Tuberculosis control programmes: Developing countries

Effective frameworks for the control of tuberculosis (TB) in low-income countries have been published, advocated and implemented since the early 1980s. Despite this, the developing world carries most of the global burden of tuberculosis. Ninety seven per cent of TB cases and 99% of TB deaths occur in low-income countries, and TB accounted for about 4% of the estimated 1,210 million disability-adjusted life years lost in the developing world in 1990. Of the existing strategies for TB control (vaccination with bacille Calmette- Guerin (BCG) chemoprophylaxis for individuals with asymptomatic M. tuberculosis (MTB) infection, and chemotherapy for sputum smear-positive cases), chemotherapy currently has the greatest potential in developing countries. However, when the various components of chemotherapy (case- finding, diagnostic delay, the problem of smear-negativity, case-holding and compliance) are examined in detail it is clear that the human immunodeficiency virus (HIV) pandemic is exposing pre-existing weaknesses in this strategy in developing countries. Furthermore, chemotherapy, in its current form, is failing to reach a number of at-risk groups including refugees, prisoners, miners, women and healthcare workers who have particularly urgent needs in relation to TB control in developing countries. The current principles of case-finding and case-holding as advocated by the International Union Against Tuberculosis and Lung Disease and the World Health Organisation must be maintained, but their effective implementation requires adaptations to the resource constraints of developing countries. For example, diagnostic pathways must be simplified and programmes should incorporate incentives to patients and healthcare providers. The needs of patients, not programmes, should be paramount. Work that assesses these needs, and suggests and implements appropriate adaptations of the accepted principles of TB control is urgently needed in developing countries.