World TB Day 2010 - New innovations are required for enhancing the global fight against Tuberculosis: the ‘Captain of all these men of death’

Abstract

Despite the availability of inexpensive and effective treatment for more than 60 years, tuberculosis (TB) remains a major global health threat (WHO Report 2009a). This is a telling and shameful indictment of the current world order. The pace at which scientific understanding has advanced over the past few decades has been unacceptably slow. Also, researchers have, in general, failed to take into account the complex interaction of factors that sustain the global TB epidemic with the factors that have led to the failure of the global community to get rid of one of the worst scourges that has affected humanity for centuries. Tuberculosis continues to be one of the top three causes of death from infectious diseases, after HIV/AIDS and malaria, causing more than 1.8 million deaths every year (Dye et al. 2008). Over the past decade, the international community has become more aware of the seriousness of the threat of TB to human health. Despair is gradually, although with faltering steps and many setbacks, being replaced by hope (Grange et al. 2009; Zumla et al. 2009). Definite signs of progress in the scaling up of TB diagnostic and treatment services worldwide have been witnessed over the past decade, and almost all countries have adopted the Stop TB strategy of the World Health Organization (WHO), including DOTS (WHO 2009a). Although these achievements are important, the global control of the TB epidemic remains elusive. There is epidemiological evidence that the number of new cases of TB are levelling out in Asia and China, even though the TBdisease burden remains at a very high level (Dye et al. 2009). By contrast, the disease continues to spread relentlessly in high HIV-endemic sub-Saharan African countries. TB also contributes substantially to morbidity and mortality in children under the age of 5 in endemic areas (Marais et al. 2009). It is, however, heartening that it has at last been recognized that children make up a significant proportion of the TB disease burden in sub-Saharan Africa (Donald et al. 2007; WHO Report 2007). The global emergence of multidrug-resistant and extensively drug-resistant (XDR) TB further compromises efforts to control the disease (Gandhi et al. 2006; Schaaf et al. 2009). Without substantially stronger domestic and international commitment to TB control, the number of TB cases will continue to rise, especially in HIV-endemic areas. Creative new strategies and pragmatic new approaches are urgently required if the epidemic is to be brought under control. TB is the most common cause of death among HIVinfected individuals in Africa (Lawn & Churchyard 2009). To reduce this risk, direct strategies to prevent TB such as Isoniazid-preventive therapy (IPT) as well as indirect measures, including antiretroviral therapy (ART) and co-trimoxazole prophylaxis, to improve the immune status of those infected with HIV need to be scaled up urgently (Churchyard et al. 2007; WHO Report 2008). Data from observational studies and a randomized control trial support the early integrated use of ART in patients with TB to reduce mortality. Earlier initiation of ART at higher CD4 counts will greatly reduce the incidence of TB in HIV-infected populations by reducing the risk of overt disease after infection and improving both the effectiveness and durability of IPT. The longstanding call for integration of TB and HIV services should now be heeded by all governments of developing countries (Harries et al. 2009). Such integration will facilitate provider-initiated HIV testing of all TB suspects and patients and their families, thereby allowing prioritization of HIV-infected TB patients for ART initiation and provision of co-trimoxazole. The prevalent misconceptions among both the community and health care workers who maintain the stigma associated with HIV and TB need to be addressed by means of education. A concerted effort is required to empower individuals with TB co-infected with HIV, so that they are able to play a key role in shaping current and future health Tropical Medicine and International Health doi:10.1111/j.1365-3156.2009.02462.x