WORCESTER, South Africa - Janine September extends her slender arm toward a nurse's syringe, hoping that the hundreds of vials of blood extracted in the past six months will help conquer a 4,000-year-old curse: tuberculosis, which kills an estimated two million every year.
Worcester, a small town among the fruit farms and vineyards outside Cape Town, has staggeringly high TB rates. It is at the fore of international field trials of a new TB vaccine, with three candidates being tested on hundreds of volunteers like the 23-year-old September.
The aim is to develop an alternative to Bacille Calmette Guerin, or BCG, a vaccine in use since the 1920s that offers little protection against adult pulmonary TB, which accounts for the majority of cases.
"This is the centre of TB vaccine research in the world, right here," says Jerry Sadoff, president and chief executive officer of Aeras Global TB Vaccine Foundation, the non-profit group financing the South African trials with grants from the Bill & Melinda Gates Foundation and the Dutch and Danish governments.
TB research has languished in recent years while attention has been focused on fighting AIDS. But there is an upsurge of interest from drug companies, driven by evidence that TB and AIDS feed off each other. Researchers hope their new TB vaccine will be ready by 2015.
"If we are able to shorten treatment and introduce one or two powerful new vaccines, then maybe the days of TB are numbered," said Marcos Espinal, head of Stop TB, a partnership spearheaded by the World Health Organization between the public and private sector.
More than 4,000 years ago, TB killed an Egyptian, according to mummified remains. Hippocrates called it "consumption" in 460 BC.
"We've been dealing with this for 4,000 years. It's a disgrace," said Espinal. "The current vaccine was introduced in 1922 and we have nine million new cases per year, which tells you there is a problem."
Without new tools, he said, it will be impossible to tame TB.
It is estimated that someone is infected every second with TB, which spreads easily through the air. China, India and Russia are among the hardest hit. But it is in sub-Saharan Africa that TB has combined with AIDS with devastating consequences, striking at the weakened immune system of its victims.
Nearly 60 per cent of South African TB patients have the AIDS virus. The emergence of drug-resistant TB strains has worsened their chances of survival. There were 2,901 cases of multi-drug resistant TB in South Africa last year, and 561 cases of extensively drug-resistant TB, which is virtually incurable. Authorities have begun to quarantine patients in isolation wards surrounded by barbed wire.
Worcester has one of the highest TB rates - if not the highest - in the world. A recent study by the South African TB Vaccine Initiative found that three per cent of infants had TB, or an incidence rate of 3,000 per 100,000. Among all age groups, there are 1,400 cases per 100,000 - double the national average in a country which is already one of the worst affected. Rates in most developed countries are well under 20 per 100,000, according to WHO.
Beneath the veneer of small-town prosperity, the spanking-new casino and the manicured grounds of the wine estates lurks chronic and deep-seated poverty and overcrowding in desolate informal settlements that are invisible to the casual visitor.
Many who toil on the farms and factories here are badly paid seasonal workers who migrate from inner-city areas, bringing their health problems with them. There is no reliable public transport system to take people in far-flung rural areas to health facilities - "the tyranny of distance," says Gregory Hussey, director of the South African TB Vaccine Initiative.
Added to that is excessively high alcohol consumption. The areas around Worcester have the world's highest rates of fetal alcohol syndrome, the legacy of farmers in the apartheid era paying their workers in wine. Children are born small and weak and so are ready prey to TB, Hussey said.
Many of the children on the ward at Brewelskloof hospital bear the telltale symptoms of alcoholic mothers, he says. At first sight, the kids tucking into minced meat and rice and squabbling over toys seem bright enough. But the jaunty girl with tight plaits who looks six is in fact 11 years old. She has multidrug-resistant TB and has been at the hospital for a year, with no early release in sight.
About 10 people a day are currently being screened in small consulting rooms at the hospital to see if they are eligible to take part in the trials. They need to be healthy, HIV negative and with no history of TB.
Volunteers are reimbursed for travelling costs and the time spent on the trials -- a considerable amount of money in a community ravaged by 50 per cent unemployment.
Clinical manager Michele Tameris says close links with local township clinics and factories has spread news of the trials through word of mouth and dispelled any suspicion. Many people volunteer because they get HIV and TB tests, with none of the stigma associated with going to a normal government clinic.
"TB is rife here and it makes it easier for us to work. Most people know someone who has had TB," says Tameris. "If you ask someone if they have had TB, they will say 'not yet,' so they are assuming they will get infected."
Results are promising from safety and immunology tests being conducted on three vaccines, including one developed by scientists at Britain's Oxford University. It is hoped that there will be large-scale trials by 2010 to determine if the vaccine works and a licensed vaccine by 2015, says Sadoff from Aeras. Much can go wrong in between, as other trials into promising HIV vaccines have shown, but Hussey and his colleagues are upbeat.
Paul Fine, professor of communicable disease epidemiology at the London School of Hygiene and Tropical Medicine, finds the targets are optimistic given that TB is much more immunologically complex than, say, measles.
"It's certainly not going to happen in the next few years," he says.
Volunteer September wants her small part to pay off.
"I hope it will help the community," she said.
