Editor's Choice

Don’t forget tuberculosis

BMJ 2011; 343 doi: http://dx.doi.org/10.1136/bmj.d4991 (Published 03 August 2011) Cite this as: BMJ 2011;343:d4991
  1. Fiona Godlee, editor, BMJ
  1. fgodlee{at}bmj.com

Not so long ago tuberculosis was seen as an “old” disease, one that had been conquered in large parts of the world and might even be eliminated. No longer. HIV/AIDS, poverty, travel, and migration have seen tuberculosis re-emerge as a global pandemic. It now affects a third of the world’s population, and although there is optimism about reaching the millennium development goal target—that global incidence should be falling by 2015, no country or region has elimination realistically in its sights.

While most cases globally are in South East Asia, Africa, and the Western Pacific region, WHO says a pandemic is under way in Europe, and drug resistant tuberculosis is a major problem. The disease kills seven people an hour in Europe, and of the 14 countries most affected by multidrug resistant tuberculosis, 12 are in the European region (www.euro.who.int/en/what-we-do/health-topics/communicable-diseases/tuberculosis). The good news is that across the region rates are falling; dramatically in the case of Portugal, which is the region’s most affected country. The bad news is that, alone among European countries, the UK has increasing notifications of the disease.

As Ibrahim Abubakar and colleagues report, the number of cases in the UK is now at its highest since the 1970s (doi:10.1136/bmj.d4281). Most cases (nearly three quarters in 2009) occur in people born outside the UK, and while rates in people born within the UK are stable, rates among immigrants are rising. The authors describe a combination of factors. Compared with other European countries, a greater proportion of migrants to the UK come from countries with a high prevalence of tuberculosis, such as the Indian subcontinent and sub-Saharan Africa, and latent Mycobacterium tuberculosis infection acquired outside the UK has created reservoirs of infection, most likely to spread among people living in high density, marginalised, urban settings.

The authors set out their recommendations for bringing the situation under control. There’s no single intervention that will work, they say, but a range of strategies, targeting not only migrants from countries with a high incidence of tuberculosisbut also homeless people, drug misusers, and offenders.

It’s at the local level that the UK is failing most, they say. Of 112 English primary care trusts that responded to a survey, nearly half had no migrant screening programme and no designated adviser on tuberculosis control. They see some opportunity in the proposed changes to the English NHS, with enhanced public health activity, but they warn that devolved commissioning could take us in the wrong direction. Commissioning groups as currently envisaged will be too small to have workable plans for managing outbreaks, they say, and the cost of treating drug resistant tuberculosis would be better funded at sub-national level through the NHS Commissioning Board.

Portugal, the Netherlands, and New York have shown what can be achieved with intensive and sustained effort. The UK is currently heading in the wrong direction and must quickly learn what lessons it can.

Notes

Cite this as: BMJ 2011;343:d4991

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