The global emergency of tuberculosis: what is the cause?
Identifieur interne : 004946 ( Istex/Corpus ); précédent : 004945; suivant : 004947The global emergency of tuberculosis: what is the cause?
Auteurs : J M Grange ; A. ZumlaSource :
- Perspectives in public health [ 1466-4240 ] ; 2002-06.
English descriptors
- KwdEn :
- Active tuberculosis, Aids patients, Bacillus, Biphasic nature, Bull world health, Centre, Chronic disease, Communicable disease surveillance centre, Curr opin pulm, Ethnic minority populations, Global, Global emergency, Grange, Health june, Human history, Human population, Human race, Infectious diseases, International health, Massive effort, Mdrtb, More cases, Multidrug resistance, Overt disease, Overt tuberculosis, Royal society, Russian prisons, Strict supervision, Tuberc lung, Tubercle, Tubercle bacillus, Tuberculosis, Tuberculosis control, Tuberculosis patients, Union tuberc lung, World health organization, World today, Young adults.
- Teeft :
- Active tuberculosis, Aids patients, Bacillus, Biphasic nature, Bull world health, Centre, Chronic disease, Communicable disease surveillance centre, Curr opin pulm, Ethnic minority populations, Global, Global emergency, Grange, Health june, Human history, Human population, Human race, Infectious diseases, International health, Massive effort, Mdrtb, More cases, Multidrug resistance, Overt disease, Overt tuberculosis, Royal society, Russian prisons, Strict supervision, Tuberc lung, Tubercle, Tubercle bacillus, Tuberculosis, Tuberculosis control, Tuberculosis patients, Union tuberc lung, World health organization, World today, Young adults.
Abstract
The treatment of tuberculosis is cheap and highly effective, yet worldwide the disease remains a serious cause of illness and death; so serious as to have been declared a ‘global emergency’ in 1993. It is principally a disease of poverty, with 95% of cases and 98% of deaths occurring in developing countries. The incidence of tuberculosis is increasing worldwide, partly due to poverty and inequity and partly to the HIV/AIDS pandemic, which greatly increases the risk of infection proceeding to overt disease. Around 30% of AIDS-related deaths are due to tuberculosis. The emergence of multidrug resistant tuberculosis (MDRTB) is an increasing threat to tuberculosis control. Although treatable with alternative drugs, the cost is enormous and, accordingly, not undertaken in many poor nations. While the overall global incidence of MDRTB is low, it occurs in certain ‘hotspots’ including Russian prisons. Due to adverse socio-economic factors, London has not escaped the general rise in incidence and, without the introduction of active control strategies, there could be a serious epidemic as occurred in New York City ten years ago which required an enormous financial outlay for its control. In view of the global emergency of tuberculosis, the WHO ‘Stop TB’ campaign has called for the universal adoption of its directly observed therapy, short course (DOTS) strategy. Also, through the Massive Effort Against Diseases of Poverty, several international agencies are urging the establishment of effective control programmes worldwide. London should take the lead and set an example.
Url:
DOI: 10.1177/146642400212200206
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ISTEX:E108F39FD3DF2D3DF2CC69BA465BAD4F88140C8DLe document en format XML
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It is principally a disease of poverty, with 95% of cases and 98% of deaths occurring in developing countries. The incidence of tuberculosis is increasing worldwide, partly due to poverty and inequity and partly to the HIV/AIDS pandemic, which greatly increases the risk of infection proceeding to overt disease. Around 30% of AIDS-related deaths are due to tuberculosis. The emergence of multidrug resistant tuberculosis (MDRTB) is an increasing threat to tuberculosis control. Although treatable with alternative drugs, the cost is enormous and, accordingly, not undertaken in many poor nations. While the overall global incidence of MDRTB is low, it occurs in certain ‘hotspots’ including Russian prisons. Due to adverse socio-economic factors, London has not escaped the general rise in incidence and, without the introduction of active control strategies, there could be a serious epidemic as occurred in New York City ten years ago which required an enormous financial outlay for its control. In view of the global emergency of tuberculosis, the WHO ‘Stop TB’ campaign has called for the universal adoption of its directly observed therapy, short course (DOTS) strategy. Also, through the Massive Effort Against Diseases of Poverty, several international agencies are urging the establishment of effective control programmes worldwide. London should take the lead and set an example.</div></front></TEI><istex><corpusName>sage</corpusName><keywords><teeft><json:string>mdrtb</json:string><json:string>tubercle</json:string><json:string>grange</json:string><json:string>tuberculosis</json:string><json:string>world health organization</json:string><json:string>global emergency</json:string><json:string>tuberculosis control</json:string><json:string>royal society</json:string><json:string>infectious diseases</json:string><json:string>massive effort</json:string><json:string>health june</json:string><json:string>bacillus</json:string><json:string>active tuberculosis</json:string><json:string>tuberc lung</json:string><json:string>communicable disease surveillance centre</json:string><json:string>young adults</json:string><json:string>tubercle bacillus</json:string><json:string>multidrug resistance</json:string><json:string>human race</json:string><json:string>bull world health</json:string><json:string>human history</json:string><json:string>russian prisons</json:string><json:string>chronic disease</json:string><json:string>biphasic