XDR-TB or not XDR-TB? That is the question.

IZINDABA 318 A top-level think tank on KwaZulu-Natal's perplexing 'outbreak' of XDR-TB has recommended urgent inpatient point prevalence surveys and better screening of HIV-positive TB-symptomatic patients in order to better assess its country-wide extent. Speaking after provincial health, World Health Association (WHO) and Medical Research Council (MRC) officials met in Pietermaritzburg at the end of March, Dr Bruce Margot, KwaZulu-Natal's TB chief, admitted: 'We're still on tenterhooks'. He said that 'within 6-9 months we'll know whether we need to panic or whether we can be a lot more confident and relaxed'. Margot admitted that inpatient screening was not 'part and parcel' of routine TB surveys and that HIV-positive TB-symptomatic patients were being missed on an unacceptable scale. Ethical clearance for the inpatient surveys is expected by mid-May. The news has TB programme managers across the nation waiting to exhale in spite of initial emergency XDR-TB surveillance results revealing that 64% of cases until February were confined to the Tugela Ferry district hospital in KwaZulu-Natal. Fears of a nightmare country-wide XDR scenario, heightened by isolated but ongoing XDR diagnoses in every single province since the Tugela Ferry outbreak (2 years ago), exist precisely because of a lack of proper XDR surveillance and adherence to treatment guidelines. Margot and Dr Tony Moll, the Church of Scotland Hospital (Tugela Ferry) principal medical officer, concurred that with the anomaly of 55% of TB cases being XDR and just 45% being MDR at Tugela Ferry, the XDR outbreak there remained an enigma. Moll said this remained deeply puzzling but that with global TB experts now probing the phenomenon with Pepfar and Doris Duke Foundation funding, he was hopeful that an explanation would be found. Significantly, Moll added that if his own surveillance at Tugela Ferry had been confined to just TB suspects in his outpatient department, 'we would not have found any XDR'. This points to a 'tip of the iceberg' phenomenon, but Margot quickly added that in KwaZulu-Natal sites where surveillance was strong and the context was similar to Tugela Ferry (high HIV and TB rates), XDR prevalence was dramatically lower. 'There is something unusual happening there that we just don't understand,' he said. According to the national TB programme manager, Dr Lindiwe Mvusi, by early March this year 185 lives were lost among the 314 confirmed XDR cases country-wide. She said that second-line drugs, obtained last October, 'seem' to be working and that …