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.
|1.||Pursue high-quality DOTS expansion and enhancement|
|Secure political commitment, with adequate and sustained financing|
|Ensure early case detection and diagnosis through qualityassured bacteriology|
|Provide standardised treatment with supervision, and patient support|
|Ensure effective drug supply and management|
|Monitor and evaluate performance and impact|
|2.||Address TB/HIV, MDR-TB, and the needs of poor and vulnerable populations|
|Scale up collaborative TB/HIV activities|
|Address the needs of TB contacts, and of poor and vulnerable populations, including women, children, prisoners, refugees, migrants and ethnic minorities|
|3.||Contribute to health system-strengthening based on primary healthcare|
|Help improve health policies, human resource-development financing, supplies, service delivery and information|
|Strengthen infection control in health services, other congregate settings and households|
|Upgrade laboratory networks, and implement the PAL|
|Adapt successful approaches from other fields and sectors, and foster action on the social determinants of health|
|4.||Engage all care providers|
|Involve all public, voluntary, corporate and private providers through PPM approaches|
|Promote use of the ISTC|
|5.||Empower people with TB, and communities through partnership|
|Pursue advocacy, communication and social mobilisation|
|Foster community participation in TB care|
|Promote use of the Patients’ Charter for TB Care|
|6.||Enable and promote research|
|Conduct programme-based operational research and introduce new tools into practice|
|Advocate for and participate in research to develop new diagnostics, drugs and vaccines|