Tuberculosis (TB) is still the most important human infectious disease on a global scale. In 2016, there were an estimated 10.4 million cases (incidence 136/100000 inhabitants) and 1.7 million deaths,1 surpassing even the mortality rates of HIV infection.1 Thirty European countries2 reported an incidence of 11.4/100000, the highest of which was in Romania, with 68.9/100000. In Western Europe, Portugal and Spain stand out, with rates of 17.8/100000 and 10.5/100000, respectively (4877 cases), but underreporting is common in Spain,3,4 so the real incidence is higher than the officially reported figures.

The last official report on TB in Spain5 recorded an incidence in 2014 of 10.8/100000 (5018 cases), and concluded that TB needs to decline at a faster rate if targets are to be reached. Measures have been proposed to reduce diagnostic delay, to improve contact tracing, treatment compliance, and to disseminate information on HIV, resistance, and risk factors. Other recommendations should also be mentioned, such as reducing underreporting of cases, ensuring universal health cover (repealing Act 16/2012 which limits healthcare for immigrants), introducing systematic use of rapid molecular tests for the diagnosis of TB and resistance,6 and prescribing shorter treatments for latent tuberculosis infection (LTI), thus promoting adherence.7

The Plan for the Prevention and Control of Tuberculosis in Spain,8,9 prepared in 2007 by a large working group from the scientific societies, autonomous communities, and representatives of the Ministry of Health, was approved by the Commission on Public Health of the Interterritorial Council of the National Health System (CISNS) on November 15, 2007, and by the CISNS itself on June 18, 2008. Although this document lays down the foundations for the control of TB, these were unfortunately not built upon, largely due to a lack of political commitment, which is a top priority in all WHO strategies. While there has been little hesitation in investing significant resources in epidemics widely reported in the media (SARS, avian flu, Ebola) that have little or no impact on health in our country, investment in TB remains lacking, despite the fact that it continues to generate thousands of cases and a number of deaths every year.

The above-mentioned Plan of 20078 must be updated and implemented in Spain.10 Currently, however, there are no full-time staff dedicated to TB programs in most of the autonomous communities, nor in central administration. According to a recent assessment of the Plan,11 8 autonomous communities failed to meet 70% of the requirements for a satisfactory therapeutic outcome, with limited contact tracing, microbiological data, etc. If the Plan was working as intended, cases of TB and deaths would be avoided, and the suffering to patients, their families, and the entire community (high economic costs12) caused by this ancient disease would be mitigated.

The dream is still to eliminate TB as a public health problem (less than 1 case per million inhabitants).13

Unfortunately, with the current epidemiological situation and measures for the control of TB, this dream cannot be realized in the short to medium term, while the WHO continues to opt for more and more ambitious strategies, such as DOTS14 in 1995, Stop TB15 in 2006, and End TB16 in 2014. One of the objectives of End TB is to reduce the incidence of TB by 90% between 2015 and 2035. For Spain, this would mean a shift from an estimated incidence in 2015 of 15/100000 to 7.5/100000 in 2025, and to 1.5/100000 (still far from 1 case per million inhabitants) in 2035 (720 cases).

Can we achieve these goals? Spain is certainly in a position to do so, but a significant political commitment will be needed that must be translated into actions as soon as possible, as and when the Plan is updated and implemented. The effectiveness of this Plan must be demonstrated, particularly in terms of coordination of activities, epidemiological surveillance, microbiological aspects, diagnosis and treatment of LTI,7 teaching and international cooperation, without forgetting adherence to guidelines for optimal diagnosis, prevention and treatment.17