Published Date: 2008-01-18 15:00:14
Subject: PRO/EDR> Tuberculosis, XDR - Botswana, South Africa
Archive Number: 20080118.0222

TUBERCULOSIS, XDR - BOTSWANA, SOUTH AFRICA
****************************
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: Wed 16 Jan 2008
Source: MyWay News, Associated Press report [edited]
<http://apnews.myway.com//article/20080116/D8U76PIO0.html>


Health authorities on Wednesday [16 Jan 2008] reported the 1st known
cases of virtually untreatable tuberculosis in Botswana, following
fears that the highly contagious strain has spread beyond neighboring
South Africa.

The health ministry said there were 2 cases of so-called extremely
drug resistant tuberculosis, or XDR-TB, as well as 100 cases of the
slightly more manageable multidrug-resistant TB, or MDR-TB. Although
XDR-TB has been reported in other parts of the world, especially
former Soviet republics, it is particularly lethal in southern
Africa, where AIDS incidence is high, because it combines with AIDS to kill.

The drug resistant forms of TB have developed largely because
patients don't stick to their 6-month course of treatment. For the
past few months, health professionals have warned that XDR-TB,
although only confirmed in South Africa, had spread to other southern
African nations like Swaziland and Lesotho hard hit by the AIDS
epidemic, but hadn't been diagnosed because of lack of laboratory facilities.

Nearly 400 cases have been reported so far in South Africa, but there
may be more cases. Testing methods are inaccurate and out of date and
many patients die before they are diagnosed. Botswana is the only
other country in southern Africa with testing facilities.

Several provinces in South Africa have taken legal action to force
drug resistant TB patients to stay in hospitals in isolation units
surrounded by wire fences and protected by guards. Although forced
confinement of patients violates most medical ethics, authorities say
they have no choice but to put the wider public good above individual
rights. Confinement for XDR-TB is at least 6 months, usually much
longer. Dozens of patients with the disease escaped from 2 hospitals
in South Africa's Eastern Cape province just before Christmas, saying
they wanted to spend the festive season with their families. South
African police mounted door-to-door searches for the patients; 8
still reportedly remain at large.

[Byline: Sello Motseta, AP writer Clare Nullis]

--
Communicated by:
ProMED-mail Rapporteur Brent Barrett

[WHO estimates about 400 000 cases of multidrug-resistant
(MDR)-tuberculosis (defined as resistant to isoniazid and rifampin)
occur annually. In an international, retrospective survey of nearly
18 000 TB isolates collected from 2000 through 2004, 20 percent of
samples were MDR-TB, and 10 percent of these (or 2 percent overall)
were XDR-tuberculosis (resistant to isoniazid, rifampin,
fluoroquinolones, and at least one of the 3 injectable
anti-tuberculosis drugs capreomycin, kanamycin, and amikacin) (MMWR
Morb Mortal Wkly Rep 2006; 55(11):301-5, available at
<http://www.cdc.gov/MMWR/preview/mmwrhtml/mm5511a2.htm>).

Although XDR-TB is present throughout the world, the international
survey suggested that it is most common in Asia and Eastern Europe.
However, because of poor surveillance and lack of resistance testing,
the frequency in Africa is unknown and probably much higher than has
been reported. So it is not surprising that Botswana has found MDR- and XDR-TB.

According to the WHO
(<http://www.who.int/entity/tb/features_archive/xdr_mdr_policy_guidance/en/index.html>):
"The laboratory plays a critical role in identifying MDR- and XDR-TB
cases; however, as a result of historical neglect, few national TB
programmes have capacity for drug-susceptibility testing (DST) for
the 1st-line drugs and even fewer have the capacity to test for
2nd-line drug resistance. Assessment of recent laboratory capacity
indicates that less than 5 percent of MDR-TB cases are currently detected."

In a new study published in the 1 Dec 2007 issue of Clinical
Infectious Diseases (Pillay M, Sturm AW. Clin Infect Dis. 2007
45:1409-14), the authors tracked the development of drug resistance
in KwaZulu Natal, South Africa in one particular strain of
_Mycobacterium tuberculosis_, identified as the F15/LAM4/KZN strain,
over 12 years, which coincided with the introduction of the directly
observed therapy-based and directly observed therapy-plus-based
tuberculosis-control programs. It was postulated that the
introduction of these programs in the absence of susceptibility
testing or drug resistance surveillance has been instrumental in the
development of XDR in this highly transmissible F15/LAM4/KZN strain.
The news release does not state whether the XDR-TB strains in
Botswana are related to the KwaZulu Natal strain, although this may
be possible because of cross-border travel between these 2 adjacent
countries. - Mod.ML

Both countries can be located on the HealthMap/ProMED-mail interactive map at
<http://healthmap.org/promed?v=-22.2,23.8,5>. - CopyEd.MJ]

See Also

2007
----
Tuberculosis - Uganda (02): MDR, susp. RFI 20071004.3284
Tuberculosis - Uganda: deadly strain, RFI 20071002.3255
Tuberculosis, XDR - South Africa (11): fugitives 20071002.3251
Tuberculosis, XDR - South Africa (10): Western Cape 20070627.2071
Tuberculosis, XDR - worldwide (02) 20070623.2034
Tuberculosis, XDR - South Africa (09): Western Cape 20070604.1805
Tuberculosis, XDR, airplane exposure - multicountry (03) 20070601.1778
Tuberculosis, XDR, airplane exposure - multicountry (USA, France,
Canada, Czech Rep.) 20070529.1738
Tuberculosis, XDR - South Africa (08): Western Cape 20070425.1349
Tuberculosis, XDR, 2003-2006 - Europe (Germany, Italy) 20070403.1132
Tuberculosis, XDR - South Africa (07): Eastern Cape 20070326.1044
Tuberculosis, XDR, 1993-2006 - USA 20070322.1005
Tuberculosis, XDR - South Africa (06) 20070319.0959
Tuberculosis, XDR, 1991-2003 - Spain 20070302.0738
Tuberculosis, XDR - South Africa (05) 20070228.0717
Tuberculosis, XDR - South Africa (04) 20070220.0638
Tuberculosis, XDR - South Africa (03) 20070209.0504
Tuberculosis, XDR - worldwide 20070205.0456
Tuberculosis, XDR - South Africa (02) 20070128.0375
Tuberculosis, XDR - South Africa: interventions 20070126.0349
...................................ml/mj/dk

*##########################################################*
************************************************************
ProMED-mail makes every effort to verify the reports that
are posted, but the accuracy and completeness of the
information, and of any statements or opinions based
thereon, are not guaranteed. The reader assumes all risks in
using information posted or archived by ProMED-mail. ISID
and its associated service providers shall not be held
responsible for errors or omissions or held liable for any
damages incurred as a result of use or reliance upon posted
or archived material.
************************************************************
Become a ProMED-mail Premium Subscriber at
<http://www.isid.org/ProMEDMail_Premium.shtml>
************************************************************
Visit ProMED-mail's web site at <http://www.promedmail.org>.
Send all items for posting to: promed@promedmail.org

(NOT to an individual moderator). If you do not give your
full name and affiliation, it may not be posted. Send
commands to subscribe/unsubscribe, get archives, help,
etc. to: majordomo@promedmail.org. For assistance from a
human being send mail to: owner-promed@promedmail.org.

############################################################
############################################################