My elective and much of Yale’s work here in Tugela Ferry is focused on treatment of patients with TB and HIV coinfection. People with HIV are much more likely to get TB, and they are more likely to do poorly and die from TB than people who are HIV negative. TB is the leading cause of death in HIV positive patients in
Multidrug resistant (MDR) TB is described as TB with resistance to the two most potent TB drugs: rifampin and isoniazid. Every Wednesday, I go to
It was through Yale’s research that the epidemic of MDR and XDR TB was identified in KwaZulu Natal. A 2006 landmark paper described an outbreak of MDR and XDR at Church of Scotland Hospital in Tugela Ferry. Of 542 patients with positive sputum TB culture results, 221 (41%) had MDR-TB and 53 (10%) had XDR. The mortality rate among patients with XDR-TB was 98%, with a 16 day median survival from time of sputum collection. All XDR patients for whom HIV status was known were HIV positive. There was significant evidence that XDR was transmitted nosocomially (through the hospital); a high proportion of patients had recent hospitalizations, few patients had been treated for TB previously, and there was genetic clustering of XDR TB strains.[1]
To put a human face to these numbers, I would like to describe a particular patient that I met briefly on the Female TB ward. N. was a twelve year old orphaned girl with HIV and TB. Monica, my roommate and the internal medicine resident from Tufts, was managing the female TB ward while N. was admitted. Each night, Monica would share with me the drama of the day. N. was doing very poorly. Thinking that the patient had a superimposed bacterial lung infection, Monica and the pharmacist made heroic efforts to acquire special antibiotics from another hospital two hours away. The patient responded very well to the first day or two of antibiotics. She was up and out of bed, walking to the bathroom on her own. Her respiratory status was much improved. Unfortunately, the nursing staff on this ward was not accustomed to delivering these types of antibiotics, which must be delivered on a strict schedule every 8 hours. After several missed doses, N.’s status deteriorated. Her chest x ray clouded up – either worsening consolidation from infection or a pleural effusion. Several days later, N. died.
Needless to say, this death was very hard on Monica. She had invested incredible amounts of effort and care in this child. She couldn’t help but think – in another setting, would N. have lived? Perhaps. In the
This last point is important. A week after N. died, her culture and sensitivity came back. She had XDR TB. Perhaps we could have done more to help her, but the truth is that she was very sick with an organism against which we have no effective medications. The XDR epidemic is here and it is real. Without new TB medications, better access to ARV therapy, and stronger infection control measures, XDR will continue to win the fight.
Though N.’s story is very sad, I can also describe more uplifting efforts to fight MDR and XDR. At the MDR clinic in Greytown on Wednesdays, we see about 20 patients a week who are doing well on outpatient MDR therapy. My very first day, I witnessed two healthy patients who had completed two years of MDR therapy and were stopping the treatment regimen. This was certainly cause for celebration. The group of doctors and nurses based at Greytown is pioneering community-based care of MDR patients. Before this program, all of the patients were admitted to the hospital for treatment, with the assumption that they would not be able to adhere to treatment and would be a public health risk at home. With evidence that most MDR and XDR TB is transmitted through the hospital, community-based care seems like it might work. Evidence is forthcoming.
[1] Andrews, et al. “Multidrug-Resistant and Extensively Drug-Resistant Tuberculosis: Implications for the HIV Epidemic and Antiretroviral Therapy Rollout in
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