We searched the Cochrane library, PubMed, and Ovid for items published between Jan 1, 1946, and Nov 21, 2018. We used the search terms “tuberculosis” in combination with “epidemiology”, “pathophysiology”, “risks”, “diagnosis”, “test”, “treatment”, “prevention”, “vaccine”, “infection”, “quality”, “political will”, “patient-centered”, “person-centered”, “drug-resistant”, “drugs”, “access”, and “prognosis”. We prioritised research published since 2014, but we also included other papers of
SeminarTuberculosis
Introduction
Tuberculosis—the leading cause of death worldwide from an infectious disease among adults—has been considered a global public health emergency for the past 25 years.1 Although public health approaches to tuberculosis have saved tens of millions of lives, modest progress has been made to control (let alone to end) tuberculosis. Drug-resistant forms of tuberculosis are currently on course to be the world's deadliest pathogens, responsible for a quarter of deaths due to antimicrobial resistance.2 Great ambition and radical action are needed to tackle this completely curable pathogen, which remains one of the greatest health problems in the world.
The global tuberculosis situation is dire, but now is also a time of great promise and discovery for the disease. Numerous advances have been made in our understanding of the epidemiology, risk factors, and pathophysiology of tuberculosis, and new diagnostics and treatment for all forms of tuberculosis infection and disease are appearing on the horizon. Access to these innovations remains a substantial challenge for the majority of people living with the disease, but if the political will that seems to be building in the tuberculosis community and beyond3 is put into action, with a focus on the rights of people affected by the disease, the next decade might finally see the devastation caused by this age-old disease start to abate.
Section snippets
Epidemiology, pathogenesis, and risk factors
Tuberculosis continues to cause considerable morbidity and mortality globally. According to WHO,4 an estimated 10 million people became newly sick with tuberculosis in 2017; 8·7 million (87%) of these individuals reside in 30 high-burden countries. Among these 10 million individuals, only 6·4 million were diagnosed and officially notified. 1·3 million people are estimated to die from tuberculosis each year.4
Tuberculosis is a disease of poverty. Although most high-income countries have estimated
Diagnosis
Although multiple advances have been made in the diagnosis of tuberculosis, no reliable, simple, point-of-care test exists to definitively diagnose the disease. Clinicians often seek bacteriological diagnosis, but this evidence is also supplemented by clinical findings, radiological evidence, and tests for bacterial products that indicate the presence of M tuberculosis. WHO currently endorses a range of diagnostic and drug susceptibility tests (appendix).
New developments exist for the use of
Treatment
The treatment landscape for tuberculosis has changed dramatically over the past 5 years, with the introduction of two new drugs, bedaquiline and delamanid, and multiple clinical trials whose results are being used to radically alter the care of people with all forms of tuberculosis.57 More tuberculosis treatment studies are happening than ever before in the history of the disease, and not only will these studies help improve the care of people living with tuberculosis, but they should also help
Support for successful outcomes
Adherence support aimed at ensuring successful tuberculosis treatment has historically relied on the use of directly observed therapy (DOT). The use of DOT has shown mixed results in multiple studies and meta-analyses, largely because the term appears to be a catch-all phrase for radically different treatment support approaches. When coupled with emotional support, nutritional supplementation, and other types of enablers, DOT can be a way to ensure daily contact with vulnerable individuals and
Prevention
Prevention efforts have focused on tuberculosis vaccination and the treatment of latent tuberculosis or tuberculosis infection. Immunisation with the BCG vaccine is known to protect children from severe and disseminated forms of disease, decrease infection by 30%, and potentially offer some protection to adult populations.164 In general, the vaccine is not thought to be immunogenic enough to induce long-term immunity, although some studies show that intrapulmonary administration might be more
How to modernise tuberculosis care
For too long, tuberculosis care has relied on antiquated tools that are no longer fit for purpose. This can and must change.175 As described in this Seminar, many new tools and solutions already exist in some form (figure 2); however, these developments have not come together to serve those who need them the most. For some improvements to be made, such as the development of a better vaccine or a shorter drug therapy, new investments are urgently needed. High-quality systems for data management
Political will to end tuberculosis
On Sept 26, 2018, a UN meeting focused on tuberculosis was held in New York, NY, USA.178 The pledges made by multiple, high-level delegations, including heads of state from high burden tuberculosis countries, such as South Africa, could herald a new level of political commitment in the fight against tuberculosis. Although similar meetings held to discuss HIV and Ebola led to substantial increases in funding for research and treatment, the effects of the UN tuberculosis meeting are not yet
Conclusions
Although tuberculosis continues to be one of the most important public health problems of the 21st century, clinical and scientific advances exist that stand to revolutionise the diagnosis, treatment, and prevention of all forms of this disease. Access to these diagnostic and therapeutic advances must be guaranteed for all as part of a human rights-based approach to tuberculosis. The political will to eliminate tuberculosis is stronger than ever; this intention must be matched with unparalleled
Search strategy and selection criteria
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