Semin Respir Crit Care Med 2004; 25(3): 245-253
DOI: 10.1055/s-2004-829520
Copyright © 2004 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA.

Tuberculosis as a Major Global Health Problem in the 21st Century: A WHO Perspective

Rajesh Gupta1 , Marcos A. Espinal1 , Mario C. Raviglione1
  • 1World Health Organization, Geneva, Switzerland
Further Information

Publication History

Publication Date:
08 December 2004 (online)

 

The World Health Organization, the Global Partnership to Stop TB, and the Millenium Development Project have all adopted the following 2005 targets for tuberculosis control: to detect at least 70% of all estimated sputum smear-positive cases and to treat successfully at least 85% of them. Although implementation of the DOTS strategy is the foundation for proper tuberculosis control, basic DOTS implementation may not be enough to reach these targets. Instead, evidence from several countries indicates that, although cure rates are approaching the global target, the case detection target may not be met, even with 100% DOTS implementation in designated public facilities. Thus, tuberculosis control must be critically examined to foster higher performance. In the context of an expanded framework for tuberculosis control, we present four strategic interventions through which cure and case detection rates may be significantly improved: (1) wider involvement of community workers, (2) engagement of private practitioners, (3) proper management of drug-resistant tuberculosis, and (4) efforts focused on controlling tuberculosis and human immunodeficiency virus. We conclude that, although country-based estimates need further refinement to ascertain the impact of each intervention, a fundamental shift in the approach to tuberculosis control is required if the global targets are to be reached rapidly.

KEYWORDS

Tuberculosis - policy - HIV - drug resistance - private practitioners - community care

