Superbug poses dire threat to Africa

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By STEPHANIE NOLAN
Toronto Globe and Mail
Tuesday, May 22, 2007

Tony Moll knew there was a problem, a grave problem. To tell him so, he had a ward full of patients who were sicker by the day.

But the gentle doctor, a veteran of 20 years of practice in a rural town in the low hills of KwaZulu-Natal province, never considered that he was looking at a problem that some public-health experts say may be the worst threat to humanity in the past half-century.

When the lab called to tell him just what was wrong with those patients, the news left him "in shivers." The Church of Scotland Hospital in Tugela Ferry, an old mission station of low, graceful stone buildings where Moll is the chief physician, now has the macabre title of "home of XDR TB" -- extensively drug-resistant tuberculosis.

The TB bacillus, a bug that has been pesky but totally treatable since the advent of antibiotics in the 1940s, has suddenly morphed into something virtually incurable. And the disease is spread not with a complex exchange of bodily fluids, like AIDS or Ebola, but simply by laughing, talking, coughing or breathing.

Feeding off a vulnerable population and a health system staggering under the challenge of the AIDS epidemic, XDR may already have spread from South Africa, creating the danger of an uncontrollable epidemic on the continent.

After Moll got the call from the lab, he started keeping track of patients with XDR. In a matter of days, it killed 52 out of 53 people who had it, most within two weeks of arriving at the hospital.

Almost all of them were diagnosed posthumously, because the TB killed them before the lab ever got the diagnostics finished.

"We're losing ground again, facing another untreatable condition," said Moll, a veteran of the fight with AIDS. "It's put us in a hopeless situation."

The journey to Moll's terrifying discovery began in early 2005, when he noticed something peculiar. The staff at his hospital had become accustomed to the marvelous "Lazarus effect" of anti-retroviral treatment for AIDS: seeing desperately sick people quickly start gaining weight and return home or go back to work. But now, in his ward, he had two men in their 30s on ARVs whose HIV infections were suppressed to undetectable levels. Yet their TB, which would normally have cleared up in a matter of weeks, kept getting worse.

He suspected multi-drug-resistant TB, or MDR, believed at the time to be as bad as the disease could get. So he collected sputum from 45 patients and sent it off to a lab in Durban for cell culturing. (The only way to tell if a TB strain is drug-resistant is to grow cultures from a patient sample, zap it with the different drugs and see which, if any, fail to kill it.) The process takes six to eight weeks. "In that time, we more or less forgot about it," Moll said. One of his two young men died.

But the phone call from the lab, when it eventually came, slammed the issue to the top of their agenda: Of the 45 samples, 10 were indeed drug-resistant. But they weren't resistant to just one or two of the drugs used against TB. They were resistant to all six medications available for use in Tugela Ferry. In other words, there was nothing to cure that TB at all.

"That was so scary," Moll said. His first thought, he confessed, was personal -- for himself and his staff. "Because you're talking about airborne transmission, and this means if a patient has got it, you as a doctor or a nurse working with that patient are breathing it in ... you are breathing in XDR as part of your job." Four health workers were among the 52 people who had died.

Immediately, he called the provincial Department of Health and wrote to the national government, expecting a five-alarm response. In his head, he started making plans for how these emergency cases would be handled.

But he didn't get the urgent response he had anticipated. "We were shouting on deaf ears for quite a long time ... everybody just had another problem, cholera here or overwhelming HIV there."

No one seemed to understand the threat of an incurable strain of TB spreading through a community where up to 40 percent of adults have HIV.

TB is already one of the most common infections in people with HIV-AIDS, and their weakened immune systems make them terribly vulnerable to XDR.

Nearly two years after Moll's discovery, South Africa is still trying to come to grips with what's brewing in its midst. Some 340 people have been diagnosed with XDR, and more than half of them have already died.

Yet in Tugela Ferry and other communities, people with this highly contagious, lethal disease are still lying in hospital beds next to patients who don't have it, or they are being sent home to live with their families until a hospital bed in the main treatment center in Durban becomes available, a wait that can last for months.

At the international AIDS conference in Toronto last August, Moll shared the news of his 52 dead XDR patients and finally got worldwide attention. Teams of international researchers soon flocked here: The World Health Organization sent advisers, while a European team traced all the contacts of the XDR patients.

In one of the few bits of good news in this story, they found that the XDR bug isn't as infectious as regular TB. Research has also found that the spread of the bacteria was almost certainly nosocomial -- hospital-related -- since virtually all of the cases to date have been people who had previously been hospitalized at a time when a then-undiagnosed XDR patient was also in the ward. Genetic typing shows that 89 percent of the XDR patients have had the same bacteria.

But even in the King George V Hospital in Durban, the specialist referral center for XDR, patients are still in mixed wards and staffers rarely wear respirators or even masks, complaining that these are hot and uncomfortable and make it hard to communicate with patients.