laringeal TB (see Chapter 11). Therapy with anti-tuberculosis drugs was identified as the most effective measure for controlling patient´s production of infectious particles and thus readily reversing infectivity (Gunnels 1977). Therefore, patients should only require isolation while they were sputum positive and before initiation of specific therapy. Hospitalization was either abolished or reduced to a few weeks for most patients (Kaplan 1977). Once a patient´s diagnosis and treatment program had been defined, physicians who had no particular expertise in chest medicine could maintain a quality treatment program in most instances. That was the end of the phthisiologist´s era.
1.7. A global health emergency
Someone in the world is newly infected with TB bacilli every second. Overall, one-third of the world's population is currently infected with
the TB bacillus.
5-10 % of people who are infected with TB bacilli (but who are not infected with HIV) become sick or infectious at some time during their life. People with HIV and TB infection are much more likely to de- velop TB.
World Health Organization Fact sheet N°104 Revised March 2006
In Europe and in the US, the general improvement in public health helped to reduce the burden of TB well before the arrival of specific drugs. TB program activities, reinforced by successful chemotherapy, resulted in a pronounced reduction of in- fection and death rates. The disease became greatly controlled but it never quite disappeared. Then, in around 1985, cases of TB began to rise again in industrial- ized countries. Several inter-related forces drove this resurgence, including increase in prison populations, homelessness, injection drug use, crowded housing and in- creased immigration from countries where TB continued to be endemic. Above all, the decline in TB control activities and the human immunodeficiency vi- rus/acquired immunodeficiency syndrome (HIV/AIDS) epidemic were two major factors fueling each other in the reemergence of TB.
TB programmes had become loose in industrialized countries because the disease was considered close to elimination. A study performed in 1991 showed that 89 %
46 History
of 224 patients discharged on TB treatment were lost to follow-up and failed to complete therapy. More than a quarter were back in hospital within a year, still suffering from TB (Brudney 1991). This study reflected the occurrence of incon- sistent or partial treatment, which was going on everywhere (Clancy 1990). Pa- tients cease to take all their medicines regularly for the required period for different reasons: they start to feel better, doctors and health workers prescribe the wrong treatment regimens, or the drug supply is unreliable. Uncompliance frequently results in the emergence of bacteria resistant to drugs and ultimately in the emer- gence of a “superbug”, resistant to all effective drugs (Iseman 1985). Multidrug- resistant TB, or MDR-TB, refers to M. tuberculosis isolates that are resistant to at least both isoniazid and rifampicin, the two most powerful anti-tuberculosis drugs. MDR-TB takes longer to treat with second-line drugs, which are more expensive and have more side-effects (see Chapters 18 and 19).
In the early ’90s, an extensive outbreak of highly resistant TB affected more than 350 patients in New York City. The strain was resistant to all first-line anti- tuberculosis drugs and almost all patients had HIV/AIDS. The hospital environ- ment was the setting where more than two thirds of the patients acquired and transmitted the infection. As a consequence, this outbreak affected mainly HIV- infected patients and health care workers (Frieden 1996). At that time, New York City became the epicenter of drug-resistant TB, where one in three new cases were found resistant to one drug and one in five to more than one drug. Important HIV/AIDS related hospital outbreaks of MDR-TB similar to the one occurred in New York were described also in non-industrialized countries like Argentina (Ri- tacco 1997).
Indeed, the HIV/AIDS epidemic has produced a devastating effect on TB control worldwide. While one out of ten immunocompetent people infected with M. tuber- culosis will fall sick in their lifetimes, among those with HIV infection, one in ten per year will develop active TB. In developing countries, the impact of HIV infec- tion on the TB situation, especially in the 20-35 age group, is overwhelming. While wealthy industrialized countries with good public health care systems can be expected to keep TB under control, in much of the developing world a catastrophe awaits. In poorly developed countries, TB remains a significant threat to public health, as incidences remain high, even after the introduction of vaccination and drug treatment (Murray 1990). The registered number of new cases of TB world- wide roughly correlates with economic conditions: highest incidences are seen in the countries of Africa, Asia, and Latin America with the lowest gross national products (see Chapter 7).
