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Published Date: 2007-10-02 11:04:46
Subject: PRO/EDR> Tuberculosis, XDR - South Africa (11): fugitives
Archive Number: 20071002.3251

TUBERCULOSIS, XDR - SOUTH AFRICA (11): FUGITIVES
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A ProMED-mail post
<http://www.promedmail.org>
ProMED-mail is a program of the
International Society for Infectious Diseases
<http://www.isid.org>
Date: Sun 30 Sep 2007
Source: IOL (Independent Online, South Africa) [edited]
<http://www.iol.co.za/index.php?set_id=1&click_id=13&art_id=vn20070930102816754C772750>

A hunt is on for 2 patients with a deadly form of tuberculosis who
disappeared after the Cape High Court ordered they return to Brooklyn
Chest hospital. The pair, diagnosed with extremely drug resistant
(XDR) tuberculosis, are presumed by health department officials to be
in hiding. Their disappearance has sparked fears about the risk they
pose to their families and communities because their strain of TB is
not only potentially lethal, but also contagious.
Initially 4 XDR-TB patients absconded from the hospital to return to
their families. One of them was photographed near his home holding
his 2-year-old daughter and apparently coughing over her. After
failed attempts to persuade them to return to the hospital, the
health department won an urgent interdict in the Cape High Court on
Friday [28 Sep 2007] to insist that the 4 go back to hospital. The
authorities went to fetch the patients and 2 were readmitted on
Friday [28 Sep 2007] night. But Health MEC (Member of the Executive
Council) Pierre Uys told Weekend Argus the other 2 had "completely
disappeared." He said authorities, including the Sheriff of the Court
and the police, had searched all night with no luck. "Unfortunately,
only 2 have been isolated. It is clear that the other 2 might be in
hiding, which poses a danger to their communities." He said
authorities would continue the search.
City executive director for health Dr Ivan Toms said he understood
both patients would return to hospital tomorrow [1 Oct 2007], but
that officials would do their best to have them in isolation as soon
as possible. In the meantime, the City is leading a TB testing system
in the communities of the 4 patients. Toms said immediate family and
others who had come into regular contact with them would be tested.
The interdict allows the health department to forcibly return the 4
patients to the hospital and keep them there until they have tested
sputum negative, meaning they could no longer infect others, for 3
consecutive months. The entire process could take more than a year.
Faiza Steyn, spokesperson for the health department, said the
interdict barred the media from divulging the identities of the 4
patients. One patient, from Uitsig, told a daily newspaper earlier
this week that despite his concerns about his business, he had agreed
to voluntarily return to Brooklyn Chest on Monday [1 Oct 2007].
Questions have also been raised over the possible infringement of the
patients' human rights. A senior health department official, who
asked not to be named, said the case would "spark legal and ethical
debate" over the rights of patients. "We are facing a dilemma -- the
freedoms of the individual versus the rights of the community not to
be infected. "In this case, the right of the individual has been
curtailed, but the rights of the people, especially those who are
vulnerable such as children, have been protected," the official said.
Human Rights Commission CEO Tseliso Thipanyane said the HRC (Human
Rights Commission) was "rightly concerned" about the welfare of the
patients. "TB is a highly infectious disease and with this strain
there is no easy cure. Therefore, you have to protect the rights of
others. "What also has to be looked at is the issue surrounding their
stay at the hospital. It is relevant to their human rights whether
they are getting proper health care, and whether their relatives have
access to them," said Thipanyane.
[Byline: Leila Samodien]
--
Communicated by:
ProMED-mail
<promed@promedmail.org>
[This news release reminds us that extensively drug-resistant (XDR)
tuberculosis in South Africa is not restricted to KwaZulu-Natal
province, where it was initially described in 2006. XDR tuberculosis
is by definition resistant to the fluoroquinolones and at least one
of the 3 injectable anti-tuberculosis drugs capreomycin, kanamycin,
and amikacin, in addition to isoniazid and rifampin. XDR tuberculosis
in KwaZulu-Natal has been associated with HIV infection and rapid
progression to death in most patients. Of 53 patients with XDR
tuberculosis initially described in KwaZulu-Natal, 55 percent claimed
they had never been treated, which implies that they had primary
infection with an XDR strain of _Mycobacterium tuberculosis_, and
genotyping analysis revealed that 85 percent of the 46 isolates
tested belonged to the KwaZulu-Natal family of tuberculosis strains,
which had been recognized in the province for a decade
(<http://content.nejm.org/cgi/content/full/356/7/656>). Whether cases
outside of KwaZulu-Natal have this genotype is not known.
The full extent of the XDR tuberculosis in countries that share
borders or migrant work forces with South Africa (such as Lesotho,
Swaziland, Mozambique, and Zimbabwe) is unknown because none of those
countries have the "laboratories and clinical experts necessary to
diagnose and track the disease" as reported in ProMED-mail posting
20070128.0375.