nature</json:string><json:string>overt tuberculosis</json:string><json:string>overt disease</json:string><json:string>human population</json:string><json:string>more cases</json:string><json:string>international health</json:string><json:string>ethnic minority populations</json:string><json:string>aids patients</json:string><json:string>strict supervision</json:string><json:string>tuberculosis patients</json:string><json:string>curr opin pulm</json:string><json:string>union tuberc lung</json:string><json:string>world today</json:string><json:string>centre</json:string><json:string>global</json:string></teeft></keywords><author><json:item><name>J M Grange</name><affiliations><json:string>Centre for Infectious Diseases and International Health, Royal Free and University College Medical School, Windeyer Institute for Medical Science, Room G40, 46 Cleveland Street, London W1P 6DB, England,</json:string><json:string>E-mail: sophia@hagia.freeserve.co.uk</json:string></affiliations></json:item><json:item><name>A Zumla</name><affiliations><json:string>Centre for Infectious Diseases and International Health, Royal Free and University College Medical School, Windeyer Institute for Medical Science, Room G40, 46 Cleveland Street, London W1P 6DB, England,</json:string><json:string>E-mail: a.zumla@ucl.ac.uk</json:string></affiliations></json:item></author><subject><json:item><lang><json:string>eng</json:string></lang><value>AIDS</value></json:item><json:item><lang><json:string>eng</json:string></lang><value>DOTS</value></json:item><json:item><lang><json:string>eng</json:string></lang><value>HIV</value></json:item><json:item><lang><json:string>eng</json:string></lang><value>multidrug resistance</value></json:item><json:item><lang><json:string>eng</json:string></lang><value>poverty</value></json:item><json:item><lang><json:string>eng</json:string></lang><value>tuberculosis</value></json:item></subject><articleId><json:string>10.1177_146642400212200206</json:string></articleId><language><json:string>eng</json:string></language><originalGenre><json:string>research-article</json:string></originalGenre><abstract>The treatment of tuberculosis is cheap and highly effective, yet worldwide the disease remains a serious cause of illness and death; so serious as to have been declared a ‘global emergency’ in 1993. It is principally a disease of poverty, with 95% of cases and 98% of deaths occurring in developing countries. The incidence of tuberculosis is increasing worldwide, partly due to poverty and inequity and partly to the HIV/AIDS pandemic, which greatly increases the risk of infection proceeding to overt disease. Around 30% of AIDS-related deaths are due to tuberculosis. The emergence of multidrug resistant tuberculosis (MDRTB) is an increasing threat to tuberculosis control. Although treatable with alternative drugs, the cost is enormous and, accordingly, not undertaken in many poor nations. While the overall global incidence of MDRTB is low, it occurs in certain ‘hotspots’ including Russian prisons. Due to adverse socio-economic factors, London has not escaped the general rise in incidence and, without the introduction of active control strategies, there could be a serious epidemic as occurred in New York City ten years ago which required an enormous financial outlay for its control. In view of the global emergency of tuberculosis, the WHO ‘Stop TB’ campaign has called for the universal adoption of its directly observed therapy, short course (DOTS) strategy. Also, through the Massive Effort Against Diseases of Poverty, several international agencies are urging the establishment of effective control programmes worldwide. 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It is principally a disease of poverty, with 95% of cases and 98% of deaths occurring in developing countries. The incidence of tuberculosis is increasing worldwide, partly due to poverty and inequity and partly to the HIV/AIDS pandemic, which greatly increases the risk of infection proceeding to overt disease. Around 30% of AIDS-related deaths are due to tuberculosis. The emergence of multidrug resistant tuberculosis (MDRTB) is an increasing threat to tuberculosis control. Although treatable with alternative drugs, the cost is enormous and, accordingly, not undertaken in many poor nations. While the overall global incidence of MDRTB is low, it occurs in certain ‘hotspots’ including Russian prisons. Due to adverse socio-economic factors, London has not escaped the general rise in incidence and, without the introduction of active control strategies, there could be a serious epidemic as occurred in New York City ten years ago which required an enormous financial outlay for its control. In view of the global emergency of tuberculosis, the WHO ‘Stop TB’ campaign has called for the universal adoption of its directly observed therapy, short course (DOTS) strategy. Also, through the Massive Effort Against Diseases of Poverty, several international agencies are urging the establishment of effective control programmes worldwide. London should take the lead and set an example.</p></abstract><textClass><keywords scheme="keyword"><list><head>keywords</head><item><term>AIDS</term></item><item><term>DOTS</term></item><item><term>HIV</term></item><item><term>multidrug resistance</term></item><item><term>poverty</term></item><item><term>tuberculosis</term></item></list></keywords></textClass></profileDesc><revisionDesc><change when="2002-06">Published</change></revisionDesc></teiHeader></istex:fulltextTEI><json:item><extension>txt</extension><original>false</original><mimetype>text/plain</mimetype><uri>https://api.istex.fr/document/E108F39FD3DF2D3DF2CC69BA465BAD4F88140C8D/fulltext/txt</uri></json:item></fulltext><metadata><istex:metadataXml wicri:clean="corpus sage not found" wicri:toSee="no header"><istex:xmlDeclaration>version="1.0" encoding="UTF-8"</istex:xmlDeclaration><istex:docType PUBLIC="-//NLM//DTD Journal Publishing DTD v2.3 20070202//EN" URI="journalpublishing.dtd" name="istex:docType"></istex:docType><istex:document><article article-type="research-article" dtd-version="2.3" xml:lang="EN"><front><journal-meta><journal-id journal-id-type="hwp">sprsh</journal-id><journal-id journal-id-type="publisher-id">RSH</journal-id><journal-title>The Journal of the Royal Society for the Promotion of Health</journal-title><issn pub-type="ppub">1466-4240</issn><publisher>
