Tuberculosis control: recalling past insights
Authors: Brian G Williams
Journal: The Lancet Global Health (2018)

The Article by Florian Marx and colleagues (April, 2018)1Marx FM Yaesoubi R Menzies NA et al.Tuberculosis control interventions targeted to previously treated people in a high-incidence setting: a modelling study.Lancet Glob Health. 2018; 6: e426-e435Summary Full Text Full Text PDF PubMed Scopus (28) Google Scholar represents an important advance in the understanding of tuberculosis and its management. The conventional wisdom has been that short-course chemotherapy for tuberculosis is a sterilising cure but the very high incidence of tuberculosis in previously treated patients suggests otherwise, with important implications for managing this infectious disease that continues to be one of the most important causes of mortality worldwide. In this context, it is of interest to recall the observations of Anthony Davies2Davies JCA The eradication of tuberculosis in Rhodesia with particular reference to the midlands and south eastern provinces. Phase one. London School of Hygiene & Tropical Medicine, 1966: 19Google Scholar who was concerned with the control of tuberculosis in the 1960s in what was then Rhodesia but is now Zimbabwe. In his thesis at the London School of Hygiene & Tropical Medicine (London, UK), written 52 years ago, he noted the following: “We must eradicate [tuberculosis] TB, and we must do it now, both as crusaders and as properly equipped scientists. All available resources must be used. Chemotherapy, computers, prophylaxis and prevention, case finding and kindness can be blended in a properly constructed epidemiological model which will tell us exactly where we are going and how fast… Tuberculosis is a relapsing disease—this was well recognized and emphasized before specific chemotherapy was available. In the early days of chemotherapy when the custom of resecting residual diseased lung was widespread I was able to study first-hand the specimens from several hundred such resections—there is little doubt that even after chemotherapy encapsulated lesions may contain pus under tension, and that without chemotherapy tubercle bacilli may survive in this type of lesion for many years… Life-long follow up is an arduous, and with modern chemotherapy a somewhat tedious and boring process for both doctor and patient… It may be suggested that in the absence of a comprehensive health infrastructure this task is impossible. On the other hand, for the very same reason it may be mandatory. In a country where the infrastructure is not ideal the body of patients known to have had tuberculosis provide a ready-made… network of people with whom an intimate doctor/patient relationship has been forged by many months of chemotherapy—this is a dividend from the money invested in treatment and to discard it would be prodigal.” Davies' insights into the pathology of tuberculosis and his understanding of tuberculosis management in resource-poor countries remain a lesson to us all. I declare no competing interests. Tuberculosis control interventions targeted to previously treated people in a high-incidence setting: a modelling studyIn this high-incidence setting, the use of targeted active case finding in combination with secondary isoniazid preventive therapy in previously treated individuals could accelerate decreases in tuberculosis morbidity and mortality. Studies to measure cost and resource implications are needed to establish the feasibility of this type of targeted approach for improving tuberculosis control in settings with high tuberculosis and HIV prevalence. Full-Text PDF Open Access