South Africa’s time to invest in ending TB is long overdue

Each year the global community commemorates World TB Day on 24 March. On this day, 140 years ago, Robert Koch discovered the bacillus that causes tuberculosis. Amazingly, the Bacillus Calmette Guerin (BCG) vaccine, still used routinely, was first injected into a human in 1921 — 101 years ago. TB is an old disease — it was discovered in Egyptian mummies dating back to 600 BC. 

Despite being an ancient disease, there’s been inadequate investment in vaccine technology compared to Covid-19 which was first identified in December 2019. How is it possible to work so rapidly on a vaccine for Covid-19 — which we are grateful for — but not for a disease as old as TB? The lack of political commitment and investment in TB has often been cited as reasons why many countries continue to have significant burdens of this ancient disease. It is therefore not surprising that this year’s theme for World TB Day is “Invest to end TB, save lives”. 

The World TB Report reported that globally, 10 million people developed TB in 2020 with 1.3 million deaths in people who were HIV negative and a further 214,000 in people living with HIV. These numbers have increased for the first time since 2005, mostly due to service delivery disruptions caused by the Covid-19 pandemic. More importantly, the number of TB patients diagnosed and treated declined from 7.1 million in 2019 to 5.8 million in 2020, indicating that just over half of all those estimated to have TB in 2020 were diagnosed and treated. 

South Africa has historically had a large TB burden estimated at 328,000 in 2020 and currently contributing 3.3% of the global burden. Since 2010, there have been close to 1 million TB deaths in South Africa. On the positive side, the country was one of nine countries to show a reduction in TB incidence between 2015 and 2020, one of ten countries that account for 70% of the gap between the estimated burden and the number of people on treatment for drug-resistant TB, and one of six countries that contribute to the 74% of people on treatment. 

The country largely funds its TB programme from domestic resources and is not reliant on donors. This is in line with the other BRICS countries — Brazil, Russia, India, China — which cumulatively contribute 65% of the global domestic funding for TB.

According to South Africa’s first-ever TB prevalence survey that was conducted in 2018 and reported in 2021, the overall TB prevalence is 737/100,000 with 675/100,000 in females and 1,094/100,000 in males, with the highest prevalence of 1,107/100,000 for those aged 35-44 years. Of concern was the high percentage of those with symptoms who delayed seeking care (66.6%) and a high percentage of asymptomatic TB (57.8%). The survey also found that people living with HIV are more likely to have been diagnosed.  

The Covid-19 pandemic disrupted access to routine healthcare services. During the lockdown in 2020, the number of screenings for TB in the public health sector declined by 19.2% and GeneXpert tests for TB declined by 26% compared to 2019. The restrictions resulted in significantly fewer people diagnosed in 2020 (206,192) compared to 2019 (265,433). 

Furthermore, data from the Department of Health for the last year shows that only 77.8%, against the target of 85%, were successfully treated in 2019, indicating a gap in successful treatment completion rates. Gauteng was the best performing province with an 83.5% rate and the Northern Cape the worst performing at 70.8%. For this reason, this year, the World TB Day event in South Africa is being hosted in the Northern Cape. 

Partnerships between civil society organisations and government are key to eliminating TB as a public health threat in South Africa. As a welcome move, partners, through the South African National Aids Council (Sanac), have developed a TB recovery plan that is in the process of being finalised. The plan includes: 

• A commitment by all partners to find the “missing” 150,000 people with TB;


• Use of TB Check (see description below) to screen at least 1 million people in communities in the next year;


• Implementation of the targeted universal TB testing strategy in high-TB risk groups irrespective of symptoms (people living with HIV, TB contacts, and those with previous TB) and increase in the number of TB tests done in the next year from 2 million to 4 million;


• Expanding access to TB preventive therapy for those at risk for TB to prevent the spread of TB and close the tap on new infections; and


• Decrease the stigma associated with TB — anyone can get TB as it is an airborne disease — and it is curable.