City of Cape Town

The City of Cape Town has adopted an approach to city transport planning geared to accommodating future uncertainty. This approach has generated new data needs, and necessitated new forms of transport surveys. In addition to household travel surveys required to calibrate models, surveys of diverse disciplinary experts are required to develop plausible scenarios of future travel demand against which the robustness of public transport system improvements can be tested. The aims of this paper are to share experiences in surveying experts to assist in scenario building, and to draw lessons from this experience for future planning cycles. The expert survey was administered using the Delphi panel technique, in two waves. The first wave sought expert insight into: (1) plausible scenarios of Cape Town’s future from the perspective of different fields of disciplinary expertise; and (2) the implications these plausible scenarios may have for travel demand characteristics. The second wave sought to: (1) test a set of propositions about the future arising from the first wave; and (2) establish the extent of divergence within and across disciplinary experts on these propositions. Panellists in some categories found extrapolating current trends into the near future easier than estimating a range of possible and plausible outcomes in the far future. In future planning cycles this limitation might be overcome by a combination of facilitated expert focus groups and anonymous expert Delphi panels that enables both panellist training and promotes unbiased independent thought.

Recurrent tuberculosis (TB) accounts for 30% of the annual TB burden in Cape Town. To better understand mechanisms behind recurrences, we assessed the association between neighborhood factors and the cumulative number of TB episodes per individual between 2003 and 2015. We used TB notification data, previously geocoded, and probabilistically linked with 2011 Census data at the neighborhood level. Individuals were grouped by follow-up time after their first TB episode: 5-10 years (FUT5-10) and over 10 years (FUT10+). Ordinal regressions adjusted for age and sex examined associations, with robust standard errors for neighborhood clustering. A secondary analysis from 2009 onward included HIV status, restricted to individuals with at least five years of follow-up. In the FUT10+ cohort, 9.6% had two TB episodes and 2.1% had three or more; this was 7.9% and 1.3% in FUT5-10, and 7.4% and 1.3% in the secondary analysis cohort (SAC). A higher cumulative number of episodes was associated with neighborhood household size across cohorts (FUT10+ aOR = 1.23 (95% CI 1.15-1.31), FUT5-10 aOR = 1.26 (95% CI 1.16-1.37), annual neighborhood TB incidence (FUT10+ aOR  = 1.13 (95% CI 1.06-1.20), FUT5-10 aOR = 1.11 (95% CI 1.04-1.19)), neighborhood socioeconomic index (FUT10+ aOR  = 0.98 (95% CI 0.95-1.01), FUT5-10 aOR = 0.94 (95% CI 0.91-0.97), SAC aOR = 0.93 (95% CI 0.88-0.98)) and HIV infection (SAC aOR = 1.83 (95% CI 1.59-2.10)). These findings highlight that neighborhood-level risk factors contribute to recurrence and suggest the role of reinfection in recurrent TB. Targeting neighborhoods with high TB incidence, larger households, and lower socioeconomic status may improve screening and reduce TB burden in Cape Town.

Background: Reductions in United States (US) funding for TB and HIV programmes have raised concerns and challenges for TB care and management in South Africa and globally. We used mathematical modelling to illustrate the potential impact of unmitigated funding disruptions, estimating long-term effects on TB incidence and mortality over 2025-2035. Methods: Stakeholder-informed scenarios were modelled, assuming both minimal and maximal disruptions to key TB and HIV services, including preventive therapy for people living with HIV (PLHIV), TB testing, TB treatment initiation, and antiretroviral therapy (ART) coverage. Results and discussion: Between 2025 and 2035, reduced ART coverage was projected to result in 235,000-1,000,000 additional HIV infections; and a 12-41% increase in TB episodes, and 21-72% rise in TB deaths among people living with HIV. Overall, 220,000-730,000 additional TB episodes and 67,000-225,000 TB deaths are anticipated, potentially reversing years of progress. Although mitigation efforts were not included in the model, early responses in South Africa have involved increased diagnostic testing and additional domestic funding. To maintain progress in TB and HIV control, rapid and sustained programmatic responses and funding are essential to prevent substantial setbacks and avert avoidable illness and death. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement Bill and Melinda Gates Foundation under Project Linganisa (grant number INV-019496 and INV-063625). The conclusions and opinions expressed in this work are those of the authors alone and shall not be attributed to the Foundation. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes All data produced in the present study are available upon reasonable request to the authors

Rabies is the oldest documented fatal zoonotic disease, spread between mammals through infected saliva. Outbreaks have only been documented for terrestrial species, with disease risk for marine mammals rarely considered. In June 2024, rabies was confirmed in a marine top predator, the Cape fur seal (CFS, Arctocephalus pusillus pusillus ). We provide the context and timeline of rabies detection following mounting reports of seal aggression, whereby inter-species (seal to domestic dog) transmission prompted diagnostic testing of CFS in South Africa. Laboratory-confirmed cases (n = 94) conservatively date the outbreak in CFS to August 2022; rabies has since been declared endemic to CFS. Aberrant behaviour, hyper-aggression, elevated injury prevalence and confirmation of in-utero transplacental infection were found in this wide ranging, amphibious, highly gregarious and abundant species. Spatio-temporal overlap with vagrant sub-Antarctic pinnipeds makes spillover to other marine mammals possible, creating a subsequent gateway for rabies transmission to Subantarctic Islands and Antarctica, currently rabies-free. At least 135 people have been bitten by suspected or confirmed rabid seals, most receiving post-exposure prophylaxis. Rabies detection in CFS increased between 2022 and 2025 in both diagnostic and systematic surveillance sampling. This suggests an outbreak which is still in an active expansion phase. Considering the tri-partite alliance (FAO-WOAH-WHO) target of zero dog-mediated rabies by 2030, the increasing number of seal attacks towards dogs, and humans raise urgent considerations that should be addressed under One Health.

South Africa’s worsening inequality and unemployment and high greenhouse gas emissions require climate-resilient strategies that empower local governments. Responding to the country’s highly contested energy transition and bringing together decarbonization and development priorities are critical for all spheres of government. The energy transition presents a confluence of challenges and opportunities for climate action that are exacerbated in urban settings. The needs of vulnerable households must deliberately be centred for energy transition responses that support just and inclusive climate action. Targeting energy poverty sheds light on household energy behaviour that can promote inclusive shifts to cleaner, affordable, and safe energy sources and inform appropriate urban climate action strategies by local governments. Drawing from experience with energy poverty alleviation in the City of Cape Town (CCT), we argue that a context-sensitive understanding of energy poverty is required to support urban climate resilience and inclusive development. CCT has made progress with centring energy poverty in its climate resilience and urban development strategies, signified in the establishment of the Energy Poverty Alleviation team in 2017, plus the inclusion of energy poverty as a pillar in the 2050 Energy Strategy. We reflect on these efforts to mainstream energy poverty alleviation within CCT and elaborate on interventions and partnerships that demonstrate this strategic commitment. We further emphasize five priorities for research and innovation for climate action from the vantage point that energy poverty alleviation is a critical dimension of local governments’ climate action strategies and South Africa’s broader just energy transition.