Tuberculosis: a forgotten plague?

Tuberculosis has long been overshadowed in the media by HIV, malaria and now ‘sexy’ new pandemics such as swine flu. Why has tuberculosis been forgotten by the UK public and how can we move it into the media spotlight to raise awareness and improve funding?

After HIV, tuberculosis is the world's second most lethal infectious disease, but in this country the public has consigned it to history and novels such as Jane Eyre. Indeed when asked about tuberculosis by former BBC health correspondent Glenda Cooper, one journalist said ‘consumption has been eradicated in the developed world’. This is not a rare assumption; many of my own contemporaries, working in politics, journalism and education, are similarly ignorant of the facts.

According to the World Health Organization (WHO), roughly one-third of the world's population are infected with tuberculosis bacilli, with a new infection occurring every second. Of those with latent tuberculosis, one in 10 will go on to get active disease; 9.4 million people in 2008. In 2007, according to estimates, $1.1 billion went into research and development funding for HIV and malaria, which led to an estimated 863,000 deaths in 2008,¹ received $468.5 million; tuberculosis, meanwhile, received just $410.4 million.²

Drug resistance is spreading, with half a million people now infected with MDR-tuberculosis. Extensively drug-resistant (XDR) tuberculosis is an even more frightening phenomenon. At the start of this year, 58 countries had reported cases of XDR-tuberculosis and many more countries cannot survey the extent of drug resistance due to inadequate laboratory facilities.³ The medications used to treat tuberculosis have barely changed since the 1970s and are associated with side-effects which threaten adherence. Treatment is over an extended period with high levels of morbidity and money is needed for medical, social and psychological support.

‘Where youth grows pale and spectre-thin and dies’ – Keats

In the UK malaria affects the likes of Cheryl Cole and other jet-setting safari lovers. Meanwhile HIV was first recognized in a relatively affluent, successful population of white men in the developed world. Such is the media interest in these diseases. Tuberculosis, however, remains a disease of the ne'er-do-wells. When consumption in London was at its peak, affecting the likes of Jane Austen, Edgar Alan Poe, and the Bronte sisters to name but a few, ‘the vanished bloom and wasted flesh’ of sufferers was splashed across play-houses, poetry and novels.⁴ In this country it has been relegated to stories about badgers and cattle, and occasionally headlines such as ‘Afghan tuberculosis threat to our troops’ or ‘Migrant brings tuberculosis to Scotland’. Forgotten are the 1.8 million people worldwide who die from tuberculosis each year.⁵

In 2009 in the UK there were 9153 notified cases of tuberculosis – one-third of which were in London.⁶ While in the US incidence has declined by over 50% in the last 10 years, in England and Wales the number of cases has risen by almost 50%.

Where are we going wrong?

For the general public and even health professionals, the concept of latent tuberculosis can be difficult to understand. A long course of medication with unpleasant side-effects to treat the mere potential of a disease can be hard to stomach. Perhaps it is the aggressive approach taken by the USA in the screening and diagnosis of latent tuberculosis that separates their success in lowering incidence and the UK's failure.

All new entrants to the USA from countries with an incidence of tuberculosis greater than 20 per 100,000 population are screened for latent tuberculosis.⁷ On arrival to the UK with a normal chest radiograph, further investigation for tuberculosis is only suggested for people from countries with an incidence of more than 500 per 100,000, missing out pretty much the entirety of the South Asian subcontinent.⁸

A paper published earlier this year in Thorax looked at the NICE guidelines on new entrant screening for tuberculosis and, importantly, in today's financial climate, discussed their cost-effectiveness.⁹ Their research demonstrated that by screening people from countries with a prevalence of 160 per 100,000 population and by replacing the tuberculin skin test with interferon gamma tests, they not only identified more cases of latent tuberculosis but at significantly less expense than the current NICE protocol.

Other important differences between the UK and USA screening programmes include the use of a lower cut-off for positive tuberculin skin tests by the US as well as a policy of ignoring previous BCG vaccination when interpreting these tests. In fact is has been suggested that the tuberculin skin test should either be scrapped or switched to the 5 mm cut-off used by the Americans. Interferon gamma tests have been shown to be comparable in the detection of tuberculosis, but are less user-dependent and require fewer clinic visits. The US is also more aggressive in its targeting and treatment of at-risk groups, using outreach programmes to target intravenous drug users, the homeless and prison populations.