REFERENCES

  • 1 WHO .Official Records of the World Health Organization, No 6. Geneva; WHO 1947
    Google Scholar
  • 2 Fox W, Ellaed G A, Mitchison D A. Studies on the treatment of tuberculosis undertaken by the British Medical Research Council Tuberculosis Units: 1946-1986, with relevant subsequent publications.  Int J Tuberc Lung Dis. 1999;  10(suppl 2) S231-S279
    PubMedGoogle Scholar
  • 3 Rouillon A. The mutual assistance programme of the IUATLD: development, contribution and significance.  Int J Tuberc Lung Dis. 1991;  66 159-172
    PubMedGoogle Scholar
  • 4 Enarson D A. The International Union Against Tuberculosis and Lung Disease model national tuberculosis programme.  Int J Tuberc Lung Dis. 1995;  76 95-99
    PubMedGoogle Scholar
  • 5 United States Public Health Service Coorperative Investigation of Antimicrobial Therapy of Tuberculosis . Report on thirty-two week observations on combinations of isoniazid, streptomycin and PAS.  Am Rev Tuberc. 1954;  70 521-526
    PubMedGoogle Scholar
  • 6 Livings D G. Results of original course of chemotherapy for pulmonary tuberculosis: data from Cooperative Study, General Regimens (INH-PAS; INH-SM daily; INH-SM daily-PAS). Transactions of the 17th Conference on the Chemotherapy of Tuberculosis, Memphis, Tennessee February 1958: 19-27
    Google Scholar
  • 7 Newman R, Doster B, Murray J F, Ferebee S. Rifampin in initial treatment of pulmonary tuberculosis: a U.S. Public Health Service Tuberculosis Therapy Trial.  Am Rev Respir Dis. 1971;  103 461-476
    PubMedGoogle Scholar
  • 8 World Health Organization .Forty-fourth World Health Assembly: Resolutions and Decisions. Resolution WHA 44.8 . Geneva; WHO 1991 WHA44/1991/REC/1
    Google Scholar
  • 9 Raviglione M C, Pio A. Evolution of WHO policies for tuberculosis control, 1948-2001.  Lancet. 2002;  359 775-780
    CrossrefPubMedGoogle Scholar
  • 10 World Bank .World Development Report 1993: Investing in Health. New York; Oxford University Press 1993
    Google Scholar
  • 11 World Health Organization .Global Tuberculosis Programme: Framework for Effective Tuberculosis Control. Geneva; WHO 1994 WHO/TB/94.179
    Google Scholar
  • 12 World Health Organization .The Potential Economic Benefits of the DOTS Strategy against TB in India, 1996. Geneva; WHO 1996 WHO/TB/96.218
    Google Scholar
  • 13 Raviglione M C. The TB epidemic from 1992-2002.  Tuberculosis. 2003;  83 4-14
    CrossrefPubMedGoogle Scholar
  • 14 Klaudt K. The political causes, solutions of the current tuberculosis epidemic, I: The politics of emerging and resurgent infectious diseases. Basingstoke WJ New York; Macmillan 2000
    Google Scholar
  • 15 Raviglione M C, Dye C, Schmidt S, Kochi A. Assessment of worldwide tuberculosis control.  Lancet. 1997;  350 624-629
    CrossrefPubMedGoogle Scholar
  • 16 World Health Organization .Global Tuberculosis Programme: Report of the Ad-hoc Committee on the Tuberculosis Epidemic. London, March 17-19, 1998. Geneva; WHO 1998 WHO/TB/98.245
    Google Scholar
  • 17 Stop TB Initiative .Tuberculosis and Sustainable Development. Report of a conference, Amsterdam, 22-24 March 2000. Geneva; WHO 2000 WHO/CDS/STB/2000.6
    Google Scholar
  • 18 World Health Organization .Global DOTS Expansion Plan: Progress in TB Control in High-Burden Countries 2001, 1 year after the Amsterdam Ministerial Conference. Geneva; WHO 2001 WHO/CDS/STB/2001.11
    Google Scholar
  • 19 Stop TB Partnership .Global Plan to Stop Tuberculosis. Geneva; WHO 2001 WHO/CDS/STB/2001.16
    Google Scholar
  • 20 Available at: http://www.developmentgoals.com/About_the_goals.htm. Accessed November 30 2003
  • 21 Dye C, Watt C J, Bleed D. Low access to a highly effective therapy: a challenge for international tuberculosis control.  Bull World Health Organ. 2002;  80 437-444
    PubMedGoogle Scholar
  • 22 World Health Organization .Global Tuberculosis Control: Surveillance, Planning, and Financing. WHO Report 2003. Geneva; WHO 2003 WHO/CDS/TB/2003.316
    Google Scholar
  • 23 World Health Organization .Global Tuberculosis Control: Surveillance, Planning, Financing. WHO Report 2004. Geneva; WHO 2004
    Google Scholar