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<contrib-group><contrib contrib-type="author" xlink:type="simple"><name name-style="western"><surname>Grange</surname><given-names>J M</given-names></name><aff>Centre for Infectious Diseases and International Health, Royal Free and University College Medical School, Windeyer Institute for Medical Science, Room G40, 46 Cleveland Street, London W1P 6DB, England, <email xlink:type="simple">sophia@hagia.freeserve.co.uk</email>
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<contrib-group><contrib contrib-type="author" xlink:type="simple"><name name-style="western"><surname>Zumla</surname><given-names>A</given-names></name><aff>Centre for Infectious Diseases and International Health, Royal Free and University College Medical School, Windeyer Institute for Medical Science, Room G40, 46 Cleveland Street, London W1P 6DB, England, <email xlink:type="simple">a.zumla@ucl.ac.uk</email>
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<pub-date pub-type="ppub"><month>06</month><year>2002</year></pub-date><volume>122</volume><issue>2</issue><fpage>78</fpage><lpage>81</lpage><abstract>
<p>The treatment of tuberculosis is cheap and highly effective, yet worldwide the disease remains a serious cause of illness and death; so serious as to have been declared a ‘global emergency’ in 1993. It is principally a disease of poverty, with 95% of cases and 98% of deaths occurring in developing countries.</p>
<p>The incidence of tuberculosis is increasing worldwide, partly due to poverty and inequity and partly to the HIV/AIDS pandemic, which greatly increases the risk of infection proceeding to overt disease. Around 30% of AIDS-related deaths are due to tuberculosis.</p>
<p>The emergence of multidrug resistant tuberculosis (MDRTB) is an increasing threat to tuberculosis control. Although treatable with alternative drugs, the cost is enormous and, accordingly, not undertaken in many poor nations. While the overall global incidence of MDRTB is low, it occurs in certain ‘hotspots’ including Russian prisons.</p>
<p>Due to adverse socio-economic factors, London has not escaped the general rise in incidence and, without the introduction of active control strategies, there could be a serious epidemic as occurred in New York City ten years ago which required an enormous financial outlay for its control.</p>
<p>In view of the global emergency of tuberculosis, the WHO ‘Stop TB’ campaign has called for the universal adoption of its directly observed therapy, short course (DOTS) strategy. Also, through the Massive Effort Against Diseases of Poverty, several international agencies are urging the establishment of effective control programmes worldwide. London should take the lead and set an example.</p>
</abstract><kwd-group>
<kwd>AIDS</kwd>
<kwd>DOTS</kwd>
<kwd>HIV</kwd>
<kwd>multidrug resistance</kwd>
<kwd>poverty</kwd>
<kwd>tuberculosis</kwd>
</kwd-group><custom-meta-wrap><custom-meta xlink:type="simple"><meta-name>sagemeta-type</meta-name><meta-value>Journal Article</meta-value></custom-meta><custom-meta xlink:type="simple"><meta-name>search-text</meta-name><meta-value> Article The Journal of The Royal Society for the Promotion of Health; June 2002, 122 (2), pp. 78-81 78 The Journal of The Royal Society for the Promotion of Health June 2002 Vol 122 No 2 The global emergency of tuberculosis: what is the cause? J M Grange, A Zumla John M Grange, MSc, MD, Visiting Professor, Centre for Infectious Diseases and International Health, Royal Free and University College Medical School, Windeyer Institute for Medical Science, Room G40, 46 Cleveland Street, London W1P 6DB, England Email: sophia@hagia.freeserve.co.uk Ali Zumla, PhD, FRCP, Professor and Director, Centre for Infectious Diseases and International Health, as above Email: a.zumla@ucl.ac.uk Corresponding author: John M Grange Received 4 March 2002 and accepted 4 April 2002 Key words AIDS; DOTS; HIV; multidrug resistance; poverty; tuberculosis Abstract The treatment of tuberculosis is cheap and highly effective, yet worldwide the disease remains a serious cause of illness and death; so serious as to have been declared a 'global emergency' in 1993. It is principally a disease of poverty, with 95% of cases and 98% of deaths occurring in developing countries. The incidence of tuberculosis is increasing world- wide, partly due to poverty and inequity and partly to the HIV/AIDS pandemic, which greatly increases the risk of infection proceeding to overt disease. Around 30% of AIDS-related deaths are due to tuberculosis. The emergence of multidrug resistant tuberculosis (MDRTB) is an increasing threat to tuberculosis con- trol. Although treatable with alternative drugs, the cost is enormous and, accordingly, not undertaken in many poor nations. While the overall global incidence of MDRTB is low, it occurs in certain 'hotspots' including Russian prisons. Due to adverse socio-economic factors, London has not escaped the general rise in incidence and, with- out the introduction of active control strategies, there could be a serious epidemic as occurred in New York City ten years ago which required an enormous finan- cial outlay for its control. In view of the global emergency of tuberculosis, the WHO 'Stop TB' campaign has called for the uni- versal adoption of its directly observed therapy, short