Extensively drug‐resistant tuberculosis (XDR‐TB) among health care workers in South Africa

Objective To determine the clinical profile and outcomes of health care workers (HCWs) with extensively drug resistant tuberculosis (XDR‐TB) in the Eastern and Western Cape Provinces of South Africa. Method Retrospective case record review of 334 patients with XDR‐TB reported during the period 1996–2008 from Western and Eastern Cape Province, Cape Town, South Africa. Case records of HCWs with XDR‐TB were analysed for clinical and microbiological features, and treatment outcomes. Results From 334 case records of patients with XDR‐TB, 10 HCWs were identified. Eight of ten were HIV‐uninfected, and four of 10 had died of XDR‐TB despite treatment. All 10 HCWs had received an average of 2.4 courses of TB treatment before being diagnosed as XDR‐TB. Conclusions In the Eastern and Western Cape provinces of South Africa XDR‐TB affects HCWs, is diagnosed rather late, does not appear to be related to HIV status and carries a high mortality. There is an urgent need for the South African government to implement WHO infection control recommendations and make available rapid drug susceptibility testing for HCWs with suspected multidrug‐resistant (MDR)/XDR‐TB. Further studies to establish the actual risk and sources of infection (nosocomial or community) are required.     

Review of multidrug‐resistant and extensively drug‐resistant TB: global perspectives with a focus on sub‐Saharan Africa

Tuberculosis (TB) remains a global emergency and is responsible for 1.7 million deaths annually. Widespread global misuse of isoniazid and rifampicin over three decades has resulted in emergence of the ominous spread of multidrug‐resistant TB (MDR‐TB) and extensively drug‐resistant TB (XDR‐TB) globally. These difficult to treat resistant forms of TB are increasingly seen in Asia, Eastern Europe, South America and sub‐Saharan Africa, disrupting TB and HIV control programmes. We review the latest available global epidemiological and clinical evidence on drug‐resistant TB in HIV‐infected and uninfected populations, with focus on Africa where data are scanty because of poor diagnostic and reporting facilities. The difficult management and infection control problems posed by drug‐resistant TB in HIV‐infected patients are discussed. Given the increasing current global trends in MDR‐TB, aggressive preventive and management strategies are urgently required to avoid disruption of global TB control efforts. The data suggest that existing interventions, public health systems and TB and HIV programmes must be strengthened significantly. Political and funder commitment is essential to curb the spread of drug‐resistant TB.     

Scaling up Xpert MTB/RIF technology: the costs of laboratory‐ vs. clinic‐based roll‐out in South Africa

Objective The World Health Organization recommends using Xpert MTB/RIF for diagnosis of pulmonary tuberculosis (PTB), but there is little evidence on the optimal placement of Xpert instruments in public health systems. We used recent South African data to compare the cost of placing Xpert at points of TB treatment (all primary clinics and hospitals) with the cost of placement at sub‐district laboratories. Methods We estimated Xpert’s cost/test in a primary clinic pilot and in the pilot phase of the national Xpert roll‐out to smear microscopy laboratories; the expected future volumes for each of 223 laboratories or 3799 points of treatment; the number and cost of Xpert instruments required and the national cost of using Xpert for PTB diagnosis for each placement scenario in 2014. Results In 2014, South Africa will test 2.6 million TB suspects. Laboratory placement requires 274 Xpert instruments, while point‐of‐treatment placement requires 4020 instruments. With an Xpert cartridge price of $14.00, the cost/test is $26.54 for laboratory placement and $38.91 for point‐of‐treatment placement. Low test volumes and a high number of sites are the major contributors to higher point‐of‐treatment costs. National placement of Xpert at laboratories would cost $71 million/year; point‐of‐treatment placement would cost $107 million/year, 51% more. Conclusion Placing Xpert technology at points of treatment is substantially more expensive than placing the instruments in smear microscopy laboratories. The incremental benefits of point‐of‐treatment placement, in terms of better patient outcomes, will have to be equally substantial to justify the additional cost to the national health budget.