In South Africa, XDR TB and HIV Prove a Deadly Combination

In South Africa, XDR TB and HIV Prove a Deadly Combination...

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15 FEBRUARY 2008 VOL 319 SCIENCE 894 CREDIT: KARIN SCHERMBRUCKER/AP CAPE TOWN, SOUTH AFRICA— A gaunt man with dark, deep-set eyes nods toward the uni- formed security guards at the gate and the nurses who wear double-thick “respirator” masks when they make their rounds. The cheer- less ward, surrounded by a 3-meter fence, is “more like a prison than a hospital,” he says. “Many patients are depressed; they don’t want to be here,” the chief nurse tells a visitor as a TV soap opera drones in a nearby room. That feeling is understandable. The two dozen men and women in the isolated ward are undergoing harsh and possibly futile treat- ment for the often lethal, contagious, and stig- matized disease that has brought them to Brooklyn Chest Hospital: extensively drug- resistant tuberculosis (XDR TB). The emer- gence over the past 2 years of the disease— which is even more difficult to treat effec- tively when patients are coinfected with HIV, as many are—is posing complex medical, eth- ical, and scientific issues in South Africa, the site of the largest and deadliest XDR TB out- break to date. Last year, more than 500 cases of XDR TB were diagnosed here, and the total number was probably far higher. On the medical front, the challenges include treating an infection that resists even last-ditch medications and finding the best ways to pre- vent hospital transmission of the disease (see sidebar, p. 897). Among the research chal- lenges are identifying new drug targets and rapid diagnostics, as well as investigating the molecular evolution of the TB strains that led to the emergence of this new threat. The main eth- ical quandary is the extent to which hospitals can or should isolate XDR TB patients against their will or force them to take potentially life- saving yet toxic drugs—perhaps for years. Few warning signs In August 2006, researchers made headlines at the annual AIDS meeting in Toronto, Canada, with a report that a new strain of TB, apparently resistant to almost all known drugs, had emerged in South Africa. The cases had been detected in 2005–2006 in the poor, mainly Zulu community of Tugela Ferry in South Africa’s KwaZulu-Natal (KZN) Province; nearly all the victims were also coinfected with HIV. Especially alarm- ing was the fatality rate: 52 of 53 patients had died within a median of 16 days after being tested for TB ( Science , 15 September 2006, p. 1554). XDR TB caught health care workers off guard and sparked fears of a new wave of “killer TB” outbreaks—especially in countries with high rates of HIV infection—that could jeopardize the progress in global TB control. The outbreak provided a “wake-up call,” says Mario Raviglione, director of the World Health Organization’s (WHO’s) Stop TB Department, which had first discussed the emergence of XDR TB of Tugela Ferry and elsewhere at a meeting in May 2006. WHO quickly formed a global XDR TB task force that soon made recommendations for dealing with the threat. These include better TB and HIV/AIDS control
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In South Africa, XDR TB and HIV Prove a Deadly Combination...

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