Control of tuberculosis in large cities in developed countries: an organizational problem

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.

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].

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.

Figure 3

Barcelona Tuberculosis Program: organizational aspects. Network developed and relationships among different providers for tuberculosis control in Barcelona. DOT, directly observed treatment.