Finding the Missing TB Cases When They Don’t Know They’re Missing

Let’s Start by Addressing Stigma

Throughout the mycobacterium tuberculosis’ 3 million years of existence, it has endured vacillating periods of angst from both the general public and the global health community. After years of evading the spotlight for major infectious disease eradication campaigns, TB’s fate reversed in 2015 when the global health community affirmed that the global tuberculosis (TB) epidemic has been gravely neglected and has, consequently, spiraled out of control. According to the World Health Organization (WHO), TB is the “world’s biggest infectious killer,” killing over 4,500 people every day. In 2016, there were a reported 6.3 million new TB cases and 1.7 million TB related deaths worldwide, with low- and middle-income countries bearing the bulk of the global burden of this disease.

TB in South Africa

While South Africa has achieved impressive reductions in TB incidence rates over the past few years- with a 7% reduction between 2010 and 2017- the country still bears 3% of the world’s TB cases.

To understand the magnitude of South Africa’s TB epidemic, one must compare South Africa’s rates of transmission to its fellow BRICS nations- Brazil, Russia, India, and China. While South Africa had a TB incidence rate of 567 per 100,000 population in 2017, the four aforementioned BRIC countries have TB incidence rates of 44, 60, 204, and 63 per 100,000 population respectively.

In June 2018, I presented my research on TB transmission among South African gold miners at the 5th South Africa TB Conference in Durban, South Africa. Consistent with conference chairperson, Dr. Margot Uys’, assertion that there are nearly 160,000 missing TB cases in South Africa, the theme of the 2018 conference was Embracing All to end TB. These missing TB cases in South Africa serve as one of the major determinants of high TB transmission throughout the country.

University of Zululand Choir with Choirmaster Mr. Bhekani Buthelezi with the Honorable Deputy President of South Africa, Mr. David Dabede Mabuza
While we are aware of the role missing TB cases plays on South Africa’s TB epidemic, there is one major social factor fueling this phenomena: Stigma.

Stigma and the Missing Cases

Stigma/ˈstɪɡmə/ noun. A mark of disgrace associated with a particular circumstance, quality, or person.

When searching for the underlying causes of the TB epidemic and the multitude of missing cases in South Africa- begin your search with stigma. Stigma propels the fear of gossip and the fear of being seen receiving TB treatment by other members of the community. These fears prevent people from seeking TB treatment from clinics, in turn, exacerbating the transmission of TB disease.

In addition to stigma’s role in impeding TB care seeking, stigmatization also obstructs TB testing and treatment outreach to specific populations in South Africa. Stigmatization specifically fuels the high incidence rates of TB among healthcare workers, gold miners, and people living with HIV.

Health care workers

Tuberculosis awareness campaigns are increasingly focusing on healthcare workers given their elevated susceptibility to TB. According to Dr. Edward Nardell, professor of Immunology and Infectious Diseases at Harvard T.H. Chan School of Public Health, 54% of healthcare workers worldwide have latent TB. The situation is complicated even further in South Africa given 16% of healthcare workers are living with HIV - putting them at an even higher risk for contracting TB. Furthermore, stigma spurs TB transmission among healthcare workers given their aversion to being seen by patients and colleagues while receiving treatment where they work and their fear of being penalized by their employers.

Health facility administration must recognize that healthcare workers are exceptionally vulnerable to TB disease and must have the necessary protective gear, employee health services, and counseling to prevent, monitor, and quickly respond to health workers’ contraction of TB disease.

Valencia Lyle explaining her research to 5th SA TB Conference Attendees

Gold miners

The poorly ventilated, dark, and congested conditions of South African gold mines are ideal terrains for transmitting TB disease. Additionally, the poor living conditions of many gold miners residing in miner communities which frequently include informal accommodations, inadequate access to water and sanitation, and the hostel-style living arrangement whereby several miners sleep in the same room, further fuels the high incidence rates of TB among this population. Since public health practitioners began assessing differences in TB incidence rates between gold miners and the general population, TB incidence rates in gold miners (currently 1890 per 100,000 population) in South Africa have greatly exceeeded the incidence rates in the general population of South Africa(currently 567 per 100,000 population).

I attended the 5th South Africa TB Conference to disseminate information on the results of my research and concurrently urge the global health community to strongly consider mining communities when planning TB prevention and treatment outreach activities. In addition to the global health community’s obligation to curtail the high rates of TB transmission among gold miners, gold mining companies must also ensure that they provide a wide range of TB prevention equipment and strategies to their employees. Strong and effective collaboration between global health actors and gold mining companies could render notable reductions in TB transmission rates of gold miners.

People Living with HIV

The population most susceptible to TB disease is people living with HIV. According to the WHO, the risk of developing TB is about 16 to 27 times higher in people living with HIV in contrast to individuals not living with the infection. There were nearly 1 in 5 adults between 15 and 49 years of age living with HIV in South Africa in 2016. This high prevalence of HIV among South African adults substantiates the high incidence rates of TB among the general population.

Considering HIV’s effects on the immune system, TB spreads faster to other parts of the body, is more lethal when left untreated, and has a higher risk of returning when a person is HIV-positive. Active case finding, scaling-up awareness campaigns, and eliminating stigma to safeguard people living with HIV’s access to TB testing and treatment are fundamental to reducing the prevalence of TB in South Africa.

Embracing All to End TB

From the millions of people living with HIV to the millions of people worldwide living with alcohol use disorders at a threefold risk for developing TB, we must embrace all vulnerable populations in our endeavor to end TB. According to the WHO, there are 4.3 million missing TB cases worldwide. These statistics implore us all to assume the responsibility of ensuring that TB prevention and treatment efforts reach all vulnerable populations. While linking the 4.3 million individuals with undiagnosed TB to healthcare may appear to be a colossal undertaking, Honorable Minister of Health of the Republic of South Africa, Dr. Aaron Motsoaledi, declared that when it comes to reaching the missing cases, we should “not be asking can we do it, but can we afford not to do it?”