A Viewpoint published Online First by The Lancet calls for new-age sanatoria to be created in countries with a high burden of drug-resistant tuberculosis, in order to deal with the growing threat of extensively-drug resistant tuberculosis (XDR-TB). The Viewpoint is by Professor Keetan Dheda, University of Cape Town, South Africa, and Professor Giovani Miglori, WHO Collaborating Centre for TB and Lung Diseases, Tradate, Italy.
Sanatoria were used across many countries up to the 1970s to help isolate people with tuberculosis from the general community, but were gradually dismantled as living conditions improved, and vaccination and drug treatments arrived, leading to huge falls in infection rates especially in high-income countries. However, years of using the antibiotics rifampicin and isoniazid has led to some half a million cases of multi-drug resistant TB (MDR-TB) globally. Of these, between 25,000 and 50,000 cases are XDR-TB. In high-burden countries such as South Africa, MDR-TB and XDR-TB treatment eats up around half of the TB drug budget, despite only representing a small proportion (1-2%) of total cases. Large numbers of treatment failures occur in XDR-TB cases, and also in many MDR-TB cases, but such patients can survive for months or even years, exposing the community to potential infection. These cases are not responsive to any known treatment (many of them are completely drug-resistant). The authors say that once again, after 60 years, we are faced with TB patients for whom there is no effective treatment.
The authors ask: "How should we deal with these people who are living with failed treatment and who still have the capacity to transmit disease…Is the discharging of these patients, who often live in a single room with many other family members, into impoverished communities justifiable?" They add that the lack of or restricted palliative care facilities means there is nowhere for patients to die in dignified surroundings while infection control in ensured.
This is not just a problem for high-burden, resource-constrained countries. In high-income countries, XDR-TB patients are usually treated in isolation rooms in respiratory or infectious disease departments. But this can mean extremely long hospital stays with no guarantee of successful treatment. Furthermore, soon to be published data from five reference centres in the European Union* show that infection control procedures are far from ideal, exposing other patients and health-care workers to risk of contracting XDR-TB.
The authors advocate for facilities where state-of-the-art palliative care and laboratory facilities can be provided to dying patients in a safe and dignified setting; there, destitute people for whom treatment has failed could voluntarily reside on a long-term basis with social, educational, and recreational facilities, and receive good nutrition and care from support groups and a multidisciplinary team within an infection-controlled setting, thereby reducing transmission within the community and to family members, including children.
They conclude: "The time for rebuilding so-called new sanatoria under a new vision has come and is overdue…We have now come full circle and once again there are large numbers of patients for whom there are no effective antituberculosis drugs. The pool of untreatable cases is accumulating and will need swift action to avoid a human catastrophe."
Professor Keetan Dheda, University of Cape Town Lung Institute, South Africa. T) +27 21 406 7650 / +27 845577754 E) keertan.dheda@uct.ac.za
Professor Giovani Miglori, WHO Collaborating Centre for TB and Lung Diseases, Tradate, Italy. E) giovannibattista.migliori@fsm.it
Note to editors*: The 5 EU Countries cannot be disclosed as per ECDC policy, but they include 2 central European EU countries, 2 western EU countries at low incidence, and 1 western EU country at intermediate incidence. Please contact the ECDC tuberculosis programme with any enquiries on this point: emma.huitric@ecdc.europa.eu
Journal
The Lancet