SA losing battle against multidrug-resistant Tuberculosis
16 August 2012 Leave a comment
‘ We have a long waiting list. We are losing the MDR-TB battle…’
“More than half the children admitted to Brooklyn Chest Hospital in Ysterplaat near Cape Town have multiple-drug-resistant tuberculosis – and that’s just the tip of the iceberg. We have a long waiting list. We are losing the MDR battle.’ said Dr Riaan Willemse to the Voice of America journalist. VOA: “The country has the highest new-infection rate in the world… and its doctors often misdiagnose TB, mistaking it for a ‘middle-ear infection’…
Tuberculosis linked to HIV is biggest killer in South Africa:
Reprint from “Voice of America: Part One of a five-part series on Child Health in South Africa”
Tuberculosis Meningitis kills half of the children admitted at Brooklyn Chest Hospital, South Africa:
“Amid the noise of crying and moaning children, a little boy lies in a cot, curled up and silent, his eyes staring blankly at the ceiling. His doctor, Mariaan Willemse, said he’s got a very severe form of tuberculosis meningitis – an extremely dangerous strain of brain TB that’s killing many youngsters in South Africa. A young patient with potentially fatal MDR TB in isolation in a hospital in South Africa
Dr Willemse heads the children’s section of Cape Town’s Brooklyn Chest Hospital. International health experts regard it as one of the world’s leading TB treatment centers. The hospital is in the epicenter of South Africa’s TB epidemic. According to the World Health Organization (WHO), the country has the highest rate of new TB cases annually. Thousands of people in South Africa continue to be infected by a disease that’s been virtually eradicated in the developed world. TB is primarily an illness of poverty. It thrives when people live together in large numbers in close proximity,
WHO says every year at least 500,000 babies and children become infected with TB worldwide and an estimated 70,000 die of it – many in South Africa, India and China. In a recent statement, Dr. Maria Raviglione, director of the WHO’s Stop TB Department, said, “We have made progress on TB: death rates are down 40 percent overall compared to 1990 and millions of lives have been saved. But unfortunately, to a large extent, children have been left behind, and childhood TB remains a hidden epidemic in most countries.”
Only the very sickest children are admitted to Brooklyn Chest Hospital and half will die:
Willemse’s hospital is so overburdened with young patients that it cannot help all the children who are contracting TB. “We always have a waiting list. So as the one goes out there’s already somebody (else) waiting to come in,” she told VOA, and added that Brooklyn Chest is thus forced to admit only the sickest children. In adults, TB mostly attacks the lungs. But Willemse explained that in small children, with their undeveloped bodies, it concentrates in the lymph nodes. “This allows the TB to pass more easily into the brain,” she said. Looking down at another of her tiny patients, Willemse commented, “He was basically in a coma when he arrived here five months ago. Before he got sick, he was a normal four-year-old boy running around. Now he’s cortically blind…His eyes are working but his brain cannot interpret the images…. He’s (deaf) and he’s also a quadriplegic. And at this stage also he’s unable to swallow so he’s being fed with a tube.” Like many of her young patients, when the boy arrived at her surgery he was unconscious. The prognosis for children with TB meningitis at such an advanced stage is not good, said the doctor. “Fifty percent of them will die of the disease and the other 50 percent will have severe (brain) damage. They become spastic quadriplegic, meaning that their arms and legs don’t work and are very stiff. They’ll probably have to be looked after at home for the rest of their lives,” said Willemse.
Doctors in SA often misdiagnose TB meningitis: believing it’s an ear-infection:
Doctors often misdiagnose TB meningitis, which adds to the pressure the disease is putting on South Africa’s public health system. “It’s easy to mistake it for other common childhood illnesses. It usually starts with just a bit of a headache; the smaller child may be vomiting, having a fever,” said Willemse. She added that doctors often mistakenly diagnose children who have TB, thinking they have conditions like middle ear infection. They then prescribe antibiotics that obviously don’t heal the youngsters.“In two days the child is still not eating, is still vomiting, is now starting to become very sleepy, lethargic, and doesn’t want to play anymore. But the mom often (doesn’t) go back to the same (doctor) because it didn’t work (the first time) so she goes somewhere else – up until the child has convulsions. And then they know that this is something serious….” But by this stage, said Willemse, it’s often too late to save the child from permanent disability, or even death.
She said that perhaps the most difficult part of her job is to tell parents that their previously healthy child will never be the same again, because of TB meningitis.“I can’t tell them upfront, ‘Your child won’t be able to walk or won’t be able to sit.’ I can’t say that, but I can tell them that ‘I already see there is a lot of brain damage. And I already know that your child is not going to be normal; your child did have severe damage.’ And that’s not nice at all. It’s a heavy burden sometimes. One sometimes lies awake at night, and you pray for them.”
Mother infected her unborn baby with multidrug-resistant Tuberculosis:
In another corner of the hospital’s children’s ward, Willemse gestured towards an infant in a cot and explained, “She’s six months old. She’s been here for a month. The mommy died two days after the baby was born. She was born very prematurely. This child’s mother had TB while she was pregnant.”
