title: Spread of extensively drug-resistant tuberculosis in KwaZulu-Natal province, South Africa.
abstract: BACKGROUND
  In 2005 a cluster of 53 HIV-infected patients with extensively drug-resistant tuberculosis (XDR-TB) was detected in the Msinga sub-district, the catchment area for the Church of Scotland Hospital (CoSH) in Tugela Ferry, in KwaZulu-Natal province (KZN), South Africa. KZN is divided into 11 healthcare districts. We sought to determine the distribution of XDR TB cases in the province in relation to population density.
  
  
  METHODS
  In this cross-sectional study, the KZN tuberculosis laboratory database was analysed. Results of all patients with a sputum culture positive for Mycobacterium tuberculosis from January 2006 to June 2007 were included. Drug-susceptibility test results for isoniazid, rifampicin, ethambutol, streptomycin, kanamycin and ofloxacin were available for all patients as well as the location of the hospital where their clinical diagnosis was made.
  
  
  RESULTS
  In total, 20858 patients attending one of 73 hospitals or their adjacent clinics had cultures positive for M. tuberculosis. Of these, 4170 (20%) were MDR-TB cases. Four hundred and forty three (11%) of the MDR tuberculosis cases displayed the XDR tuberculosis susceptibility profile. Only 1429 (34%) of the MDR-TB patients were seen at the provincial referral hospital for treatment. The proportion of XDR-TB amongst culture-confirmed cases was highest in the Msinga sub-district (19.6%), followed by the remaining part of the Umzinyati district (5.9%) and the other 10 districts (1.1%). The number of hospitals with at least one XDR-TB case increased from 18 (25%) to 58 (80%) during the study period.
  
  
  CONCLUSIONS
  XDR-TB is present throughout KZN. More than 65% of all diagnosed MDR-TB cases, including XDR-TB patients, were left untreated and likely remained in the community as a source of infection.
authors.affiliation: KwaZulu-Natal Research Institute for Tuberculosis and HIV (K-RITH), Durban, South Africa. moodleyp@ukzn.ac.za
authors.forename: Prashini
authors.initials: P
authors.lastname: Moodley
authors.forename: N Sarita
authors.initials: NS
authors.lastname: Shah
authors.forename: Nabihah
authors.initials: N
authors.lastname: Tayob
authors.forename: Cathy
authors.initials: C
authors.lastname: Connolly
authors.forename: Nicola
authors.initials: N
authors.lastname: Zetola
authors.forename: Neel
authors.initials: N
authors.lastname: Gandhi
authors.forename: Gerald
authors.initials: G
authors.lastname: Friedland
authors.forename: A Willem
authors.initials: AW
authors.lastname: Sturm
mesh_terms: D000995:Antitubercular Agents / Q000627:therapeutic use; D003430:Cross-Sectional Studies; D004977:Ethambutol / Q000627:therapeutic use; D054908:Extensively Drug-Resistant Tuberculosis / Q000188:drug therapy* / Q000453:epidemiology; D006801:Humans; D007538:Isoniazid / Q000627:therapeutic use; D007612:Kanamycin / Q000627:therapeutic use; D008826:Microbial Sensitivity Tests; D015242:Ofloxacin / Q000627:therapeutic use; D012293:Rifampin / Q000627:therapeutic use; D013019:South Africa / Q000453:epidemiology; D013307:Streptomycin / Q000627:therapeutic use
chemical_list: D000995:Antitubercular Agents; D007612:Kanamycin; D004977:Ethambutol; D015242:Ofloxacin; D007538:Isoniazid; D012293:Rifampin; D013307:Streptomycin