course (DOTS) strategy. Also, through the Massive Effort Against Diseases of Poverty, several interna- tional agencies are urging the establishment of effec- tive control programmes worldwide. London should take the lead and set an example. A global emergency "The tubercle bacillus is an index by inversion of the real progress of the human race. By it the claim of civilization to dominate human life may fairly be judged. Tuberculosis will decrease with the substantial advance of civilization, and the disease will as surely increase as civilization retro- grades." John B Huber, 19071 Tuberculosis is a preventable and curable disease. As a result of decades of painstaking research and extensive clinical trials, we have a treatment for this disease that is not only highly effective, but is among the most cost-effective ways of prolonging healthy human life.2 Indeed, three years of healthy life could be purchased for the cost of a pint of beer in a London pub if invest- ed in tuberculosis control. This scourge should therefore have been eradicat- ed or reduced to a mere shadow of its former self. Tragically, this is not the case. There are more cases of tuberculosis in the world today than in any previous time in human history. Indeed, so serious has the public health problem posed by this disease become that, in 1993, the World Health Organization took the unprecedented step of declaring it a 'global emergency'. Tuberculosis is a very chronic disease, often of a biphasic nature. Initial infection, usually of the lung, leads to the development of a primary complex consisting of a pulmonary lesion at the site of implantation of inhaled tuber- cle bacilli and enlarged lymph nodes at the hilum of the lung. The develop- ment of the primary complex is accompanied by a conversion to tuberculin reactivity. In the absence of immunosuppression, only 5% of infected per- sons develop clinically overt tuberculosis, either within the thorax or, follow- ing blood-borne dissemination, in more distant organs such as the meninges, bones and kidneys. In the other 95% of those infected, the only evidence of infection is a positive tuberculin reaction and, in some cases, pulmonary scars evident on radiological examination. Healing of the primary complex is not due to the elimination of all viable tubercle bacilli, as some remain in the lung tissue in an as yet poorly under- stood 'persister form' for years or even decades.3 Under conditions of low- ered immune responsiveness, these persisters can give rise to post-primary 79The Journal of The Royal Society for the Promotion of Health June 2002 Vol 122 No 2 Tuberculosis: what is the cause? tuberculosis by so-called endogenous reacti- vation. Alternatively, post-primary disease may be due to exogenous reinfection, espe- cially in regions where the risk of infection is high and in communities in which immunosuppression due to HIV infection is common. Around 5% of non-immuno- suppressed persons overcoming their pri- mary infection eventually develop post-pri- mary tuberculosis. Patients with primary tuberculosis are usually not infectious but the characteristic immune-mediated massive tissue destruction in post-primary tubercu- losis generates large pulmonary cavities which are ideal breeding grounds for tuber- cle bacilli. Cavities communicate with the bronchial tree, enabling bacilli to enter the sputum and therefore rendering the patient infectious. An understanding of this chronic and biphasic nature of tuberculosis enables the behaviour of the disease in the human pop- ulation to be appreciated.4 Skin test surveys have shown that one-third of the human population, around 2,000 million people, have been infected by the tubercle bacillus. In the industrially developed nations, around 20% of the population are infected, and many are in the older age ranges. By contrast, in developing nations, such as those in sub-Saharan Africa, around half the population, including many young adults, are infected. At least 95% of all cases of tuberculosis, and 98% of deaths due to it, occur in the developing nations and the majority are poor people aged between 15 and 54 years. From this infected pool, around eight million new cases of tuberculosis develop each year. As this is a very chronic disease, and as only a minority of patients world- wide receive adequate therapy, there are roughly double this number of patients - 16 to 20 million - with active tuberculosis at any given time. Each year, around 1.7 million deaths are officially attributed to tuberculosis, which until recently, had the highest recorded mor- tality of all infectious diseases of adults. This disease has now been overtaken by AIDS as a cause of death but it is important to note that 30% of deaths attributed to AIDS, around one million deaths annually, are actually caused by tuberculosis. Thus, the true number of deaths due to tubercu- losis in 2002 will be between two and three million. Worldwide, one in seven deaths, and a quarter of preventable deaths, of young adults are due to tuberculosis.5 Unless tuberculosis control is radically improved, the future is bleak. With the pre- sent levels of control, it has been estimated that, between 2000 and 2020, one billion people will be added to the infected pool, 200 million will develop active tuberculosis and 35 million will die of it.6 The 'cause' of tuberculosis In microbiological terms, tuberculosis is caused by members of the Mycobacterium tuberculosis complex; usually the human tubercle bacillus, M. tuberculosis, but occa- sionally by the bovine tubercle bacillus, M. bovis, or by M. africanum - a rather heteroge- neous group of strains occurring in West and Central Africa. In sociological terms, however, the cause of tuberculosis could be said to be poverty, inequity, injustice and conflict.7, 8 As tuberculosis principally affects young adults in the