The mother infected her child with another potentially fatal kind of TB, namely multidrug resistant, or MDR, TB. “It’s a manmade disease,” said Willemse. It has developed as a result of people with normal TB not completing their treatment. “The drugs have side effects, such as nausea, and so many people stop taking them. Many adults default with their treatment, after which the TB germ develops resistance to the routine antibiotics with which we treat the condition,” the doctor explained. “They then infect their children with MDR (TB).” Six months of treatment usually wipes out normal TB. But MDR TB patients need 18 months of medication to heal. They’re hospitalized and injected with drugs for six months, followed by 12 months of treatment at a local clinic. he injected medicines have dangerous side effects, especially for very young patients. They can make the children go deaf. They can damage their kidneys and their thyroid glands. But Willemse emphasized that the drugs still offer MDR TB sufferers’ the best chance of survival.
Losing the battle: ‘people don’t know how infectuous the disease really is’…
After decades of government programs, as well as local and international interventions aimed at ending South Africa’s TB scourge, Willemse sees no sign of it abating soon. In fact, based on her experience, she said it’s getting worse. “More than half of the children admitted to Brooklyn Chest have MDR TB, and that’s just the tip of the iceberg. We are losing the MDR battle,” she said. Giving reasons for this, Willemse said cases of MDR TB aren’t picked up in time at South African clinics. In addition, TB patients aren’t being counseled properly at many public health facilities. As a result, she said, they don’t realize how infectious the disease is and how important it is for them to complete their treatment – and how easily they can pass TB on to their children.
Many people refuse to get tested for TB:
Willemse said TB patients themselves are also responsible for spreading the disease. “I think the crux is that the adult who is coughing and losing weight must go to the clinic and must be tested for TB. But it’s a major problem that there are people who are still unwilling to be tested.”Willemse said TB infection rates in South Africa will drop in the future if health services improve but predicted that the country will never be a TB-free society. There’s too much poverty, she said, and this means the conditions that allow TB to thrive will endure well into the future.
More than 1,000 miles away from Brooklyn Chest Hospital, another doctor, Taryn Gaunt, is also dealing with a flood of TB cases in the Eastern Cape. She said, “South Africa can implement all the interventions it wants to fight TB. But at the end of the day, only when the standard of living radically improves in the country will we be able to talk about the possible eradication of TB. Until them, we’re locked into this terrible cycle where we invest so much money in trying to fight a disease that just seems to have no end.”
THE ENTIRE VOICE-OF-AMERICA SERIES ON THIS SUBJECT CAN BE FOUND ON:
Tuberculosis Linked to HIV Is Biggest Killer in South Africa:
Tuberculosis is the leading cause of death in South Africa. A more dangerous form of the disease, multi-drug resistant tuberculosis — is gaining ground in the country.
The World Health Organization reports an estimated 440,000 MDR-TB infections occurred around the world in 2008 and one-third of those infected died. Lisa Schlein has this report for VOA from the King George Hospital in Kwazulu Natal, a leading center of MDR-TB expertise.
Sister Flora Nsubane shows a group of visitors around the King George Hospital in Kwazulu Natal, a world leader in the treatment of tuberculosis. They wear masks to protect them from getting infected with multi-drug resistant tuberculosis, or MDR-TB.
“This is a 32-bedded ward…It is always full because it is the only TB ward that we have,” said Nsubane. Patients who are sick with more virulent strains of MDR-TB and extensively drug-resistant tuberculosis or XDR-TB, stay in separate wards. Sister Flora says the “survival rate” for children with MDR-TB is about 80 percent because they are kept in this hospital up to a year where their treatment is closely supervised. She says adults are admitted for six months and once their sputum is negative they are sent home.
“Then they continue with out patient treatment. And, at home, we have discovered that family members are not good support teams. Why? If the patient says I am tired of taking eight tablets a day and maybe the family member says no, it is O.K., you can take it tomorrow,” she said. “And then that increases resistance and they take long to be cured.
“Tuberculosis is an infectious bacterial disease which affects the lungs. It spreads widely among people living in overcrowded, dirty places. It is treatable with a six-month course of antibiotics.
MDR-TB and the more severe form of extensively drug-resistant tuberculosis do not resond to the standard six-month treatment with first-line anti-TB drugs. It can take two or more years to treat these diseases with drugs that are less effective and more expensive than the drugs used to treat ordinary TB.People with HIV are at great risk of developing tuberculosis.
WHO reports TB has tripled in the past 15 years in countries, such as South Africa, with high HIV prevalence.
Sister Flora says at one time, TB and HIV were treated in isolation. But now, she says, all patients admitted to King George’s hospital are treated for both HIV and drug resistance at the same time. “So, if the patient comes here for TB, the following day we do counseling for HIV and 2…we initiate treatment,” she said.
The World Health Organization reports MDR-TB threatens to become the dominant strain of TB over the next few decades. It says significant investment into research and development of new drugs and possible vaccines is needed. Yet, relatively little money is allocated for TB control and research. The Global Fund to Fight HIV/AIDS, Tuberculosis and Malaria is one of the few international agencies that funds multi-drug resistant TB.
Currently, it provides money for treatment for 30,000 people with MDR-TB though there are nearly half a million people infected and in need of treatment.