Elsevier

The Lancet

Volume 379, Issue 9829, 19–25 May 2012, Pages 1902-1913
The Lancet

Review
Scaling up interventions to achieve global tuberculosis control: progress and new developments

https://doi.org/10.1016/S0140-6736(12)60727-2Get rights and content

Summary

Tuberculosis is still one of the most important causes of death worldwide. The 2010 Lancet tuberculosis series provided a comprehensive overview of global control efforts and challenges. In this update we review recent progress. With improved control efforts, the world and most regions are on track to achieve the Millennium Development Goal of decreasing tuberculosis incidence by 2015, and the Stop TB Partnership target of halving 1990 mortality rates by 2015; the exception is Africa. Despite these advances, full scale-up of tuberculosis and HIV collaborative activities remains challenging and emerging drug-resistant tuberculosis is a major threat. Recognition of the effect that non-communicable diseases—such as smoking-related lung disease, diet-related diabetes mellitus, and alcohol and drug misuse—have on individual vulnerability, as well as the contribution of poor living conditions to community vulnerability, shows the need for multidisciplinary approaches. Several new diagnostic tests are being introduced in endemic countries and for the first time in 40 years a coordinated portfolio of promising new tuberculosis drugs exists. However, none of these advances offer easy solutions. Achievement of international tuberculosis control targets and maintenance of these gains needs optimum national health policies and services, with ongoing investment into new approaches and strategies. Despite growing funding in recent years, a serious shortfall persists. International and national financial uncertainty places gains at serious risk. Perseverance and renewed commitment are needed to achieve global control of tuberculosis, and ultimately, its elimination.

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

References (107)

  • SH Kaufmann

    Fact and fiction in tuberculosis vaccine research: 10 years later

    Lancet Infect Dis

    (2011)
  • F Forti et al.

    Pristinamycin-inducible gene regulation in mycobacteria

    J Biotechnol

    (2009)
  • EL Corbett et al.

    Comparison of two active case-finding strategies for community-based diagnosis of symptomatic smear-positive tuberculosis and control of infectious tuberculosis in Harare, Zimbabwe (DETECTB): a cluster-randomised trial

    Lancet

    (2010)
  • I Abubakar et al.

    Tuberculosis in the UK—time to regain control

    BMJ

    (2011)
  • Global tuberculosis control

    (2011)
  • P Glaziou et al.

    Lives saved by tuberculosis control and prospects for achieving the 2015 global target for reducing tuberculosis mortality

    Bull World Health Organ

    (2011)
  • WHO Policy on Collaborative TB/HIV Activities

    (2010)
  • Antiretroviral therapy for HIV infection in adults and adolescents: recommendations for a public health approach, 2010 revision

    (2010)
  • FX Blanc et al.

    Earlier versus later start of antiretroviral therapy in HIV-infected adults with tuberculosis

    N Engl J Med

    (2011)
  • DV Havlir et al.

    Timing of antiretroviral therapy for HIV-1 infection and tuberculosis

    N Engl J Med

    (2011)
  • SS Abdool Karim et al.

    Integration of antiretroviral therapy with tuberculosis treatment

    N Engl J Med

    (2011)
  • ME Torok et al.

    Timing of initiation of antiretroviral therapy in human immunodeficiency virus (HIV)-associated tuberculous meningitis

    Clin Infect Dis

    (2011)
  • Treatment of Tuberculosis Guidelines

    (2009)
  • A Loeliger et al.

    Protease inhibitor-containing antiretroviral treatment and tuberculosis: can rifabutin fill the breach?

    Int J Tuberc Lung Dis

    (2012)
  • H Getahun et al.

    Development of a standardized screening rule for tuberculosis in people living with HIV in resource-constrained settings: individual participant data meta-analysis of observational studies

    PLoS Med

    (2011)
  • Guidelines for intensified tuberculosis case finding and isoniazid preventive therapy for people living with HIV in resource constrained settings

    (2010)
  • A Gupta et al.

    Symptom screening among HIV-infected pregnant women is acceptable and has high negative predictive value for active tuberculosis

    Clin Infect Dis

    (2011)
  • C Akolo et al.

    Treatment of latent tuberculosis infection in HIV infected persons

    Cochrane Database Syst Rev

    (2010)
  • NA Martinson et al.

    New regimens to prevent tuberculosis in adults with HIV infection

    N Engl J Med

    (2011)
  • K Middelkoop et al.

    Antiretroviral therapy and TB notification rates in a high HIV prevalence South African community

    J Acquir Immune Defic Syndr

    (2011)
  • JE Golub et al.

    Isoniazid preventive therapy, HAART and tuberculosis risk in HIV-infected adults in South Africa: a prospective cohort

    AIDS

    (2009)
  • C Kabali et al.

    Completion of isoniazid preventive therapy and survival in HIV-infected, TST-positive adults in Tanzania

    Int J Tuberc Lung Dis

    (2011)
  • E Nathanson et al.

    MDR tuberculosis—critical steps for prevention and control

    N Engl J Med

    (2010)
  • Multidrug and Extensively Drug resistant TB (M/XDR-TB): 2010 Global Report on Surveillance and Response

    (2010)
  • Guidelines for the programmatic management of drug-resistant tuberculosis, 2011 update

    (2011)
  • A Zumla et al.

    Drug resistant tuberculosis—current dilemmas, unanswered questions, challenges and priority needs

    J Infect Dis

    (2012)
  • A Skrahina et al.

    Alarming levels of drug-resistant tuberculosis in Belarus: results of a survey in Minsk

    Eur Respir J

    (2012)
  • R McNerney et al.

    Tuberculosis diagnostics and biomarkers: needs, challenges, recent advances and opportunities

    J Infect Dis

    (2012)
  • A Zumla

    The Global Fund Round 11 cancellation fiasco: turning disaster into opportunity?

    Int J Tuberc Lung Dis

    (2012)
  • MJ van der Werf et al.

    Multidrug resistance after inappropriate tuberculosis treatment: A meta-analysis

    Eur Respir J

    (2011)
  • ZF Udwadia et al.

    Totally drug-resistant tuberculosis in India

    Clin Infect Dis

    (2012)
  • A Zumla et al.

    Rational use of anti-TB drugs in the EU: better patient care and less drug resistance

    Eur Respir J

    (2012)
  • D Falzon et al.

    WHO guidelines for the programmatic management of drug-resistant tuberculosis: 2011 update

    Eur Respir J

    (2011)
  • A Gupta et al.

    Maternal tuberculosis: a risk factor for HIV mother-to-child transmission

    J Infect Dis

    (2010)
  • VF Gomez et al.

    Impact of tuberculosis exposure at home on mortality in children under 5 years of age in Guinea-Bissau

    Thorax

    (2011)
  • A Sandgren et al.

    Childhood tuberculosis in the European Union/European Economic area, 2000 to 2009

    Euro Surveill

    (2011)
  • HJ Menzies et al.

    Epidemiology of tuberculosis among US- and foreign-born children and adolescents in the United States, 1994–2007

    Am J Public Health

    (2010)
  • LJ Lighthelm et al.

    Xpert MTB/RIF for the rapid diagnosis of tuberculous lymphadenitis from fine needle aspiration biopsy specimens

    J Clin Microbiol

    (2011)
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