Elsie, Bernard and their five children share a tiny tin-walled single room in Nyalenda, an informal settlement in Kisumu, in Kenya's Nyanza Province. They are both infected with HIV and TB.
"We can't infect them [children] with HIV that easily unless something bad happens, but we know if we don't take care, we could give all of them TB," Elsie, told IRIN/PlusNews.
Studies show that children are likely to acquire TB infection from adults living in the household as well as those having a relationship with them or the family but living away.
Good hygiene practices are an important component of TB infection control and prevention, but maintaining them is not easy in an informal settlement, where houses are crammed together and sanitation facilities hard to come by.
Regular hand-washing, good ventilation, and coughing and sneezing away from other people are all useful tools in TB prevention. Through a community-based organization, Hygiene at Home, Elsie and her family have been receiving lessons on how to have good hygiene in their household.
"When the house is this small, even if you sneeze or cough away from the rest, that ‘far away’ is still close - you can't help it. We have no proper toilets, and water is scarce and you can't use the little available to wash your hands all the time," Elsie said.
"Now I make sure I have some water in my house just for hand-washing, and I have a tin where my husband and I can spit sputum and close it again tightly... the children are a little safer," she said.
Peninah Sewe, the coordinator of the Hygiene at Home initiative, told IRIN/PlusNews that if TB infections in informal settlements were to be contained, proper hygiene was vital.
"Hygiene in health facilities is emphasized, but little is done to promote hygiene amongst TB-infected households, which is important. People living in poor conditions must be helped to keep good hygiene within their homes," she said. "Providing people with handkerchiefs, giving them antiseptics or soap to take home might appear small-time gestures, but are very important in keeping infections under control."
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Through a network of volunteers, Hygiene at Home contacts households in informal settlements in Kisumu and educates them about how to prevent the infection from spreading.
"We teach them how to sneeze and cough in a way that protects the person closest to them. We also teach them how to use small amounts of water to ensure good hand hygiene," Sewe told IRIN/PlusNews.
Kenya is ranked at 13 on a list of 22 countries with the highest TB burdens in the world, and has the fifth highest burden in Africa.
Senior government officials say they recognize the need to improve prevention methods in tandem with treatment programmes.
"As we step up treatment programmes, we might hit a brick wall when we don't promote measures that help in curtailing new infections or re-infections, because… our treatment programmes are strained," Joseph Sitenei, director of the National Leprosy and TB Control Programme, told IRIN/PlusNews.
Door-to-door initiatives could have more impact than big campaigns. "There are campaigns on prevention covering even issues like hygiene, but many people cannot conceptualize them,” Victor Amata, a clinical officer, told IRN/PlusNews. “With face-to-face initiatives, where households are visited, it easy for them to understand."