"It was the height of summer in February 2005 and the hospital was filled with patients with both TB and HIV/AIDS," recalled Dr. Tony Moll, the anti-retroviral program manager at the Church of Scotland Hospital in Tugela Ferry.
"I remember there were two patients who just weren't getting better. I don't know why, but I had this terrible feeling that something really sinister was happening," Moll said.
In most instances, HIV/AIDS positive patients being treated with both anti-retrovirals and tuberculosis drugs improved, Dr. Moll explained, but not these two. "They were getting worse by the hour."
With a lack of testing facilities in his rural hospital in South Africa's Kwazulu-Natal province, Dr. Moll asked for special permission to have the sputum samples of 45 patients sent to Durban and tested for resistance to TB drugs.
Nurses collected samples from the two very ill patients, as well as 43 others being treated with TB and anti-retroviral drugs, and sent them off. By the time the results came back eight weeks later, 10 of the patients were dead, including the two who had been very ill.
Of the 45 samples, 10 were resistant to all six TB drugs they tested for.
"I got a cold shiver, with such fear in my heart," Moll said. "I thought, 'This is airborne. Could I be infected? Could my staff be infected?' To go into a new realm of XDR-TB, which is basically untreatable, was almost unthinkable," he said, using the acronym for Extremely Drug-Resistant Tuberculosis.
Moll's worst fears eventually were realized: Four of the hospital nurses died in those first few months. From that point on, the hospital began identifying more and more patients — and in almost all cases, the patients with XDR-TB were dead before the lab results were back. Most die within 16 days of being identified as a possible XDR-TB case. The mortality rate of XDR-TB is 84 percent.
Since the first two cases, close to three years ago, doctors at the Church of Scotland Hospital have identified 266 people with XDR-TB.
That is just one small hospital. Across South Africa, doctors in all nine provinces have reported XDR-TB cases.
"It seems to be simmering, with increasing numbers each month," says Moll said. "It's not explosive, but it's slow, insidious, increasing numbers."
With recent U.S. fears of tuberculosis being stoked by a Georgia man's trans-Atlantic, South Africa's struggles serve as an ominous reminder of how deadly the disease can be.
The South African government has installed extractor fans in all TB wards and hospital staff use surgical face masks, but doctors claim there is a lack of good isolation facilities available. It has been reported that small rural clinics and hospitals can sometimes wait for up to three weeks with an XDR-TB patient in a general ward before a bed is available in one of the few urban hospitals better equipped to deal with the disease.
Experts claim a drug to deal specifically with XDR-TB is more than a decade away, so doctors use a combination of six to eight TB drugs to treat it.
Currently, a small group of XDR patients have been treated for more than five months in a Durban hospital, but their results have fallen short of doctors' expectations.
"Ultimately we need prevention, as the current treatment regime just isn't the way to go," Moll said. "The bulk of the patients just die so quickly."