Tackling TB – All hands on deck
In 1882 Dr Robert Koch announced his discovery of a Tuberculosis (TB)-causing bacterium. His ground-breaking work received a Nobel Prize. World TB Day marks this announcement and is commemorated annually on the 24th of March. It’s been 137 years since and TB remains a leading killer across the world.
In 2017 1.6 million people died from the disease. This, according to the World Health Organization’s (WHO) Global Tuberculosis Report released last year. In 2017 TB resulted in 22 000 deaths among HIV-negative South Africans and 56 000 deaths in those with both HIV and TB. With at least 330 people dying daily, TB is the leading natural cause of death in the country.
The University of Cape Town’s (UCT) Institute of Infectious Disease and Molecular Medicine (IDM) is based within the Faculty of Health Sciences (FHS). The Institute is a leading research centre on infectious disease in Africa. Speaking to the IDM’s positionality, Director, Professor Valerie Mizrahi says: “Unfortunately, we have a high burden of TB in this country and Cape Town is a heavily TB-burdened city, with high rates of HIV co-infection. However, we have a strong group of TB researchers in the IDM and elsewhere in the University. Our research groups have established outstanding clinical and laboratory capabilities for investigating new ways to intervene in TB by working at the intersection of the laboratory, clinic, and community. We are able to bring many disciplines to bear on this problem.”
The IDM covers the full spectrum of TB research – something for which UCT is recognised internationally. “We work along the entire continuum from fundamental research on the biology of Mycobacterium tuberculosis – the causative agent of TB, through to preclinical and clinical research. Our researchers are particularly well known for their work on understanding the progress from infection to disease; for evaluating new interventions, in particular vaccine candidates and new diagnostics, and for novel biomarkers discovery,” says Mizrahi.
SATVI Walkers at the top of Table Mountain raising awareness about TB, 24 March 2019
The cost of care
The health economics of TB cannot be ignored. There’s a substantial cost, often carried by impoverished families, to support a relative living with the disease. According to The economic burden of TB diagnosis and treatment in South Africa study, “direct costs, include transport costs to and from the health facility and any costs for medication or consultation incurred by individuals while seeking care”. While “indirect costs include the time lost while being unable to work due to seeking care, or being too ill to work.”
A report cited in The Economist offered some light on the cost of TB treatment and care: Treating a case of DR-TB (Drug Resistant TB) can be 8 to 25 times more expensive that treating a case of drug-sensitive TB. In the next 35 years, MDR-TB (Multi-Drug Resistant TB) will cost the global economy $16.7 trillion.
Mizrahi estimates that of the research revenue raised by members of the IDM, at least 20% - 30% supports research on TB – this includes a major focus on HIV-associated TB.
Up close and personal
It’s an alarming reality – that being located in what seems to be the epicentre of the disease means engaging with more patients daily than institutions in the north do in a year.
In fact, it is estimated that at least 8 out of every 10 South Africans have been infected with the TB bacterium. Mizrahi adds: “We don’t need to be inspired here to work on TB because we see it daily. In a room of students and staff in the Institute, many would have been affected in some way by TB.” In fact, the FHS Student Development and Support Committee reports that about seven students contract TB annually.
For Mizrahi the disease is up close and personal. “Both my mother and father had TB.” A reality which she thinks offers the Institution an edge: “It’s sobering, yet inspiring to be working on a disease with such urgent unmet needs. We need a suite of new tools to control TB more effectively, and have the kind of impact on the epidemic that’s needed to meet the ambitious targets set in the End TB Strategy. And we here at UCT are part of a global community of researchers in an active pursuit of those, namely, diagnostics, biomarkers, drugs, and vaccines.”
Working under the umbrella of the IDM are the South African Tuberculosis Vaccine Initiative (SATVI), the Wellcome Centre for Infectious Disease Research in Africa (CIDRI-Africa) and the Desmond Tutu HIV Centre (DTHC) amongst others. In 2018, these groups announced some major research findings, which have brought hope to the field.
SATVI and DTHC collaborated on the first prevention of M.tuberculosis Infection (POI) trial. It showed that sustained infection can be prevented by BCG revaccination of adolescents with 45% efficacy. These results provided proof-of-concept for the novel POI trial design and highlight the crucial question of whether BCG revaccination of M.tuberculosis-uninfected populations could have long-term impact on TB disease.
SATVI and CIDRI-Africa worked together on the first efficacy trial of an adjuvanted protein subunit TB vaccine which showed that M72/ASO1E vaccination of M.tuberculosis-infected adults offered 54% protection against progression to TB disease. Results for both trials were published in the New England Journal of Medicine.
Andiswa Vazi, CIDRI-Africa's Study Coordinator at Radio Zibonele, 22 March 2019
We all breathe TB
March saw various activities commemorating World TB Day. Just in the UCT community Shawco Health, TB Proof, and FHS invited Miss South Africa, Tamaryn Green, who was a sixth-year medical student when she won her title, to speak about her journey with TB. She recounted her fear of people finding out about her status and how she eventually used the Miss SA platform to gain traction for her #BreakTheStigma campaign. The SATVI team tackled the World TB Day Three Peaks Challenge – an awareness campaign – by hiking up Devil’s Peak, Platteklip Gorge, and Lion’s Head in one day.
CIDRI-Africa hosted some community activities. Zandile Ciko, CIDRI-Africa’s Public Engagement Manager, says we all breathe TB so it’s important to talk about it. It’s important to have open conversations and create spaces for people to ask questions: “Having activities such as radio and television interviews creates a platform for constructive dialogues around TB. Unfortunately, TB is not a household topic and activities such as these drive a change in that behaviour.”
Ciko says CIDRI-Africa employs a multi-faceted approach in engaging with the community of Khayelitsha by developing an understanding of TB research. This includes: “consultation on how best to deal with challenges that arise from clinical trials, and creating a space where the community believes that research is ultimately people-centred.”
At the Desmond Tutu HIV Foundation’s (DTHF) Aerobiology TB Research Facility launch in Masiphumelele in February, UCT Vice-Chancellor, Professor Mamokgethi Phakeng, said: “Our research doesn’t just happen in Rondebosch, it happens in the communities. It happens here because that’s the best way to explore the questions that are of importance to our society. And so we engage with the people and we appreciate the fact that they open to us, and they talk to us about the disease that we want to understand.”
The site is surrounded by 23 000 residents in the informal settlement. The building houses internationally renowned UCT researchers and scientists, as well as support staff whose work forms part of the TB project in collaboration with the IDM. This work is sponsored by the DTHF the Bill and Melinda Gates Foundation and the South African Medical Research Council.
Maintaining awareness, speaking out, and destigmatisation of the problem is important, says Mizrahi. “South Africa, with its high burden, gives us a special responsibility to play a leading role in tackling this problem… What we still haven’t gotten quite right is how to advocate more powerfully for TB in the way that has been done for HIV/AIDS. Advocacy plays a crucial role in heightening public awareness and keeping the disease at the forefront of people’s minds.”
“We need to do better. We need new tools, and I’m proud to be part of a research enterprise that’s contributing so significantly to global efforts to control TB.” Mizrahi concludes, “I’d like to see a world free of TB in my lifetime.”