In the first Comment with The Lancet Series on Tuberculosis, Lancet Editor-in-Chief Dr Richard Horton and Executive Editor Dr Pamela Das say that, Despite the inclusion of tuberculosis in the Millennium Development Goals (MDGs), tackling this infection as a wider development problem has hardly begun. One difficulty is that the central development issue for tuberculosis is its complex intersection with poverty. They say: "Efforts to control TB should therefore include more than just ministries of health. Policy and practice must also include ministries responsible for finance, housing, social development, and education. Indeed, our Series concludes that treatment-related actions will be insufficient to reach global goals. There is an urgent need to assess interventions for social and economic determinants, such as malnutrition, alcohol use, poor housing, indoor air pollution, and poverty."
Lancet Press Office T) +44 (0) 20 7424 4949 E) pressoffice@lancet.com / tony.kirby@lancet.com
For second Comment, see earlier release on HIV/TB co-infection.
The third Comment looks at the interaction of age and immunity with TB, and is written by Dr Peter R Donald, Stellenbosch University, Tygerberg, South Africa, and colleagues. They point out risk of TB disease after infection with Mycobacterium tuberculosis is highest at ages four years and younger, followed by the period of lowest risk between 5-10 years. During adolescence, risk rises sharply again to a second peak at ages 20-30 years. The authors say: "Age-related differences in disease risk are accompanied by differences in the response to infection and clinical features of disease."
Such information is crucial to aid development of vaccines, as well as the age at which they should be administered. The authors conclude: "The dynamic interaction of age and immunity, as well as its influence on pathogen evolution, needs to be considered in the development of future vaccination strategies."
Dr Peter R Donald, Stellenbosch University, Tygerberg, South Africa. T) +27 (0)82 6035355 / +27 (0) 21 9389592/ +27 (0) 21 5541686 E) prd@sun.ac.za
The fourth Comment looks at TB in women and children, and is written by Professor Ben Marais, Stellenbosch University, Tygerberg, South Africa and colleagues. They say: "Globally, 700 000 women die from TB every year; this disease kills more women than do all causes of maternal mortality combined. Case-fatality rates seem to be higher in women than in men, and women are more often diagnosed with extrapulmonary tuberculosis." They add that children younger than 15 years contribute 15-20% of the global TB disease burden, with incidence rates about half those reported in adults; and highlight the need for child-friendly formulations and child dose-ranging studies of TB drugs.
They conclude: "Women and children have unique susceptibilities and might encounter substantial barriers to access appropriate care. Subgroups that require particular consideration include HIV-infected pregnant women, socially or culturally marginalised individuals, and very young or immunocompromised children. Young children are particularly susceptible, and every effort should be made to prevent exposure to tuberculosis and to provide preventive treatment should exposure occur."
Professor Ben Marais, Stellenbosch University, Tygerberg, South Africa. E-mail contact preferred. E) bjmarais@sun.ac.za
The fifth Comment looks at the role of the community in TB response, and is written by Paula Akugizibwe, AIDS and Rights Alliance for Southern Africa, Cape Town, South Africa and Bobby Ramakant, Stop TB Citizen News Service, Indira Nagar, Lucknow, India. They say: "In many countries, especially where tuberculosis is fuelled by HIV, government healthcare providers have been outstripped of their ability to cope with the levels of service delivery needed to meet targets. Therefore advance on the implementation of tuberculosis programmes needs broader community engagement."
The authors note "the persistence of the historically coercive model of tuberculosis control, a model that inherently disenfranchises patients and can lead to violation of rights, alienation of patients, and reinforcement of stigma, thus undermining the improved outcomes that the model ostensibly aims to achieve" and conclude: "The mindset of top-down TB control urgently needs to be scrutinised and challenged at all levels of health leadership. We need a much more progressive model to harness and optimise the effect of community participation, without which our collective potential to overcome this community disease cannot be realised."
Paula Akugizibwe, AIDS and Rights Alliance for Southern Africa, Cape Town, South Africa. T) +27 83 642 0817 E) paula@arasa.info
The final Comment looks at migration and TB, and is written by Dr Henry M Blumberg, Emory University, Atlanta, USA, and colleagues. They say that nearly 1 billion—or one of seven—people are migrants. An estimated 740 million are internal migrants and 200 million are international migrants, with most (130 million) moving from one developing country to another and 70 million moving from a developing to a developed country. The authors say: "Migrants are disproportionately affected by TB, a reflection of the high rate of disease in their country of origin due to poverty and made worse by limited health-care and public health infrastructure. Migration has significantly affected the epidemiology of TB in high-income countries in Europe, USA, and Canada, which have a low incidence of TB but where most cases now occur in migrants (ie, foreign-born individuals); most cases of multidrug-resistant TB are imported as well."
They conclude: "Unfortunately, governmental public policies towards migrants have been antagonistic to TB control efforts by furthering stigma and marginalisation... Each country should first ensure that, everywhere, all patients with tuberculosis have easy access to diagnosis and treatment free of charge, and that undocumented migrants are not deported until completion of treatment, as stated by the International Union Against Tuberculosis and Lung Disease... In view of globalisation and migration, the mantra, 'tuberculosis anywhere is tuberculosis everywhere' rings true."
Dr Henry M Blumberg, Emory University, Atlanta, USA. T) +1 404-727-399 E) henry.m.blumberg@emory.edu
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The Lancet