Well, there are already a lot of strategies developed and implemented towards to the goal of dramatically reduce the global burden of TB in line with the Millennium Development Goals and the Stop TB Partnership targets, which has been showed during the last years in many countries all over the World.

There are two targets for TB:

MDG 6, Target 8: Halt and begin to reverse the incidence of TB by 2015

Targets linked to the MDGs and endorsed by the Stop TB Partnership:

– by 2015: reduce prevalence and deaths due to TB by 50% compared with a baseline of 1990

– by 2050: eliminate TB as a public health problem.

2015 targets have been reached in many places, however in many countries of Africa and Asia, are so far yet from it.

So the best way is to keep it TB in mind, to improve conditions, to address the social determinants and reduce also the impact of HIV on TB, as many other elements that are known contribute with TB epidemiology in the World (addressing TB also in vulnerable populations, eg. prisoners).

I attached some of my TB papers related specificly to this topic.

Finally, please if you consider this answer appropriate, please upvote it using the green up arrow click. Thanks.

Thanks Dr Morales for your thoughtful answers and sending your papers on TB.

Hi Harish,

I would like to answer with some different angle. There are standard treatment available for the cure of TB. Even then we can not get rif of TB. The most probable reasons are:

1.Poverty in developing countries. (Multiple families are living in single room house)

2. Low literacy rate; That is big cause of late diagnosis and spreading TB.

3. No accurate diagnosis at a  proper time.

3. Not proper treatment and follow up for 9 months that may produce MDR TB cases.

4. Finally, No prime importance of Government polices to handle health issues.

There are two best ways to eliminate the TB

1. Raise awarenes for TB not only in cities also in villages.

2. Build new hospitals or atleast seperate the buildings only for diagnosing, and treatment of TB.

Best.

Sajjad

Timely diagnosis and proper supervised therapy...

I take the point from Sayan, it is important to have successfully chemotherapy treatments (to reduce active transmitters), to improve the quality of housing (better ventilation), population nutrition and a close monitoring to new cases (remember that at least one third of the population may have an inactive primary node) that may appear. Just like in the diseases for eradication (smallpox) we rely in a permanent and effective surveillance of respiratory symptomatics. Finally I agree with the fact  that a reduction of HIV infections will reduce TB cases (they're coinfections).

As pointed out by Alfonso, Eliminating tuberculosis in endemic regions requires a multi-disciplinary approach. It is important to address the social determinants of health. Individuals living in poor housing conditions (crowded spaces , lack of ventilation) are more likely to progress to active tuberculosis. However in many third world countries, this would mean eradicating poverty which itself is a difficult task (due to politics, economy, etc.). It is important to monitor treatment of   Tb patients  to ensure adherence and avoid  the emergence of resistance. 

Diagnostic and treatment have to be improved in HIV-infected individuals. Another major issue is MDR-tuberculosis, it is important to improve access to MDR-TB therapy in endemic regions.

Finally, we should pay close attention to latent Tuberculosis infection in some particulars groups such as  HIV-infected individuals, miners etc.

I agree with Christophe Toukam in the fact that if we eliminate active TB, we have to dedicate a special effort to monitor latent Tuberculosis which represent a reservoir for the bacillus.

Completely in agreement about the need to address the social determinants and the pending work in developing societies (also in developed societies with some marginalized groups) to reduce poverty and raise the quality of life in order to advance TB control and reduction.

Its not easy to eliminate TB, especially in developing countries like India where 40% population is infected with the bacteria. The disease  usually occurs when there is a drop in immunity due factors like malnutrition etc. As such chronic diseases are hard to eliminate.

However, we can reduce the burden of TB by ensuring all patients receive DOTS treatment and addressing social determinants like malnutrition, overcrowding and poverty.

The best bet would be DOTS (Directly observed treatment short course). Another vital task to consider specially in Iran is to diagnose MDR (Multi-drug resistant) cases as early as possible. 

Early detection of open cases & put them in to effective chemotherapy is the only way at present. So, make a system of community-based TB surveillance system to detect infectious cases as early as possible before it spreads to contact family/work place members.

Dr Sarkar thanks for your response!

I am very concerned about the  multiple drug resistant strains which are unresponsive to chemotherpy and pose a greatest threat to the society! Any suggestions to this emerging aspect of the tuberculosis?

