MDR-TB in rural Western Cape, South Africa

I�m spending this month at Brewelskloof tuberculosis hospital in Worcester, a small town in South Africa�s Western Cape province.  It�s just a bit over an hour�s drive from Cape Town, but it�s a completely different world from that fairly cosmopolitan city.  It�s a farming town � lots of vineyards, some other fruit, a few livestock � and there�s not much else going on, although the setting is beautiful: grapes growing everywhere, ringed by mountains, spring wildflowers currently in bloom.  I�m gathering data on a cohort of patients with multidrug resistant tuberculosis (MDR TB), so I spend most of my time combing through paper hospital charts, doing my best to translate Afrikaans, and typing into a clunky Access database.  Not particularly exciting work, but the data is beginning to tell a few interesting stories. 

This population � at least the subset of people from these farming communities who get MDR-TB � is really disadvantaged.  Walking through expansive upscale shopping malls and trendy organic markets in the city (Cape Town, that is) on the weekends, it�s clear that there�s money in this country somewhere.  The hospital in Worcester is also immediately surrounded by lovely homes and estates.  The typical MDR-TB patient we read about, though, lives in a shack without water or electricity, has about a 6^th grade education, is trying to make ends meet through seasonal farm work, and binge drinks heavily on the weekends.  The tricky thing is that the same social factors that breed and spread MDR (poverty, crowding, and malnutrition that predispose to TB, and home and work instability and frequent intoxication that make it hard to take your TB drugs every day for six months) make it even hard to complete the two years of more-toxic treatment required to treat drug resistance.  

I�m also observing long delays before patients with MDR TB in their sputum got onto appropriate treatment.  Cultures take several weeks (and AFB smears, we�re told, tend to be reviewed hastily here and rarely come back positive), and then drug susceptibility testing take more time.  But besides waiting for lab results, there also must be other delay somewhere along the process of realizing a culture shows MDR, notifying the clinic, finding the patient, and getting them into treatment, because we are often seeing gaps of 3, 4, even 6 months between when a sputum is collected and when appropriate MDR treatment is started.  Plus, while waiting for the DST results, sometimes patients get a single drug added, or are started on treatment regimens with only 1 or 2 drugs that turn out to be active, which is exactly what you don�t want to see.  Starting first-line therapy after a positive smear or culture is automatic here, I�m told, even in patients with risk factors for drug resistance, but I�m curious to analyze whether these first-line regimens negatively impact either MDR outcomes or transmission of MDR within patient�s households and communities.

Finally, on a somewhat related note, all this reading of paper charts makes me appreciate electronic medical records.  But not everyone here views computers the same way.  We were talking today with South African collaborators about electronic records, about plans for expanding our electronic database to capture a broader slice of hospital�s data for research purposes, and even about the possibility of transitioning to a electronic medical record for clinical use.  The rural clinician in the group was puzzled about how this would work: the doctors would have to go back to their offices at the end of the day and type in everything they had done?  The idea of placing computers within the ward blew him away.  Another researcher mentioned that he�d been abroad and seen a clinical pharmacologist with an iPad, who was able to look up information about pharmacokinetics to show the team as they rounded; he�d been amazed.  But none of them really have a vision for what computers could add to their clinical or research work.  My American mentor/collaborator and I tried to convey the potential usefulness of an electronic record for prompting doctors to enter data that the hospital wants to collect, for keeping track of outcomes or adverse events in real time, or for retrospectively answering questions that no one has thought of yet, but I don�t think we got through.  I imagine that the push toward electronic charting isn�t so far away for a country like South Africa, but it will be a tough transition in isolated pockets like this one.  For one thing, they need to get internet; here in Worcester, I can�t connect long enough to find the CoE blog, so I�ll be posting this in a few days once I get to Cape Town for the weekend � where internet is still spotty, but slightly less so.  

Emily Kendall

PGY-2, Internal Medicine