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An Alternate Model of Care of Multiple and Extensively Drug-Resistant Tuberculosis (MDR and XDR TB)
Posted by plosmedicine on 31 Mar 2009 at 00:11 GMT
Author: Nesri Padayatchi
Position: Centre for the AIDS Programme of Research in South Africa (CAPRISA)
Institution: Doris Duke Medical Research Institute, Nelson R Mandela School of Medicine, University of KwaZulu-Natal
Additional Authors: Gerald Friedland
Submitted Date: July 31, 2007
Published Date: August 1, 2007
This comment was originally posted as a “Reader Response” on the publication date indicated above. All Reader Responses are now available as comments.
The province of KwaZulu-Natal (KZN) in South Africa, is one of the worst areas affected by the M(X)DR TB epidemic. This coupled with the high HIV prevalence rate has resulted in an extremely high mortality rate . The 1999 SA guidelines for the management of MDR TB recommend that one specialized TB treatment center be established in each of the nine provinces in South Africa . The 2006 WHO guidelines recommend that the TB treatment strategy for each country should be determined by the results of TB drug surveillance for that country.
In South Africa, the last comprehensive drug resistance surveillance was conducted in 2001-2002 and indicated that the prevalence of drug resistance was generally low but varied widely in each of the nine provinces . There is mounting evidence that in KwaZulu-Natal, the rate of drug resistance has risen substantially since this survey [4,5]. The current specialized TB treatment center in this province is heavily overburdened and unable to cope with the rising limited transport and desire to be closer to families and communities is contributing to increasing treatment default with resultant drug resistance and its transmission. Thus the previous uniform centralized national strategy is no longer appropriate. An alternate short term strategy for care of M(X)DR TB patients is urgently needed and proposed below.
It is necessary and desirable that treatment centers be decentralized and be developed closer to where patients reside. This will increase treatment capacity as well as facilitate the transition to ambulatory home based care. Initiation of treatment can begin at the central facility with rapid transfer to local centers or home, as determined by patients’ needs. In such circumstances community support and family care must be incorporated into the treatment strategy.
The process of decentralizing care should be implemented in a controlled and phased manner with a well defined plan. Training of health care workers at all levels to provide competent care and treatment for M(X)DR-TB is critical. Consultation and support from the central TB treatment facility staff is needed to accomplish this and a reliable system of communication as patients pass through the various treatment sites is necessary. Creating favorable work environments is critical for retaining staff as low staff salaries and poor morale has been shown to impair treatment delivery and undermine the control of resistance . In addition, care for patients' needs should be a shared responsibility between informed health care personnel, trained community workers, families and patients themselves. Appropriate responsibility is necessary and must be taken at each level. Although patients may remain infectious, continuing contact with families, is possible and desirable, and can be safely accomplished with proper precautions. Infection control to reduce transmission of drug susceptible and resistant TB in both health care and home settings has been woefully neglected. Even in resource limited settings, however, much can be done. In institutional settings, simple low cost strategies to reduce transmission need to be implemented. These include improving natural ventilation, sitting in the open, covering of mouths during coughing, and respirator masks for staff. In home settings, similar precautions can be taken to protect family members. Voluntary limitation of mobility can be proposed and accepted by patients if accompanied by strengthening comprehensiveness, continuity, adherence counseling and social support . With these in place, involuntary confinement is rarely needed.
In areas with high HIV prevalence, TB programmes should be harmonized with HIV services, to potentially improve the outcome of both diseases. Starting antiretroviral therapy in most roll out programs includes extensive counseling about medications and adherence. Similar counseling is lacking but needed for Tb patients. Information exchange between TB and HIV programs is critical. Experience in the treatment of MDR TB in HIV infected patients has been less successful and there is limited information about XDR TB treatment, with or without HIV co infection. Nevertheless, in co infected patients, the best outcome is likely if the two diseases are treated concomitantly. Treatment success stories such as those in Latvia and Peru  can inform this strategy. Finally, in order for this decentralization of M(X)DR TB to be effective, there must be sufficient governmental political and financial commitment.
The paradigm shift towards increased utilization of community and home based care with support and shared responsibility from trained health workers needs to take place now. The current situation is untenable and no longer serves the full needs of the patients and community. The longer we wait for the perfect solution in the face of rising case loads, the more devastating morbidity and mortality will result.
1 Gandhi NR, Moll A, Sturm AW, Pawinski R, Govender T, Lalloo U, Zeller K, Andrews J, Friedland G 2006. Extensively drug-resistant tuberculosis as a cause of death in patients co-infected with tuberculosis and HIV in a rural area of South Africa. Lancet 368(9547):1575-1580.
2. Medical Research Council. 1999. The management of multidrug resistant tuberculosis in South Africa. http:www.doh.gov.za/tb/docs/md... (Accessed: 17 November 2003). ed., Pretoria: Medical Research Council.
3. Weyer K, Van der Walt M, Brand J, Lancaster J, Levin J. 2003. Survey of Tuberculosis Drug Resistance in South Africa. Report to: Department of Health. ed., Pretoria: Medical Research Council.
4. Makhaye C. Deadly TB on upward spiral in KZN. Sunday Tribune 2006, November 12
5. Vella V, Marra C, Maluleke M, Hlope H, Peer A, Tefera A. Surveillance of XDR and MDR at COSH, 2005-2006. KwaZulu-Natal Epidemiology Bulletin March 2007;15.
6. Migliori GB, Espinal M, Danilova ID, Punga VV, Grzemska M, Raviglione MC 2002. Frequency of recurrence among MDR-TB cases 'successfully' treated with standardised short-course chemotherapy. Int J Tuberc Lung Dis 6(10):858-864.
7. World Health Organization. Guidelines for the prevention of tuberculosis in health care facilities in resource-limited settings. Geneva: WHO, 1999.
8. Singh JA, Upshur R, Padayatchi N. XDR-TB in South Africa: No Time for Denial or Complacency. PLoS Med 2007;4(1):e50
9. Rich M, Cegielski P, Jaramillo E, K L. WHO Guidelines for the programmatic management of drug-resistant tuberculosis; 2006.