Is the future of South Africa’s TB plans locked up in the mysterious minds of teens?

Fourteen months, seven facilities (in the Eastern Cape, Western Cape and KwaZulu-Natal), two types of treatment (hundreds of pills), six months in hospital and two missed years of school. 

That’s what it took for Akona Tshwete* (13) to recover from tuberculosis (TB), according to his doctor, Juli Switala, a paediatrician at the health organisation, the Aurum Institute, who was speaking at last week’s seventh South African TB Conference in Durban.

The situation could have been avoided, says Switala, if Tshwete had access to a treatment programme geared towards his and other teens’ specific needs.

TB treatment can be tough to take. For teens of up to 16 years, drug courses are between four and six months, depending on the severity of their TB, according to World Health Organization guidelines issued in March. 

South Africa’s national plan to treat TB aims to get 100% of people diagnosed with the disease onto treatment by the end of 2022. The document also outlines plans to make sure that 90% of those who have a form of TB that responds to regular medicines do complete a course of treatment by 2022, and the same goes for 75% of those who have drug-resistant TB.  

But adolescents (10 to 19 years) pose a particular challenge to TB projects. 

In short: grown-ups are terrible at finding out how teenagers experience TB, and haven’t done enough to ask them, Graeme Hoddinott, a senior researcher at Stellenbosch University’s Desmond Tutu TB Centre, says. 

Puberty, which strikes between the ages of eight and 14, makes adolescents more likely to fall ill with TB. Researchers think this might be because teens lose the protection of their primary school immune system (which is good at controlling infection) in exchange for something closer to adult immunity (which is not as good at keeping disease at bay). 

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During puberty, Hoddinott says, teens also undergo hormonal changes, which researchers think may increase the likelihood of TB infection progressing to the disease, says Hoddinott. 

Moreover, teenagers spend a great deal of their time in classrooms, where the risk of getting infected with TB can be as high as in clinics, according to a study published in the The American Journal of Respiratory and Critical Care Medicine in February. The research analysed the air in 72 classrooms at two South African schools and compared it with the air in public health clinics. They found the risk of infection in clinics and classrooms was the same.

TB also spreads through the air, so once adolescents are infected, their budding social lives mean they have more opportunities to pass the germ on to their peers. Research, for instance, shows that teens hang out in groups where they gather in close proximity to each other (also called congregate settings) more often than adults in their thirties. 

Does our health system look after teens?  

The way health services in South Africa are set up isn’t working for adolescents. “We’re serving them very badly,” says Hoddinott.  

Switala explains: “Teens no longer need child services, but they’re not quite adults either, so they often fall through the cracks.” 

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Switala’s statement is supported by data. A 2019 study, for example, shows adolescents were more likely than young adults (20 to 24) and adults (25 and older) to stop taking their TB pills before the end of their regimen. Several other studies have also found that the risk of teens not taking their treatment continues, and often increases, when they become young adults.

As a result, many young people still die of this treatable disease – a fate that befell more than 18,000 adolescents (10 to 19) and children (younger than 10) in the country between 2004 and 2016.  

TB was the leading cause of death among adolescents living in South Africa in the decade leading up to 2018, according to Statistics South Africa data. 

What makes teenagers happy? 

Researchers say TB treatment programmes need to be based on compassion and an understanding of what teens are going through during adolescence – rather than judging them for it.  

Teenagers need five things to be happy: good health, a feeling of connectedness to other people, a safe home environment, education and the freedom to make decisions about their lives, a 2021 Journal of Adolescent Health article argues. When all these boxes are ticked, the research shows, adolescents are better equipped for adult life. 

But TB interferes with this process, according to a study published in Pathogens in 2021. How? The treatment disrupts their routines and the disease exposes them to severe stigma. 

People on treatment for drug-resistant TB, have to, for example, isolate themselves at home or in hospital until doctors have established that they’re no longer infectious. But this can interrupt  teens’ daily routines such as school. Because of the stigma accompanying the disease, TB treatment may also cause a rift in teens’ relationships with their friends, family or romantic partners.