JAMA: Global Tuberculosis. Perspectives, Prospects, and Priorities

In the Journal of the American Medical Association this month, Tom Frieden, Karen Brudney and Anthony Harries remind readers that a key challenge in TB control is “forgetting”: political leaders forget the poor; health leaders forget simple, low-tech interventions; patients forget how sick they were and may stop treatment when they get better. The solution lies in persisting with basic TB control principles, not just in planning but in actual implementation.

Despite great progress in tuberculosis control since the World Health Organization declared tuberculosis a global emergency 20 years ago, the disease remains a major public health problem. The JAMA article emphasises that the greatest risk to tuberculosis control is lack of implementation of effective and currently available strategies and tools.

Newer diagnostic tests for tuberculosis enhance but cannot yet replace smear microscopy because of their expense and  the need for suitable infrastructure. All patients diagnosed with tuberculosis should receive prompt, complete and effective treatment, but as many as 10–30% of patients with laboratory-detected tuberculosis do not start treatment -- a problem that has so far received far less attention than it deserves.

Regular, structured supervision of tuberculosis diagnostic and treatment centres combined with programme management and evaluation are essential to tuberculosis control and to ensuring treatment completion rates as close to 100% as possible, but these activities do not receive the consistent financial support that they need.

Treatment observation is often official policy but is difficult to implement well and often not actually practised. Within hospitals, the simplest ways to reduce the spread of tuberculosis spread, such as keeping windows open and constructing outdoor waiting areas, are often the most effective and least expensive, but the least used.

Molecular tests will improve the diagnosis of drug-resistant tuberculosis, but effective treatment requires drug susceptibility testing.

The authors conclude that innovation in tuberculosis control is crucial and new technology can and should be appropriately used, but this must be accompanied by effective core public health practice.

Frieden TR, Brudney KF, Harries AD. Global Tuberculosis. Perspectives, Prospects, and Priorities. JAMA, published on line September 4, 2014