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Prevention and control

The first, and to date, only licensed vaccine against TB was introduced in 1921 in order to reduce the incidence of pulmonary disease: it consisted of an attenuated strain of Mycobacterium bovis ( M. bovis bacille Calmette-Guérin (BCG)). Experimental studies in different geographical areas showed it to be highly efficacious in the prevention of meningitis and disseminated disease (so-called ‘miliary TB’) in children, whereas it provides unpredictable immunity against pulmonary disease. Currently, it is prescribed to neonates in endemic countries where there is a risk of being infected shortly after birth (see chapter 26 , figure 4). In Europe, several countries (for instance, Austria, Denmark, Germany and Spain) have discontinued their mass universal vaccination programmes. However, several non-EU/EEA countries such as Belarus and Uzbekistan recommend three BCG vaccinations, with the last dose given during adolescence. Some European countries continue to suggest BCG vaccination for individuals at particular risk of being infected (such as healthcare workers).

Due to the narrow target of the BCG vaccine, the WHO advises that the best preventive approach is to focus on interrupting transmission, by case-finding and antibiotic treatment of infectious cases.

The WHO public health approaches, the DOTS (Directly Observed Treatment, Short course) strategy and Stop TB strategy, launched in 1996 and 2006, respectively, aimed to reduce the global burden of TB and have changed the global epidemiological situation. Over the past decade, they have contributed to the achievement of the United Nations Millennium Development Goals, related to the reduction of 1990 TB prevalence and mortality by 50%, by 2015.

The Stop TB strategy, a revised and updated public health approach, added new components in the fight against TB, to take account of the new epidemiological features of the disease, particularly TB/HIV co-infection and the rise of MDR-TB (table 1).

The fight against TB/HIV co-infection relies on HIV diagnosis and anti-HIV therapy and on the application of the ‘3 Is’: intensified case finding, infection control, and isoniazid preventive therapy for latent infection.

In order to combat the MDR/XDR-TB epidemic, a WHO-convened Task Force developed a specific global MDR-TB and XDR-TB Response Plan in 2007–2008, and in 2009 a governmental conference launched the Beijing Call for Action. Recommendations were developed for the control of XDR-TB, including the following:

• Prevent XDR-TB through basic strengthening of TB and HIV control.

• Improve the management of individuals suspected to be affected by XDR-TB through accelerated access to laboratory facilities with rapid DST for rifampicin and isoniazid resistance.

• Strengthen the management of XDR-TB through adequate use of second-line drugs and patient-centred approaches to ensure support and supervision.

• Better protection of healthcare workers against infection.

• Implement XDR-TB surveillance activities through the network of supra-national and national reference laboratories.

• Initiate advocacy, communication and social mobilisation activities to inform and raise awareness about TB and XDR-TB.

However difficult it is to reach, the ultimate goal of international and national public health activities is the elimination of TB, decreasing the incidence of new infectious cases (i.e. those with a positive result on direct microscopic examination of the sputum) to less than 1 per 1 million population by 2050.

Table 1 – The World Health Organization-recommended strategy for tuberculosis (TB) control (the Stop TB strategy). DOTS: Directly Observed Treatment, Short course; MDR-TB: multidrug-resistant TB; PAL: Practical Approach to Lung Health; PPM: public–private mix; ISTC: International Standards for TB Care. Reproduced and modified from World Health Organization, Global Tuberculosis Control 2011, with permission from the publisher.