developing world, the economic impact on their families and com- munities is devastating. Thus, up to 30% of a family income is lost if a money-earner develops the disease and on average 15 years of income is lost if this person dies of tuberculosis. The total economic loss due to tuberculosis in the world is estimated to be US$12 billion annually. Investment in tuberculosis control could give at least a six- fold return on the investment.6 The human cost of tuberculosis in the developing nations is also immense. In Zambia, for example, preventable infectious disease, notably tuberculosis, AIDS and malaria, are responsible for many maternal deaths, more than all obstetric causes, result- ing in large numbers of orphaned children.9 Even in the world's richest nations, there is a clear link between poverty and other forms of social disadvantage and tuberculo- sis. In England and Wales, and especially in London, the link between poverty and tuberculosis is clear.10 In addition, much of the burden of tuberculosis in England and Wales is borne by ethnic minority popula- tions. While this is partly due to the fact that many members of these groups are from countries with a high incidence of the dis- ease, a lack of ready access to effective med- ical care sensitive to the particular cultural characteristics of the patients leads to delayed diagnosis, poor contact tracing and failed therapy.11 Care is required in equating a reduction in disease prevalence with improved socio- economic factors.12 While some workers regard improvement in health as being the natural and inevitable consequence of improved standards of living, others argue that such improvements are the cumulative effect of numerous specific health innova- tions resulting from much advocacy and research. Without a very clear understand- ing of local factors, changes such as the so- called health sector reforms that form part of that rather loosely defined process termed globalisation can actually deprive the poorest in the community of key aspects of health care. Thus, while there are good the- oretical reasons for advocating 'horizontal', locally managed, comprehensive primary health care services, the breakdown of 'ver- tical' disease-specific programmes, including national tuberculosis control services, can deprive primary health care of crucial fac- tors such as regular drug supplies and dedi- cated microscopy services. Tuberculosis and HIV - the 'cursed duet' In the 1980s, it became apparent that HIV infection was emerging as a very important predisposing factor to the development of overt tuberculosis in those infected by the tubercle bacillus. As mentioned above, only 5% of those with latent tuberculosis will eventually develop overt post-primary dis- ease. In those who become infected with HIV, the risk increases to 8% annually, or 50% at some period during their shortened life span.13 Those developing AIDS are much more susceptible, and if such patients are exposed to a source case, their risk of developing tuberculosis is extremely high. Furthermore, the course of the disease is 'telescoped' so that extensive pulmonary or disseminated tuberculosis develops within a few months. This phenomenon has been responsible for a number of mini-epidemics of tuberculosis in centres caring for AIDS patients and calls for measures to ensure AIDS patients are not exposed to such source cases. In the year 2002, an estimated one mil- lion people will develop HIV-related tuber- culosis and in sub-Saharan Africa, where over 80% of the world's AIDS-related deaths occur, at least 30% of cases of tuber- culosis will be HIV-related.4, 6 Many of these patients have other medical conditions requiring therapy and, on account of the atypical presentation of disease, diagnosis is far from easy, particularly in the increasing numbers of children with HIV-related tuberculosis.14 Tragically, HIV infection is now spreading at an alarming rate in all parts of Asia, where most of the world's cases of tuberculosis occur. Unless the spread of both infections are controlled, the catastrophe facing many Asian countries will greatly exceed that currently occurring in Africa. Little wonder that tuberculosis and HIV infection have been termed the 'cursed duet'.15 The 'third epidemic' - multidrug-resistant tuberculosis The greatest threat to the successful control of tuberculosis is the emergence of mul- tidrug resistance. By definition, this is resis- tance to isoniazid and rifampicin, the two most powerful drugs included in present- day anti-tuberculosis regimens, with or with- out additional resistances. Many cases of multidrug resistant tuberculosis (MDRTB) are treatable by means of prolonged thera- py with more expensive and more toxic drugs given under strict supervision. This of course raises the cost of therapy consid- erably; in the United Kingdom each case costs around £60,000, one hundred times the cost of managing a case of drug-sus- ceptible disease.16 Accordingly, in many parts of the world, no effective treatment is provided for such disease. An international surveillance project by the World Health Organization and the International Union Against Tuberculosis and Lung Disease revealed that MDRTB is present in almost all 72 countries surveyed and that the prevalence varies enormously from region to region.17 Worldwide, only 1% of all new cases are multidrug-resistant, the prevalence rises to, for example, 30% in Latvia, 32% in the Ivanovo Oblast (district) of the Russian Federation and 35% in the Henan province of China. The situation in Russia is particularly worrying as, since the collapse of communism in 1991, the inci- dence of the disease increased from 34 cases per 100,000 population to 85 per 100,000 by 1998. This has been attributed to poverty, malnutrition, poor housing, con- flict, a fragmentation of the tuberculosis services and, in