Two-thirds of South Africans are already infected with TB. No one is safe, it appears
By Olivia Rose-Innes and Ilse Salzwedel

If you want to avoid getting TB, don’t breathe,’’ says Professor Nulda Beyers, director of clinical research at the Desmond Tutu TB Centre in Cape Town.

She’s serious. These days tuberculosis is so rife in South Africa that it’s almost impossible to avoid exposure.

In fact, according to the South African National Tuberculosis Association (Santa) it’s suspected that at least 66 per cent of our population is infected – but in most cases the bacterium is harboured in a dormant state so the carrier is unaware of the infection.

This means that two-thirds of South Africans have TB – that’s double the already staggering global figure, which is closer to one-third. And this includes many people from privileged backgrounds.

Although the poverty-stricken TB stereotype persists, these days, says Beyers, no one should think they’re immune to this debilitating and potentially fatal disease.

The bugs versus the body

Most infected people never actually develop active TB. This means they don’t get sick, aren’t infectious and may not even realise they’re carrying the bacteria.

This is because the immune system controls the infection by forming “walls” around the bacteria, where they lie dormant, or latent.

But this dormant sickness doesn’t mean they’re safe. Ten in 100 people with latent TB will develop active TB in their lifetime – most likely within the first two years of infection.

Active TB can also occur directly after infection if the bacteria overcome the body’s immune defences and multiply. Some people develop TB disease within weeks of becoming infected – their immune system is simply too weak to stop the bacterial growth.

Other people with latent TB get sick later, when their immune system becomes weakened through, for example, diseases or behaviours that cause immune suppression (most notably HIV, chemotherapy, poor nutrition or drug abuse).

How does active TB manifest? It usually attacks the lungs and can destroy parts of the tissue, making it difficult to breathe. Less commonly, the bacteria spread to other parts of the body, including the digestive and urogenital tracts, bones, joints, nervous system, lymph nodes and skin.

They can even attack the brain as a deadly form of meningitis or break down vertebrae, causing sufferers to become humpbacked. A rare form of TB has also been known to disfigure the soft tissue of the face.

But, says Beyers, there can be a grey area between infection and disease. “Some people get infected and then only develop a very mild form of the disease – often with flu-like symptoms. So they may be unaware that they ever had it.’’

Tests, treatments and deterrents

The standard initial diagnostic test for TB infection is the tuberculin skin test: a small amount of testing fluid called tuberculin is injected under the skin of the arm and a small lump at the injection site usually indicates TB infection. Simple as that.

But TB is a complicated disease that’s shrouded in shame. One of the biggest myths is that infected people need to be avoided or isolated for months. This inescapable stigma means that many people are afraid to get tested or make their diagnosis known.

“Some people hide their TB status because they think they’ll lose their job if they come clean,” says Professor Umesh Lalloo, head of the respiratory unit at the University of KwaZulu-Natal and the Nkosi Albert Luthuli Central Hospital.

“But if treatment is carried out correctly, a person with active TB will be non-infectious two weeks after starting treatment.”

Yes, TB is a dangerous and potentially fatal disease, but it can be treated effectively. One caveat: the drug regimen (typically a six- to nine-month course) must be strictly adhered to. Many people stop taking their medication because they start feeling better or experience unpleasant side effects.

Tragically, this results in the development of drug-resistant strains of TB (see box on opposite page), which are making the epidemic much harder to control. Lastly, as always, prevention is better than cure.

To protect yourself from contracting TB you need to follow a healthy lifestyle and support your immune system with good nutrition, regular exercise and sufficient rest. To further improve your chances, know your HIV status and don’t smoke.

Tobacco smoke increases the risk of TB infection, latent TB becoming TB disease and TB-related death. To make matters worse, second-hand smoke is also linked to an increased risk of infection in children. Yet another reason to quit.

Should you get tested?

A TB test is strongly recommended in any of the following cases:

• You’ve spent time recently (i.e. in the last two years) with someone who has TB or you work in an environment where rates of infectious TB are very high (e.g. large healthcare institutions).
• You are HIV-positive, or have another condition that causes immune suppression. If someone with latent TB contracts HIV, the risk of developing active TB rises from 10 per cent during his or her lifetime to 10 per cent a year.

You develop symptoms that suggest TB – such as a persistent cough, coughing up sputum or blood, chest pain, fatigue, unexplained loss of weight or appetite, chills and fever, night sweats and shortness of breath or wheezing.

Other less common symptoms include joint pain, diarrhoea, loss of hearing, a persistent lump or lesion and swollen fingers or toes.

• If you are due to undergo chemotherapy, your doctors may advise a TB test and treatment for latent TB if you test positive.
• Children under five are at high risk of developing TB disease once they have been infected. For example, if your child’s teacher or childminder has been diagnosed with TB, it is a good idea to have your child tested for TB.

In all of these high-risk cases, a positive TB test will require treatment. Even if your diagnosis is latent TB, you should still take a prophylactic course of drugs to prevent the development of active TB.

