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The famous Nobel Prize awarded novel “Der Zauberberg” by Thomas Mann describes the life of posh people treated for lung tuberculosis (TB) over months or even years in a private hospital in the Swiss alpine village of Davos about a hundred years ago. Medical treatment options were limited, but food, wine, and entertainment were excellent. The situation is quite different for most people suffering from TB today.
In 1993 the World Health Organization (WHO) declared tuberculosis to be a global health emergency: one out of three of the world population are infected. According to the “Fifth Annual Report on Global TB Control”, 8.7 million people contracted active tuberculosis (TB) in 1999 and 1.7 million people died from it. Although the major toll has to be paid by the poorest people in the poorest countries—those who also struggle most with the HIV epidemic!—Europe is by no means free from TB and problems thereof.
In the WHO European region, comprising 51 countries, the yearly incidence of new TB cases (defined as smear-positive) is 10 per 100 000 population. Although the incidence is ≤10 in 30 of these countries (including all Western European states), it is still >20 in 9 countries with peaks of 46 in Romania, 43 in Kazakhstan, and 35 in Kyrgzystan.
Another challenge is multidrug resistant tuberculosis (MDR-TB), defined as resistance of Mycobacterium tuberculosis to at least isoniazid and rifampicin. Although not a significant problem in Western Europe with a prevalence of less than 1%, high MDR-TB prevalence is currently a major problem in Estonia (14%), Latvia (9%), and parts of the Russian Federation (6–9%). While other Eastern European countries such as Poland, Slovakia, and Slovenia have low MDR-TB prevalence rates (<1%), surveillance in large parts of the Russian Federation and the former Soviet Republics of Central Asia is not existent. This lack of data is a major concern!
A few years ago, the “Stop TB” programme was launched by WHO and several other institutions like the World Bank. Major goals of this initiative are to assess progress towards the WHO year 2005 targets for TB case detection (70%) and treatment success (85%) and to increase the access to direct observed, short course treatment (DOTS) for as many TB patients as possible. DOTS is considered to be the key to control MDR-TB, which is associated with non-compliant treatment. From a global perspective, the number of countries implementing the DOTS strategy (at least in part) increased by 8 during 1999, bringing the total to 127 (out of 211). However, the proportion of the world’s population that had access to DOTS increased only slightly from 43% in 1998 to 45% in 1999. If the present trend continues, the target of 70% case detection under DOTS will not be reached until 2013.
New cases of TB still continue to rise year by year, mainly because of increasing incidence in those African countries which are most affected by the epidemic of HIV/AIDS. If this trend is maintained, approximately 10 million new cases are expected in 2005 with most cases in Africa. With the constant influx of Africans emigrants, this worrisome development is likely to affect the rest of the world, including Europe.
The WHO efforts to fight TB are both laudable and necessary. Where can they lead us? In developed countries, increased awareness of the emerging problem of TB is important to provide further funding of vaccine and drug development. The efficacy of the only available vaccine, BCG, is far from optimal and researchers have been struggling for improvement. The task has proven to be difficult, but not impossible—for example, recombinant technology is promising. Also, the possibility of developing new TB drugs should be intensely explored. Finally, incentives such as grants need to be created to support young scientists interested in TB research. There is hope, so let us not give up the fight.
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