Hidden toll from TB

Shocking results from a study involving post-mortem examinations at a hospital in KwaZulu-Natal Province have revealed the extent to which tuberculosis (TB) is taking a toll on the lives of young, HIV-positive South Africans.

The study, published in the 22 June issue of the PLoS Medicine journal, found that out of 240 inpatients aged between 20 and 45 - who died after being admitted to Edendale Hospital between October 2008 and August 2009 - 94 percent were HIV-positive and half had TB.

South Africa is battling devastating dual epidemics of HIV and TB, with 80 percent of TB cases occurring in people who are also HIV-infected. While TB is known to be the country's leading cause of death, the difficulty of diagnosing the disease in HIV-positive people makes it hard to determine the true number of TB-related deaths.

KwaZulu-Natal has the country's highest HIV prevalence and greatest TB burden; even so, the results were a surprise. "Young people were coming in and dying, but we didn't know how many cases of TB we were missing," Dr Douglas Wilson, head of medicine at Edendale Hospital and one of the study's co-authors, told IRIN/PlusNews. "We were absolutely staggered by the amount of TB we found."

We didn't know how many cases of TB we were missing. We were absolutely staggered by the amount of TB we found

Of the 50 percent of patients in the sample being treated for TB, 58 percent of these were still culture-positive when they died, meaning that active TB was detected by culture testing their tissue samples.

The majority (70 percent) did not have drug-resistant strains of TB, so prompt treatment with a six-month course of first-line TB drugs could probably have saved their lives. "They just started [treatment] too late," said Wilson.

In the 17 percent of patients who were on antiretroviral (ARV) treatment when they died, the proportion of culture-positive TB was about the same. ARV treatment prevents TB when started early enough, so the finding implies that these patients also started ARV treatment too late.

Since the study, the South African government has revised its HIV/AIDS treatment guidelines to recommend that patients co-infected with TB start ARV treatment earlier; Edendale has already implemented the change.

Wilson said he would also like to see earlier diagnosis, particularly at primary care clinics, where most TB cases are handled.

He said a major public health campaign should encourage people to ask for a sputum test and chest x-ray if they experienced any of the common symptoms of TB. "We need patient activism to increase on this," he said.

Hidden burden of MDR-TB

Seventeen percent of the patients in the study who had TB were found to have multi-drug resistant (MDR) strains, despite a significant portion being on their first course of TB treatment.

Read more:

Turning the tide against drug-resistant TB

Poor MDR-TB knowledge among nurses

TB patients not getting HIV counselling

Activists call for integrated HIV/TB services

The authors surmised that many had probably contracted drug-resistant TB in their community rather than as a result of failing to adhere to treatment. "These findings point to a hidden burden of MDR disease among HIV-coinfected individuals in KZN [KwaZulu-Natal]," they said.

Wilson noted that Edendale Hospital was one of four sites in KwaZulu-Natal where state-of-the-art equipment for more rapid diagnosis of MDR-TB had been installed but was not yet operational due to resource constraints. "I'm hoping this study will help focus attention on the problem," he said.

The authors suggested that routine TB screening for hospitalized patients, especially those who were HIV-positive, and earlier initiation of TB and ARV treatment could help reduce the TB death toll.

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