ReviewScaling up interventions to achieve global tuberculosis control: progress and new developments
Introduction
Tuberculosis is a major global public health problem. Although substantial progress has been made, tuberculosis is still one of the most important infectious causes of morbidity and death in the world.1 While the USA and most western European countries have reached record lows in tuberculosis rates and incidence is decreasing worldwide, the number of new cases in some metropolitan areas, such as London (UK), has doubled in the past 10 years.2
The 2010 Lancet's Tuberculosis Series provided a comprehensive overview of global tuberculosis control and research efforts and challenges.3 In this Review we provide a 2-year update, describe progress towards international targets, review important recent developments, and define key areas that hamper progress. We also emphasise the need to enhance strategic investments in areas that have enabled progress, and to intensify efforts to identify solutions for persistent difficulties. The global call to action is reiterated in view of current economic uncertainties.
Section snippets
Progress towards global targets
Progress towards global targets for tuberculosis control and improvements of estimates of the burden of disease caused by tuberculosis are discussed in detail in the WHO's latest global tuberculosis control report;4 the most important findings are summarised here.
In 2010, an estimated 8·8 million (range 8·5 million to 9·2 million) incident cases of tuberculosis occurred, with 1·4 million deaths caused by tuberculosis. The highest incidences were in sub-Saharan Africa (figure 1), linked to the
Drug-resistant tuberculosis
The emergence of drug-resistant tuberculosis is a major threat to global tuberculosis control.4, 24, 25 Despite policy recommendations for diagnosis, infection control, and case management,24, 25, 26 major structural, economic, and political constraints hamper control efforts.27 To comprehensively assess global trends is difficult because laboratory facilities for drug susceptibility testing are insufficient in most countries with endemic tuberculosis. A survey done in Minsk (Belarus) reported
Infection control
Outbreaks of drug-resistant tuberculosis have re-emphasised the importance of infection control to restrict transmission in health-care facilities. A WHO policy document48 for infection control defined the key principles and activities to be implemented, but there are major resource implications and no well-established system to monitor implementation. In a survey of 149 low-income and middle-income countries, 34 had done a national assessment and 45 had a national plan for tuberculosis
Care provider and community involvement
Non-governmental and other civil society organisations galvanised massive support for HIV/AIDS and a similar movement is needed for tuberculosis. In many countries, universal access to quality-assured tuberculosis diagnosis and treatment cannot be ensured without engagement of a wide range of public and private health-care providers operating outside national programmes. However, many unlinked providers continue to diagnose and treat tuberculosis without oversight or an infrastructure to ensure
Progress in tuberculosis research
Progress in key areas related to diagnosis, treatment, and prevention, is outlined in the International Roadmap for Tuberculosis Research53 published by the Stop TB Partnership and WHO in 2011, emphasising the need for ongoing investment across the full research spectrum from basic science to operational implementation.
New approaches to increase case detection
Increasing early detection of tuberculosis has the potential to improve individual outcomes and reduce transmission within communities. Although improved diagnostics will increase tuberculosis detection in patients accessing health services with symptoms and signs of active tuberculosis, many patients have few symptoms, and thus do not fulfil definitions of suspected tuberculosis, or cannot reach the appropriate health services because of barriers to access. Prevalence surveys of areas endemic
Non-communicable diseases and tuberculosis
Non-communicable diseases—smoking-related and occupational lung disease, diet-related diabetes mellitus, and alcohol and drug misuse—are important risk factors for tuberculosis at a population level97, 98 and cross-programme links need to be strengthened.100 The Tuberculosis and Tobacco framework, the Practical Approach to Lung Health guidelines, and the tuberculosis and diabetes framework,101, 102 recommend bi-directional screening and actions to improve health behaviour of tuberculosis
Financing and funding
Funding for tuberculosis control reached $4·2 billion in 2011,4 with domestic sources accounting for $3·6 billion (86% of total funding) and the Global Fund contributing $0·5 billion (82% of all external funding). Despite increased funding in recent years, funding gaps remain large—$1·2 billion in 2011, and $2 billion in 2012—compared with the requirements stated in the Global Plan to Stop TB 2011–2015.106 Funding gaps especially constrain scale-up of services for multidrug-resistant
Conclusions and reiteration of the call to action
Progress is evident, but the path towards tuberculosis elimination remains long, arduous, and challenging. The large case detection gap shows the inadequacies of health services that are either poorly functional, inaccessible to patients, or failing to capture all active cases early enough to reduce transmission. HIV-associated tuberculosis still presents a formidable challenge, especially in sub-Saharan Africa, as does the continued threat of drug-resistant tuberculosis. Improved care of
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