Background:  Mycobacterium tuberculosis is a prototype, airborne infectious agent, remaining suspended in droplet nuclei for prolonged periods of time and posing a high risk of infection to susceptible populations, notably children and immune-suppressed individuals, in congregate settings. South Africa faces one of the most devastating TB epidemics in the world with more than 400,000 cases per annum, compounded by a large burden of some 10,000 incident cases of multidrug-resistant TB (MDR-TB). The HIV epidemic in South Africa has been one of the fastest-growing epidemics ever recorded, with more than 5 million South Africans currently estimated to be infected. Epidemiologic and molecular genetic studies have confirmed both nosocomial and community transmission of MDR-TB in South Africa, while public health concerns have been amplified by the emergence of extensively drug-resistant TB (XDR-TB) throughout the country, associated with exceptionally high mortality in HIV co-infected XDR-TB patients. While increasing access to HIV treatment and care poses hope for the management of HIV-associated TB, it inadvertently brings together highly vulnerable individuals with infectious cases of M(X)DR-TB, often in congregate settings. Health care facilities comprise complex and diverse environments, and their planning, design, and management are often completely detached from the intended function, with the emphasis on aesthetics and comfort rather than on functionality and fundamental principles to ensure a safe environment. Most public health facilities lack adequate and appropriate airborne infection control measures, both from an administrative (patient and procedure flow) and environmental (engineering control of airborne infection) perspective.  Juxtaposed on high prevalence of HIV (in patients and health care workers), opportunities for M(X)DR-TB transmission are therefore ideal.    

Conclusions:  Appropriate infection control in high HIV-prevalence settings is of paramount concern. The risk of XDR-TB transmission in such environments require immediate and urgent intervention, including early detection of TB drug resistance, segregation of infectious patients, use of appropriate personal respiratory protection, a rapid response to outbreak situations, and urgent implementation of appropriate infection control interventions. The development of appropriate standards for facility design, environmental infection control measures and functional methods for in-house risk assessment and management to prevent airborne infection are also urgently needed.