ADDIS ABABA, 28 April 2010 (IRIN) - At St Peter TB Specialized Hospital, high in the mountains of Entoto, north of the Ethiopian capital, Addis Ababa, a masked Johannes* is suffering from multi-drug resistant tuberculosis (MDR-TB) and has spent the last month at the hospital.

While the doctors are glad he is receiving treatment, they are also worried - Johannes is a bus conductor in heavily populated Addis Ababa, so there is no telling how many people he could have infected before seeking treatment. Many are unlikely to be diagnosed and treated in time to prevent further infections.

"Diagnosis and treatment of MDR-TB remains a challenge; so far we have only two centres in Addis Ababa that can do the culture and drug sensitivity testing required," Diriba Agegnehu, TB/HIV programme officer for the UN World Health Organization (WHO) in Ethiopia, told IRIN/PlusNews.

"Breaking the transmission cycle is key to ending MDR-TB, so we need to move fast," he added.

Ethiopia, which ranks seventh on WHO's list of 22 high burden TB countries globally, is one of three countries in Africa with more than 5,000 estimated new MDR-TB infections annually. Of these, 1.6 percent of new cases and 11.8 percent of re-treatment cases are MDR-TB.

Treatment

So far, St Peter is the only facility able to treat MDR-TB in the country.

"We are treating 89 patients, but we have a waiting list of 170 patients," said Abdusamed Adem, director of medical services at the TB hospital. "We urgently need to open new centres."

More than 100 diagnosed MDR-TB patients have died while on the treatment waiting list. Having diagnosed 390 cases of the disease outside the capital, the Ethiopian government is now racing to build testing and treatment centres in several of administrative regions.

According to WHO's Diriba, the government and its partners are expanding the diagnosis and management of MDR-TB cases into the states. The expansion and strengthening of laboratories in different parts of the country is under way in Bahir Dar in the northwest, Mekele in the north, Adama in the east and Awassa in the south; the government also plans to build at least one treatment centre and one lab in each of these cities.

"Staff have also been trained on MDR-TB management and infection control both in-country and abroad in countries with more experience such as Cambodia and Lesotho," he added.

Strengthening DOTS

"The main cause of MDR-TB is failure to properly implement DOTS [directly observed treatment short course] service. Hence improving the quality and expansion of DOTS service to reach the majority the people in the rural Ethiopia is an important step in the fight against MDR-TB," said Diriba

The country's case detection rate for regular TB is 35 percent, far below the WHO recommended 70 percent for a successful DOTS programme.

A strong community-based healthcare system that uses task-shifting and more than 30,000 "health extension workers" to follow up patients means that when patients are diagnosed, the treatment success rate is about 84 percent, close to the WHO target of 85 percent.

"The country's DOTS programme is under-utilized - health-seeking behaviour in Ethiopia is still low; this has to be dealt with," said Akram Eltom, HIV team leader for WHO in Ethiopia. "A good DOTS programme is the best protection against MDR-TB."

So far, the country, through WHO's Green Light Committee and the Global Fund to fight AIDS, Tuberculosis and Malaria, has enough funds to treat MDR-TB patients until 2014, but according to Diriba, with expanded diagnosis and treatment, more funding may be necessary and partner organizations are supporting the effort.

Adherence

"We will also need to reinforce adherence counselling as we expand because second-line TB drugs have more side-effects compared with the usual anti-TB drugs," he noted. "They also last for longer, 18 to 24 months."

For people on both HIV and TB medication it is even harder; an estimated 25 percent of Ethiopian TB patients are co-infected with HIV.

Daniel*, a 34-year-old bus driver, has been at Addis's TB hospital for a month, being treated for MDR-TB; he was already on life-prolonging antiretrovirals.

"I feel nausea and vomit a lot, and I am always fatigued," he told IRIN/PlusNews.

Daniel's mother, who nurses him at the facility, says despite the weakness from the drugs, his condition has greatly improved. "At least now he can sit up and eat," she said.

Patients are admitted to hospital for three months, after which there is intensive follow-up by the local health centre, the TB hospital, family members and health extension workers.

Abdusamed said mandatory monthly visits to the hospital for out-patients were an expense many patients living outside Addis Ababa could ill afford.

"We have some help from GHC [the Global Health Committee] in providing nutrition and transport to out-patients, but they will need more support as the programme grows," he said.

Staffing issues

"The staff turnover here [at St. Peter's] is very high, largely because of the high-risk nature of MDR-TB... if a nurse gets infected, her family is also at risk, so when they get other jobs they leave," Abdusamed said. "In addition, there are few incentives; for example, health workers - even those in high-risk situations such as ours - are not insured against contracting illnesses."

Despite the challenges facing the programme, specialists say the government's commitment to improving health infrastructure, training health workers and following WHO's guidance on MDR-TB is a reason for optimism.

"So far, treatment outcomes are good; one patient has completed the two-year treatment course and has been cured," Abdusamed said. "Based on our record of patients still on treatment, conversion from smear positive to smear negative is happening within a fairly short time and side-effects are minimal."