Part I: The deadly new tuberculosis

TUGELA FERRY, KwaZulu Natal Province, South Africa — Two health workers trudge up a steep, rocky hill carrying a blue cooler full of freezer packs and vials of medicine. They are visiting the hut of Msezini Ximba to give him his daily shot to fight multiple drug-resistant tuberculosis.

There isn’t much conversation as one health worker prepares the syringe, Ximba removes some clothing and the drug is administered. 

As quick as it is, this daily injection means everything to Ximba, helping him to battle this deadly, infectious disease and allowing him to continue living at home. He had spent eight months in isolation in the hospital, leaving his wife and three children behind. Asked if it helped to receive the treatments at home, he shook his head emphatically and said, “Very much.”

KwaZulu Natal, the sleepy, tropical province on South Africa’s Indian Ocean coast, is the epicenter of a worldwide epidemic of a new drug-resistant tuberculosis.

The South African government’s battle against the disease raises troubling questions that other countries will soon have to face, the most pressing of which is how best to limit its spread.

This series deals with the issue of whether tuberculosis sufferers should be forcibly quarantined to prevent infecting others, or treated at home and educated about contamination.

Although South Africa has the world’s largest number of XDR-TB patients, the disease has been confirmed in 48 other countries, from Russia to Peru and the United States. Tuberculosis has been killing people for at least 5,000 years. Today, the lung disease causes the deaths of 1.7 million people each year, primarily in the developing world.

TB spreads when an infected person coughs, sneezes or talks, sending droplets of bacteria into the air. If inhaled, the bacteria can multiply in the lungs, killing live tissue and leaving in its place dead tissue that restricts breathing.

The more dangerous drug-resistant varieties are relatively new, emerging in the past 20 years.  Drug-resistant tuberculosis occurs when patients fail to complete the standard treatment for regular tuberculosis, or if they have been prescribed the incorrect dose. Having been exposed to the drugs without being killed, the TB bacteria become stronger than and resistant to cheap, commonly used drugs.

Multiple drug-resistant tuberculosis (MDR-TB) is impervious to the first-line TB treatments, while extensively drug-resistant tuberculosis (XDR-TB) is unaffected by both first and second-line treatments. These diseases can be particularly lethal: A 2005 outbreak of XDR-TB killed 98 percent of those affected, most of them before the disease was diagnosed. The disease can only be battled by an expensive cocktail of drugs that must be strictly administered daily for two years.

Today, the World Health Organization estimates that there are 500,000 new MDR-TB cases each year, causing 110,000 deaths. An estimated 7 percent of those cases may actually be XDR-TB.

Development of drugs to combat the new strains of TB is slow. The last TB drug came to market more than 35 years ago, and the few promising candidates in clinical trials are five to 10 years away.

That is why South Africa isolates its MDR and XDR patients. Fearful of allowing an airborne disease to run unchecked among its 5.7 million HIV-positive people who are especially vulnerable to TB, South Africa quarantines most of these patients in hospitals surrounded by razor wire.

In his hut in rural KwaZulu Natal, Msezini Ximba is right in the middle of this international public health debate.  He is one of 37 patients — 13 who have XDR — being treated in a pilot program that allows patients to stay at home and receive treatment rather than be forcibly quarantined.

The two health workers drove more than 100 kilometers across the district to inject eight patients. They injected an older woman who was completely deaf, a common side effect of these medications, at the back of the car, and a nearly comatose 15-month old baby under some acacia trees. Both patients might otherwise have been quarantined.

The program has its weaknesses. After noon, the health workers pulled up beside a school, blew the car horn and waited 15 minutes for a man they inject who lives nearby. But he never showed up. Although it is dangerous to skip the daily treatments, there is nothing health workers can do — except come back tomorrow and listen to his apologies.

The program is risky for the healthcare workers: Many of those who died in the original outbreak were HIV-positive healthcare workers who contracted the illness from treating their patients. The workers typically wear special masks and gloves when administering shots and are careful to stay near doors and windows. Despite the risks, the community health workers appreciate the benefits for their patients.

Public health experts are concerned whether it is safe to send these patients home. 

“We don’t want to be doing something that exacerbates the problem,” says Bruce Margot, an official with the KwaZulu Natal Department of Health, which funds the program. So far, according to Margot, the study has seen zero cases of transmission, rates that are far lower than in the community at large.

The cost of five teams, five four-wheel-drive vehicles, fuel, medicine and salaries to treat the patients at home for a month is around $10,000, whereas the cost for treating those same patients in the isolation facility in Durban would be roughly $300,000 a month. The treatment is free for the patients.

Not all patients are eager to take advantage of the community program, largely because of the stigma that surrounds an MDR or XDR diagnosis.

“I asked for admission until I finished the injections,” said an MDR patient, who identified himself as Brookline, on his way to the provincial MDR hospital for several months. “I’m afraid of the stigma in the community. They are going to gossip about me.”

For a patient like Thandiwe Zungu, though, being treated at home is a vast improvement over the hospital. 

“I was crying, because I was so lonely there,” she said of the three months she spent in the provincial hospital, separated from her child and mother.  “It is better to be home than in the hospital.”

Part 2 of this series looks at the effect of the outbreak on children.

Part 3 of this series examines the debate among public health officials about isolating patients.