particular, the very high risk of infection in overcrowded Russian pris- ons.18 There are reportedly one million inmates in Russian prisons and 100,000 of these have active tuberculosis with, in one limited study, a quarter having MDRTB. Although WHO treatment guidelines are increasingly being adhered to, the treatment failure rate is high and many prisoners are discharged with active disease. Concern has therefore been expressed at this situation and a spokesperson for Médecins Sans Frontières has stated that, "It is only a matter of time before multi-drug resistant tuberculosis of Russian origin becomes a daily real- ity worldwide. The cost of the epidemic to the world will be counted in billions of pounds and may become unmanageable." The growing problem of tuberculosis in London Tuberculosis in England and Wales declined fairly steadily from the high levels in the late 19th century to a very low incidence in 1988. Since that year, the trend has reversed and the reported incidence has risen unremittingly. The burden of disease has been felt particularly in London in which, in the year 2000, 2,938 cases - 45% of the 6,572 cases throughout England and Wales - were reported and in which the notifica- tion rate has doubled since 1988.19 Certain boroughs of London, notably Tower Ham- lets, have been particularly affected and the distribution of disease reflects socio-eco- nomic factors. The disease is particularly common among the ethnic minorities: almost two-thirds of patients in London were born abroad although over half of these had been resident in the UK for over five years. Tuberculosis is also common among the homeless, the alcohol-dependent and asylum seekers. Owing to problems of detection and notification, estimation of the impact of HIV infection in England and Wales, and London in particular, is not easy. The notified percentage of HIV-infected tuberculosis patients rose from 2.2% in 1993 to 3.3% in 1999, but this is considered to be an underestimate and as many as 10% of cases could be HIV-related. The most worrying aspect of the tuber- culosis situation in London is that the trends are mirroring those seen in New York a decade ago, where there was a massive rise in the prevalence of tuberculosis and a sharp increase in the numbers of cases that were multidrug-resistant. Although the epi- demic in New York was brought under con- trol, with the numbers of reported cases now being in decline, the cost was enor- mous, around one billion dollars. There is of course no guarantee that the trends in London will follow the same pattern but they could well do so. Likewise, the num- bers of cases of MDRTB may not increase dramatically as they did in New York, although it is noteworthy that the numbers of isoniazid-resistant cases in just one area of London has risen from one in 1995 to 37 in 2000.20 As a consequence of these worry- ing trends, many workers and organisations in the field have sounded warnings but to lit- tle avail. The massive effort required for the control of tuberculosis in this, one of the world's wealthiest cities, seems to be largely confined to good intentions and glossy brochures. Tuberculosis control strategies - global and local Thecontrolstrategyfortuberculosisadvocat- edbytheWHOisknownas'DOTS'-direct- lyobservedtherapyshortcourse-anditisthe basis of the WHO 'Stop TB' campaign.21 DOTS is a six-point strategy based on: ! Government commitment to tuberculosis control ! A regular supply of drugs, free at the point of delivery to the patient ! Case finding based on sputum microscopy ! Therapy administered under direct supervision ! Training of staff ! Audit of efficacy of the control programme Five of these points are obvious and straightforward, but there has been some debate over the methods used, and in some instances, even the desirability of directly supervising the treatment. Under some cir- cumstances, imposition of strict supervision may even be counterproductive. As local cultural factors have a key influence on the perception of the disease and its treatment, attitudes to 'authority' and the development of stigma, strategies for supervision must be developed locally in the light of these fac- tors.22 The need for a 'holistic' assessment of health care strategies is now well appreci- ated and the term 'political ecology' has been applied to the interdisciplinary analysis of the manifold local biological, environ- mental, anthropological and economic fac- 80 The Journal of The Royal Society for the Promotion of Health June 2002 Vol 122 No 2 Tuberculosis: what is the cause? 81The Journal of The Royal Society for the Promotion of Health June 2002 Vol 122 No 2 Tuberculosis: what is the cause? tors affecting disease and its control.23 Despite intense lobbying by the WHO and clear evidence of the effectiveness and cost effectiveness of DOTS-based pro- grammes from several extensive studies, only about 25% of tuberculosis patients worldwide have access to such programmes. The question has arisen as to whether rig- orously applied DOTS programmes can lead to a reduction in the incidence of MDRTB in a community. While they may well pre- vent resistance developing in a patient (acquired resistance) it is less clear whether they can reduce the incidence of MDRTB due to transmission of resistant bacilli (initial resistance). The question really hinges on whether resistant tubercle bacilli are as able to cause active tuberculosis as drug-suscepti- ble bacilli. While a mathematical model assumes that multiple resistant bacilli are less 'fit' to cause disease,24 it is not yet clear whether they are indeed less virulent. Accordingly, so-called 'DOTS-plus' strategies for the management of MDRTB havebeenproposedbut,astheyarebasedon laboratory facilities for the identification of MDRTB and the provision of lengthy alter- native treatment regimens, they are very cost- ly to