Control Of TB In Large Cities In Developed Countries
COMMENTARY Open Access
Control of tuberculosis in large cities in developed countries: an organizational problem Joan A Caylà* and Angels Orcau
Abstract
Tuberculosis (TB) is still a serious public health issue, even in large cities in developed countries. Control of this old disease is based on complicated programs that require completion of long treatments and contact tracing. In an accompanying research article published in BMC Public Health, Bothamley and colleagues found that areas with a ratio lower than one nurse per forty notifications had increased rates with respect to TB notifications, smear-positive cases, loss to follow-up and treatment abandonment across the UK.
Furthermore, in these areas there was less opportunity for directly observed therapy, assistance with complex needs, educational outreach and new- entrant screening. In this commentary, we discuss the importance of improving organizational aspects and evaluating TB control programs. According to Bothamley and colleagues, a ratio of one nurse per forty notifications is an effective method of reducing the high TB incidences observed in London and in other cities in developed countries, or to maintain the decline in incidence in cities with lower incidences. It is crucial to evaluate TB programs every year to detect gaps early. See related article: http://www.biomedcentral.com/ 1471-2458/11/896
Introduction Tuberculosis (TB) is a contagious bacterial disease that can be fatal without treatment, and any delay in diagno- sis of pulmonary and laryngeal cases increases the chances of transmission. The incidence of TB is greater in large cities than in non-urban areas or in the country as a whole, as Bothamley and colleagues describe in their article published this month in BMC Public Health [1]. The authors also found that cities that did not
the target of one nurse per forty TB notifica- tions
achieve the target of one nurse per forty TB notifica- tions had worse TB control indicators than cities reach- ing this target. The authors concluded that control depends on adequate numbers of specialist TB nurses for early detection and case holding. They also observed strikingly high incidences in 2009 in cities such as Man- chester (59.1/100, 000). And London (44.4/100, 000) in relation to other English cities. In other western Eur- opean cities, in general, the incidences were also lower [2,3] (Figure 1). These data led to London appearing widely in the media as ‘the European capital of TB’ [4]. Following publication of a paper in The Lancet with the subtitle ‘London has one of the highest rates of TB in Western Europe. And the city homeless population are most at risk and the hardest to treat’ [5].
Discussion TB affects the most vulnerable populations. Including HIV-infected people, drug abusers, the homeless and immigrants, in a disproportionate way. These popula- tions mostly live in urban settings. And, as such, influ- ence TB epidemiology in large developed cities [6,7]. TB control programs have to adapt to any new challenge. And new control strategies should be implemented when a new problem arises [8]. New York City, for instance, had to deal with a serious epidemiological situation when the AIDS epidemic broke out.
patients with TB
From 1978 to 1992, the number of patients with TB nearly tripled due to HIV infection, drug resistances and the abandonment of TB programs, but fortunately they were able to apply comprehensive control measures (including directly observed therapy (DOT) and control of nosocomial transmission) and the situation reversed [9]. The peak of incidence was observed in 1992 (3, 811 cases, inci- dence of 52.0/100, 000), declining to 10.8/100, 000 (895 cases) in 2008 [10]. TB was considered a political prior- ity and the New York TB program received substantial funds; DOT was the rule with a high number of DOT workers. The use of incentives for patients dually infected with TB and HIV (the equivalent of $100/
* Correspondence: jcayla@aspb.cat Epidemiology Service, Public Health Agency of Barcelona, Pl. Lesseps, 1, 08023, Barcelona, Spain
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patients with TB
month for adherent patients) or a $25 ‘show-up vou- cher’ to inmates to encourage them to continue their TB treatment after release from prison, along with other measures to elevate the status of DOT workers and recognize them as the true heroes of modern public health, contributed to the effectiveness of the program [11]. With the financial crisis, the New York model is diffi-
cult to replicate in most cities due to its high cost. And TB programs should include new control strategies based on improvements in health organization. Solid public health organization, combined with precise knowledge of local healthcare. And the social system, along with the co-operation of hospitals. And specialized clinics, could help to better implement specific control strategies.
maintain a team of nurses
Unfortunately, in many cities it is very difficult to cre-ate or maintain a team of nurses dedicated solely to TB due to relatively low TB incidence. And also because of limited resources dedicated to this disease. For example in Barcelona, the TB Program has had, from its incep- tion in 1987, public health nurses (PHN). Who carry out follow-up with patients and perform contact tracing but are also in charge of other communicable diseases. The program also involves active surveillance of cases (reporting of cases is promoted, microbiological results. And hospital discharges are monitored, and the link between AIDS and TB registers is also monitored). In
the first few years, we observed the influence on TB epi- demiology of injecting drug users (IDU) and persons with HIV infection, and incidence increased until it peaked in 1992 (1, 096 cases, 67/100, 000) [12]. DOT was added early for those patients with predictors of poor adherence (homeless, IDU, prisoners). The inclu- sion of DOT in methadone programs and tight coordi- nation between the TB programs in the prisons and the city was very useful in achieving a high level of treat- ment completion among IDU [13].
use of antiretroviral treat- ments
Following the increase use of DOT and the use of antiretroviral treat- ments, TB incidence decreased, but with the massive immigration observed from 2000 onwards, this decline has been attenuated (Figure 2). Consequently, since 2003 we have incorporated community health workers (CHW) to help PHN in follow-up and contact tracing. These CHW also visit the patient at home, at the hospi- tal, at the DOT facility and act as translators and cul- tural mediators [14]. The link between surveillance, control and operational
research has always been a priority, and has facilitated coordination among all health workers involved in TB control (clinicians, microbiologists, epidemiologists, social services managers). In the last few years, TB care services have been reorganized due to massive immigra- tion and to concentrate the contact tracing in five TB Units. All large hospitals in the city have TB clinical units that carry out diagnosis, treatment, monitoring of
Figure 1 Incidence of tuberculosis in selected European Union cities, 2009. Incidence of this disease in cities of low-incidence European Union countries showing high level of incidence in several urban areas. Source: references [1-3].
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Figure 2 The evolution of tuberculosis in Barcelona, 1986-2010. The graph shows tuberculosis cases per 100, 000 inhabitants over time. During the 1990s a high incidence period was observed, mostly due to HIV-infected injecting drug users. With the implementation of control measures and the generalization of antiretroviral treatments. The annual decline was about 10%. This decline was attenuated during the low incidence period due to massive immigration from high burden countries. TB, tuberculosis; IDU, injecting drug users; HAART, highly active antiretroviral therapy.
DOT Services DOT at home
DOT at a long-stay facility
Other DOT services
Drug Users Care Centres
Prison