Dear Harish

as for MDR-TB, it seems roughly half of MDR is transmitted, and half arises through failing chemotherapy of drug sensitive TB.

So we need three things:

For existing MDR cases:

1. rapid diagnosis and

2. good management of MDR cases to prevent transmission of these drug resistant strains.

1. requires quality diagnostics with quick turnaround time; and 2. probably requires new drugs to make MDR treatment shorter and more effective and increase treatment success from the current rate of 2/3. Importantly, most MDR patients in the world do not have access to MDR treatment so this is a distribution issue.

For cases of drug sensitive TB:

3. optimised treatment to prevent new resistance. This probably involves not only good supervision but also optimisation of drug doses, since even with 100% compliance some patients do not achieve drug levels which are high enough and are at risk of resistance (http://www.ncbi.nlm.nih.gov/pubmed/22021624; http://www.ncbi.nlm.nih.gov/pubmed/22467670). Of course, better and shorter treatment regimens would be very helpful here.

MDR TB unresponsive to chemotherapy is really a greater challenge. We need to detect them early and stop further spread to family contacts from them. I know there is machine called Gene Expert that detects it in a short time. But use of it in a remote community is impossible as it is expensive. Some drugs are available which might be useful, at least for some patients. But stopping transmission to generate a new case is really very important by any means even if we can not cure a patient. Development of newer drug for MDR TB is also a need of the time.

You are absolutely right. If you have scope (particularly fund) of studying epidemiology of this kind of transmission in a resource poor setting, you are most welcome to our institute and we would be happy to collaborate with you. We are part of Indian Council of Medical Research and I am of public health background.

Greetings Harish Chandra

I would like to touch on a few points that Sajjad Ashraf raised.

What makes TB so unique is that it is a jigsaw puzzle with many pieces. A few people pointed out improved chemotherapy, others pointed out improved diagnostics and I would like to touch on Poverty and Education.

1) Poverty

I big problem is that most of the people affected are too poor to seek out medical attention (even though tb drugs are free), this due to the fact that primary health care facilities are just out of reach for them. Another thing, how can you expect a person who struggles to get food to be able to follow their prescription religiously.  Malnutrition as well, I have noticed that Junk food is more affordable than fruit and vegetables.

2) Education

This is the most important one. We need to educate the masses. Teach them the importance of sticking to your prescription. In South Africa we have a massive tv and radio campaign where we inform people that even if you start to feel better, you must continue taking in your medicine.  The un-educated masses have now started to smoke some of these drugs, or selling them for money.

Dear Harish

Unfortunately it is not possible in near future because;

1- difficulty in diagnosis and treatment in developing countries

2- increasing of immunocomprised person due to progress in medicine

3- it has still a long duration of treatment compared to most infectious diseases

4- emergence of MDR-TB

Europe successfully defeated tuberculosis once previously, through industrialisation and a steady increase in the standard of living. This was done without the battery of drugs we have today. The greatest gap in our knowledge is how and why, on a molecular level, some latent TB infections become activated. More research into this is needed, along with improved health services (incorporating the good points raise by Norbert above), and also sustained political effort to reduce unemployment and increase incomes for poor communities, in both developed and developing nations. For countries with a high HIV burden, efforts to reduce new HIV infections (ART, condom use etc...) should have a knock-on positive effect on TB incidence. No quick fixes I'm afraid. Even if you implemented a global vaccination programme tomorrow, for every new born, with a vaccine that was 100% effective, it would take many decades to get rid of TB.

Infection control measures are very important like environmental control measures to reduce the concentration of infectious droplet nuclei, ventilation (natural and mechanical), filtration, negative pressure ventilation and ultraviolet germicidal irradiation. Environmental Health Officer to be designated in all sectors to monitor and take action to protect environment. One example is windows and doors should be checked on a daily basis to ensure they are in proper position (open or closed as called for in the plan). Generally all windows and doors should be open when natural ventilation is the primary environmental control to allow for the free movement of air. Fans should be checked on a monthly basis to ensure they are clean, Air conditioning rooms to be cleaned every week and air filtration to be implemented.

Implementation and awareness of infection control measures even at community level