A leading activist group is calling on the South African government to declare the country’s tuberculosis epidemic a public health emergency. The Treatment Action Campaign made the plea this week at South Africa’s fourth TB Conference in Durban.
The Treatment Action Campaign says TB is the leading cause of death in adults and children. Marcus Low, the group’s head of policy, said, “South Africa has the highest TB infection rate on the planet. Though in terms of absolute numbers, China and India have higher numbers. But when you take the size of our population into account South Africa has the highest rates and that is largely drive by our high HIV rate.”
HIV attacks the immune system, making people more susceptible to TB infection. However, while TB is closely tied to HIV, it has not generated the same response.
“HIV is a disease that had a significant footprint in the U.S. and Europe. So there was a lot of drug development. But TB is really a disease of poor countries. So we don’t have the same investment in research and development. We’re really facing a pretty serious crisis in South Africa. We have in the region of 450,000 new infections every year. And it’s the number one cause of natural death in South Africa,” he said.
The Treatment Action Campaign gained prominence in South Africa in the early years of the HIV/AIDS epidemic. It helped wage a major legal battle against the government and drug companies to make antiretrovirals more available.
Low said, “We want to see the same kind of widespread social mobilization that we had around HIV around TB. Now, in some ways it’s a bit more complicated because with HIV if you provide people with treatment -- and they take -- they get well. With TB there are many more social factors that make it much harder to deal with.”
One of those social factors is TB among South Africa’s prison population.
“We have a lot of overcrowded correctional facilities in South Africa – and often filled with over 200 percent occupancy. So that creates the ideal environment for the spread of TB and of course drug resistant forms of TB. So to deal with something like that it’s not just a matter for the department of health. It’s a matter that the department of justice has to look at how many people we are incarcerating – and the prison system has to be reformed to insure that we have better infection control,” he said.
Some of the very first cases of drug resistant tuberculosis were found in the eastern rural town of Tugela Ferry in KwaZulu-Natal Province. The province was also the heart of the HIV/AIDS epidemic. The World Health Organization announced in late 2006 that a deadly new strain was found there and labeled it XDR-TB or extensively drug resistant TB.
“In South Africa, the rate of normal tuberculosis – drug susceptible tuberculosis – seems to be stabilizing. But the really worrying thing is that the rate of drug resistant tuberculosis is going up. And indications are most of these cases are not people who are developing drug resistance. Instead they are infected with strains of TB that are already resistant. You know, that’s extremely worrying. We simply don’t have very good treatment for drug resistant TB,” said Low.
The treatment is long and often not successful.
“At the moment it takes about two years to treat someone. There are severe side effects. They have to take something like 14,000 pills in that time and six months of weekly injections. So it’s the one area where we really don’t have an answer. Part of the problem is that TB has become a disease of poor countries, poor people. And for that reason the pharmaceutical industry does not really invest in TB research anymore,” he said.
Mortality rates for multi-drug resistant and extensively drug resistant TB are very high. It’s estimated 50 percent of those diagnosed with XDR-TB in 2010 died.
Activists and researchers have said that because TB drugs are not profitable, research funding may have to come from organizations like the Gates Foundation or TB Alliance.
South Africa’s National Strategic Plan for HIV, STIs and TB does list tuberculosis as a priority. And the country’s health minister is scheduled to address the TB conference on Friday.
But Treatment Action Campaign’s Marcus Low said it can be difficult getting a national strategy implemented on the local level.
“South Africa has nine provinces. And these provinces have significant autonomy in what they do. So whereas national policy may be good, these policies may not be implemented in the various provinces. That’s the one kind of problem we face. The other thing is that if to want to fix the problem of TB in prisons, as I explained earlier, you need other government departments to get involved and that unfortunately hasn’t been happening in recent years.”
Low said diagnosing and monitoring the TB epidemic have been a problem. There is new technology for rapid diagnosing called GeneXpert. But it currently looks at resistance to only one drug. And since South Africa still heavily depends on paper record keeping instead of digital, Low said the epidemic may be worse that currently thought.
South Africa has been getting more HIV infected people on treatment. That also offers an opportunity to screen them for TB.
In its call for a TB public health emergency, the Treatment Action Campaign says, “We can continue to let people die of preventable TB, or we can act with urgency and determination to defeat it.”