Key Points
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Improvements in socioeconomic conditions contributed thoroughly to the decline in tuberculosis (TB) incidence and mortality in most industrialized countries in the twentieth century. The discovery of effective tools to combat the TB epidemics in the early twentieth century (sputum smear microscopy, Mycobacterium bovis bacillus Calmette–Guérin vaccine and the first anti-TB drugs) raised high hopes for worldwide control in the second half of the century.
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However, in the 1970s interest in TB declined for about two decades. Owing to the emergence of the HIV/AIDS pandemic and the reports of anti-TB drug resistance, TB returned to the global public health agenda in the early 1990s. To address this, in 1991 the 44th World Health Assembly adopted a resolution recognizing TB as a major public health problem and in 1995 promoted DOTS (directly observed therapy, short course) as its solution.
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To improve TB control further and address the specific challenges of TB–HIV coinfection and multidrug-resistant TB (MDR-TB), in 2006, the WHO launched the Stop TB Strategy. This strategy builds on the expansion of high-quality DOTS, emphasizing the need to reach out to poor and vulnerable populations and fostering private sector and community involvement in TB care and control.
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As a result of worldwide efforts, 46 million patients with TB were successfully treated between 1995 and 2010, and up to 7 million lives were saved, including 2 million women and children. Global mortality rates fell by 40% between 1990 and 2010, and the international target of 50% mortality reduction by 2015 may be achieved if the current rate of decline is sustained.
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In 2010, there were 5.8 million official notifications of TB cases worldwide, up from 3.4 million in 1995, and there were an estimated 8.8 million incident cases (range, 8.5 million–9.2 million) of TB globally.
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The emergence of TB–HIV coinfection and of anti-TB drug resistance showed the limits of the current control tools, pointing at the need for wider research and development efforts for optimal diagnosis, prevention and treatment of all forms of TB in people of all ages.
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The fight against TB is becoming more and more multi-faceted and has to be carried out on many fronts. As attention is gradually shifting towards the aspiration of TB elimination, actions are required on four distinct and simultaneous fronts to achieve this ambitious goal: securing the core TB control functions; health system support; investing in research; and addressing the social determinants of TB.
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Realizing the Stop TB Strategy's vision of a TB-free world will require policies and actions beyond the remit of TB control programmes and non-state health stakeholders, and will need contributions from other sectors to eradicate the key determinants of the epidemic. In the context of health and human development, research to accelerate progress in TB control is inextricably associated with efforts to alleviate poverty and promote social and economic development.
Abstract
Tuberculosis (TB) is an ancient disease, but not a disease of the past. After disappearing from the world public health agenda in the 1960s and 1970s, TB returned in the early 1990s for several reasons, including the emergence of the HIV/AIDS pandemic and increases in drug resistance. More than 100 years after the discovery of the tubercle bacillus by Robert Koch, what is the status of TB control worldwide? Here, we review the evolution of global TB control policies, including DOTS (directly observed therapy, short course) and the Stop TB Strategy, and assess whether the challenges and obstacles faced by the public health community worldwide in developing and implementing this strategy can aid future action towards the elimination of TB.
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Acknowledgements
The authors thank Katherine Floyd, Diana Weil and Paul Nunn for their contribution to many of the elements described in this Review.
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Lienhardt, C., Glaziou, P., Uplekar, M. et al. Global tuberculosis control: lessons learnt and future prospects. Nat Rev Microbiol 10, 407–416 (2012). https://doi.org/10.1038/nrmicro2797
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