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ANCIENT DISEASE OP-ED

TB kills 148 South Africans daily — here’s what we need to do better to eliminate it

TB kills 148 South Africans daily — here’s what we need to do better to eliminate it
With an estimated 148 deaths every day, South Africa continues to grapple with one of the world's highest tuberculosis rates. (Photo: GCIS / Spotlight)

Is there hope that we will be able to eliminate TB in South Africa? Thousands of scientists, researchers, academics, policymakers/government officials and members of civil society will meet this week to focus on ways to decrease new infections deaths.

Tuberculosis (TB) is curable, yet every day more than 148 South Africans die from this disease. This is like an average-size plane crashing with all on board dying every day. If this is not bad enough, more than 760 South Africans are infected with TB daily as well. We were terrified during the Covid-19 pandemic and took extreme measures to protect ourselves and our loved ones. So, why are we not outraged that this disease, which is thousands of years old, is still killing South Africans? 

Regrettably, the situation is similar in other high-burden TB countries. According to the World Health Organization (WHO), globally we are not on track to reach 2025 targets set by the United Nations at the UN High Level Meeting and are unlikely to reach the 2030 targets as well.

The WHO says countries should aim for “80% reduction in TB incidence and 90% reduction in the number of TB deaths by 2030 compared to 2015”. At present the incidence of TB in South Africa is 468 persons per 100,000. This represents a more than 50% reduction since 2015 and means that South Africa has actually achieved the 2025 target. This is significant, but the country is far from achieving its 2030 and 2035 targets and we need to do better. More than 54,000 people die annually in South Africa. 

Between 4 and 7 June, thousands of scientists, researchers, academics, policymakers/government officials and members of civil society will meet in Durban at the 8th SA TB Conference. It will focus on ways to decrease new TB infections as well as deaths from TB. Under the theme “Accelerating progress to end TB” it will highlight progress made since the last conference in 2022, the continuing challenges in the fight against this deadly disease, as well as new research that will hopefully be translated into national policy and eventually implemented. 

There will be calls by civil society organisations to declare TB a public emergency and requests for more funding for research and implementation of key interventions to reduce TB incidence and mortality. But without increased political will and a refocused effort towards achieving the 2030 goals, it will be difficult to advocate for additional funds in the current economic environment.

Why is TB so difficult to eliminate? There are many reasons. The first is to understand that, like Covid-19, people with TB can have symptoms (cough, chest pains, weight loss, night sweats) but can also be asymptomatic. It is also the case that many people with symptoms either ignore them as not important or delay seeking treatment. People with TB disease can infect up to 15 people in a year if not treated. It is also important to know what the risk factors for TB acquisition are. They include undernutrition, HIV infection, alcohol use, diabetes and smoking. These conditions are all highly prevalent in South Africa.

What can be done

Is there hope that we will be able to eliminate TB in South Africa?

As noted, there are several risk factors that we can work to change, but change would require intervention outside the health sector and a government-wide response. There is a need to address critical issues such as poverty and unemployment, which contribute to undernutrition. Implementing measures to reduce tobacco use, increasing taxes on tobacco and alcohol products, and strengthening the primary health system could significantly improve public health outcomes, provided there is strong political commitment and effective implementation and accountability mechanisms in place. 

From a biomedical perspective, there is much that can be done as well – globally as well as in South Africa. 

First, we need to be able to find individuals who have contracted TB – those with symptoms and those without. This means doing better at screening and testing patients who attend clinics and are admitted to hospital. Targeted universal TB testing is now policy and all persons living with HIV, have had household contact to individuals living with TB, and those with previous TB infectious should be offered a TB test irrespective of their symptoms and at no cost in clinics and hospitals. Once screened and tested, those with confirmed TB must be put on treatment and be successfully treated, often through a six-month course of drugs. We also need to screen and test people in communities, especially those known to have high levels of TB, and test all individuals who have had household contact with someone who has TB, regardless of symptoms. We can now also use digital X-ray equipment in communities to rapidly screen large numbers of people and offer them a TB test. 

Read more in Daily Maverick: Yes we can eliminate tuberculosis, but it will need a mass screening campaign

Because more than 50% of people living with TB are also living with HIV, it is critical that those living with HIV are tested for TB annually, and for TB preventive treatment to be made available to them and to individuals living with them. This means investing far more in communication around the importance of TB and creating awareness of TB services available in primary health facilities at no cost.

Promising research 

There has been significant progress in research and development recently, which is another cause for optimism. Researchers are testing the potential use of tongue swabs as an easier way to collect samples for TB testing, as well as low-cost molecular tests. Others are working to develop TB vaccines for adolescents and adults, which could be a game changer. The current vaccine to combat TB is only for children and more than 100 years old.

There is also ongoing research to develop a two-month course of anti-TB drugs (compared with the current six-month treatment). Some of these products, like tongue swabs, are likely to be available over the next two to five years, and if affordable and implemented swiftly and at scale, will make TB prevention, diagnosis and treatment so much easier. 

We look forward to the new research and implementation lessons that will be presented at the SA TB Conference 2024, and helping to advance this great work so that we can move more swiftly towards the end of TB in South Africa. DM

Yogan is the director, HIV and TB delivery, and Gaurang is the senior programme officer, TB at the Bill & Melinda Gates Foundation.

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Comments - Please in order to comment.

  • Gareth Kantor says:

    TB is an airborne disease.
    Which means it’s transmitted in crowded, poorly ventilated airborne spaces. Infected persons, a large proportion of whom have no obvious symptoms, breathe out the TB germ and it spreads invisibly in the air on tiny aerosols. Case finding and better drugs are good strategies but what about prevention? Until effective vaccines arrive, improving indoor air quality through better ventilation in taxis, schools, bars and other occupied public spaces is helpful and should be a priority. Oh and it’ll work for flu, measles, RSV and other airborne infections too.

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