airy courtyard in the middle of the new wing, to enable patients to take in fresh air. When complete, it will be a picturesque sight with lush greens and trees that have been planted to provide shady shelter on those humid days for which the province is notorious.

One observation noted during the media tour of Catherine Booth Hospital was its lengthy distance from the heart of Durban: it is nestled among a sprinkling of villages in the middle of nowhere. So, why was such a remote location chosen to house this modern facility?

“Availability of space determines location of these sites. If we had to look for fresh land on which to build, somewhere close to the centre of human activity, probably we might have to wait 10 years for building plans to get approval,” said Bruce Margot, head of TB Control in KZN.

“But at Catherine Booth Hospital, land already existed in its complex, hence the decision to locate the facility here was an easy one.”

Catherine Booth Hospital is a 170-bed facility founded by William Booth in 1912, under the auspices of the Salvation Army. He named it after his wife, Catherine.

South Africa, with an estimated number of 490 000 new TB cases in 2009, ranks fourth among the 22 high-burden TB countries in the world. MDR-TB is largely caused by patients’ non-adherence to drug regimes, inappropriate drug routines and, increasingly, by direct transmission.

Other locations for new or improved TB wards include Modimolle Hospital in Limpopo, Bongani Hospital in Mpumalanga, West End Hospital in the Northern Cape, Tshepong Hospital in Klerksdorp in the North West, and Pearson Hospital in the Eastern Cape.

Revolutionary TB diagnosis

Presiding at the main TB Day function at Prince Mshiyeni Hospital, Umlazi in Durban, Minister of Health Dr Aaron Motsoaledi said South Africa had many dubious honours in the health sphere. It was one of the high-burden countries, which collectively account for 80% of world TB prevalence.

South Africa was ranked number one per unit of population. There are 948 cases of TB per 1 000 of population in South Africa, with Zimbabwe a close second at 700 TB cases per 1 000 of population, Motsoaledi noted.

The minister said South Africa’s co-infection rate of 73% was the highest in the world, with five of the worst affected countries being in the Southern African Development Community. After South Africa come Zimbabwe, Mozambique, the Democratic Republic of Congo and Tanzania.

“If TB were a snake, the head would be in South Africa and its teeth would be in eThekwini,” quipped Motsoaledi.

In noting that 80% of HIV deaths were caused by TB, he called for bold action to turn the tide against the pandemic; interventions should include effective rapid detection. To this effect, it is now possible to detect TB within two hours, thanks to groundbreaking technology in the form of GeneXpert machines.

The GeneXpert machines will diagnose TB within two hours, cutting waiting time from weeks or months on end previously. This diagnostic delay led to an increase in mortality resistance and ongoing disease transmission.

The National Health Laboratory Services has implemented the GeneXpert as an effective alternative to smear microscopy for diagnosis of TB and screening for MDR-TB.

The minister noted it was generally difficult to diagnose TB in HIV-positive patients. But with the advent of GeneXpert technology, more people with TB could now be detected easily.

The machine is the only one of its kind in Africa and one of five outside the United States.

And one of these was unveiled on 24 March at Prince Mshiyeni Hospital in Umlazi, Durban.

“Starting today (24 March), South Africa is set to turn a corner in the fight against TB. This technology is revolutionary beyond description,” enthused Motsoaledi.

The GeneXpert is easy to use, thus eliminating the need for trained medical technicians.

“If the minister can operate this technology, then surely anyone else could do it,” joked Motsoaledi.

For this reason, smaller versions of the GeneXpert will be used in communities.

Traditionally, the GeneXpert boasts an accuracy rate of 98%. The significance of this break-though is more pronounced in South Africa than elsewhere in the world because of this technology’s capacity to increase the diagnosis of TB and find more people.

The GeneXpert comes in three varieties: GX4, which processes 16 sputa in eight hours; the GX16, with capacity to handle 64 sputa in eight hours; and the Infinity 48, which handles 197 sputa in eight hours.

Over the next 18 months, a national rollout of GeneXpert will be on the way, as nine GeneXpert 16 machines are to be located at nine provincial sites that have high TB prevalence. In addition, there are 20 of the GX4 variety ready to be deployed.

Fifty-four laboratory technicians (55, if you add the minister) have been trained to operate the GeneXpert, even though there is no need for highly trained experts to handle this innovation.

Other interventions

Donors have made available R100m for construction of MDR facilities in all nine provinces. One of these, at Catherine Booth Hospital, will soon be commissioned. This state-of-the-art facility will accommodate very ill patients to be consigned indoors for 18 months.

“But prevention should always come before technology,” emphasised Motsoaledi.

He called for a change in the passive attitude toward TB, citing it as a third intervention. He deplored the present healthcare system, which he claimed was renowned for four negative outcomes: unsustainable, extremely destructive, extremely costly and hospital-centric.

Motsoaledi emphasised that home visits for TB patients were part of the new strategy to combat the scourge. “About 18 000 families have been visited to date, and half of all TB families will be visited by March 2012,” he noted.

“We need to get nurses and doctors out into the community. I would rather have shortages of nurses in hospitals because as foot soldiers in this war, they needed to go to the frontline of the battle.”

The minister called for responsibility on the part of affected families, saying prevention was better than technology.

“Take TB seriously, so that collectively we can beat it,” he pleaded.

The Lilly MDR-TB Partnership

In recognition of the fact that MDR-TB cannot be halted by medicine alone, in 2003 pharmaceutical company, Lilly, officially created the Lilly MDR-TB Partnership. This public-private initiative now mobilises more than 20 partners on five continents to tackle the scourge of TB and MDR head-on.

Eli Lilly and Company is contributing US$120m in cash, medicines, advocacy tools and technology to focus global resources on prevention, diagnosis and treatment of patients with MDR-TB; and an additional US$15m to the Lilly TB Drug Discovery Initiative, to accelerate the discovery of new drugs to treat TB.

The company has made this investment to ensure thousands of MDR-TB patients receive the care and medication they need to combat this disease.

In collaboration with the four countries hardest hit by MDR-TB (China, India, Russia and South Africa), the partnership undertakes
the following:

• Promotion of community support and patient advocacy;
• Implementing MDR-TB healthcare treatment and training programmes, and strengthening surveillance of drug resistance;
• Transferring Lilly drug-manufacturing technology to local pharmaceutical companies and supplying medicines at concessionary prices;
• Facilitating the conducting of research for new drug discovery; and

Working with policy-makers to raise awareness and prevent the spread of MDR-TB.

David Mwanambuyu

Acknowledgement:

“Black Business Quarterly” was part of a media tour of KwaZulu-Natal from 22 to 24 March, facilitated by the Department of Health and Lilly MDR-TB Partnership.