Mine strikes worsen TB infections

SA mining is known to have a high incidence of TB, and this is particularly true of the gold mining sector. According to a Chamber of Mines review of the gold mining industry's TB programmes, undertaken in June, 73% of the mining industry's cases occurred in this sector in 2009. TB incidence is 15 times higher among gold miners than among the general population, says the report.

Miners diagnosed with first-time TB typically receive their treatment at work daily as part of the Dots (recognised directly observed treatment, short-course) programme. The system is used countrywide in various forms in communities, institutions and clinics. It has helped greatly in defeating treatment defaults and dropouts - a major problem, since treatment courses for first-time TB usually last six months.

During normal working times, miners who fail to turn up for treatment are "paraded", explains the report. This means they are excluded from having access to areas such as work stations and canteens. However, these sanctions become ineffective during a strike.

"We've received reports of some miners turning up for their TB treatment despite the strike," says Dr Thuthula Balfour-Kaipa, the Chamber of Mines head of health services. "Obviously, personal-safety problems in particular could make that less likely."

The fact that some mineworkers do arrive for treatment under these circumstances underlines Lalloo's generally positive view of mines' efforts in the areas of TB treatment and education.

But Balfour-Kaipa believes that memories of how workers who were diagnosed with TB used to be dismissed more than 20 years ago linger on, and that this contributes to labour distrust of mining companies' TB programmes. Both she and Lalloo are concerned that the strike will have a detrimental effect on workers' health.

Defaulting on TB treatment incurs a twofold risk for the patient: the increased chance of relapse from not having completed the treatment; and the danger of developing resistance to the drugs used. Drug resistance necessitates another, longer, course of multidrug treatment, often including a daily injection.

Then there's the broader risk of the patient infecting his or her family, friends, workmates and other members of the community.

What frustrates many researchers and medical professionals is that the high rate of TB among SA miners has been recognised for well over a century. In 1903 the Milner Commission undertook an investigation into TB on the mines. The parallels of this commission were spotlighted by Paula Akugizibwe of the Aids & Rights Alliance for Southern Africa two years ago at the second national SA TB Conference.

At that conference, minister of health Aaron Motsoaledi first expressed his dramatic imagery: "If TB and HIV are a snake in Southern Africa, the head of the snake is here in SA. People come from all over the Southern African Development Community to work in our mines - and export TB and HIV along with their earnings. If we want to kill a snake, we need to hit it on its head."

This is more than vivid rhetoric. A 2010 study led by Oxford University's David Stuckler found that 10% growth in TB incidence in the SA mining sector pushed the rate 0,9% higher in sub-Saharan countries.

Lalloo believes there is a huge tide of history that SA has to turn in controlling TB. "The Western world conquered its TB by the 1960s, thanks to socioeconomic improvements as well as antibiotics and other drugs. But SA, the wealthiest country on the African continent, quadrupled its TB rate from 1990 to 2007."

The key to what was going wrong, he believes, was the homeland system. This allowed the creation of "a concealed TB epidemic" even though in SA, TB was, and still is, a notifiable disease.

"Mining labour was, of course, originally recruited from [the homelands] - and sent back there. When apartheid was dismantled, there seemed to be an upsurge in TB. But it had always been there, just cleverly hidden. This was particularly clear in what is now KwaZulu Natal, where there were many small bantustan pockets. Even Umlazi's Prince Mshiyeni Memorial Hospital, about 25km from the Durban CBD, wasn't then 'in' SA."

Though mine labour is also now drawn from communities in mining areas, there remains a risk of yet again reproducing the old geographical patterns if fired strikers from rural areas return home with undiagnosed TB acquired or revived during the strike.

Finding TB cases has long been a challenge, says Prof Salim Abdool Karim, director of the Durban-based Centre for the Aids Programme of Research in SA. He points to a second, initially hidden, TB epidemic. Occurring at the beginning of this century, it was concealed this time by HIV/Aids.

"At first the HIV epidemic seemed to behave according to predictions, with cases appearing to level off around 2000/2001 as deaths and new infections offset each other," he says.

But in fact, the TB infection rate was silently marching upwards. Patients weren't "just dying of HIV shame", as Lalloo recalls some clinics putting it. Extremely drug-resistant TB (XDR-TB) was first spotted at Tugela Ferry in 2005 and 2006. It came on top of an increasing incidence of multi drug resistant TB (MDR-TB). Now totally drug-resistant TB has been found in India. "But I wouldn't be surprised if it was somewhere among us as well ," says Lalloo.

Already SA has the world's third-highest TB incidence. Of the 336000 new active disease cases notified in 2010, about 2% were MDR-TB, and about 10% of those XDR-TB.

At least three out of five TB patients are also HIV-positive, fighting two infections at once. The potential of this co-epidemic to spin further out of control in a country with the world's highest number of HIV-positive people continues to focus the medical profession's attention.

Though the World Bank assesses mines' TB treatment programmes as "good", the Chamber of Mines report concedes that they're not perfect. Surveying seven sites for Harmony, AngloGold Ashanti and Gold Fields mines, it found:

Opportunities for TB case-finding were poorly used - for instance, fewer than half the patients were asked about a cough, a key signal;

Some sites relied simply on the "parading" system, having no diary to book or follow up patient appointments and no system to trace patients who didn't return for periodic review ;

There was a high number of missed opportunities to have TB detected before patients died ;

Reports and data from autopsies weren't routinely or systematically used to evaluate care processes, and patient records were poorly maintained ;

Patients who transferred offsite were poorly followed up, possibly lost to TB treatment ; and

The patients' charter for tuberculosis care wasn't routinely displayed for patients to see.

Beyond the mines, the public health and economic fallout of wider-spread infection could be far-reaching, as SA's already overburdened public health system would struggle to cope.

The World Bank points out: "For every 100 infectious TB patients in SA, only 58 are now being found and cured by the health system."

FM

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http://www.fm.co.za/economy/local/2012/10/29/mine-strikes-worsen-tb-infections