1.7. A global health emergency 47 Supervised treatment, including sometimes direct observation of therapy (DOT), was proposed as a means of helping patients to take their drugs regularly and com- plete treatment, thus achieving cure and preventing the development of drug resis- tance. The Directly-Observed Treatment, Short-course (DOTS,
http://www.who.int/tb/dots/whatisdots/en/index.html) strategy was promoted as the official policy of the WHO in 1991 (see Chapter 7).
The World Health Organization estimates that eight million people get TB every year, of which 95% live in developing countries. An estimated two million people die yearly from TB. World Health Organization (http://www.who.int/tb/en) de- clared TB a global health emergency in 1993 (World Health Organization 2006). In 1998, the IUATLD joined with the WHO and other international partners to form the Stop TB Initiative, a defining moment in the re-structuring of global ef- forts to control TB. The original Stop TB Initiative has evolved into a broad Global Partnership, Stop TB Partnership (http://www.stoptb.org), with partners gathered in Working Groups to accelerate progress in seven specific areas: DOTS Expansion, TB/HIV, MDR-TB, New TB Drugs, New TB Vaccines, New TB Diagnostics, and Advocacy, Communications and Social Mobilization.
The World Health Assembly of 2000 endorsed the establishment of a Global Part- nership to Stop TB and the following targets:
• By 2005: 70% of people with infectious TB will be diagnosed and 85% of them cured.
• By 2015: the global burden of TB disease (deaths and prevalence) will be reduced by 50% relative to 1990 levels.
• By 2050: The global incidence of TB disease will be less than one per mil- lion population (elimination of TB as a global public health problem) In spite of these global efforts, TB continues to pose a dreadful threat. A notorious example is the sudden emergence in 2005, in a rural hospital located in Kwa-Zulu- Natal, a South African province, of a deadly form of TB associated with HIV/AIDS. This outbreak illustrates the devastating potential of what came to be called extensively drug resistant TB (XDR-TB) (Gandhi 2006). XDR-TB was de- fined as MDR-TB with further resistance to second-line drugs (see Chapter 19). XDR-TB can develop when these second-line drugs are also misused or misman- aged and, therefore, also become ineffective (Raviglione 2007). The menace of XDR-TB is not restricted to that remote African setting. A recent survey, per- formed by 14 supra-national laboratories, on drug susceptibility testing results from 48 countries confirmed this. From 19.9 % of identified MDR-TB isolates, 9.9 %
48 History
met the criteria for XDR-TB. These isolates originated from six continents, con- firming the emergence of XDR-TB as a serious worldwide public health threat (Shah 2007).
Nowadays, treating TB is feasible and effective, even in low income countries, if based on reliable public health practice, including good laboratory infrastructure, appropriate treatment regimens, proper management of drug side-effects and re- sources to maintain adherence and prevent spread. The emergence of XDR-TB should stimulate the improvement of these basic control measures.
It is also crucially important to intensify research efforts devoted to developing effective TB vaccines, as well as shortening the time required to ascertain drug sensitivity, improving the diagnosis of TB, and creating new, highly effective anti- tuberculosis medications. Without supporting such efforts, we still run the risk of losing the battle against TB.
Disease names related to different clinical forms of TB
Name Clinical form
Phthisis Original Greek name for TB
Lung Sickness TB
Consumption TB
Lupus vulgaris TB of the skin
Mesenteric disease TB of the abdominal lymph nodes
Pott’s disease TB of the spine
Scrofula TB of the neck lymph nodes
King´s evil TB of the neck lymph nodes
White Plague TB especially of the lungs
White swelling TB of the bones
Milliary TB Disseminated TB
Acknowledgement: This chapter is dedicated to Professor Pino Pincherle (1893-1996),
radiologist, founder and director of the Sanatorio Pineta del Carso in Trieste, Italy. Since the establishment of the Sanatorium, in 1933, Professor Pincherle was responsible for all physiotherapy treatment and radiologic exams, but after only five years he was compelled to sell his part in the Sanatorium due to racial laws. In 1939 the family emigrated to Brazil. He is the grandfather of Sylvia Cardoso Leão, author of this chapter.
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