The TB in the air we breathe

The TB in the air we breatheInside a TB lab. PHOTO: Joyrene Kramer/Spotlight

Wedged between mountain and sea on a breathtaking stretch of Cape Peninsula coast, the township of Masiphumelele is home to 23 000 people on about 40 hectares of land.* Despite its name which means ‘we shall succeed’ in isiXhosa, living conditions here are dire. It is overcrowded, sanitation is not what it should be, and infectious diseases like HIV and tuberculosis (TB) are rife.

Professor Robin Wood in the new laboratory. Photo by Joyrene Kramer.

According to University of Cape Town Emeritus Professor Robin Wood, TB infections in the community are astronomically high, particularly amongst children and adolescents.

‘So at the moment, here in Masiphumelele,’ says Wood. ‘Kids of about five years old; 20% of them are infected with TB before they go to school. At the time they’re 14, about 50% are infected, and by the time they leave school, 65 to 70% of them are infected.’

These rates, he says, are applicable to other impoverished communities in the Western Cape, and across South Africa.

The question is ‘why?’

This is what Wood endeavours to learn at a new world class tuberculosis facility officially launched in the heart of Masiphumelele, at the Desmond Tutu HIV Foundation – of which Wood is CEO – on February 20. He says the new Aerobiology TB Research Facility will operationalise leading technology for studying TB transmission, by capturing and analysing exhaled breath from patients recruited at two local clinics: one in Masiphumelele and another in the nearby township of Ocean View.

The patients are brought to the laboratory, where, inside an airtight unit, their breath in captured for an hour. About 500 liters of expired air is collected, and then scanned for TB particles.

‘So what we do,’ says Wood. ‘We identify bugs in the air that people are breathing out. We use new techniques to show that the organisms are TB and that they are alive, without having to culture them (slowly grow them in the lab), which normally takes around six weeks or so. So we’re getting a measure of the infectivity, which I think is key.’

Not nearly enough being done to stop transmission

Photo by Joyrene Kramer

Referring to the fight against TB, Wood argues that prevention is just as important as cure. He says that while treatment of TB patients in South Africa is effective, not nearly enough is being done to stop transmission of the disease.

‘The philosophy behind the new centre,’ says Wood. ‘It is that we have a TB epidemic, which is now worse than anywhere else in the world. I think we need a new approach to this. For example, we know that infection is being acquired by children in schools, but again, we do nothing about it. So my feeling is, I’m trying to get people to refocus. This is an infectious disease. Why don’t we try and address people who are getting it, and try to stop them from getting it? Treatment is good; people used to die on average in two years after getting infected, treatment changed that around dramatically. But it hasn’t decreased the rate at which people are getting infected.’

Over the years, Wood’s research has taken innovative approaches to exploring TB transmission and the socio-environmental factors that drive it.

One such approach is to give people CO2 breath monitors that also tracked their location using GPS. This kind of research helps researchers to understand in which settings the most air is being swapped – with such settings presenting a higher risk of TB transmission if someone in that setting is coughing out or exhaling TB bacteria. One 2017 study co-authored by Wood found that the risk of TB transmission in Masiphumelele was particularly high in schools.

In 2011 he co-authored research published in the South African Medical Journal showing that the risk of becoming infected with TB in Pollsmoor Prison was around a staggering 90% a year. In a landmark judgement in 2012 the Constitutional Court found the state could be held liable for Dudley Lee contracting TB whilst being held in Pollsmoor. Wood wrote an expert affidavit in that case drawing on the 2011 study.

Not enough has materialised

There are around 322 000 TB infections in South Africa per year. South Africa’s National Strategic Plan on HIV, TB and STIs for 2017 – 2022 includes an objective to ‘promote TB infection control’. To this end it specifies: ‘infrastructural changes to improve ventilation; introducing appropriate legislation and building regulations; developing norms and standards for housing and congregate settings including schools and public transport; and developing guidelines for TB infection control in congregate settings and households.’

Yet, a frustrated Wood says not enough of this has materialised. Inside his office, adjacent to the new Aerobiology TB Research Facility, a rubber stress ball sits on his desk.

‘So one of my pet annoyances is that we know where TB spreads, particularly at high rates, for example prisons such as Pollsmoor,’ says Wood. ‘We lock people up for 23 hours a day in rooms with no ventilation and we’re surprised that an airborne disease takes place in such numbers. Why don’t we do something about that? So that’s all we have to do in prisons: we have to change the socio-environmental circumstances they’re in. It’s not rocket science. This is a disease that is spread airborne. So it’s the amount of air that people swap with each other. And that’s determined by indoor environments with crowding and not enough ventilation.’

A mural outside the laboratory. Photo by Joyrene Kramer.

At the Aerobiology TB Research Facility, Wood hopes to soon test adolescents, including pupils from the Masiphumelele High School, which is next door to the premises.

‘One of my arguments is that if we want to control TB, we have to stop infecting children. Where they’re getting infected and how they get infected is something we need to further explore,’ he says.

Also on the Desmond Tutu HIV Foundation’s premises, a youth centre has computers for pupils to work on, while a youth friendly clinic offers free sexual and reproductive health services. The buildings are bright and sunlit, built around a courtyard with trees and flower beds. After school, pupils stream across a dirt road from the school to the centre, where a homework club is hosted daily from 3 to 4:30pm.

‘So we’ve always tried to mix social activity with health,’ says Wood. ‘This new era biology TB unit, it’s just the latest addition to a spectrum of things we do here in Masi.’

*These figures are estimates. When contacted by Spotlight, City of Cape Town spokesperson Simon Maytham said the city’s last official Masiphumelele population figures were from the Stats SA 2011 census. ‘Masi is comprised of an informal settlement component, a temporary relocation area and a number of formal erven with backyard tenants, and we only have some of this info as it stands,’ he said.