DOTS Not Enough When it Comes to TB in South Africa. 29/9/09
Dr. Robin Wood, director of the Desmond Tutu HIV Centre in Cape Town, has many startling slides to illustrate the astronomical problem of tuberculosis in South Africa—from photos of desperately poor, overcrowded shantytowns in the Western Cape to graphs that document the escalating rates of HIV/TB co-infection in his native country.
But there’s one image that gets at the crux of a perplexing problem in this epidemic: A photo of a TB clinic door plastered with awards for successfully implementing the DOTS strategy, or Directly Observed Treatment, Short-course. Juxtaposed to that is a graph showing exponential growth in TB rates in the clinic’s community.
“Why is TB control failing in South Africa?” asks Dr. Wood, a renowned physician-scientist who has been on the front lines of HIV/AIDS treatment, research and prevention for two decades and has recently done cutting-edge research on the deadly intersection of HIV & TB in South Africa.
It is obviously not a failure to implement DOTS, a strategy at the heart of most TB control programs in the developing world. Instead, Dr. Wood suggested at a briefing with USAID staff today in Washington, it’s an overreliance on DOTS in settings where transmission is a “pressure infection” being transmitted at nearly unprecedented rates. He said the situation today in South Africa is similar to what happened in New York in the 1840s, when Irish immigrants with very little natural TB immunity came to the U.S., and the epidemic spread like wildfire.
“If you live in a sea of TB,” as so many South Africans do, DOTS is just not enough to control the disease, Dr. Wood said.
So what is needed? Dr. Wood isn’t calling for anything radical.
There’s good ventilation, for starters, in the shacks and other buildings where TB is now being transmitted at shockingly high rates. Simple steps, like adding a window grid and fan to these tiny homes, churches, and other places where many poor South Africans live, could make a huge difference.
Another vital change, he said, would be to move away from clinic-based treatment, to community care, and to launch an aggressive public health campaign in affected communities, as happened in the U.S. and Europe when TB was ravaging those countries.
Dr. Wood also suggested that when health workers do their surveillance and testing, they need to redefine the term “household,” which is currently seen through a Western prism as those who live in the same dwelling. His research, by contrast, shows that “it’s the surrounding social network” that’s driving TB, which should prompt community workers to look at a larger number of possible transmitters.
But of all the steps that could have an impact, Dr. Wood said, earlier initiation of antiretroviral drugs is the one sure-fire thing that will reduce TB mortality.
Overall, Dr. Wood warned that health experts are very far behind the curve of this epidemic, with a dearth of epidemiological information, inadequate drugs and diagnostics, and a weak infrastructure to ramp-up prevention and treatment. “We’ve just waited until [a patient] got the disease, and then we’re playing with case management,” he said.
He noted that the WHO and the South African government have declared TB an emergency in Africa years ago and called for extraordinary measures. “Well, there have been no extraordinary measures,” he said.
Dr. Wood is in Washington this week for a series of policy forums, Capitol Hill meetings, community sessions, and press interviews organized by the IDSA/HIVMA Center for Global Health Policy. This is part of the Global Center’s efforts to make the voices of developing country physicians heard in American policy debates.
Tomorrow, Dr. Wood will be participating in an expert panel discussion on the global threat of tuberculosis and the U.S. strategy for combating the disease. This will be a live, interactive webcast, so please tune in and submit questions. The Kaiser Family Foundation is hosting the event on Tuesday, Sept. 28, at 1 p.m. EDT.