Important note: Information in this article was accurate in 2006. The state of the art may have changed since the publication date.
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Wall Street Journal - August 18, 2006
Marilyn Chase
TB has long been known to co-infect vast swathes of AIDS patients in the developing world, and can trigger an early death despite treatment with AIDS drugs. Multi-drug resistant TB poses special problems for public health officials using standard generic regimens in programs of directly observed therapy.
The new strain dubbed XDR-TB (for extremely drug resistant) represents the most virulent of MDR-TB yet. The new study, conducted by a team led by U.S. and African researchers, investigated the outbreak in a rural district hospital in KwaZulu-Natal.
Researchers screened 1,539 people, of whom 544 patients had sputum samples testing positive for TB. Out of those, 221 patients had resistance to one or more staple drugs. Of those with drug-resistant TB, 53 patients were identified as infected with the extreme strain XDR-TB.
The super-resistant strain of TB has up to now been very rare, making an outbreak in 53 people all the more striking. In the only previously-published study on the XDR strain, the U.S. Centers for Disease Control and Prevention earlier this year reported that from 2000 to 2004, the combined efforts of CDC and the World Health Organization surveyed 17,690 collected samples of TB bacillus from the world's TB labs, and found a total of 353 cases -- or 2% of the collected patient samples -- were XDR. The prior report was published in the CDC's publication Morbidity and Mortality Weekly Report (MMWR) in March 2006. TB is believed to kill about two million people world-wide each year.
While resistant TB often arises from incomplete or ineffective drug treatment, half of the patients with XDR-TB had never been treated for TB before -- a worrisome sign that they were newly infected with the extreme strain and that XDR is being transmitted in the community. All of the XDR-TB patients who were screened for the AIDS virus -- some 44% of the group -- turned up HIV-positive and most had already suffered severely weakened immune systems.
The devastation was nearly complete. During the outbreak, 52 of 53 patients, or 98% of those with XDR-TB, died, most within a month of giving their initial sputum sample. The median survival was a mere 16 days.
In the outbreak, two health-care workers also died of XDR-TB. "It is rapidly and nearly completely fatal," said U.S.-based researcher Neel R. Gandhi in a late-breaking presentation here Thursday. He added the arrival of XDR-TB in AIDS-stricken areas of southern Africa threatens the success of newly deployed AIDS drugs as well as the classic DOTS regimens for TB -- potentially reversing hard-won gains in the war against the twin epidemics.
Dr. Gandhi did the study while affiliated with Emory University School of Medicine in Atlanta, now at Albert Einstein College of Medicine Montefiore Medical Center, Division of Infectious Diseases. Co-workers included Tony Moll, a researcher at the Church of Scotland Hospital, as well as patients and health-care workers in KwaZulu-Natal, South Africa.
AIDS and TB already act in deadly synergy, said researcher Peter Small, who heads TB programs at the Seattle-based Gates Foundation. Without swift ramp-up of intensified programs to quash it, he added XDR-TB could prove "the Achilles heel" of current treatment programs.
Write to Marilyn Chase at marilyn.chase@wsj.com
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