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Coercive measures to halt XDR-TB?

29th January 2007

07092006_tbpatient2.jpgThe discovery of a new and lethal strain of drug-resistant tuberculosis in a rural South African town has prompted ethical questions about how to contain what may be an emerging public health crisis.

The new strain, known as extensively drug-resistant tuberculosis (XDR-TB), showed a median survival of just 16 days for 52 out of 53 patients in Tugela Ferry, KwaZulu-Natal, according to the World Health Organisation (WHO).

KwaZulu-Natal is the epicentre of South Africa's HIV/AIDS epidemic, and a high proportion of tuberculosis patients there already have multi-drug resistant strains (MDR-TB), which are resistant to at least rifampicin and isoniazid.

South Africa's high prevalence of HIV/AIDS, large migrant worker population and growing tourist industry mean that the emergence of XDR-TB could rapidly develop into a global public health threat, according to an article in the online journal PLoS Medicine.

The article pinpointed a lack of infection control in institutions, together with the tendency of poorer patients to stay out of hospital during treatment to avoid loss of income. Lack of supervision meant such patients could stop taking their antibiotics unbeknown to healthcare professionals, fuelling the rise of resistant strains of TB.

They would then continue to live among the non-infected population as they continued their daily lives, contributing to the spread of the disease.

The article called on the South African government to rethink its policy of suspending welfare payments to patients hospitalised at state expense, and to offer additional payments to compensate loss of income from employment to others. Only then, it said, would patients be drawn into the healthcare system for adequate monitoring.

But it said there were human right implications in controlling such an epidemic. "An important question that we must come to terms with is the extent to which judicially sanctioned restrictive measures should be employed to bring about control of what could develop into a lethal global pandemic," the article said.

"Measures that rely on voluntary cooperation and are the least restrictive in terms of interfering with human rights are preferred. However, if such measures prove to be ineffective, then more restrictive measures may need to be contemplated," it added.

It said the use of involuntary detention might "legitimately be countenanced as a means to assure isolation and prevent infected individuals possibly spreading infection to others."

"There are many such justifications emerging in the field of public health ethics that recognise that prevention of harm and protection of public health are legitimate ethical norms. Human rights doctrine also recognises the limitation of many rights in a public health emergency, provided the measures employed are legitimate, non-arbitrary, publicly rendered, and necessary."

It noted the lack of discussion of such concrete measures between the WHO and the South African government at a recent disease conference, calling for fuller public discussion of the issues at stake.

"Ultimately in such crises, the interests of public health must prevail over the rights of the individual" it said.

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Tuesday 30th January 2007 @ 16:35

It is really a matter of great concern from public health point of view due to emergence of the new strain. Is it different from Beizing strain?All countries should come forward and urge the South African government to take adequate community health action to avoid a potential pandemic.

Dr. Sadhu Charan Panda, Editor,"Journal of Community Medicine" ISSN 0973-2454
V.S.S.Medical College,Burla-768017,INDIA

Luisetta Mudie

Wednesday 31st January 2007 @ 12:01

I'm not an expert, but a quick look at some of the news coverage would indicate that XDR-TB is very specific to S.Africa and probably not related to the Beijing strain. Thank you for your comment.

Luisetta Mudie

World page editor, hc2d.co.uk

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