implement.25 Considerable operations research will be required to determine the feasibility and overall cost-effectiveness of introducing 'DOTS-plus' strategies in resource-poor regions. Whatever the theo- retical benefits of the 'DOTS-plus' strategy, itshouldonlybeestablishedinregionswhere there is already a highly effective DOTS strategy, thereby ensuring that all patients have access to high-quality treatment, with the emergence of further cases of acquired MDRTB thereby being prevented.26 Forging ahead - positive action, or mere words? Almost a decade after the declaration of tuberculosis as a global emergency by the WHO, there are signs that the massive advo- cacy effort is bearing fruit and that national and international bodies, both governmen- tal and non-governmental, are heeding the many dire warnings. Thus in the last few years there have been many calls for funding and political action, establishment of con- sortia to develop new drugs and vaccines and a sustained campaign to rebalance the gross inequities and injustices that scan- dalise the human race. Thus, for example, the Global Alliance for TB Drug Develop- ment was launched in Bangkok in October 2000 with the aim of developing new drugs, new and simpler treatment regimens, and improving the therapy of both latent and multidrug-resistant tuberculosis. In addition, tuberculosis, together with malaria and HIV/AIDS, has been specially targeted for action by the Advocacy Forum for Massive Effort Against Diseases of Poverty which was launched in October 2000, in the Swiss city of Winterthur, under the sponsorship of the World Health Orga- nization and UNAIDS. The WHO Stop TB campaign is attracting major funding from governments and non-governmental foundations, and is financing many control activities worldwide. There is certainly a move towards genuine altruism, but it is also clear that all nations, rich and poor alike, will be adversely affected unless the major infec- tious diseases are overcome. Infection respects no borders and global health issues are therefore of local importance. More recently, the WHO, UNICEF, UNAIDS, the World Bank, UNESCO and UNFPA have produced strong evidence that a well- targeted spending of US$66 billion a year by 2015 could save as many as eight million lives a year and generate six-fold economic benefits, more than US$360 billion a year, by 2020, and have urged strenuous action to facilitate this spending.6 All these initiatives are very encouraging, but it must never be forgotten that there are still more cases of tuberculosis in the world today than in any previous period of human history and the incidence is not abating. Also it must not be overlooked that the one in seven deaths of young adults attributable to thisdiseaseinthedevelopingnationsisnodif- ferent to that in USA and Europe at the beginning of the 20th century when no effec- tivetherapywasavailable.1 TheMassiveEffort Against Diseases of Poverty needs global support to achieve its aims, but poor nations can hardly be expected to make the huge investment of financial and human resources required for control of tuberculosis when they see the consequence of complacency and backsliding in one of the great financial centres of the world; namely, London. References 1 Huber JB. Civilization and tuberculosis. Brit J Tuberc 1907;1:156-8 2 Murray CJL. Resource Allocation Priorities: Value for Money in Tuberculosis Control. In: Porter JDH, McAdam KPWJ, editors. Tuberculosis: Back to the Future. Chichester: Wiley, 1994. pp. 193-211 3 Orme IM. The latent tubercle bacillus (I'll let you know if I ever meet one). Int J Tuberc Lung Dis 2001;5:589-93 4 WHO. Global Tuberculosis Control. Geneva: World Health Organization, 2001 5 Murray CJ, Styblo K, Rouillon A. Tuberculosis in developing countries: burden, intervention and cost. Bull Int Union Tuberc Lung Dis 1990;65(1):6-24 6 WHO. Scaling Up the Response to Infectious Diseases: A Way out of Poverty. Geneva: World Health Organization, 2002 7 Grange JM, Zumla A. Tuberculosis and the pover- ty-disease cycle. J R Soc Med 1999;99:105-7 8 Grange JM, Zumla A. Tuberculosis in disadvan- taged groups. Curr Opin Pulm Med 2001;7:160-4 9 Ahmed Y, Mwaba P, Chintu C, Grange JM, Ustianowski A, Zumla A. A study of maternal mortality at the University Teaching Hospital, Lusaka, Zambia: the emergence of tuberculosis as a major non-obstetric cause of maternal death. Int J Tuberc Lung Dis 1999;3:675-80 10 Moore-Gillon J. Tuberculosis and Poverty in the Developed World. In: Davies PDO, editor. Clini- cal Tuberculosis. 2nd edition. London: Chapman and Hall, 1998. pp. 383-93 11 Festenstein F, Grange JM. Tuberculosis in Ethnic Minority Populations in Industrialised Countries. In: Porter JDH, Grange JM, editors. Tuberculosis - an Interdisciplinary Perspective. London: Imper- ial College Press, 1999. pp. 313-38 12 Grange JM, Gandy M, Farmer P, Zumla A. His- torical declines in tuberculosis - nature, nurture and the biosocial model. Int J Tuberc Lung Dis 2001;3:208-12 13 Dolin PJ, Raviglione MC, Kochi A. Global tuber- culosis incidence and mortality during 1990-2000. Bull World Health Org 1994;72:213-20 14 Donald PR. Childhood tuberculosis. Curr Opin Pulm Med 2000;6:187-92 15 Chretien J. Tuberculosis and HIV. The cursed duet. Bull Int Union Tuberc Lung Dis 1990;65:25-8 16 London TB Group. TB Control in London. Next Steps. London: Communicable Disease Surveil- lance Centre, 2001 17 WHO/IUATLD. Global Project on Anti-tubercu- losis Drug Resistance Surveillance. Anti-tubercu- losis Drug Resistance in the World. Report No. 2. Geneva: World Health Organization, 2000 18 Stern V, editor. Sentenced to Die? The Problems of TB in Prisons in Eastern Europe and Central Asia. London: International Centre for Prison Studies, King's College London, 1999 19 Communicable Disease Surveillance Centre. Tuberculosis Update. September 2000. London: Public Health Laboratory Service, 2000 20 Communicable Disease Surveillance Centre. Drug resistant tuberculosis in north London. Commun Dis Rep CDR Wkly 2000;10(32):285-8 21 WHO. Use DOTS More Widely. WHO Report on the Tuberculosis Epidemic. Geneva: World Health Organization, 1997 22 Farmer P. DOTS and DOTS-plus: not the only answer. Ann NY Acad Sci 2001;953:165-84 23 Mayer JD. Geography, ecology and emerging infectious diseases. Soc Sci Med 2000;50:937-52 24 Dye C, Williams BG. Criteria for the control of drug-resistant tuberculosis. Proc Natl Acad Sci 2000;97:8180-5 25 Farmer P, Kim JY. Community based approaches to the control of multidrug resistant tuberculosis: introducing 'DOTS-plus'. 