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Tuberculosis control and research strategies for the 1990s: memorandum from a WHO meeting] Estrategias de control e investigacion de la tuberculosis en el decenio de 1990: memorandum de una reunion de la OMS.
BOLETIN DE LA OFICINA SANITARIA PANAMERICANA. 1993 May; 114(5):429-36.Mycobacterium tuberculosis, the pathogenic agent causing tuberculosis, is carried by one third of the world's population. Some 8 million new clinical cases of tuberculosis are diagnosed annually. Pulmonary tuberculosis is the most infectious clinical manifestation, tubercular meningitis is the principal form causing infant death, and tuberculosis may affect various other organs. Untreated tuberculosis has a fatality rate of over 50%. Chemotherapy greatly reduces the rate, but some 2.9 million persons die of tuberculosis each year because of the inadequacy of many national treatment programs. Tuberculosis is the most important cause of death from a single infectious agent in the world. An estimated one fourth of avoidable deaths to adults aged 15-59 in the developing world are attributed to tuberculosis. Tuberculosis is especially prevalent in Africa south of the Sahara and in Southern Asia. Two new obstacles threaten to aggravate the problem: the HIV epidemic and drug resistance. HIV infection is the most serious risk factor yet identified because it converts latent tuberculosis infection into active disease. In Africa almost half of all persons seropositive for HIV are also infected with tuberculosis. Ineffective treatment programs favor the formation of pharmacoresistent strains, and drug resistance has become a major problem in various parts of the world. Effective measures exist to control tuberculosis. Although it does little to protect adults against infectious forms of tuberculosis, the BCG vaccine prevents the most lethal forms. Coverage of infants the BCG is over 80% in the developing world as a whole, but under 60% in sub-Saharan Africa. Chemotherapy can cure almost all cases and convert cases with positive sputum into noninfectious cases, reducing transmission. Normal treatment must be administered over at least 12 months, straining the resources of health services in developing areas. The introduction of a shorter therapy has revolutionized treatment in some national programs, which have achieved cure rates of 80% in new patients. Evaluation of some national programs has demonstrated that well managed short duration chemotherapy is cost effective even under difficult conditions. Progress in controlling tuberculosis has been slower than expected in developing countries because of excessive optimism about the prospects for quick declines as occurred in the industrialized countries, and because of lack of resources. A well organized and vigorous international effort under World Health Organization leadership is required to bring the tuberculosis problem to the world's attention, mobilize assistance on a wide scale, and provide information and direct support to national programs. Research will be needed to adapt proven control techniques to local cultures, develop new drugs, shorten treatment regimens, and encourage greater patient compliance.