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South Africa has worst TB prevalence in the world - report
Kerry Cullinan - Health-e
2008-03-25

South Africa has by far the worst TB prevalence rate in the world, with almost 1000 South Africans out of every 100 000 living with the disease in 2006. This is according to the Global TB report released in Geneva on Monday 16th March, based mainly on 2006 statistics supplied to the World Health Organisation by over 200 countries.

Despite a global slowing down in new TB cases since 2003, South Africa recorded the worlds second highest rate of new cases (incidence rate) in 2006 after Swaziland. More people died of TB in South Africa in that year than in any other country in the world some 218 per 100 000. Zimbabwe and Mozambique had the next highest TB death rates. The global TB cure rate for 2005 was 78%, but South Africas cure rate was only 58%. This was third worst in the world. Uganda was bottom of the class with a 32% cure rate, followed by Russia with a 55% cure rate. Zimbabwe did marginally better than South Africa with a 59% cure rate.

In contrast, China, Bangladesh and Vietnam reported cure rates of 90%. Former Archbishop Desmond Tutu told a gathering of TB health workers in Cape Town last week that South Africas health system was in trouble and we must admit it. Meanwhile the report blames the poor outcomes in Africa and Europe on high rates of HIV infection, drug resistance and weak health services. In absolute numbers, South Africa has the fourth biggest TB population in the world, after India, China and Indonesia. Some 44% of South Africans who are living with TB are also HIV-infected. However, this could well be an underestimate as the report says that only one in five African TB patients were tested for HIV. Kenya and South Africa have made the biggest improvements in testing TB patients for HIV in the continent. However, Rwanda, Brazil and Malawi are doing best at testing. The number of HIV positive TB patients on antiretroviral therapy more than doubled but fell far short of global targets, mainly because not enough patients are being tested for HIV.

Interesting, Europe had lower treatment success rates than Africa in 2006, mainly as a result of drug-resistant TB in Eastern Europe and Russia. Russia and South Africas struggles with drug-resistant TB were reflected in poor outcomes for TB patients being re-treated after failing to respond to earlier TB treatment. Some 16% of Russians and 11% of South Africans died while being retreated. The cost per capita of treating TB patients was also very high in these countries as drug-resistant TB is very expensive to treat. Funding for the disease has more than tripled since 2002 with the most important source being the Global Fund to fight AIDS, TB and Malaria. However, the report concludes on a negative note: Overall, there are several signs that global progress in TB control is slowing and that there are parts of the world where much more needs to be done to achieve the global targets that have been set. This week, TB experts Dr Richard Chaisson and Dr Neil Martinson warned in the New England Journal of Medicine that in some parts of Africa, TB rates had more than doubled since 1990, mainly as a result of HIV. Tuberculosis is the most common coexisting condition in HIV-infected adults, killing 30 to 40% of adults and one in five children, said Chaisson, who directs the Johns Hopkins University Centre for Tuberculosis Research in the USA. The current tests and treatment are not enough to stop tuberculosis in Africa, and new approaches are urgently needed, said Martinson, deputy director of the Perinatal HIV Research Unit in Soweto. The most commonly used test in Africa the sputum smear does not work well to detect TB in HIV-infected patients. 

Chaisson and Martinson argue that better use must be made of improving laboratory facilities, detecting patients with TB earlier and making highly sensitive culture tests widely available in Africa.

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