To answer this question, we analysed the Ideal Clinic Initiative Framework, tuberculosis infection prevention and control guidelines and our clinic ethnography data of four selected primary health care facilities in KwaZulu-Natal, South Africa. Find out what opportunities and challenges the implementation of health system reform can bring for the prevention and control of TB at South African primary health care facilities. Presented by Gimenne Zwama at the 6th Global Symposium on Health Systems Research. 

By Gimenne Zwama

World Bank photo

It is sometimes hard to imagine life before the COVID-19 pandemic. More than a year ago, we were driving across the beautifully lush South African province of KwaZulu-Natal to visit different health facilities. For our research project Umoya Omuhle, which translates to “good air” from isiZulu, we were interested in improving ways to prevent the bacteria that cause TB from being transmitted through the air at health facilities. At that time, conversations about infection prevention and control measures were not trending as they are today. However, the World Health Organization had already long-established recommendations for ways to prevent the transmission of TB in health facilities. One of which you will certainly have become familiar with: wearing a mask.

During the first three days we spent at each of the six primary health care facilities, it quickly became clear that wearing a surgical mask (for patients) or respirator (for health care workers) was the exception, not the rule. When asked, health care workers often became slightly embarrassed. They know that they are supposed to wear a respirator to protect themselves, but find them suffocating and unbearable to wear in hot temperatures (to which you may be able to relate to by now). There is also stigma among patients and staff towards surgical masks and respirators, particularly if they are only worn by one or a few patients and staff members. An added problem is that the effective use of respirators requires trying on different shapes and sizes through “fit-testing”, but none of the facilities we visited had the capability to do this.

If, at this time, you would have told us that a year later masks would become a familiar sight on the streets and even an appealing source of revenue to the retail industries, we would have been very surprised. To date, a quick Google search shows that the estimated global COVID-19 death toll has surpassed half a million over a 7-month period (though likely to be an underestimate). Strikingly, 1.5 million people died from TB in 2018, and this has been a roughly consistent yearly pattern of the past two decades. Could this pandemic be an opportunity for the return of the mask to prevent TB?

But how effective is mask-wearing for TB and COVID-19? The lack of evidence on the effectiveness of masks in filtering the air we breathe has previously limited the ability to implement strict rules around any type of mask wearing. This lack of clarity coupled with the uncomfortable and fidgety experience of wearing a respirator or mask in stuffy, overcrowded clinics has led to problems with mask-wearing. Let’s discuss the current evidence on what we know, and what we don’t know about mask-wearing for disease protection.

We know that TB bacteria and COVID-19 viruses can move through the air via variously sized droplets and particles. TB bacteria are known to spread in small droplets and can hang around and travel in the air, like specs of dust, after being coughed up. The disease spreads when another person breathes them in – this is known as airborne transmission. In contrast, the virus that causes COVID-19 is mostly carried in bigger, heavier droplets, which settle on surfaces and are then transferred from a person’s hands to their mouth, nose, or eyes. However, recent evidence suggests that COVID-19 may be also spread via the airborne route, similar to TB.

Different types of masks can effectively filter the air of most droplets and bigger particles by collecting them on the mask surface when breathing, talking, laughing, singing, coughing or sneezing. We know that respirators, known as N95 or FFP2/3 masks, protect the wearer from breathing in both large and small droplets containing viruses and bacteria. Although they cannot filter all the tiny particles, they are particularly helpful in high-risk healthcare settings. Surgical masks protect other people from the person wearing the mask coughing, sneezing or breathing out bigger droplets. These are therefore best used by patients and are known to halve the risk of spreading TB. Less is known about the effectiveness of fabric or paper masks, and although they work similarly to surgical masks, they are thought to be less protective. They can, however, provide some protection to others if the fabric or paper used is dense, layered and fits snugly onto the face of the wearer. These are therefore best used by the public, those who do not experience any symptoms but may unknowingly be infected and potentially infectious.

In short, we know that none of these masks are 100% perfect in preventing COVID-19 and TB, but wearing something that covers your mouth and nose is likely to reduce the risk of you passing disease to other people. Because the particles and droplets collect on the mask surface, it is crucial to properly and regularly wash your hands to protect yourself, especially immediately before and after you use any type of mask. Physical distancing is another important measure, especially for COVID-19 prevention. Distancing reduces the opportunity to inhale potentially dangerous particles as there is more time for bigger particles to settle on the ground before reaching you. Opening the windows or being outside means that potentially infectious particles are quickly dispersed and are less likely to be inhaled. And, painfully, the less time you spend with others, the less you potentially expose yourself and others.

