Disease experts working in KwaZulu-Natal, South Africa, announced today that the first six patients treated for multidrug-resistant TB through an innovative community-based program have been successfully cured. This marks a major medical accomplishment and a remarkable personal turn-about for both the doctors and patients involved.
This new approach to treating multidrug-resistant TB (MDR-TB) grew out of a crisis. About four years ago, health care workers in KwaZulu-Natal were faced with a burgeoning epidemic that was overwhelming the local hospital; doctors were diagnosing more than 2,000 MDR-TB cases a year but only had 500 hospital beds available for treatment. And the prolonged hospitalization required to treat MDR-TB patients—about six months—was not just a major burden on the health care systems; it also took a heavy toll on the patients and their families.
In response, a coalition of American and South African health professionals joined with the KwaZulu-Natal Department of Health to devise a unique solution: treating patients in their homes, with care delivered by injection teams who visit each patient on a daily basis to administer medications, monitor progress, and provide support.
The project was spearheaded, in part, by the Tugela Ferry Care and Research Collaboration (TF CARES), a group of researchers and clinicians from several U.S. medical schools, including Yale University and Albert Einstein College of Medicine, and the Nelson R Mandela School of Medicine – University of KwaZulu Natal (UKZN) in Durban, South Africa.
“This idea came by necessity,” said Dr. Claudio Marra, of the Istituto Superiore di Sanita in Italy who also works for the KwaZulu-Natal Department of Health. “You couldn’t treat all the patients in the hospital even if you wanted to.”
One early concern was that this approach could put a patient’s family member at risk of infection. But the researchers built in extensive infection control training for families and they are closely monitoring for transmission (The project applied for and received ethical approval from University of KwaZuluNatal, Yale and Albert Einstein College of Medicine.)
In addition, they conducted a survey to assess transmission risk within families of an infected patient. They found a transmission rate of 3.7 percent, a relatively low number, said Dr. Marra.
“This is before the family knows they have a TB patient at home,” he said. “So given the right information about infection control, to keep someone in home is going to be feasible, humane and affordable.”
A community-based approach also helps to reduce hospital-based transmission, a huge problem in the old, overcrowded health care facilities that serve this part of the world.
Making the program work is not simple. The injection teams, usually of two staff nurses, pack the required medicines and syringes in their bags and drive across KwaZulu-Natal’s unpaved rural roads, traveling as far as 30 kilometers to each patient’s home; they see 8 to 15 patients a day, depending on the area they’re working in.
The nurses also use the visits to find out how the patient is doing, reinforce messages about infection control, talk to them about side effects they may be experiencing, and myriad other issues. Because 85 percent of the patients are co-infected with HIV, they also make sure they are getting proper HIV care and antiretroviral treatment if eligible. The injection teams report back to the researchers each week.
More than 110 patients are now enrolled in this community-based treatment program. The six patients who are cured today first began treatment in 2008, and they have now finished the difficult 2-year regimen. Another five patients who started their treatment at the TB referral hospital in Durban, but who later transferred into the home-based program, have also recently finished treatment.
These patients and others will be followed by the researchers to track outcomes and inform future planning.
Already, clinicians have started to see positive results. Dr. Marra said that in the last two years, the number of MDR patients has decreased from the high in 2007. “Consider that in 2007, we were diagnosing between 34 and 40 patients a month with MDR or XDR. Now are on the order of 10 or 15 a month.”
Melissa Lygizos, a study coordinator for the project and a Doris Duke Clinical Research Fellow, pointed out another transformation.
“Before the program started, there were many patients who didn’t want to present for treatment or who would leave, because it was such a burden to be admitted for six months and they would have to go to Durban, many hours from where they live,” she said. “In this setting, it’s a really wonderful way to get patients treated in a much more humane way.”
Dr. Gerald Friendland, who works with TF CARES and is also a professor of medicine and epidemiology and public health at Yale, said there is a significant need to scale up this innovative approach to MDR-TB treatment in other resource-poor settings.
But right now, there are not enough resources, training, or facilities to do so. That that can be surmounted, he said, through increased and sustained funding for TB operational research. “And we believe will in the end, it will be proven to be more humane, effective and cost effective,” he said.