Bronwyn Thompson,
medical technologist

Although I work in a pathology lab, it’s difficult to determine if that’s where I contracted TB. You could be standing in a supermarket queue where someone coughs and that might be enough to get infected.

In my early twenties I had a persistent cough. As a gymnast it started becoming difficult to do full exercise routines. My boyfriend Tarren suggested I get tested for TB but I had the ‘’I can’t get it’’ mindset.

Plus I didn’t have typical symptoms such as weight loss and my cough was fairly mild.

When I had lung function tests done for the Aerobics-Gymnastics National Championships in 2006, the results showed my lung function was down.

Eventually, my doctors did a TB culture and chest X-ray, just to eliminate it as a possibility. When the doctor called with the news – fairly advanced TB, mostly in the left lung – I burst into tears.

I was distraught, but also ridiculously ashamed. I had to tell my family and the group of interns I’d been working with.

I was sure Tarren would be infected, but luckily he wasn’t. I became so anxious I’d infect people that I started putting bars of disinfectant soap around the house.

It was hard to stick to the treatment. The side effects got me down and my room looked like a pharmacy. At first it felt like everyone at the clinic was staring at me when I headed to the clear- ly marked TB section with my sputum bottle.

But I got over it and I was never made to feel rejected or isolated – when I told people they’d just put their arms around me.

These days I’m happy to talk about it – it’s vital to get the word out. It’s so unnecessary that people die from an essentially curable disease, purely through stigma and lack of knowledge.

Rob Erasmus,
general manager of Cape Town’s Volunteer Wildfire Services

I was scuba diving with a large group on the wreck of the Mauri between Hout Bay and Llandudno. As I was surfacing, I had pain in my chest and signalled to the dive master that something was wrong.

He suggested I descend again and try to come up slower. We did this three or four times but it didn’t help.

Eventually I’d used up my own air tanks and the half-empty tanks of the divers who’d already surfaced. I was forced to surface, which caused my lung to rupture.

I only found out later this was because the air pressure that had built up during my ascent proved more than my sick lung could take. I had to be emergency airlifted to hospital.

Tissue tests confirmed that my left lung was badly infected with TB. I was extremely unhappy with the doctor who’d done my medical exam before the dive, which included a chest X-ray.

I couldn’t have been more surprised to discover I had TB. I don’t remember having any symptoms and don’t know where I could’ve gotten it.

I was working for Cape Nature Conservation and had been in contact with some sick wild animals, so I might have picked it up then.

How do you catch TB?

When an infectious person coughs, sneezes, talks, laughs or spits, droplets containing Mycobacterium tuberculosis (the bacterium that causes TB), spray into the air.

People nearby may inhale these bacteria and become infected. But despite the fact that TB is mainly spread through the very air we breathe, transmission usually only occurs after substantial exposure to someone with active TB.

In addition, people with active TB, or TB disease, are also more likely to pass the bugs to family members, colleagues or people they interact with daily.

After inhaled TB bacteria have settled in your lungs, one of two things can happen.

Either your immune system manages to contain the bacteria and keep them in an inactive or ‘’latent’’ state, or the bacteria multiply and run amuck, leading to the development of TB disease.

Can you protect your child against TB?

It’s essential that babies receive the Bacillus Calmette-Guérin (BCG) vaccination, because it prevents serious types of TB such as TB meningitis or disseminated TB (which spreads to other organs and limbs) in children under two, says Professor Willem Hanekom, laboratory director of the South African TB Vaccine Initiative at the University of Cape Town.

“This vaccine is 80 per cent successful and is one of the safest vaccines.’’ Currently BCG is the only TB vaccine in the world for the prevention of the disease.

Unfortunately it doesn’t work for adults, Hanekom says. “It’s also not effective against pulmonary TB, the most common type of TB.”

TB gets extreme

South Africans were shocked to learn of a frightening form of TB called extreme drug-resistant or XDR TB. Professor Umesh Lalloo, head of the respiratory unit at the University of KwaZulu-Natal, is the man who blew the whistle on it last year.

Lalloo has been involved in TB and HIV research for ten years and identified the XDR strain through research in the Tugela Ferry area. Further investigation has shown that XDR is rearing its ugly head all over South Africa and in countries across the globe.

What makes XDR so virulent? “If you’re extremely resistant to TB drugs, there are very few treatment options,” says Lalloo. “And if someone is HIV-positive as well there’s an almost 100 per cent mortality rate.”

Lalloo says South Africa’s TB infection rate has almost doubled in the last eight years. “In 2000 we reported about 500 new cases in every 100 000 people,’’ he says.

“This has now grown to about 1 000 new cases per 100 000. Even more worrying is the fact that South Africa’s statistics don’t compare well with those of neighbouring countries, even though we are – on paper at least – one of the best resourced countries in Africa.’’

Ideally, Lalloo says, there should be systems in place to identify at least 80 per cent of TB infections. “Of that 80 per cent, we must be able to cure at least 80 per cent of cases if we want to prevent the spread of XDR-TB.”

Tuberculosis centre

TB treatment pays off

Major new TB plan for SA