  • 24 Dye C, Watt C J, Bleed D M, Williams B G. What is the limit to case detection under the DOTS strategy for tuberculosis control?.  Tuberculosis. 2003;  83 35-43
    CrossrefPubMedGoogle Scholar
  • 25 World Health Organization .An Expanded DOTS Framework for Effective Tuberculosis Control. Geneva; WHO 2002 WHO/CDS/TB/2002.297
    Google Scholar
  • 26 World Health Organization .Community Contribution to TB Care: Practice and Policy. Geneva; WHO 2003 WHO/CDS/TB/2003.312
    Google Scholar
  • 27 Okello D, Floyd K, Adatu F, Odeke R, Gargioni G. Cost and cost-effectiveness of community-based care for tuberculosis patients in rural Uganda.  Int J Tuberc Lung Dis. 2003;  7 S72-S79
    PubMedGoogle Scholar
  • 28 Nyrienda T E, Harries A D, Gausi F et al.. Decentralisation of tuberculosis in an urban setting, Lilongwe, Malawi.  Int J Tuberc Lung Dis. 2003;  7 S21-S28
    PubMedGoogle Scholar
  • 29 Floyd K, Skeva J, Nyrienda T E, Gausi F, Salaniponi F. Cost and cost-effectiveness of increased community and primary care facility involvement in tuberculosis care in Lilongwe, Malawi.  Int J Tuberc Lung Dis. 2003;  7 S29-S37
    PubMedGoogle Scholar
  • 30 Dudley L, Azevedo V, Grant R, Schoeman J H, Dikweni L, Maher D. Evaluation of community contribution to tuberculosis control in Cape Town, South Africa.  Int J Tuberc Lung Dis. 2003;  7 S48-S55
    PubMedGoogle Scholar
  • 31 Dick J, Henchie S. A cost analysis of the tuberculosis control programme in Elsies River, Cape Town.  South Africa Medical Journal. 1998;  88(suppl 3) 380-383
    PubMedGoogle Scholar
  • 32 Sinanovic E, Floyd K, Dudley L, Azevedo V, Grant R, Maher D. Cost and cost-effectiveness of community-based care for tuberculosis in Cape Town, South Africa.  Int J Tuberc Lung Dis. 2003;  7 S56-S62
    PubMedGoogle Scholar
  • 33 Uplekar M, Rangan S. Tackling TB: The Search for Solutions. The Foundation for Research in Community Health Mumbai, India; 1996
    Google Scholar
  • 34 Uplekar M, Juvekar S, Morankar S, Rangan S, Nunn P. Tuberculosis patients and practitioners in private clinics in India.  Int J Tuberc Lung Dis. 1998;  2 324-329
    PubMedGoogle Scholar
  • 35 Panthania V, Almeida J, Kochi A. TB patients and for-profit health care providers in India. Geneva; WHO 1997 WHO/TB/97.223
    Google Scholar
  • 36 Uplekar M W, Shepard D S. Treatment of tuberculosis by private practitioners in India.  Tubercle. 1991;  72 284-290
    CrossrefPubMedGoogle Scholar
  • 37 Uplekar M, Panthania V, Raviglione M. Private practitioners and public health: weak links in tuberculosis control.  Lancet. 2001;  358 912-916
    CrossrefPubMedGoogle Scholar
  • 38 Quy H T, Lan N TN, Lonnroth K, Buu T N, Dieu T T, Hai L T. Public-private mix for improved TB control in Ho Chi Minh City, Vietnam: an assessment of its impact on case detection.  Int J Tuberc Lung Dis. 2003;  7 464-471
    PubMedGoogle Scholar
  • 39 Murthy K JR, Frieden T R, Yazdani A, Hreshikesh P. Public-private partnership in tuberculosis control: experience in Hyderabad, India.  Int J Tuberc Lung Dis. 2001;  5 354-359
    PubMedGoogle Scholar
  • 40 Uplekar M. Involving private health care providers in delivery of TB care: global strategy.  Tuberculosis. 2003;  83 156-164
    CrossrefPubMedGoogle Scholar
  • 41 Lee K, Buse K, Fustukian S Health Policy in a Globalizing World. Cambridge, MA; Cambridge University Press 2002
    Google Scholar
  • 42 World Health Organization .Informal consultation on private practitioners' involvement in control of communicable diseases with a focus on tuberculosis. Geneva; WHO 2000 WHO/CDS/TB/2000.282
    Google Scholar
  • 43 Available at: http://www.unaids.org/en/default.asp. Accessed 1 December 2003
  • 44 Raviglione M C, Harries A D, Msiska R, Wilkinson D, Nunn P. Tuberculosis and HIV: current status in Africa.  AIDS. 1997;  11(suppl B) S115-S123
    PubMedGoogle Scholar
  • 45 Dye C, Scheele S, Dolin P, Pathania V, Raviglione M C. Consensus statement. Global burden of tuberculosis: estimated incidence, prevalence, and mortality by country. WHO Global Surveillance and Monitoring Project.  JAMA. 1999;  282 677-686
    CrossrefPubMedGoogle Scholar