Of course the Americans haven't got it all right. The US continues to advise 9 months of single agent isoniazid treatment for latent tuberculosis infection when evidence clearly shows there is no benefit beyond 6 months and a significant rise in drug toxicity.¹⁰

The majority of UK cases – but importantly not all – occur in foreign-born individuals. There has been no decline in the incidence of tuberculosis in our UK-born population. Our lack of experience with tuberculosis outside major cities can result in a delay to diagnosis and treatment, perhaps because the medical population do not consider tuberculosis as a differential in so-called ‘Middle England’.

The way forward

On 24 March each year, World Tuberculosis Day celebrates Dr Robert Koch's discovery in 1882 of the cause of tuberculosis: the tuberculosis bacillus. It is a day used to increase the awareness of this worldwide epidemic. The WHO, using the Stop Tuberculosis partnership, aims to halve the numbers of deaths due to tuberculosis by 2015. They are on track to achieving this in America, Asia and the Eastern Mediterranean. Global incidence has been falling since 2004; not so in the UK.¹¹

Incidence in some areas of London exceeds 80 per 100,000 with Newham (East London) having the highest rate in the country with 117 cases per 100,000.¹² These rates are comparable to high incidence countries in North Africa and Asia. Conferences, held yearly at the Royal Society of Medicine on World Tuberculosis Day, promote debate on current topics among healthcare professionals involved with tuberculosis. This year the continued rise in incidence in London was the topic under discussion.

Tuberculosis Alert was set up just over 10 years ago in response to the resurgent threat of tuberculosis in the UK. Its aims are to heighten awareness of tuberculosis and support community-based treatment in the UK and abroad. Tuberculosis Alert continues to grow, recently appointing a journalist as member of the trustees and also creating a new post in communications and publicity. The power of publicity to help improve funding and investment should not be underestimated.

Perhaps a documentary is due, looking at the many patients we see in places such as East London, living in conditions which promote the spread of tuberculosis, uneducated in the risks or symptoms? Outreach work to gain access to the more vulnerable members of society, including intravenous drug users and prison inmates, is already underway with the help of find-and-treat teams in London, but they need to be extended to other major cities. Other lessons can be learned from the USA; screening for latent and active tuberculosis in new entrants needs to be more aggressive.

Headlines such as those in the Daily Mail in January this year ‘Schoolgirl, 15, dies from tuberculosis after government warns immigration has caused disease to soar’ highlight immigration as the issue. A 15-year-old schoolgirl dying from a curable disease should be what grabs the attention here. In 2006 an all-party parliamentary group (APPG) for tuberculosis was established. This group consists of MPs from the three major parties and holds meetings in parliament roughly every 2 months to lobby and raise awareness through debate in the commons. On its website its aims seem to focus, in the majority, on tackling tuberculosis globally, but perhaps we should be looking closer to home.

As professionals working within the health system it is our duty to help put tuberculosis on both the public agenda and that of the new Government. Educate your local MP, encourage them to join the APPG for tuberculosis, campaign for further funding to improve services and to expand research into new medications. We can support our patients to speak out about their experiences of tuberculosis, reduce delay to diagnosis and help to dispel the stigma attached to this disease. Let us help highlight the dangers of increasing cases of MDR and even more frighteningly (or attention-grabbingly for journalists), XDR tuberculosis. Let us champion the new developments such as those in rapid diagnostics, vaccines and potential new drugs. Organizations such as Tuberculosis Alert have branched into the avenues of powerful new media outlets such as Facebook and Twitter, the use of which should be explored further.

We live in multicultural societies with mass worldwide travel and immigration and the epidemiology of disease within a country can be fluid like its people. Tuberculosis hides as latent infection and conceals itself in places other than the lungs. As health professionals it is vital we maintain our broad knowledge of disease to enable early diagnosis and effective treatment. We need to push for funding and exposure to enable us to take steps towards where much of the UK public already believe we are – having tuberculosis confined to the history books. At the moment, we are nowhere near.

DECLARATIONS

Competing interests

PDOD is Secretary and a trustee of the group tuberculosis Alert; JLK has no competing interests

Funding

None

Ethical approval

Not applicable

Guarantor

JLK

Contributorship

PDOD acted in an advisory role

Acknowledgements

Speakers at the RSM conference on 24 March 2010 were John Watson, Nick Herbert, Glenda Cooper, Louise Holly, Mike Mandelbuam, Peter Omerod, Ann Denis, Guy Thwaites, Philip Monk, Sue Jamieson, Grace Smith, Steve Welch and Peter Davies. The full programme can be found on the RSM and tuberculosis Alert websites (www.rsm.ac.uk, www.tbalert.org)