- The Washington Times - Sunday, January 28, 2007

Public health officials in South Africa are recommending the forcible quarantine of patients infected with a particularly virulent and incurable strain of tuberculosis. And though quarantine may encroach on a victim’s civil liberties, it may be necessary to prevent an epidemic, said a report published last week in an Internet peer-review medical journal.

Extensive drug-resistant tuberculosis (XDR-TB) has killed at least 74 persons in South Africa. More than 400 have been diagnosed with the disease, and an estimated 30 are infected each month, according to the study in the PLoS (Public Library of Science) Medicine.

“XDR-TB represents a major threat to public health. If the only way to manage it is to forcibly confine, then it needs to be done,” Jerome Singh, a co-author of the study and human rights lawyer at Durban’s Center for the AIDS Program of Research in South Africa, told Reuters News Agency last week.

XDR-TB is usually fatal within days or weeks and highly contagious among those living with HIV/AIDS.

“It is here, it is really scary, and it is an emergency,” said Dr. Paul Nunn, the World Health Organization’s coordinator of HIV and drug-resistant tuberculosis programs.

“Drug-resistant TB is found all over the world. It has been identified in 26 countries. But in sub-Saharan Africa, we have a population that has TB and is HIV-positive. It is a combination that is explosive,” Dr. Nunn told The Washington Times.

Dr. Jim Yong Kim, who founded Partners in Health with Dr. Paul Farmer, recently returned from Lesotho, where he saw the burgeoning epidemic firsthand.

“I’ve been to some of the worst places in the world dealing with TB — the prisons of Russia and the slums and clinics of Haiti and Peru. This is the worst epidemic I’ve seen,” Dr. Kim said.

He was in Lesotho to start an anti-HIV program, but his clinics were overwhelmed with HIV-positive patients who were then diagnosed with TB.

“We started seeing all these coughers. Last year, before we came, only four or five people were treated for TB. In four months, we’ve already identified 120, and that is in one village,” Dr. Kim said.

“In the United States, the TB rate is seven per 100,000. The rate here is 400 to 500 per 100,000. Among all cases of TB, 25 percent had multidrug-resistant tuberculosis (MDR-TB).

“We don’t have any idea how high the rate is of MDR-TB, but our fear is that it will be quite high,” he said.

Though India, China and Russia have large TB and HIV populations, for the most part, they do not live together in close communities. South Africa is different.

As many as 5.5 million of 45 million South Africans test positive for HIV, and many more carry the latent TB bacteria.

Medical authorities had been warning that the HIV-TB combination was explosive and deadly, but health specialists worldwide sat up and took notice only last year, when 53 persons at Tugela Ferry, South Africa, were diagnosed with XDR-TB, and all but one died in 25 days.

In all, 170 XDR-TB cases have been diagnosed in that area.

“Thirteen of the people who died in South Africa had the same genetic fingerprint. They were all taking anti-retrovirals for HIV and attending an ARV literacy class on how to take their medicines. Someone brought XDR-TB into that room, and they all died,” Dr. Nunn said.

“Sixty percent had never been treated for TB. They caught it. It was like a match going off in that clinic. This is an absolutely frightening epidemic,” Dr. Kim said.

And with worldwide air travel, the price of a plane ticket could easily spread XDR-TB here. Dr. Nunn cited a case the WHO is investigating but is yet to be reported: A man with XDR-TB boarded an airplane in Beirut last year and coughed blood on his flight to Paris. The man died shortly thereafter. The WHO is investigating whether he passed the disease to other passengers.

The WHO said the XDR-TB outbreak must be taken as seriously as outbreaks of bird flu and severe acute respiratory syndrome.

WHO guidelines recommend that TB-infected patients voluntarily restrict their movements and abstain from mixing with the general population. South African medical authorities are saying that may not be enough.

If voluntary “measures prove to be ineffective, then more restrictive measures may need to be contemplated. … Rights can usually be restricted if doing so is reasonable and justifiable. … The use of involuntary detention may legitimately be countenanced as a means to assure isolation and prevent infected individuals possibly spreading infection to others,” according to the PLoS paper.

This could prove especially difficult in South Africa, where a strong code of individual rights was enshrined in the post-apartheid constitution.

Dr. Kim said it is legal in the United States to quarantine someone with TB who refuses to take medication.

More than 9 million people are infected with drug-susceptible Mycobacterium tuberculosis each year. As many as 20 percent of that population will recover without treatment, but as many as 1.7 million die because they are not diagnosed and do not get the proper drugs.

Susceptible strains of TB respond readily to first-line antibiotics, and virtually all can be cured if diagnosed and treated. A rural country lab with a simple microscope and slides can diagnose it. The disease takes about $16 worth of drugs and six months of treatment to cure, according to the WHO.

But when TB victims begin feeling better, some stop taking their antibiotics, and drug-resistant strains of tuberculosis can evolve. MDR-TB is defined as a strain that resists at least two of the four first-line TB drugs. Health officials estimate that 300,00 to 600,000 people are infected with MDR-TB each year. About 2 percent of that group contract the deadly XDR-TB strain.

Dr. Nunn said it costs about $10,000 and an average two years of treatment to cure MDR-TB. There are no estimates for treating and curing XDR-TB, because most patients die within weeks.

In November, the Centers for Disease Control and Prevention (CDC) revised its definition of XDR-TB to strains that resist two front-line drugs, as well as three or more of the six classes of second-line drugs. Complicating the problem is that, unlike drug-susceptible TB, XDR-TB takes sophisticated laboratory tests to accurately diagnose.

Dr. Kim said that because of the lack of sophisticated lab equipment, samples from his clinics in Lesotho had to be shipped to Massachusetts for diagnosis.

“We are dealing with a type of TB that is virtually untreatable,” Dr. Nunn said.

“XDR-TB is obviously a very severe problem, especially when you don’t have the drugs to treat it,” said Dr. Anthony Fauci, director of the National Institutes of Health.

He said tuberculosis is difficult to catch unless the immune system is already compromised, by a disease such as AIDS, for example, or malnutrition. He said it takes more than a casual contact to spread TB. “You need to be very close, or living with a person. We need to pay attention to XDR-TB, but we do not need to panic,” he added.

Christine Sizemore, who oversees NIH research on TB drugs, said there are “several candidates in early clinical development, and several more coming along,” but even if they are successful, the new drugs are years from being available.

Dr. Ken Castro, who heads the CDC’s program for TB elimination, said 47 persons have been diagnosed with MDR-TB in the United States since 1992, 15 of them since 2000.

“The growing reality is that it is here in our own midst, and it is virtually untreatable,” he said in a telephone interview from Atlanta.

Which is why the PLoS Medicine report is recommending forcible isolation of XDR-TB patients.

“It is not a priori unethical to restrict the movement of those whose infection poses risks to public health. … Ultimately in such crises, the interests of public health must prevail over the rights of the individual,” the report stated.

Dr. Kim said that XDR-TB can be contained, and that small improvements in South African rural clinics — such as ultraviolet lights to kill bacteria, and fans blowing bad air out through windows — can accomplish a lot.

Still, hundreds of millions of dollars need to be appropriated for new drugs, new diagnostic methods and comprehensive treatment programs for infected areas, he said.

“In the mid-1980s, there were no drugs for HIV, and now look at all that we have. If there is a will — a political will, in collaboration with scientists and researchers — we can develop these drugs and diagnostics.

“But I worry we won’t do it until there is a Rock Hudson or Magic Johnson of XDR-TB,” he said.

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