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24 March 2023 | Story Profs Gladys Kigozi-Male, Christo Heunis, and Michelle Engelbrecht | Photo Supplied
Prof Christo Heunis, Prof Michelle Engelbrecht, Prof Gladys Kigozi-Male
From the left, Prof Christo, Prof Michelle Engelbrecht, and Prof Gladys Kigozi-Male.

 Opinion article by Profs Gladys Kigozi-Male, Christo Heunis, and Michelle Engelbrecht, Centre for Health Systems Research and Development, University of the Free State.


Each year on 24 March, the world commemorates World TB (Tuberculosis) Day. This date coincides with the day in 1882 when Robert Koch announced his discovery of the Mycobacterium Tuberculosis, the germ that causes TB. This infectious disease is transmitted through airborne droplets when an infected person coughs, sings, shouts, or sneezes. TB primarily affects the lungs (i.e., pulmonary TB), but other organs in the body such as the pleura, lymph nodes, abdomen, genitourinary tract, skin, joints and bones, or meninges (i.e., extra-pulmonary TB) can also be affected. TB can be cured; effective anti-TB drugs have been available for almost eight decades. Despite this, TB continues to wreak havoc across the world and in South Africa. According to a report released by the World Health Organisation (WHO), an estimated 304 000 new TB cases were reported in South Africa in 2021 and 56 000 people succumbed to the disease in the same year

A world without TB

In 2014, the sixty-seventh World Health Assembly endorsed a global strategy and targets for TB prevention, care, and control. The strategy envisions a world without TB, aiming to end the epidemic by 2035. By this target date, a reduction in TB deaths of 95% and new infections of 90% – compared to the respective levels in 2015 – are anticipated. Further to this, the United Nations’ Stop TB Partnership was mandated to drive activities to end the global TB epidemic. In 2015, the partnership launched the 90-(90)-90 targets; to reach at least 90% of people with TB and place them on appropriate treatment, including at least 90% of vulnerable populations such as people living with HIV, and to ensure that at least 90% of people with TB are successfully treated. Despite commendable progress, persisting high TB infection and death rates are adversely affecting global and national efforts to end the TB epidemic. With a treatment success rate of only 78% in 2020, South Africa is sorely challenged to attain the global target of 95%.

TB with mental health illness

One of the challenges confronting TB control is the frequent comorbidity of TB with mental health illness. There is compelling evidence linking TB to common mental health problems such as depression, anxiety, and alcohol misuse. Research indicates that TB patients can experience mental health problems at any time during the course of their TB treatment. Undiagnosed mental illness among TB patients may result in poor health-seeking behaviour and non-adherence to treatment, subpar quality of life, and negative treatment outcomes. The WHO's Global End TB Strategy thus recommends integrated patient-centred TB care. This implies that TB care should be provided in close collaboration with other primary health-care (PHC) programmes such as mental health. However, in many countries – South Africa included – efforts to integrate mental health and TB care are confronted by challenges such as limited capacity, nonrecognition of mental health as a problem, insufficient resources, and TB-related social stigma. Consequently, mental health conditions in TB patients are often un-/under-/mis-diagnosed.

Taking depression as a compelling example, a scoping review reported the prevalence of depression as high as 84% among people with TB in studies conducted internationally. However, little is known about the prevalence of depression among TB patients in South Africa. Using a nine-item Patient Health Questionnaire, we assessed probable depression among a sample of TB patients attending PHC facilities in the Free State. We found that almost half (46,1%) of the 208 patients interviewed had probable depression, with 22,6%, 18,8%, and 4,8% having mild, moderate, and severe symptoms, respectively. Probable depression was almost four times more likely among patients diagnosed with extra-pulmonary TB compared to pulmonary TB patients. HIV-infected TB patients undergoing antiretroviral therapy were more than twice as likely to experience symptoms of depression compared to their counterparts who were not undergoing such therapy. This could possibly be attributed to non-adherence to antiretroviral therapy. Studies elsewhere have established a significant association between depression and ART non-adherence. We further found that the longer patients were retained on TB treatment, the less likely they were to display symptoms of depression.

Important to monitor TB patients for depression

Based on these findings, it is important to monitor TB patients for symptoms of depression – particularly those with comorbid HIV – in PHC settings. At the same time, ensuring that patients stay on treatment by providing adequate support for treatment adherence may help to mitigate depression during TB treatment. 

The theme for this year’s World TB Day is ‘Yes! We can end TB’. It is a call for concerted multi-sectoral collaboration between governments, civil society, communities, academia and technical partners, international aid and scientific organisations, the private sector, and disease control programmes in the country to eliminate the TB epidemic. To this end, TB patients attending PHC facilities in South Africa need to be routinely screened for mental health illness. Given the critical shortage of mental health specialists, screening for mental illnesses could be undertaken by trained and well-supervised non-specialist healthcare cadres such as community health workers.

