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Clinical Tuberculosis

5th Edition, April 30, 2014

Complete Document

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Active, Most Current

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ISBN: 978-1-4441-5435-1
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Product Details:

  • Revision: 5th Edition, April 30, 2014
  • Published Date: April 30, 2014
  • Status: Active, Most Current
  • Document Language: English
  • Published By: CRC Press (CRC)
  • Page Count: 470
  • ANSI Approved: No
  • DoD Adopted: No

Description / Abstract:


The past 20 years have been the most exciting in the long history of tuberculosis (TB) since the introduction of streptomycin to cure the disease. That is how it was long ago (1992) till a letter arrived on my desk from Chapman and Hall asking me to consider launching a new textbook on TB.

At that time, there was not a single up-to-date, internationally accepted textbook on TB. Perhaps, it was because, at that point in time, of the general impression all over that the final conquest of TB was happening for the past 10 years. How wrong it was. First, there was ignorance of what was going on in the developing world, and second, the advent of HIV was bringing in a new era of TB. In 1986, the United States realised that it had a problem on hand, as the number of TB cases started to increase once again after more than a century of steady decline. Then, the world slowly began to realise the fact that TB was far from conquered.

Unfortunately, almost all the expertise and scientific progress in fighting the disease had been lost. Nowhere was this more apparent than in the United Kingdom where the Medical Research Council's Research Units for TB had been closed. As I wrote in the preface to the first edition, ‘If one wished to find a symbol of the way the developed world has turned its back on the problems of disease in the developing world, then this closure would perhaps be the most poignant'.

In my search for expertise to write the chapters for the first edition, I scoured the seven seas and the continents. Fortunately, there was still just about enough international expertise left to reawaken the need to drive science in the direction required to re-engage with the problem. This was mainly provided by the International Union against TB which had maintained its scientific integrity and mission against this disease when the rest of the world had given up the fight. There was also just about enough political will, particularly in the United States, to fund such new developments.

In fact, a new army of TB workers has been trained and put into action over the past two decades. A sign of this is an advertisement for the Stop TB Partnership which was published in the London Times on World TB day (24 March) 2010. It lists 34 different member organisations. These vary from the two UK-based TB charities, TB Alert and Target TB, through professional bodies, such as the British Thoracic Society and the Royal Colleges of Nursing and General Practitioners, to companies manufacturing and marketing TB drugs, such as Glaxo SmithKline and Genus Pharma. The newly formed All Party Parliamentary Group on tuberculosis is active in bringing the problem of TB into the political forum. TB advocacy groups spurred on by current and former patients are spearheading the drive for funding and awareness. Unfortunately, the most recent news on the battle against TB is not encouraging. The world economic downturn since 2008 has had a negative impact in the fight against tubercle bacillus. Of late, the Global Fund against AIDS, TB and malaria has not received funding. Many of the Millennium Goals for world health are unlikely to be met by the target year of 2015. It has taken 15 years of very hard work and intense struggle for TB Alert, a relatively young, UK-based TB charity, to achieve a seven-figure annual turnover. Even the English membership of the International Union against Tuberculosis and Lung Disease (IUATLD) has been lost due to non-payment of the constituent member fee.

However, as I compile the fifth edition of Clinical Tuberculosis, on the kind request of the publishers, I can virtually cover all the topics required for the book from my own city of Liverpool, as there has been such a rekindling of interest in TB. A well-known and respected colleague said to me at the time I was tackling the first edition, ‘We are living in interesting times'.

Investment in new diagnostics means that we can now identify and speciate the organism almost within hours of the smear-positive sputum specimen arriving at the lab, and sensitivities to the essential drugs do not take much longer. In general clinical settings, still newer techniques that will give out results in not more than two hours are about to be rolled out. The new interferon gamma release assay (IGRA) blood tests look much more promising than the centenarian tuberculin skin test. We are also on the cusp of a new raft of drug regimens that could probably reduce the length of treatment for the fully sensitive organism to four months, and genuine, new drugs give us hope of much better cure rates in multidrug-resistant (MDR) and extremely drug-resistant TB (XDRTB).

We will have to wait longer for a new vaccine, but a number of promising vaccines are in phase I and phase II trials at the moment. All these topics are addressed in the fifth edition.

Many wonder in this age of electronic reading and instant updates as to whether there is a place for the traditional textbook. I believe there is. First, although electronic readers have their place, many readers still prefer the reliability and feel of the paper book. Second, in the far-flung parts of developing countries, power supply to read an electronic book may not be easily available. Third, there is a need to keep all aspects of practical clinical information in a single volume for easier access and as a convenient source for those engaged at the coal face of the battle against TB. But for the first time, this edition is also available in electronic format as well.

