title: Emergence of multidrug-resistant tuberculosis in a community-based directly observed treatment programme in rural South Africa.
abstract: OBJECTIVE
  Although little studied in developing countries, multidrug-resistant tuberculosis (MDR-TB) is considered a major threat. We report the molecular epidemiology, clinical features and outcome of an emerging MDR-TB epidemic.
  
  
  METHODS
  In 1996 all tuberculosis suspects in the rural Hlabisa district, South Africa, had sputum cultured, and drug susceptibility patterns of mycobacterial isolates were determined. Isolates with MDR-TB (resistant to both isoniazid and rifampicin) were DNA fingerprinted by restriction fragment length polymorphism (RFLP) using IS6110 and polymorphic guanine-cytosine-rich sequence-based (PGRS) probes. Patients with MDR-TB were traced to determine outcome. Data were compared with results from a survey of drug susceptibility done in 1994.
  
  
  RESULTS
  The rate of MDR-TB among smear-positive patients increased six-fold from 0.36% (1/275) in 1994 to 2.3% (13/561) in 1996 (P = 0.04). A further eight smear-negative cases were identified in 1996 from culture, six of whom had not been diagnosed with tuberculosis. MDR disease was clinically suspected in only five of the 21 cases (24%). Prevalence of primary and acquired MDR-TB was 1.8% and 4.1%, respectively. Twelve MDR-TB cases (67%) were in five RFLP-defined clusters. Among 20 traced patients, 10 (50%) had died, five had active disease (25%) and five (25%) were apparently cured.
  
  
  CONCLUSIONS
  The rate of MDR-TB has risen rapidly in Hlabisa, apparently due to both reactivation disease and recent transmission. Many patients were not diagnosed with tuberculosis and many were not suspected of drug-resistant disease, and outcome was poor.
authors.affiliation: Hlabisa Hospital, KwaZulu/Natal, South Africa.
authors.forename: G R
authors.initials: GR
authors.lastname: Davies
authors.forename: M
authors.initials: M
authors.lastname: Pillay
authors.forename: A W
authors.initials: AW
authors.lastname: Sturm
authors.forename: D
authors.initials: D
authors.lastname: Wilkinson
mesh_terms: D000995:Antitubercular Agents / Q000008:administration & dosage; D016000:Cluster Analysis; D015897:Comorbidity; D016172:DNA Fingerprinting; D004196:Disease Outbreaks; D006679:HIV Seropositivity / Q000453:epidemiology; D006801:Humans; D008826:Microbial Sensitivity Tests; D012424:Rural Population; D013019:South Africa / Q000453:epidemiology; D018088:Tuberculosis, Multidrug-Resistant / Q000188:drug therapy / Q000453:epidemiology*; D014397:Tuberculosis, Pulmonary / Q000453:epidemiology*
chemical_list: D000995:Antitubercular Agents