News Archive

Bloemfontein's quality of tap water compares very favourably with bottled water
2009-08-04

The quality of the drinking water of five suburbs in Bloemfontein is at least as good as or better than bottled water. This is the result of a standard and chemical bacterial analysis done by the University of the Free State’s (UFS) Centre for Environmental Management in collaboration with the Institute for Groundwater Studies (IGS).

Five samples were taken from tap water sources in the suburbs of Universitas, Brandwag, Bain’s Vlei, Langenhoven Park and Bayswater and 15 samples were taken of different brands of still and unflavoured bottled water. The samples were analysed at the laboratory of the IGS, while the interpretation of the analysis was done by the Centre for Environmental Management.

“We wanted to evaluate the difference in quality for human consumption between tap water and that of the different brands of bottled water,” said Prof. Maitland Seaman, Head of the Centre for Environmental Management.

“With the exception of two samples produced by multinational companies at their plants in South Africa, the different brands of bottled water used for the study were produced by South African companies, including a local small-scale Bloemfontein producer,” said Prof. Seaman.

According to the labels, the sources of the water vary from pure spring water, to partial reverse osmosis (as an aid to standardise salt, i.e. mineral, content), to only reverse osmosis (to remove salts). (Reverse osmosis is a process in which water is forced under pressure through a pipe with minute pores through which water passes but no – or very low concentrations of – salts pass.)

According to Prof. Seaman, the analysis revealed some interesting findings, such as:

• It is generally accepted that drinking water should have an acceptable level of salt content, as the body needs salts. Most mineral contents were relatively higher in the tap water samples than the bottled water samples and were very much within the acceptable range of drinkable water quality. One of the bottled samples, however, had a very low mineral content, as the water was produced by reverse osmosis, as stated on the bottle. While reverse osmosis is used by various producers, most producers use it as an aid, not as a single method to remove nearly all the salts. Drinking only such water over a prolonged period may probably have a negative effect on the human physiology.

• The pH values of the tap water samples (8,12–8,40) were found to be slightly higher (slightly alkaline), like in all south-eastern Free State rivers (from where the water is sourced) than the pH of most of the bottled water samples, most of which are sourced and/or treated in other areas. Two brands of bottled water were found to have relatively low pH levels (both 4,5, i.e. acidic) as indicated on their bottles and as confirmed by the IGS analysis. The health implication of this range of pH is not significant.

• The analysis showed differences in the mineral content given on the labels of most of the water bottles compared to that found by IGS analysis. The possibility of seasonal fluctuation in content, depending on various factors, is expected and most of the bottling companies also indicate this on their labels. What was a rather interesting finding was that two pairs of bottled water brands claimed exactly the same mineral content but appeared under different brand names and were also priced differently. In each case, one of the pair was a well-known house brand, and the other obviously the original producer. In one of these paired cases, the house brand stated that the water was spring water, while the other (identical) “original” brand stated that it was spring water treated by reverse osmosis and oxygen-enriched.

• Nitrate (NO3) levels were uniformly low except in one bottled sample, suggesting a low (non-threatening) level of organic pollution in the source water. Otherwise, none of the water showed any sign of pollution.

• The bacterial analysis confirmed the absence of any traces of coliforms or E.coli in any of the samples, as was also indicated by the bottling companies. This is very reassuring. What is not known is how all these waters were sterilised, which could be anything from irradiation to chlorine or ozone treatment.

• The price of the different brands of bottled water, each containing 500 ml of still water, ranged between R3,99 and R8,99, with R5,03 being the average price. A comparison between the least expensive and the most expensive bottles of water indicated no significant difference in quality. In fact, discrepancies were observed in the most expensive bottle in that the amount of Calcium (Ca) claimed to be present in it was found to be significantly different from what the analysis indicated (29,6 mg/l versus 0,92 mg/l). The alkalinity (CaCO3 mg/l) indicated on the bottle was also found to differ considerably (83 mg/l versus 9,4 mg/l). The concentration of Total Dissolved Salts (TDS) was not given on the product.

“The preference for bottled water as compared to Bloemfontein’s tap water from a qualitative perspective as well as the price discrepancy is unjustifiable. The environmental footprint of bottled water is also large. Sourcing, treating, bottling, packaging and transporting, to mention but a few of the steps involved in the processing of bottled water, entail a huge carbon footprint, as well as a large water footprint, because it also requires water for treating and rinsing to process bottled water,” said Prof. Seaman.

Media Release
Lacea Loader
Deputy Director: Media Liaison
Tel: 051 401 2584
Cell: 083 645 2454
E-mail: loaderl.stg@ufs.ac.za  
3 August 2009

 

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