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Chapters

• Editors' introduction
• Foreword from the World Health Organization
• Foreword from the European Commission
• Promoting respiratory health in Europe
• The burden of lung disease
  • Introduction: the global perspective
  • Key points
  • Respiratory deaths in Europe
  • Figure 1
  • Figure 2
  • The impact on health services
  • Figure 3
  • Figure 4
  • Figure 5
  • Figure 6
  • The “iceberg of disease”
  • Figure 7
  • Recent trends
  • Figure 8
  • Figure 9
  • Figure 10
  • Future projections
  • Terminology and data
  • Data sources
• The economic burden of lung disease
  • Background
  • Key points
  • Methods
  • The cost of respiratory disease
  • Figure 1
  • Discussion
  • Further reading
• Genetic susceptibility
  • Introduction
  • Key points
  • Figure 1
  • Figure 2
  • Monogenic diseases
  • Complex diseases
  • Figure 3
  • Complex traits
  • Conclusions and future prospects
  • Further reading
• Early-life events
  • Introduction
  • Key points
  • Abnormal antenatal lung growth
  • Low birthweight
  • Prematurity and BPD
  • Figure 1
  • Tobacco smoke exposure
  • Viral infections in infancy
  • Wheezy bronchitis
  • Conclusion
  • Further reading
• Diet and nutrition
  • Introduction
  • Key points
  • Diet as a risk factor
  • Nutritional status and interventions
  • Clinical recommendations
  • Further reading
• Outdoor environment
  • Introduction
  • Key points
  • Pollution: composition/sources
  • Pathophysiological effects of air pollutants
  • Respiratory health effects
  • Long-term consequences
  • Figure 1
  • Respiratory disease in adults and children
  • Lung cancer
  • Figure 2
  • The importance of susceptibility
  • Relevance and outlook
  • Further Reading
• Occupational risk factors
  • Introduction
  • Key points
  • Figure 1
  • Exposure history and assessment
  • Latency between exposure and disease
  • Figure 2
  • Maximum workplace concentrations
  • Exposures and their effects
  • Further reading
• Passive smoking
  • Introduction
  • Key points
  • Harmful effects of SHS on health
  • Figure 1
  • Estimates of burden of disease due to SHS
  • Measurement of SHS
  • Health benefits of smoke-free legislation
  • Protection from exposure to SHS
  • Further reading
• Tobacco smoking
  • Introduction
  • Key points
  • Epidemiology
  • Figure 1
  • Toxic effects of tobacco smoke
  • Disorders induced by tobacco smoking
  • Figure 2
  • Societal costs of smoking
  • Dependence on tobacco
  • Legislation and prevention of smoking
  • Figure 3
  • Pharmacotherapy for smoking cessation
  • Counselling for smoking cessation
  • Benefits of quitting smoking
  • Cost-effectiveness of smoking cessation
  • ERS guidelines on smoking cessation
  • Future developments
  • Conclusions
  • Further reading
• Indoor environment
  • Introduction
  • Key points
  • Indoor pollutants and health effects
  • Figure 1
  • Figure 2
  • Specific pollutants
  • Figure 3
  • Indoor air quality in schools
  • Figure 4
  • Interventions
  • Conclusion
  • Further reading
• Childhood asthma
  • Introduction
  • Key points
  • Epidemiology
  • Figure 1
  • Figure 2
  • Figure 3
  • Figure 4
  • Figure 5
  • Causes/pathogenesis
  • Clinical manifestations and consequences
  • Prevention
  • Management
  • Prognosis
  • Future developments
  • Research needs
  • Further reading
• Adult asthma
  • Introduction
  • Key points
  • Epidemiology
  • Figure 1
  • Causes/pathogenesis
  • Clinical manifestations
  • Figure 2
  • Figure 3
  • Prevention
  • Management
  • Prognosis
  • Future developments and research needs
  • Further reading
• Chronic obstructive pulmonary disease
  • Introduction
  • Key points
  • Epidemiology
  • Figure 1
  • Figure 2
  • Figure 3
  • Causes/pathogenesis
  • Clinical manifestations
  • Prevention
  • Management
  • Prognosis
  • Future developments
  • Research needs
  • Further reading
• Cystic fibrosis
  • Introduction
  • Key points
  • Epidemiology
  • Figure 1
  • Figure 2
  • Causes/pathogenesis
  • Clinical manifestations and consequences
  • Prevention
  • Management
  • Prognosis
  • Figure 3
  • Future developments
  • Research needs and unanswered questions
  • Further reading
• Bronchiectasis
  • Introduction
  • Key points
  • Epidemiology
  • Figure 1
  • Causes/pathogenesis
  • Figure 2
  • Clinical manifestations and consequences
  • Prevention
  • Management
  • Prognosis
  • Future developments
  • Research needs
  • Further reading
• Paediatric respiratory diseases
  • Introduction
  • Key Points
  • Figure 1
  • Acute bronchiolitis
  • Figure 2
  • Figure 3
  • Perinatal respiratory diseases and BPD
  • Figure 4
  • Figure 5
  • Severe community-acquired pneumonia in children
  • Figure 6
  • Tuberculosis in children
  • Figure 7
  • Immunisation
  • Figure 8
  • Congenital respiratory disorders
  • General remarks
  • Further reading
• Tuberculosis
  • Introduction
  • Key points
  • Epidemiology
  • Figure 1
  • Figure 2
  • Figure 3
  • Figure 4
  • Figure 5
  • Causes/pathogenesis
  • Clinical manifestations and consequences
  • Prevention and control
  • Management
  • Prognosis
  • Research needs
  • Future developments
  • Further reading
• Acute lower respiratory infections
  • Introduction
  • Key points
  • Figure 1
  • Influenza
  • Figure 2
  • Pneumonia
  • Figure 3
  • Figure 4
  • Figure 5a
  • Figure 5b
  • Figure 6
  • Prevention
  • Future developments
