TB on the rise in Britain

By Barry Mason
22 July 1999

The growing incidence of tuberculosis in Britain has prompted the formation of a campaign group, TB Alert. TB is caused by a bacterial infection, which can affect any part of the body, but most usually the lungs. The bacterium gradually destroys the tissues in which it is in contact. In TB of the lungs the infected person will develop a persistent cough which progressively gets worse. The coughing can often cause blood vessels to rupture and the person will cough up blood. It is accompanied by a gradual loss of weight, listlessness and high temperature. The bacteria are transmitted through the air, and so are is quite contagious, but the infection is usually caught only by living in close contact with an infected person.

One of TB Alert's first acts was to publish a report by Chris Holmes, “TB: the Killer Returns”. The report noted that London now faces an increase in TB similar to that which afflicted New York City 10 years ago. Each week, 50 new cases of TB are diagnosed in London and two people die of the disease. Speaking to the BBC, Chris Holmes said, “TB is on the increase in London because it is out of control across the world. New York had to turn to Tanzania to control its epidemic because the richest country in the world had no infrastructure to deal with it.” Dr Peter Davies, a consultant chest physician, told the BBC, “We are not going to see any decline in tuberculosis within our own country until the problem begins to be solved world-wide.”

Over the last years a number of research papers have drawn attention to the increase in TB cases. In December 1995 the British Medical Journal published an article by Meirion R. Evans, a consultant in communicable disease for the South Glamorgan Health Authority, asking, “Is tuberculosis taken seriously in the United Kingdom?”

Evan's paper explained that in a 40-year period to the end of the 1980s there had been a steady decline in TB cases. Between 1982 and 1993 the numbers began to increase, leading to an annual total—in 1995—of approximately 6,000 cases being notified. The report went on to explain that the two most vulnerable groups are the homeless and those with HIV infection.

One month later the BMJ carried another article, "Increasing incidence of tuberculosis in England and Wales: a study of the likely causes", compiled by N. Bhattie, M. R. Law, J. K. Morris, R. Halliday and J. Moore-Gilleon. They had conducted a study on the incidence of TB in the 403 local authority areas of England and Wales, together with a more in-depth study in the London Borough of Hackney. The findings showed that in the period 1988 to 1992, notified cases of TB increase by 12 per cent. The report further showed that the increase in TB was confined to the poorest sections of the population. Amongst the poorest 10 percent of the population there had been a 35 per cent increase in notified TB cases, and amongst the next 20 percent poorest, a 13 per cent increase. There had been no increase in rates of notification amongst the remaining 70 per cent of population.

Their study of Hackney had been conducted between 1986 and 1993.This is a borough with a relatively high proportion of immigrants from the Indian subcontinent and Africa, including those recently arrived. However, the researchers pointed out that whilst the increase in TB could be partially attributable to its introduction from areas abroad where it is endemic, this was not the primary factor. The report spelt out, “Socio-economic factors affecting all residents are likely to be predominantly responsible for the increase in tuberculosis—not factors specific to high risk minority groups.”

During its summer conference in Edinburgh earlier this year, the British Thoracic Society (BTS) warned that TB could make a “major re-emergence” unless certain measures were taken. The BTS expressed concern that strains of TB resistant to antibiotic treatment are now appearing and are gaining ground in Eastern Europe. The normal treatment for the disease is to give a combination of 3 or 4 specific antibiotics and the treatment has to last six months. The BTS called for people with the drug resistant type to be treated by experts in full isolation facility hospitals.

It also expressed concern at the incidence of TB amongst people with unstable lifestyles such as the homeless, drug and alcohol abusers and the mentally ill. They are more likely to fail to follow the medication regime needed to cure the disease. The BTS recommended that such patients receive Directly Observed Therapy (DOT) in which their medication is monitored by health workers or friends to ensure they comply with the medication regime.

Other key recommendations made by the group were:

• For all TB patients to be seen by an experienced lung physician.

• That there should be a full time TB nurse with clerical support for every 50 TB cases per year in each district.

• Six-month courses of treatment should be offered incorporating four different drugs taken on a daily or three times a week basis.

Dr Peter Ormerod, chairman of the Joint TB Committee of the British Thoracic Society, warned, “TB is a disease of today and has not been confined to the history books. With more than 6,200 new cases of this disease last year in the UK, we cannot be complacent. Stringent procedures for the diagnosis and treatment of TB must be in place in hospitals across the UK.”

TB in Britain was, until recently, considered a disease of the past. During the 17th and 18th century, TB (or consumption as it was then called) was thought to be responsible for 20 percent of all deaths in England and Wales. Incidence of the disease declined throughout the 19th and 20th centuries, due to progressive public health policies greatly aided by the introduction of antibiotic medication 50 years ago. Organisations devoted to combating the disease—such as the National Association for the Prevention of Tuberculosis, founded in 1899—were disbanded or disappeared in the 1960s and 1970s when it seemed that TB had been conquered.

Incidences of TB are on the increase internationally. In 1993 the World Health Organisation (WHO) called TB a “global health emergency”. Recent research figures published by WHO illustrate the devastating toll. It is the infectious disease that causes the most deaths in the world. An estimated one third—approximately 2 billion people—are infected. Of these about 10 percent will develop the disease, whilst in the remaining 90 percent it will lie dormant (although it may emerge at a later stage if the immune system comes under stress).

TB accounts for a quarter of all preventable adults deaths amongst the under-65s and half of all deaths amongst children and young people. WHO estimates that 8-10 million people a year catch the disease; an infection rate of one person per second. Three million people will die from the disease each year and it is estimated that by 2020 another 1 billion people will be newly infected.

Dr. David Heymann, Executive Director at WHO, explained that travel and drug resistance were creating a risk to health world-wide. He told the BBC, “We are moving towards a future full of new opportunities for diseases to quickly spread from one continent to another. Simultaneously, drug resistance is sending us back in history to a time when we lacked medicines to cure some diseases.”

Currently the worst affected areas include Eastern Europe with 250,000 cases a year, South East Asia with 3 million cases a year and sub-Saharan Africa with 2 million cases a year. The pattern of the disease is changing. In the industrialised developed countries it affects older people, with a quarter of all cases aged 65 and over. In developing countries, such as South America and Africa, it attacks mainly young adults. Women of child bearing age between 15 and 44 are more at risk than men of the same age. This group of women are also more at risk from HIV infection and this can exacerbate their likelihood of developing TB. For women aged 15 to 44 in developing countries the leading causes of death are TB at 9 per cent, HIV 3 per cent and heart disease 3 per cent. The cost of treatment is out of reach for many in underdeveloped countries. For patients with non-resistant TB the cost of drugs is around $2,000 per patient but this rises to $250,000 for multi-drug-resistant TB.

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