It is crucial that we continue the conversation on mask-wearing and ‘clear the air’ long after this pandemic. TB is already an existing threat to millions of lives and will continue to burden health systems of many low- and middle-income countries, such as South Africa. The COVID-19 pandemic response gives us an opportunity to establish stronger health systems and practices for sustainable TB prevention, and perhaps change embedded habits around infectious disease control. It’s now time to listen and learn from this pandemic and do our best to protect those most vulnerable to infectious diseases.

More information about fabric masks.

Credit - hand washing cartoon.

Three researchers from Umoya Omuhle feature in LSHTM Viral's podcast, explain the complex links between TB transmission, COVID-19 and the role human behaviour in controlling infectious diseases.

The way people act and behave inside health clinics can impact the spread of infectious diseases like COVID-19, TB and Ebola. Understanding how this happens is essential for effective, long-lasting public health solutions. We speak to Alison Swartz, Aaron Karat and Karina Kielmann who work through a 'systems approach' that includes social science, anthropology and epidemiology in infection prevention control in South Africa.

After presenting her research proposal to a panel of examiners during her upgrading, Chloe will be continuing her exiting research on TB control in South Africa.

Why is this important?

It is becoming increasingly apparent that a wider view of TB control is needed, not only for TB treatment today but for TB management in the future. In particular, studying the historical and anthropological elements to infection prevention and linking this to the space in which TB is controlled and treated. Taking a wide approach to research in this area can also help us to understand government responses to public health crises, such as the South African national epidemics of TB and drug-resistant (DR)-TB, and highlight notable contextual and historical issues that play a part in public health treatment and response.

What will Chloe’s project look at?

Chloe will focus on the rural community setting of Mtubatuba in the South African province of KwaZulu-Natal (KZN) and pay particular attention to the space of the primary care clinic. This work will be attached to Umoya Omuhle, which is based in the Western Cape and KZN provinces. Umoya Omuhle demonstrates a pragmatic approach to the public health problem of TB and Drug resistant-TB and is channelled through the established policy of Infection Prevention Control (IPC).

The specific question Chloe will address is: How do histories of South African TB control, public health systems and spatial realities continue to shape contemporary responses to this disease, especially now in its increasingly drug-resistant state?

Chloe will consider the issue of TB control and study the previous attempts to limit drug-resistance. She will use the concept of ‘infrastructure’ to examine how these dimensions intersect within a primary care clinic in rural KwaZulu-Natal and investigating how histories relate to infrastructure of public health work. To study this, she will use a mixture of ethnographic and historical methods, document collection and analysis, observation, and oral histories.

The Umoya omuhle project held a successful expert workshop on TB transmission in South African primary healthcare facilities from the 6th – 7th August in Durban, South Africa. TB is a key health priority for South Africa. Preventing TB, and drug-resistant TB, transmission in health facilities is essential, but implementation of well-established guidelines to prevent TB transmission in clinics remains suboptimal. The workshop gathered the perspectives of policymakers and practitioners in South Africa using a method called group model building. The process explored the drivers of TB and drug-resistant TB transmission in health facilities to understand the challenges to policy implementation, and participants' views on potential solutions. The workshop outputs will inform development of novel interventions; we will explore the potential impact of these interventions in modelling work over the next year.

Long clinic waiting times are a potential driver of TB transmission. On Thursday 8th August, a workshop on ‘patient flow’ in primary healthcare facilities gathered stakeholders' perspectives concerning methods to measure waiting times, and potential ways to reduce the time patients spend in primary health clinics.

We recently held an expert workshop on TB transmission in South African primary healthcare facilities, gathering perspectives from policymakers and practitioners.

The Umoya omuhle team attended their third investigators' meeting in Ballito, South Africa. The four-day meeting reviewed project progress to date, reviewing qualitative and quantitative data from 12 health care facilities in KwaZulu-Natal and the Western Cape provinces. The investigators also met with the project reference group which included Ms Jacqui Ngozo, Director of TB programmes, KwaZulu-Natal Department of Health; Dr Vanessa Mudaly, a senior medical officer for health programmes at the HAST Directorate in the Western Cape Provincial Government; Professor Helen Schneider, a public health specialist and health systems and policy researcher from the University of the Western Cape and Dr Thiloshini Govender, a public health medicine specialist and occupational health physician at the King Dinuzulu Hospital.

The aim of this meeting was to consider and prioritise, based on evidence obtained to date, possible interventions to reduce transmission of tuberculosis in primary healthcare facilities in South Africa. The project will employ an innovative approach - system dynamics modelling - to engage policymakers and practitioners to identify, design, and prioritise potential interventions at a meeting in August.

_{[L-R Anna Voce; Gimenne Zwama; Karin Diaconu, Sanj Karat; Idriss Kallon; Jacqui Ngozo; Indira Govender; Hayley MacGregor; Alison Grant; Alison Swartz; Thilo Govender; Tom Yates; Nicky McCreesh; Fiamma Bozzani. Photo: Adrienne Burrough]}