Tuberculosis control and elimination in 2012 and beyond.

Tuberculosis killed 1·45 million people in 2010 and about 500 000 people have drug-resistant disease. Treatment is lengthy, toxic, and costly. Moreover, diagnosis and drug-susceptibility testing are slow. On March 15, results from the Thibela TB study presented at a latebreaking session at the 2012 Conference on Retroviruses and Opportunistic Infections failed to show benefi t of community-wide isoniazid preventive therapy compared with routine targeted therapy in 27 000 South African miners. The trial hoped to set a precedent for a control policy in high-risk groups such as the miners, up to 7% of whom develop tuberculosis every year because of the predisposing conditions of silicosis and HIV infection. Experts could therefore be forgiven for feeling gloomy ahead of World TB Day on March 24, but should not be. Despite a woeful funding gap in 2012 of US$1·7 billion, tuberculosis incidence is falling (from 9·4 million in 2009 to 8·8 million in 2010). 41 million people were treated with directly observed therapy in 1995–2009, and fewer people are now dying from the disease. Ten new or repurposed tuber cu losis drugs are in phase 2–3 trials, which hopefully will reduce treatment times to about 4 months, compared with present multi drug resistant tuberculosis regimens lasting 18–24 months. Faster treatment will greatly improve adherence, reduce transmission, and cut costs. Vaccine development has also received a boost of $220 million over 5 years, which was pledged to the non-profi t vaccine developer Aeras by The Bill & Melinda Gates Foundation. Case detection is trouble some (it has plateaued at about 60%) but increased funding for Xpert MTB/RIF assays or use of low-cost alternatives, such as the point of care Determine TB-LAM, might improve detection rates in low-income settings. An ambitious target to be discussed on World TB Day is that of zero children dying from tuberculosis by 2015. To reach this goal, sustaining the gains seen so far and improving case fi nding will be vital. Some observers argue a broader vision is needed, pursuing zero infections, zero deaths, and zero stigma from tuberculosis for people of all ages. Both these objective will require commitment at the highest political levels and should be on the agenda when G20 leaders meet in Mexico in June. ■ The Lancet For more on the Thibela TB study see http://www.aidsmap.com/ Thibela-TB-Community-wideIPT-did-not-improve-TB-controlin-South-Africas-mines-at-thepopulation-level/page/2285760/