Drug-resistant TB threat among mineworkers

African mineworkers are at significant risk of becom- ing resistant to tuberculosis (TB) treatment, and those that are resistant can be included in the estimated 650 000 cases of multidrug-resistant tuberculosis (MDR TB) worldwide, of which fewer than 10% are accessing treatment, notes the Stop TB Partnership secretariat’s senior strategist, Joel Spicer.

“The growing health security and economic threat posed by drug-resistant TB threatens to undermine previous gains made to deal with the disease,” he adds.

“Many of the conditions Africa is facing – ranging from high HIV rates and sectors fuelled by migrant workers to struggling public health systems, financial gaps and congregate settings, which force large groups of people together in small environ- ments (for example, mining hostels, unventilated public transport and so on) – are perfect conditions for the rapid spreading of TB.”

He cites an article published by University of Oxford sociology professor David Stuckler in 2009, which focused on the spread of TB. It stated that TB associated with the mining sector was responsible for up to one-third of all new cases in Africa each year.

“Mineworkers do not only infect one another, but also infect their families and community members when they go home,” Spicer adds.

He explains that mineworkers spend extended periods away from their families, often in single-sex hostels, which often attract the establishment of a commercial sex industry, and that these factors increase the risk of HIV infection, in combination with the high risk of silicosis, owing to the mining environment, “These factors, in combination, create a very high risk of mineworkers being infected by TB.”

Why TB Treatment is Such a Challenging Issue

Spicer explains that mine- workers go home for breaks or are sent home when they are sick, often with different TB treatment patterns or limited access to medical service.

“When they return to work, they once again follow different treatment patterns. In addition, some mineworkers, as with many people, stop taking their medication as soon as they feel better – a fatal mistake when receiving treatment for TB.

“Six months of treatment is needed for drug-susceptible TB and the course of medication should be completed to kill the TB bacteria. If the course is not finished, your body will become resistant to the drugs,” Spicer explains.

He adds that people with MDR TB need 18 to 24 months of treatment with drugs that are extremely tough on their systems, requiring daily injections – treatment costs up to 100 times more than regular TB treatment.

He adds that while some of the larger mining companies have exemplary workplace programmes covering TB – and there are encouraging signs of broader engagement emerging – the sector as a whole could do much more to contribute to the political momentum towards solving this issue.

The Swaziland Statement, which was published on March 21, 2013, by the Swaziland government, aims to build momentum towards ending TB and reports that, in the absence of concerted efforts, TB will kill over four-million people worldwide between 2013 and 2015 and that more than five-million people in Africa will die in the next decade from TB and TB/HIV.

The Southern African Development Community (SADC) countries are at the epicentre of the epidemic, with the highest rates of TB and TB/HIV co-infection in the world, as well as a disproportionately high concentration of deaths, according to the statement.

In 2011, 80% of all new TB cases among people living with HIV in the world were in Africa and 75% of the 435 000 HIV-positive people who died of TB in 2011 died in Africa, the Swaziland Statement reports.

“The current impact of TB in Africa is unacceptable, as it is a curable disease, yet it continues to claim lives and spread through the continent’s mining industries,” Spicer emphasises. “This is an unprecedented opportunity for governments, companies, developing part- ners and civil society to come together. It makes sense from a health perspective and from an economic perspective.”

Spread of TB
Stuckler stated in his article that TB rates in the African mining sectors were the highest in the world, with about 3 000 to 7 000 cases reported for every 100 000 people.

“This is extraordinarily high,” Spicer stresses. “TB in South Africa is roughly at 1 000 cases for every 100 000 people, compared with the global rate of 125 cases for every 100 000 people.”

Spicer notes that there is disagreement with Stuckler’s estimates from industry, with a rate of 2 500 cases for every 100 000 people more commonly accepted.

“This, however, is about 20 times the global average and far beyond emergency levels,” Spicer points out.

He warns that every person with active TB who is not diagnosed and treated early is estimated to infect between 10 and 15 people a year. Therefore, the price of not acting now is rising at an exponential rate, particularly when the future costs of addressing MDR-TB are factored in.

“Mining companies and governments need to find new ways to ensure that people with TB are diagnosed and treated early, and given whatever support is required so that they complete treatment.”

He notes that one of the objec- tives of the Millennium Development Goal is to halve the number of fatalities resulting from TB and TB/HIV by 2015, with most of the global regions, except Africa, on track to reach this target.

“Globally, 1.4-million people are dying from TB every year, with 40% of those in Africa and three-quarters of the fatalities in the SADC countries,” he stresses.

Cost of TB
Consequently, Spicer notes that the cost of fully tackling TB for Africa’s healthcare system is significant and is escalating, with a shortage of about $900-million each year to fight the spread of the disease, according to the World Health Organisation.

The Global Fund to Fight Aids, TB and Malaria announced that it would commit $102-million of new funding to TB programmes in SADC countries, while the UK Department for International Development pledged $220 000 to support new engagement from the private sector.

In addition, the International Organization for Migration announced a $6.5-million programme for health and mobil- ity in the Southern African mining sector, and the Stop TB Partnership announced that $10-million would be dedicated to TB REACH projects in the SADC countries.

“The cost of TB goes beyond the healthcare sector,” Spicer stresses, adding that the World Bank is conducting an economic analysis of the impact of TB and TB/HIV in the mining sectors of South Africa, Lesotho, Mozambique and Swaziland.

The analysis studies the impact of these diseases on companies’ productivity, the resultant loss of wages by workers suffering from TB and the impact it has on their families, as well as the additional financial costs for health systems.

He notes that, shockingly, many people in the West and in donor capitols think that TB has already been eliminated worldwide, contributing to a lack of awareness and financing required to end the disease.

“TB slows down economic growth,” Spicer underscores. “It is not just a health issue, but greatly impacts on every country’s economic development. When you think that much of Africa’s growth in the short and medium term will be driven by resource extraction and that billion-dollar power sector investments in South Africa, Mozambique and beyond that rely on coal will attract mineworkers from all over Africa, it becomes clear that we have to do much more to end TB now.

“We have to get it right this time to ensure we aren’t producing additional cases of TB along with additional ounces of min-erals and kilowatts of power.”