On Thursday, 25 patients with multi drug-resistant (MDR) TB and eight with extensively drug-resistant(XDR) TB pushed their way past guards at Jose Pearson TB Hospital in Port Elizabeth, in the Eastern Cape. By Monday, 21 of them had returned, most of them voluntarily, four as a result of court orders.
MDR-TB is resistant to the two most powerful anti-TB drugs, while XDR-TB is resistant to these and at least two others. Whereas non-drug resistant TB is treated on an out-patient basis with a six-month course of drugs, South Africa's policy is to treat drug-resistant TB patients as in-patients until they are no longer infectious. XDR-TB patients, who are the most difficult to treat and pose the greatest public health risk, are required to spend up to two years in hospital, isolated from their families and facing the very real possibility that they will die before being released.
The average mortality rate for XDR-TB patients is just over 50 percent, but is closer to 85 percent for patients co-infected with HIV, according to South Africa's Medical Research Council.
Patients have described the isolation wards where they are quarantined as prison-like. While a number of the hospitals have installed pool tables, televisions and gym equipment to help patients combat boredom and depression, they have also boosted security by hiring more guards and building higher fences.
Despite such measures, patients regularly escape and have to be tracked down by health authorities fearful that the air-borne disease could be spread to families and communities.
South Africa is battling a dual epidemic of TB and HIV/AIDS. In 2006, it had both the highest TB prevalence rate in the world and the highest number of TB-related deaths, according to the Global TB report, released by the World Health Organisation this month. People living with HIV are 50 times more likely to develop an active TB infection, but in 2006, only one third of TB patients in South Africa were tested for HIV.
Ensuring that TB patients complete their six-month course of drugs is vital to containing the spread of drug-resistant TB. South Africa has a cure rate of just 58 percent, the third worst in the world after Uganda and Russia according to the WHO report, which suggests that many patients are defaulting on treatment.
Arnaud Trebucq, who provides technical assistance to the TB division of the International Union Against Tuberculosis and Lung Disease, an organisation formed to help lower-income countries combat TB and lung disease, suggestd that improving South Africa's TB cure rates would do much more to reduce the spread of MDR and XDR-TB than isolating patients who are already infected.
Drug-resistant TB patients pose the greatest threat to their families and communities during the often lengthy period before they are diagnosed, pointed out Trebucq. "If the patient reacts to the drugs, he'll be infectious for a very short time; so, controlling infection by isolating patients - it's not obvious that it will do a lot," he told IRIN/PlusNews.
The main reason to keep MDR and XDR-TB patients hospitalised, he added, was to better supervise complex and toxic drug regimens. "Usually, you give a lot of different drugs; if you keep them in the hospital, you have a better insurance they take all the drugs under directly-observed treatment," he said. "But you have to discuss with the patient how long they can stay so it's an agreement."
The WHO recommends forced confinement of TB patients only as a last resort. "There is definitely a case for isolating MDR and XDR patients within health facilities, especially when they're infectious," commented Dr Paul Nunn, head of the WHO's XDR-TB unit. "It's less clear cut when it comes to isolating them by force."
Apart from the human rights issues surrounding forced isolation, a number of recent studies have suggested that hospitals themselves can be breeding grounds for drug-resistant TB. Research conducted at at the Church of Scotland Hospital in Tugela Ferry, KwaZulu-Natal Province, where an outbreak of XDR-TB claimed 50 lives in 2006, found that most cases of drug-resistant TB were attributable to airborne infections, often contracted within the hospital, not the failure of patients to complete TB treatment.
Even at a TB hospital like Port Elizabeth's Jose Pearson, where XDR-TB patients stay on a different ward from MDR-TB patients, a report in the New York Times this week quoted a nurse saying that MDR patients there were contracting XDR-TB strains at an "intense rate".
Professor Greg Hussey, director of the Institute of Infectious Disease and Molecular Medicine at the University of Cape Town, agreed that hospitals can be "dangerous environments", especially for patients with HIV-compromised immune systems. "It would protect the patient, in a sense, if they were treated in a home-setting," he said.
Hussey is among those who believe the scale of drug-resistant TB infection in South Africa demands an alternative approach. Hospitals are already over-stretched, he told IRIN/PlusNews, and lack the resources to cater for bored patients hospitalised for long periods.
"We make assumptions on the basis of what we think is best for patients, but if you're talking about issues around compliance, you need to have a patient who trusts what you're doing for them and you need to make the environment conducive to them taking the medication."
Hussey suggested that homes and communities may be the best environments for patients who are often reasonably well and don't have symtoms that would normally require hospitalisation.