  • 46 Rieder H L, Cauthen G M, Comstock G W, Snider D E. Epidemiology of tuberculosis in the United States.  Epidemiol Rev. 1989;  11 79-98
    PubMedGoogle Scholar
  • 47 DiPerri G, Cruciani M, Danzi M H et al.. Nosocomial epidemic of active tuberculosis in HIV-infected patients.  Lancet. 1989;  2 1502-1504
    PubMedGoogle Scholar
  • 48 Daley C L, Small P M, Schecter G F et al.. An outbreak of tuberculosis with accelerated progression among persons infected with the human immunodeficiency virus: an analysis using restriction-fragment-length polymorphisms.  N Engl J Med. 1992;  326 231-235
    CrossrefPubMedGoogle Scholar
  • 49 Mukadi Y D, Maher D, Harries A D. Tuberculosis case fatality rates in high HIV prevalence populations in sub-Saharane Africa.  AIDS. 2001;  15 143-152
    CrossrefPubMedGoogle Scholar
  • 50 UNAIDS .Report on the global HIV/AIDS epidemic, June 2000. Geneva; UNAIDS 2000
    Google Scholar
  • 51 Maher D, Van Gorkom J LC, Gondrie P, Raviglione M C. Community contribution to tuberculosis care in countries with high tuberculosis prevalence: past, present, and future.  Int J Tuberc Lung Dis. 1999;  3 762-768
    PubMedGoogle Scholar
  • 52 Elzinga G, Nunn P. TB and HIV: joint problems, joint solutions.  Bull World Health Organ. 2002;  80 469-470
    PubMedGoogle Scholar
  • 53 Harries A D, Hargreaves N J, Chimzizi R, Salaniponi F M. Highly active antiretroviral therapy and tuberculosis control in Africa: synergies and potential.  Bull World Health Organ. 2002;  80 464-469
    PubMedGoogle Scholar
  • 54 De Cock K M, Chaisson R E. Will DOTS do it? A reappraisal of tuberculosis control in countries with high rates of HIV infection.  Int J Tuberc Lung Dis. 1999;  3 457-465
    PubMedGoogle Scholar
  • 55 CASCADE Collaboration . Determinants of survival following HIV-1 seroconversion after the introduction of HAART.  Lancet. 2003;  362 1267-1274
    CrossrefPubMedGoogle Scholar
  • 56 Williams B G, Dye C. Antiretroviral drugs for tuberculosis control in the era of HIV/AIDS.  Science. 2003;  301 1535-1537
    CrossrefPubMedGoogle Scholar
  • 57 World Health Organization .Strategic Framework to Decrease the Burden of TB/HIV. Geneva; WHO 2002 WHO/CDS/TB/2002.296
    Google Scholar
  • 58 Harries A D, Nyangulu D S, Hargreaves N J, Kaluwa O, Salniponi F ML. Preventing antiretroviral anarchy in sub-Saharan Africa.  Lancet. 2001;  358 410-414
    CrossrefPubMedGoogle Scholar
  • 59 Farmer P, Leandre F, Mukherjee J, Gupta R, Tarter L, Kim J Y. Community-based treatment of advanced HIV disease: introducing DOT-HAART (directly observed therapy with highly active antiretroviral therapy).  Bull World Hlth Org. 2001;  79 1145-1151
    PubMedGoogle Scholar
  • 60 Raviglione M C, Gupta R, Dye C, Espinal M A. The burden of drug-resistant tuberculosis and mechanisms for its control.  Ann N Y Acad Sci. 2001;  953 88-97
    PubMedGoogle Scholar
  • 61 World Health Organization .International Union Against Tuberculosis and Lung Disease. Anti-tuberculosis drug resistance in the world: the WHO/IUATLD Global Project on Anti-tuberculosis Drug Resistance Surveillance Geneva; 1997 WHO/TB/97.229
    Google Scholar
  • 62 Pablos-Méndez A, Raviglione M C, Laszlo A et al.. Global surveillance for antituberculosis-drug resistance, 1994-1997.  N Eng l Med. 1998;  338 1641-9
    CrossrefPubMedGoogle Scholar
  • 63 Espinal M A, Laszlo A, Simonsen L et al.. Global trends in resistance to antituberculosis drugs.  N Engl J Med. 2001;  344 1294-1303
    CrossrefPubMedGoogle Scholar
  • 64 Espinal M A, Kim S J, Suarez P G et al.. Standard short-course chemotherapy for drug-resistant tuberculosis: treatment outcome in six countries.  JAMA. 2000;  283 2537-2545
    CrossrefPubMedGoogle Scholar
  • 65 Coninx R, Mathieu C, Debacker M et al.. First-line tuberculosis therapy and drug-resistant Mycobacterium tuberculosis in prisons.  Lancet. 1999;  353 969-973
    CrossrefPubMedGoogle Scholar
  • 66 Geerligs W A, van Altena R, Lange W CM, van Soolingen D, van der Werf T S. Multidrug-resistant tuberculosis: long-term treatment outcome in the Netherlands.  Int J Tuberc Lung Dis. 2000;  4 758-764
    PubMedGoogle Scholar
  • 67 Flament-Saillour M, Robert J, Jarlier V, Grosset J. Outcome of multidrug-resistant tuberculosis in France: a nationwide case-control study.  Am J Respir Crit Care Med. 1999;  160 587-593
