Memorandum by the International Pharmaceutical
Federation (FIP)
8Q: Cases of TB fell progressively in the
UK until the mid 1980s but started to rise again in the early
1990s. Around 6,500 cases are now reported each year, an increase
of about a quarter since the early 1990s. What are the main factors
of the revival of tuberculosis infections in Britain? And how
could intergovernmental action help to reverse this trend?
The vast majority of TB cases in the UK are
notified as residents in London and the vast majority of these
are individuals not born in the UK. However, to draw from this
the conclusion that the rise of TB prevalence is due solely to
immigrants from high TB prevalence countries introducing TB into
an otherwise low incidence country would be inaccurate. Notification
statistics demonstrate that non-UK born individuals that develop
TB do so generally after they have been in the UK for some years.
Although this is not always the case, it would be worth considering
other factors, such as social deprivation and access to health
care. Why are TB rates highest in the most deprived boroughs?
What is wrong with the health and/or social systems in the UK
that individuals develop TB in the UK after many years without
disease in their countries of origin? Particular attention should
also be paid towards "hard to reach" or high risk groups
that might encourage the nosocomial spread of TB. Groups include
illegal immigrants—who would not necessarily register for
health care—street sex workers, intravenous and crack cocaine
drug users, and homeless individuals whose lives are likely to
be chaotic with TB treatment representing a low priority. Provision
of directly observed treatment (DOT) in the community, such as
in General Practitioners or community pharmacies, may improve
access to care.
Greater attention should also be paid towards
screening systems, particularly the Port of Arrival screening
offered to "high risk" immigrants for later follow-up.
The various services available are largely inefficient or of unknown/unquantified
efficiency. A comparison of systems may help to identify the best
model (alone or integrated screening) of screening strategy. In
addition, other forms of screening should be explored. For example,
the ubiquity of general practitioners and community pharmacies
provides a unique opportunity for identifying and treating individuals
infected with TB that might not normally access healthcare.
Q9: Tuberculosis is potentially curable by
long-term antimicrobial therapies. Yet the numbers of reported
cases worldwide seem to be rising. Are the necessary medicines
not getting through to patients? What are the barriers to effective
long-term therapy? Are we now seeing infections which stem from
other conditions—eg HIV/AIDS? Or are there other reasons
why a treatable disease should be spreading? How might intergovernmental
action help to deal with this situation?
TB treatment is highly efficacious and cost-effective.
Taken correctly almost all TB patients would achieve a cure. There
are many reasons why cure rates of 98% are not achieved and the
reasons depend on the setting, for example, high versus low income
countries and high versus low HIV prevalence. However, the length
of treatment must play a part with the minimum duration of six-months
treatment of TB and three-months treatment (recommended in the
UK) for latent infection. Symptoms are likely to disappear after
two weeks treatment of pulmonary TB, and extrapulmonary TB may
be asymptomatic. Therefore, to continue with over five months
additional treatment demands much of the patient both in terms
of will power and the understanding of disease. In reducing the
duration of treatment, for example, by introducing more efficacious
drug treatments or including other antituberculous drugs into
existing regimens to improve efficacy, may help to circumvent
this problem or at least reduce the impact of non-adherence. Alternatively,
greater emphasis on patient counselling and using better engagement
strategies, putting patients at the centre of their care in the
absence of much therapeutic choice, may help.
Sharing of experience between different countries,
including between high and low prevalence settings to identify
common themes and strategies, would help in the common goal of
reducing the global prevalence of TB. For example, if TB rates
in the UK relate to TB rates in high TB burden countries through
immigration then it makes sense to develop seamless strategies
that span geographical boundaries. It should be possible for a
patient to begin treatment in one country and finish treatment
in another without interruption in treatment. In the absence of
any new technological breakthroughs in TB it is worth also focusing
on what can be best made out of existing technologies. Are pharmaceutical
formulations adequate for those who struggle to adhere to treatment
or children, for example? Are these accessible? Are second-line
treatments readily available and/or affordable where needed? Does
the ubiquity of first-line TB drugs, especially in developing
countries, hampering the eradication of TB, and, if so, what measures
can be put in place to prevent this from continuing?
February 2008
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