Tuberculosis: an instrument of early mortality in life course
Authors: Barbara Reis-Santos, Marli Souza Rocha
Journal: The Lancet Infectious Diseases (2019)

The End TB Strategy is a commitment of WHO that has been endorsed by all WHO member states.1Uplekar M Weil D Lonnroth K et al.WHO's new end TB strategy.Lancet. 2015; 385: 1799-1801Summary Full Text Full Text PDF PubMed Scopus (627) Google Scholar Achieving tuberculosis incidence of less than 10 cases per 100 000 population, reducing the number of tuberculosis deaths by 95% compared with 2015, and to have no families facing catastrophic costs due to tuberculosis by 2035 are the desired goals.1Uplekar M Weil D Lonnroth K et al.WHO's new end TB strategy.Lancet. 2015; 385: 1799-1801Summary Full Text Full Text PDF PubMed Scopus (627) Google Scholar, 2Floyd K Glaziou P Zumla A Raviglione M The global tuberculosis epidemic and progress in care, prevention, and research: an overview in year 3 of the End TB era.Lancet Respir Med. 2018; 6: 299-314Summary Full Text Full Text PDF PubMed Scopus (222) Google Scholar These bold targets have led tuberculosis programmes worldwide to seek ways to enhance the disease prevention and care delivered to people with tuberculosis and to look for partnerships to develop and introduce new technologies. Engagement of the scientific community and civil society plays a key part in the success of all initiatives and a strong collaboration between governmental, non-governmental, civil society, and private sector entities is the base of the WHO strategy.1Uplekar M Weil D Lonnroth K et al.WHO's new end TB strategy.Lancet. 2015; 385: 1799-1801Summary Full Text Full Text PDF PubMed Scopus (627) Google Scholar, 2Floyd K Glaziou P Zumla A Raviglione M The global tuberculosis epidemic and progress in care, prevention, and research: an overview in year 3 of the End TB era.Lancet Respir Med. 2018; 6: 299-314Summary Full Text Full Text PDF PubMed Scopus (222) Google Scholar The need for a comprehensive range of actions is rooted in centuries of difficulties in dealing with tuberculosis. Development of tuberculosis is strongly associated with social determinants.3Saunders MJ Evans CA Fighting poverty to prevent tuberculosis.Lancet Infect Dis. 2016; 16: 395-396Summary Full Text Full Text PDF PubMed Scopus (29) Google Scholar High mortality among people with tuberculosis might reflect access barriers to proper health care and timely diagnosis and treatment, but could also be a consequence of the absence of public policies and social protection programmes. Upon entry into the health-care system, provision of care to people with tuberculosis only during treatment might not be enough to avoid early and preventable deaths. Thus, the outlook could be even worse if we consider the long-term consequences associated with tuberculosis. As the archbishop Desmond Tutu said, “[Tuberculosis] is the child of poverty—and also its parent and provider”. In their article in The Lancet Infectious Diseases, Otavio Ranzani and colleagues4Ranzani OT Rodrigues LC Bombarda S Martinez Minto C Waldman EA Carvalho CRR Long-term survival and cause-specific mortality of patients newly diagnosed with tuberculosis in São Paulo state, Brazil, 2010–15: a population-based, longitudinal study.Lancet Infect Dis. 2019; (published online Oct 29.)https://doi.org/10.1016/S1473-3099(19)30518-3Summary Full Text Full Text PDF PubMed Scopus (30) Google Scholar highlight that even after the end of treatment, people with tuberculosis remain affected by poor health outcomes, in agreement with a recent meta-analysis.5Romanowski K Baumann B Basham CA Ahmad Khan F Fox GJ Johnston JC Long-term all-cause mortality in people treated for tuberculosis: a systematic review and meta-analysis.Lancet Infect Dis. 2019; 19: 1129-1137Summary Full Text Full Text PDF PubMed Scopus (87) Google Scholar Compared with the general population of São Paulo, Brazil, the standardised mortality ratio for people diagnosed with tuberculosis was 6·47 (95% CI 6·22–6·73) over 5 years and 3·93 (3·71–4·17) among those who survived the first year. In this context, tuberculosis occurrence appears to be a representation of an accumulation of vulnerabilities and social context, which persistently affects the lives of these people. The authors found