Inadequate drug regimens select out drug-resistant strains, which
then proliferate and spread to close contacts of the XDR-infected
patients. Once drug-resistant tuberculosis has spread, rapid
drug-susceptibility testing is necessary to ensure that patients
receive a quick diagnosis and adequate treatment so that transmission
of the disease can be thereby interrupted. Such treatment requires
access to 2nd-line drugs, which are more costly, more toxic, and
weaker than 1st-line drugs. 2nd-line treatment must be given for at
least 18 months under strict monitoring and supervision, because of
the usual 2-3 month delay required for testing drug resistance. If
patients diagnosed with tuberculosis only on the basis of positive
sputum smears for the tubercle bacillus are housed together on open
wards, ventilated by open windows, patients with XDR tuberculosis may
superinfect patients with drug-susceptible tuberculosis; or if sent
home on inadequate empiric therapy, they may continue to infect
contacts in the community.
Brooklyn Hospital, located in Brooklyn, Cape Town, is a 700-bed
facility that specializes in tuberculosis treatment and has a 22-bed
isolation unit for XDR tuberculosis that was noted to be full in May
2007
().
As previously reported (ProMED-mail posting 20070604.1805), overflow
XDR-TB patients there were reported to be isolated 'in prisons and
hospital side-wards' (). Clearly,
adequate tuberculosis isolation facilities are needed to minimize
continued transmission of this drug-resistant pathogen. Involuntary
detention of contagious patients with XDR tuberculosis in inadequate
isolation facilities in prisons or hospital side wards would be
totally improper. These patients optimally require isolation in rooms
under negative pressure with an adequate air exchange rate until no
longer contagious.
The World Health Organization (WHO) has issued guidance on human
rights and involuntary detention for XDR-TB
control
(<http://www.who.int/tb/xdr/involuntary_treatment/en/index.html>) and
is reprinted from the prior ProMED-mail posting 20070126.0349:
"WHO's position with respect to the legal and ethical issues
surrounding compulsory TB treatment was published in 2001 (3) with
the specific purpose of ensuring prevention and control is
strengthened within a legal and human rights' framework. The
publication of a PLoS (Public Library of Science) Medicine journal
report (4) has highlighted again the issues around compulsory
treatment, particularly in relation to drug-resistant TB.
WHO strongly recommends that governments must ensure, as their top
priority, that every patient has access to high quality TB diagnosis
and treatment for TB and drug-resistant forms of TB. It also fully
supports the rights and responsibilities of TB patients as
recommended in the Patients' Charter for TB Care (5).
In this regard, if a patient willfully refuses treatment and, as a
result, is a danger to the public, the serious threat posed by XDR-TB
means that limiting that individual's human rights may be necessary
to protect the wider public. Therefore, interference with freedom of
movement when instituting quarantine or isolation for a communicable
disease such as MDR-TB (multidrug-resistant TB) and XDR-TB may be
necessary for the public good, and could be considered legitimate
under international human rights law.
This must be viewed as a last resort and justified only after all
voluntary measures to isolate such a patient have failed.
A key factor in determining if the necessary protections exist when
rights are restricted is that each one of the 5 criteria of the
Siracusa Principles (6) must be met, but should be of a limited
duration and subject to review and appeal. The Siracusa principles are:
- the restriction is provided for and carried out in accordance with the law;
- the restriction is in the interest of a legitimate objective of
general interest;
- the restriction is strictly necessary in a democratic society to
achieve the objective;
- there are no less intrusive and restrictive means available to
reach the same objective;
- the restriction is based on scientific evidence and not drafted or
imposed arbitrarily, that is, in an unreasonable or otherwise
discriminatory manner.
Responsibilities of TB treatment-providers to their patients are
detailed in The International Standards for Tuberculosis Care (7)."
References:
3. Good practice in legislation and regulations for TB control: an
indicator of political will (WHO, 2001)
<http://whqlibdoc.who.int/hq/2001/WHO_CDS_TB_2001.290.pdf>
4. Medicine journal (Public Library of Science, 22 January 2007)
<http://medicine.plosjournals.org/perlserv/?request=get-document&doi=10.1371/journal.pmed.0040050>
5. The patients' charter for tuberculosis care (World Care Council,
2006) <http://www.who.int/tb/publications/2006/istc_charter.pdf>
6. Siracusa principles on the limitation and derogation provisions in
the International Covenant on Civil and Political Rights (United
Nations, Economic and Social Council, 1985)
<http://www1.umn.edu/humanrts/instree/siracusaprinciples.html>
7. International standards for tuberculosis care (TB Coalition for
Technical Assistance, 2006)
<http://www.who.int/tb/publications/2006/istc_report.pdf>
A map of South Africa can be found at
<http://www.un.org/Depts/Cartographic/map/profile/southafr.pdf> and a
map for Uitsig, South Africa can be found at
<http://www.fallingrain.com/world/SF/4/Uitsig.html>. - Mod.ML]

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