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</ref-list></back></article></istex:document></istex:metadataXml><mods version="3.6"><titleInfo lang="en"><title>The global emergency of tuberculosis: what is the cause?</title></titleInfo><titleInfo type="alternative" lang="en" contentType="CDATA"><title>The global emergency of tuberculosis: what is the cause?</title></titleInfo><name type="personal"><namePart type="given">J M</namePart><namePart type="family">Grange</namePart><affiliation>Centre for Infectious Diseases and International Health, Royal Free and University College Medical School, Windeyer Institute for Medical Science, Room G40, 46 Cleveland Street, London W1P 6DB, England,</affiliation><affiliation>E-mail: sophia@hagia.freeserve.co.uk</affiliation></name><name type="personal"><namePart type="given">A</namePart><namePart type="family">Zumla</namePart><affiliation>Centre for Infectious Diseases and International Health, Royal Free and University College Medical School, Windeyer Institute for Medical Science, Room G40, 46 Cleveland Street, London W1P 6DB, England,</affiliation><affiliation>E-mail: a.zumla@ucl.ac.uk</affiliation></name><typeOfResource>text</typeOfResource><genre type="research-article" displayLabel="research-article" authority="ISTEX" authorityURI="https://content-type.data.istex.fr" valueURI="https://content-type.data.istex.fr/ark:/67375/XTP-1JC4F85T-7">research-article</genre><originInfo><publisher>Sage Publications</publisher><place><placeTerm type="text">Sage CA: Thousand Oaks, CA</placeTerm></place><dateIssued encoding="w3cdtf">2002-06</dateIssued><copyrightDate encoding="w3cdtf">2002</copyrightDate></originInfo><language><languageTerm type="code" authority="iso639-2b">eng</languageTerm><languageTerm type="code" authority="rfc3066">en</languageTerm></language><abstract lang="en">The treatment of tuberculosis is cheap and highly effective, yet worldwide the disease remains a serious cause of illness and death; so serious as to have been declared a ‘global emergency’ in 1993. It is principally a disease of poverty, with 95% of cases and 98% of deaths occurring in developing countries. The incidence of tuberculosis is increasing worldwide, partly due to poverty and inequity and partly to the HIV/AIDS pandemic, which greatly increases the risk of infection proceeding to overt disease. Around 30% of AIDS-related deaths are due to tuberculosis. The emergence of multidrug resistant tuberculosis (MDRTB) is an increasing threat to tuberculosis control. Although treatable with alternative drugs, the cost is enormous and, accordingly, not undertaken in many poor nations. While the overall global incidence of MDRTB is low, it occurs in certain ‘hotspots’ including Russian prisons. Due to adverse socio-economic factors, London has not escaped the general rise in incidence and, without the introduction of active control strategies, there could be a serious epidemic as occurred in New York City ten years ago which required an enormous financial outlay for its control. In view of the global emergency of tuberculosis, the WHO ‘Stop TB’ campaign has called for the universal adoption of its directly observed therapy, short course (DOTS) strategy. Also, through the Massive Effort Against Diseases of Poverty, several international agencies are urging the establishment of effective control programmes worldwide. London should take the lead and set an example.</abstract><subject><genre>keywords</genre><topic>AIDS</topic><topic>DOTS</topic><topic>HIV</topic><topic>multidrug resistance</topic><topic>poverty</topic><topic>tuberculosis</topic></subject><relatedItem type="host"><titleInfo><title>Perspectives in public health</title></titleInfo><genre type="journal" authority="ISTEX" authorityURI="https://publication-type.data.istex.fr" valueURI="https://publication-type.data.istex.fr/ark:/67375/JMC-0GLKJH51-B">journal</genre><identifier type="ISSN">1466-4240</identifier><identifier type="eISSN">1757-9147</identifier><identifier type="PublisherID">RSH</identifier><identifier type="PublisherID-hwp">sprsh</identifier><part><date>2002</date><detail type="volume"><caption>vol.</caption><number>122</number></detail><detail type="issue"><caption>no.</caption><number>2</number></detail><extent unit="pages"><start>78</start><end>81</end></extent></part></relatedItem><identifier type="istex">E108F39FD3DF2D3DF2CC69BA465BAD4F88140C8D</identifier><identifier type="ark">ark:/67375/M70-TJWF0RWM-G</identifier><identifier type="DOI">10.1177/146642400212200206</identifier><identifier type="ArticleID">10.1177_146642400212200206</identifier><recordInfo><recordContentSource authority="ISTEX" authorityURI="https://loaded-corpus.data.istex.fr" valueURI="https://loaded-corpus.data.istex.fr/ark:/67375/XBH-0J1N7DQT-B">sage</recordContentSource></recordInfo></mods><json:item><extension>json</extension><original>false</original><mimetype>application/json</mimetype><uri>https://api.istex.fr/document/E108F39FD3DF2D3DF2CC69BA465BAD4F88140C8D/metadata/json</uri></json:item></metadata><serie></serie></istex></record>Pour manipuler ce document sous Unix (Dilib)
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