higher mortality in people with tuberculosis who were homeless, had alcohol and illicit drug use disorders, or a combination of these factors, reinforcing the need for multisectoral, innovative, and integrated actions, such as social protection, street outreach, and person-centered care.4Ranzani OT Rodrigues LC Bombarda S Martinez Minto C Waldman EA Carvalho CRR Long-term survival and cause-specific mortality of patients newly diagnosed with tuberculosis in São Paulo state, Brazil, 2010–15: a population-based, longitudinal study.Lancet Infect Dis. 2019; (published online Oct 29.)https://doi.org/10.1016/S1473-3099(19)30518-3Summary Full Text Full Text PDF PubMed Scopus (30) Google Scholar, 6Paula HC Daher DV Koopmans FF Faria MG Brandão PS Scoralick GB Implementation of the Street Outreach Office in the perspective of health care.Rev Bras Enferm. 2018; 71: 2843-2847Crossref PubMed Scopus (4) Google Scholar However, the current situation in Brazil is not favourable. The country is facing a major economic crisis that is deepening poverty and inequality. Implementation of fiscal austerity measures can impact morbidity and mortality, and disproportionally affects the poorest people.7Rasella D Basu S Hone T Paes-Sousa R Ockã-Reis CO Millett C Child morbidity and mortality associated with alternative policy responses to the economic crisis in Brazil: a nationwide microsimulation study.PLoS Medicine. 2018; 15: e1002570Crossref PubMed Scopus (105) Google Scholar Changes in regulation of federal funding investment in strategic areas of health care and strict imposed limits on the growth of public expenditure until 2036 are consequences of a neoliberal trend in public health policies, which weakens Brazil's Unified Health System and halts years of achievements and advances.8Doniec K Dall'Alba R King L Brazil's health catastrophe in the making.Lancet. 2018; 392: 731-732Summary Full Text Full Text PDF PubMed Scopus (41) Google Scholar, 9Castro MC Massuda A Almeida G et al.Brazil's unified health system: the first 30 years and prospects for the future.Lancet. 2019; 394: 345-356Summary Full Text Full Text PDF PubMed Scopus (262) Google Scholar Additionally, Brazil has changed the national policy on mental health, with direct consequences for public health strategies for people with alcohol and illicit drug use disorders.10Guimarães TD dos Santos Rosa LC A remanicomialização do cuidado em saúde mental no Brasil no período de 2010-2019: análise de uma conjuntura antirreformista.O Social em Questão. 2019; 44: 111-138Google Scholar As tuberculosis is an infectious disease, for many years programmatic actions and research concentrated on acting during disease occurrence. In 2017, prevention initiatives have been incorporated into tuberculosis control strategies. We cannot afford to wait to include post-treatment consequences in the tuberculosis agenda. The tuberculosis landscape has changed and techniques and methods in use decades ago can no longer be expected to produce the same results. In a world of relentless change, customary vertical solutions also no longer have the same impact in solving public health challenges. Acknowledging the need for change in the way we perceive and handle tuberculosis is the first step towards achieving the End TB goals. Thus, we argue in favour of a large-scale shift beyond existing approaches to handling the burden of tuberculosis. Approaches that encompass new diagnostic tools, drugs and vaccines, innovative surveillance strategies, and introduction of digital technologies must consider the life course and context of the people involved. The clock is ticking and time is running out. If nothing is done, we will continue to propose unreachable goals and have to account for unfavourable outcomes. We declare no competing interests. Long-term survival and cause-specific mortality of patients newly diagnosed with tuberculosis in São Paulo state, Brazil, 2010–15: a population-based, longitudinal studyPatients newly diagnosed with tuberculosis were at a higher risk of death than were the source population, even after tuberculosis treatment. Post-tuberculosis sequelae and vulnerability are associated with excess mortality and must be addressed to mitigate the tuberculosis burden worldwide. Full-Text PDF Open Access