  • Further reading
• Lung cancer
  • Introduction
  • Key points
  • Epidemiology
  • Figure 1
  • Figure 2
  • Figure 3
  • Causes
  • Prevention
  • Management
  • Prognosis
  • Figure 4
  • Future developments
  • Research needs
  • Further reading
• Acute respiratory distress syndrome
  • Introduction
  • Key points
  • Definition and diagnosis
  • Pathogenesis
  • Incidence and outcome
  • Treatment options
  • Future developments
  • Further reading
• Pulmonary vascular disease
  • Introduction
  • Key points
  • Figure 1
  • Figure 2
  • Pulmonary embolism
  • Figure 3
  • Figure 4
  • Pulmonary hypertension
  • Further reading
• Interstitial lung diseases
  • Introduction
  • Key points
  • Epidemiology
  • Figure 1
  • Figure 2
  • Causes/pathogenesis
  • Clinical manifestations and consequences
  • Prevention
  • Management
  • Prognosis
  • Financial burden
  • Figure 3
  • Figure 4
  • Research needs
  • Further reading
• Sleep breathing disorders
  • Introduction
  • Key points
  • Epidemiology
  • The pathophysiology of OSAS
  • Figure 1
  • Clinical manifestations and consequences
  • Prevention
  • Management
  • Figure 2
  • Figure 3
  • Prognosis
  • Obesity hypoventilation syndrome
  • Future developments and research needs
  • Further reading
• Occupational lung diseases
  • Introduction
  • Key points
  • Acute inhalation injuries
  • Occupational infections
  • Asthma
  • COPD
  • Interstitial lung diseases
  • Figure 1
  • Types of ILD
  • Lung cancer
  • Pleural disease
  • Figure 2
  • Figure 3
  • Prevention
  • Conclusion
  • Further reading
• Rare and orphan lung diseases
  • Introduction
  • Key points
  • Specific diseases
  • Diagnosis and support
  • Therapy
  • Future developments
  • Further reading
• Immunisation against respiratory diseases
  • Introduction
  • Key points
  • Influenza
  • Figure 1
  • Pertussis
  • Figure 2
  • Streptococcus pneumoniae
  • Figure 3
  • Tuberculosis
  • Figure 4
  • Developments and research needs
  • Further reading
• Principles of respiratory investigation
  • Introduction
  • Key points
  • History
  • Physical examination
  • Laboratory methods
  • Respiratory function tests
  • Figure 1
  • Imaging techniques
  • Figure 2
  • Figure 3
  • Invasive biopsy techniques
  • Figure 4
  • Further reading
• Principles of respiratory therapy
  • Introduction
  • Key points
  • Pharmacological therapy
  • Figure 1
  • Nonpharmacological therapy
  • Figure 2
  • Figure 3
  • Other forms of treatment
  • Further reading
• Pulmonary rehabilitation
  • Background
  • Key points
  • Definition
  • Rationale
  • Application
  • Outcome
  • Setting and content
  • What is needed?
  • Conclusion
  • Further reading
• Paediatric respiratory medicine
  • Introduction
  • Key points
  • Figure 1
  • Setting
  • Figure 2
  • Training
  • Standardisation of care: towards a common goal
  • Keeping up with developments
  • Conclusion
  • Further reading
• Respiratory intensive care
  • Introduction
  • Key points
  • The role of respiratory medicine in intensive care
  • Figure 1
  • Future prospects
  • Figure 2
  • Further reading
• Thoracic surgery
  • Introduction
  • Key points
  • Standards of care
  • Figure 1
  • Figure 2
  • Figure 3
  • Changing roles
  • The future
  • Further reading
• Medical respiratory specialists
  • Introduction
  • Figure 1
  • Figure 2
  • Figure 3
  • Figure 4
  • Figure 5
  • Figure 6
• Allied respiratory professionals
  • Introduction
  • Key points
  • Respiratory technologists and clinical scientists
  • Figure 1
  • Figure 2
  • Respiratory physiotherapists
  • Respiratory nurses
  • Further reading
• Primary care practitioners
  • Introduction
  • Key points
  • Primary care practitioners
  • Primary care and chronic lung disease
  • A role for primary care practitioners
  • Conclusion
  • Further reading
• Specialist clinical training (HERMES)
  • Specialist training in respiratory medicine
  • Key points
  • Figure 1
  • Development strategy for educational standards
  • Figure 2
  • The HERMES projects: adult respiratory medicine
  • Figure 3
  • Figure 4
  • The other HERMES projects
  • Conclusion
  • Further reading
• ERS School and postgraduate education
  • Introduction
  • Key points
  • The HERMES projects
  • The ERS School web platform
  • Figure 1
  • ERS School Courses
  • School publications
  • Educational research seminars
  • Skills-based, hands-on learning
  • Strategic developments in the School
  • Further reading
• Respiratory research
  • Introduction
  • Key points
  • Fields of research
  • Advances in respiratory biomedicine
  • Conclusion
  • Further reading
• Respiratory journals and publications
  • Introduction
  • Key points
  • Figure 1
  • General medical journals
  • Types of journal article
  • Peer review in respiratory journals
  • Assessing quality and status of respiratory journals
  • Publication ethics
  • Advances in publishing
  • Open access
  • Publications of the ERS
  • Conclusions
  • Further reading
• Patient organisations and the European Lung Foundation
  • Introduction
  • Key points
  • The role of patient organisations
  • Figure 1
  • Pan-European patient organisations
  • Respiratory diseases
  • Figure 2
  • Challenges
  • The future
  • Further reading
• Recommendations and policy
  • Introduction
  • Key points
  • Approach
  • Policy context
  • Noncommunicable diseases
  • Tobacco
  • Air quality
  • Tuberculosis
  • Conclusion
  • Further reading