Tuberculosis control: past 10 years and future progress

The number of countries implementing directly observed therapy short-course (DOTS) has grown rapidly in the past decade and more than 10 million patients have now been treated under DOTS. While global case detection rates increased slightly, from 35% to 40% between 1995 and 2000, the proportion attributable to DOTS grew from less than one-third to more than two-thirds. DOTS is replacing inferior treatment but still treating fewer than 40% of estimated new TB cases. Misconceptions threaten to undermine continued success in tuberculosis control. The first misconception is that treatment observation is unnecessary. Treatment observation needs to be made more patient-friendly, but must not be abandoned. The second misconception is that health care reform will strengthen tuberculosis control. TB control is essentially a management problem. Greater accountability of governments, donors and providers is essential. A third misconception is to focus on treating multi-drug-resistant tuberculosis (MDRTB) cases without addressing the root causes of MDRTB. While it is important, on a clinical basis and epidemiologically in some contexts, to care optimally for patients with MDRTB, it is more important to address the cause of MDRTB and to fix the program generating MDRTB. The fourth misconception is an inordinate concern for sustainability. Delaying assistance will make implementation and sustainability in the future more difficult. Tuberculosis control is remarkably inexpensive and cost-effective, but efforts will fail unless programs have the ability to hire staff, purchase supplies, and contract for services efficiently. Critical issues for the future of tuberculosis control are sustained funding, technical rigor, and good management.