Control of tuberculosis in large cities in developed countries: an organizational problem
© Caylà and Orcau; licensee BioMed Central Ltd. 2011
Received: 12 October 2011
Accepted: 28 November 2011
Published: 28 November 2011
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
TB affects the most vulnerable populations, including HIV-infected people, drug abusers, the homeless and immigrants, in a disproportionate way. These populations mostly live in urban settings and, as such, influence 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 . New York City, for instance, had to deal with a serious epidemiological situation when the AIDS epidemic broke out. 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 . The peak of incidence was observed in 1992 (3, 811 cases, incidence of 52.0/100, 000), declining to 10.8/100, 000 (895 cases) in 2008 . TB was considered a political priority 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/month for adherent patients) or a $25 'show-up voucher' 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 .
With the financial crisis, the New York model is difficult 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.
It is important to evaluate TB programs every year in order to identify gaps in services, data monitoring, and so on. The audit of TB services against elements contained in the national TB Action Plan (Table 5 of the accompanying paper) is a very good example as it can detect which criterion needs to be improved in each city. The epidemiological evaluation of a TB program should be based on few indicators in order to facilitate annual evaluations (decline in TB incidence, diagnostic delay, completion of TB treatment, coverage of contact tracing, TB meningitis in children under 4 years) .
Over the next few years, with a probable decline in TB incidence, it may be difficult to maintain big teams of specialized TB nurses within the public health structures. Should this prove to be the case, the challenge of containing TB in hard-to-reach groups would be daunting and diagnostic delay would be likely to increase in a context of low-incidence and low-resource settings with the possibility of epidemic outbreaks among affected children . The recommendations of Bothamley and colleagues in relation to TB nurses, along with those of scientific societies published since 1988 , could be helpful in maintaining these resources because a ratio of specialized TB nurses to patients is established. In large cities, maintaining the TB program in a Public Health structure that also performs surveillance and control of other notifiable diseases and epidemic outbreaks could be crucial in achieving long-term resource and management expertise.
The current economic crisis will have long-term impacts on communicable disease control and it is critical to keep the public health budget  at an adequate level, although TB programs can increase their efficiency by improving their organizational structures. To take advantage of other resources for transmissible diseases, such as the resources for HIV prevention and for control of epidemic outbreaks, co-operation with other programs (including Immigration and IDU services) will be essential. Brigs stated in 1914 that 'Public health is purchasable; a community can determine its own death rate' . Following these ideas, Reichman strongly recommends fostering and maintaining the political will that allows enhancement of public health programs that can move towards the elimination of TB . Each city needs to define its needs according to its particular epidemiological situation, but the ratio of one nurse per forty TB cases, as suggested by Bothamley and colleagues, is a very good starting point.
AO and JAC are working in the Barcelona TB programs and each year organize an International TB Workshop. AO coordinates the PHN and CHW programe, analyzes the TB data base and writes an annual report.
JAC coordinates the Barcelona TB Investigation Unit and is the principal investigator at site 31 of the CDC TB Trials Consortium and of TB Research at the Spanish Society of Pneumology (SEPAR).
List of abbreviations
directly observed therapy
public health nurses
community health workers
injecting drug users.
Acknowledgements and funding
To the all health workers involved in the Barcelona TB Program in their 25th year (1986-2011).
The authors acknowledge partial support for this research from the CIBER Epidemiología y Salud Pública (CIBERESP), Spain.
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