    PubMedGoogle Scholar
  • 68 Telzak E E, Sepkowitz K, Alpert P et al.. Multidrug-resistant tuberculosis in patients without HIV infection.  N Engl J Med. 1995;  333 907-911
    CrossrefPubMedGoogle Scholar
  • 69 Narita M, Alonso P, Lauzardo M, Hollender E S, Pitchenik A E, Ashkin D. Treatment experience of multidrug-resistant tuberculosis in Florida, 1994-1997.  Chest. 2001;  120 343-348
    CrossrefPubMedGoogle Scholar
  • 70 Viskum K, Kok-Jensen A. Multidrug-resistant tuberculosis in Denmark.  Int J Tuberc Lung Dis. 1997;  1 299-301
    PubMedGoogle Scholar
  • 71 World Health Organization .Treatment of Tuberculosis: Guidelines for National Programs. 2nd ed. Geneva; WHO 1997 WHO/TB/97.227
    Google Scholar
  • 72 Enarson D A, Rieder H L, Arnadottir T, Trebucq A. Management of Tuberculosis: A Guide for Low Income Countries . Paris; International Union Against Tuberculosis and Lung Disease 2000
    Google Scholar
  • 73 World Health Organization .Guidelines for the Management of Drug-Resistant Tuberculosis . Geneva; WHO 1997 WHO/TB/96.210
    Google Scholar
  • 74 Gupta R, Kim J Y, Espinal M A et al.. Responding to market failures in tuberculosis control.  Science. 2001;  293 1048-1105
    PubMedGoogle Scholar
  • 75 World Health Organization .Guidelines for Establishing DOTS-Plus Pilot Projects for the Management of Mulridrug-Resistant Tuberculosis (MDR-TB). Gupta R, Arnadottir T Geneva; WHO 2000 WHO/CDS/TB/2000.279
    Google Scholar
  • 76 Gupta R, Cegielski J P, Espinal M A et al.. Increasing transparency in partnerships for health: introducing the Green Light Committee.  Trop Med Int Health. 2002;  7 970-976
    PubMedGoogle Scholar
  • 77 World Health Organization .Report of the Meeting of the Working Group on DOTS-Plus for MDR-TB. 24-25 October 2003. In press
    Google Scholar
  • 78 Gupta R, Espinal M A, Raviglione M C. Evidence and uncertainties.  Int J Tuberc Lung Dis. 2002;  6 651-653
    PubMedGoogle Scholar
  • 79 Suarez P G, Floyd K, Portocarrero J et al.. Feasibility and cost-effectiveness of second-line drug treatment for chronic tuberculosis patients: a national cohort study in Peru.  Lancet. 2001;  359 1980-1989
    PubMedGoogle Scholar
  • 80 Available at: www.tballiance.org/1_1_C_Missionandvision. Accessed November 30, 2003
  • 81 Tuberculosis Research Centre - Chennai . Shortening short-course chemotherapy: a randomized clinical trial for treatment of smear positive pulmonary tuberculosis with regimens using ofloxacin in the intensive phase.  Indian J Tuberc. 2002;  49 27-38
    PubMedGoogle Scholar
  • 82 Available at: www.finddiagnostics.org/find.htm. Accessed November 30, 2003
  • 83 Fine P EM. BCG vaccines and vaccination. In: Reichman LB, Hershfield ES Tuberculosis: A Comprehensive International Approach. New York; Marcel Dekker 2000: 503-522
    Google Scholar
  • 84 Available at: www.sequellafoundation.org/core.asp. Accessed November 30, 2003
  • 85 Bishai D M, Mercer D. Modeling the economic benefits of better TB vaccines.  Int J Tuberc Lung Dis. 2001;  5 984-993
    PubMedGoogle Scholar
  • 86 Koch R. Die Aetiologie der Tuberkulose.  Berliner Klinische Wochenschrift. 1882;  15 221-230
    PubMedGoogle Scholar
  • 87 World Health Organization .TB: A Global Emergency. Geneva; WHO 1994 WHO/TB/94.177
    Google Scholar
  • 88 World Health Organization . World Health Report 2003.  Geneva: WHO;. 2003; 
    PubMedGoogle Scholar

1 Combat HIV/AIDS, malaria, and other infectious diseases.

2 Have halted by 2015 and begun to reverse the incidence of malaria and other major diseases.

3 Proportion of tuberculosis cases detected and cured under DOTS.

4 The community may be defined as a group of people who have something in common and will act together in their common interest…. Many people belong to a number of different communities; examples include the place where they live, the people they work with, or their religious group.[26]

Rajesh GuptaM.P.H. 

World Health Organization

20 Avenue Appia, CH 1211 Geneva, Switzerland

Email: guptara@who.int

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