| The report begins with a global overview of MDR TB, which is identified (together with the HIV pandemic) as a threat to international TB control efforts. Attention then moves to South Africa and an overview of current knowledge regarding MDR TB in the country is presented. It is argued that the DOTS Plus strategy (which is simply an integrated approach to the management of TB and MDR TB) is already being implemented in South Africa, and should receive additional attention and support.
The bulk of the report describes how the problem of MDR TB was addressed in a systematic and hopefully sustainable way in the Lower Orange District in context of the Northern Cape and the progress made at Westend Hospital. MDR TB emerged as a problem in the district following the implementation of a TB Control Programme based on DOTS. A high incidence of MDR TB was reported, but no systems were in place to quantify the problem, nor to manage individual patients or a system to address the problem of MDR TB as a whole.
A rapid appraisal was undertaken in 1998 to explore current practices around the management of MDR TB in the province. The appraisal confirmed the lack of a coherent or standardised system for managing the problem. The provincial Department of Health indicated their support for the development of an overall system to address MDR TB based on the national MDR TB guidelines developed by the National TB Control Programme and adapted to local realities. A research proposal was developed and funding from the Department for International Development obtained.
During the twenty month period from May 1999 until December 2000, 129 patients with MDR TB were identified in the Lower Orange district. Fifty-seven patients had previously been diagnosed with MDR TB, but 72 cases were newly diagnosed. This means that 47 cases of MDR TB per 100 000 people per year were identified in the district over the two year period. The impression of an extremely high incidence of MDR TB in the district was thereby confirmed. Most of the identified and traced &lsquoold&rsquo cases were evaluated and restarted on treatment through the so-called mop-up operation, whilst newly diagnosed cases were identified by PHC workers and referred for assessment and management at the newly established specialist MDR TB clinic.
At the same time all aspects of MDR TB management were addressed in a systematic way. An MDR TB team was established in the district to drive the process and to ensure sustainability. An inpatient facility has been established (and it is hoped will be converted to a MDR TB Unit soon) at the TB unit and regular MDR TB clinics established, with clear procedures for evaluation and management of patients. Issues related to the role of laboratories were clarified. A recording, reporting and monitoring system was put in place, as were procedures for tracing close contacts.
Emphasis was on monitoring outcomes and provisional results are available. 46% of new cases, but only 26% of old cases were cured. Ethambutol resistance proved much higher than had been anticipated, and outcomes for patients in this group were particularly poor. Problems were encountered with ensuring a regular supply of Cycloserine, and the contribution of this to the poor outcome of MDR TB patients (with resistance to Ethambutol) is not known.
Although the research and work focused on the Lower Orange District (and was also initiated at Westend Hospital), hopefully it will inform debates around the management of MDR TB in South Africa and contribute to a more systematic and rational approach to the problem. The lessons which were learnt and the tools which were developed (included in the appendices) should prove useful to clinicians and managers when establishing specialist MDR TB clinics whether at provincial, regional or district level.
Until recently, the National TB Control Programme&rsquos position was that curing new smear positive patients must always remain the first priority of TB control efforts i.e. the implementation of DOTS. The reality of the emerging MDR TB epidemic cannot be ignored in South Africa and the high number of cases identified during the course of this study is alarming. Unless the problem is addressed, it is likely that the numbers will continue to increase and will constitute a significant threat to TB control efforts, increasing the mortality and morbidity associated with tuberculosis.
What is to be done? It is essential that an effective DOTS programme be in place before beginning a MDR TB treatment programme or be implemented as a simultaneous process. If this is not done, a poor TB control program would generate MDR TB cases more rapidly than a treatment program could treat. The suggestion from several quarters (including the WHO) is that DOTS Plus is the way forward. For South Africa, there is actually no other way to go, as it may become too difficult and expensive, if not impossible, to do so later on in resource poor settings. The TB Research Programme and DOTS Plus Study Group led DOTS Plus Project funded by the World Health Organisation, has added a lot of momentum to the implementation of DOTS Plus in South Africa.
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