Similar to the previous editions, we have tried to keep the book as concise but as comprehensive as possible. Some of the fourth edition chapters covering general policy rather than clinical practicalities have been omitted. Authors had been asked to write chapters of the length which can be read comfortably at a sitting – no more than 45 minutes to an hour.

We have reduced the overall chapter numbers to cut costs. In number, they are now very similar to the first edition, which has been by far the most successful of all editions, going to three print runs in all.

The overall structure of the book will be familiar to readers of previous editions. History and epidemiology is followed by the laboratory disciplines including diagnostic tests. These are followed by the clinical sections and treatment chapters. The section on TB in special situations has been expanded. Along with the regular chapter on TB and immigration, and the relatively new chapter on TB and poverty, we have added a chapter on the problem of drug resistance in India, with particular reference to the new extreme forms of drug resistance where virtually no antibiotics are effective.

Prevention remains focused on preventive therapy and vaccines. Control is again divided into the developed and developing worlds, as resources for this aspect of TB are so different. Environmental mycobacteria has an exhaustive chapter, as the problem has become increasingly serious in the developed world, and no book on human TB would be complete without a reference to the other living beings with whom we share our planet and our diseases – the rest of the animal kingdom. The very recent, controversial badger culling in the United Kingdom is receiving special attention.

All topics have received a complete rewrite, sometimes with previous authorship but also by new authors.

Of the 30 or so authors who contributed to the first edition, only 2 remain in the fifth edition – perhaps symbolic of the new army of workers who are carrying the torch in the fight against TB. It is for this very reason that I have involved two much younger colleagues for the fifth edition. Should there be a call for subsequent editions, as I hope there will be, I can pass the baton on to them knowing that it is in safe hands.

The past 20 years may have been the most interesting in terms of developments in combating the disease since the discovery of specific antibiotics over 60 years ago, but I do believe the next 20 will be all the more exciting. With the development of new drugs and drug regimens, new diagnostic technology made available to the poorest nations and new vaccines, we have a realistic chance of eliminating TB from the human race within the next 50 years, but to do so we will need political will, funds and determination.

In the conclusions chapter to the first edition, I had made a few rash predications. It is interesting to introspect 20 years later and see how wrong or right they were.

First the epidemiology: ‘Tuberculosis is likely to increase for the next decade and further due to the impact of HIV'. According to WHO, case rates peaked at about 2005, and case numbers peaked some two or three years later: right so far. But, I had predicted an HIV epidemic in Asia of the magnitude that we were then experiencing in Africa. I am happy that I have been proved wrong on that score.

On treatment front I wrote, ‘The cost of drugs should not be a problem'. Thanks to the component of DOTS and the Green Light Committee, drugs are now available free of cost to the poorest countries. There has been a real reduction in case fatalities, and the aim of 85% cure rates is making an impact on disease rates. ‘The co-ordination of disease control at a local level', I wrote about is indeed taking place through the DOTS programme. Right again. What I failed to predict completely is the problem of drug resistance which would emerge as a result of more people coming under the umbrella of drug treatment. This now poses a very real threat to disease control worldwide and promises to reverse the effect treatment has had on reducing mortality unless properly dealt with.

The call for more TB workers has indeed been answered, not just in the developed countries but also across the world. New drugs, new diagnostic techniques and new vaccines are very much evident and are undergoing trials. The call for new methods of sensitivity testing are being heeded but not the bioilluminescence technique I alluded to.

It is in the area of diagnostics that the real advances have been made, and the implementation of molecular methods aided by sequencing of the genome of the bacteria has given us by far the fastest results in the battle against TB; not foreseen by me at all at the time, probably reflecting my clinically blinkered and relatively unscientific upbringing.

So, about half right which is about what most psephologists seem to score. The future is likely to bring several new drugs and drug regimens into use even within the next five years, and molecular methods of diagnosis and sensitivity testing are likely to be improved over the same time span so that smear-negative- and extra-pulmonary disease can be diagnosed more easily.

Because of the nature of the bacteria and the need for assessment of protective efficacy of new vaccines over time, development of a new vaccine is likely to take considerably longer, perhaps another 20 years, time enough to see a big reduction in TB cases for the next generation of TB workers, but not mine.

As the case numbers of TB undergo a satisfactory decline, there is a danger that the world may take its eye off the ball and turn away as happened some 30 years ago. Then, as now, we had the opportunity to reduce the disease to negligible levels but failed to do so. As the TB advocates are now saying, even one death from TB is too many. With at least a million and a half deaths in the world from TB, we still have a long way to go. Yet, it can be done within the lifetimes of the younger adults now fighting the disease.

When the Millennium Goals were announced in 2000, special funding was earmarked for HIV/AIDS, TB and malaria. Ironically, TB is the one which has been given the least publicity and funding. I have little doubt that we could virtually eliminate TB within half a century, but the indifference of the political class in this regard will probably ensure that it will be the last of the Big Three Infectious Diseases to be conquered.