If you happen to have a Lancet collection that stretches as far back as 1911, you can read the Editor of the day, Squire Sprigge, passionately looking forward to the day that the “demon of tuberculosis” is finally mastered. In 2011, that day still seems some way off. An article published last week in Emerging Infectious Diseases reported that in Toronto, Canada, about 20% of homeless people with tuberculosis die within 12 months of being diagnosed—the same proportion as 10 years earlier.
The problems in Toronto are mirrored in many modern metropolises. Tuberculosis finds its niche in poverty and social exclusion, with rates of disease in the most vulnerable and marginalised communities orders of magnitude higher than those in the general population. Homeless people are the engines of transmission because the two assumptions that hold true for the general population—that people with symptoms will seek medical help, and that they will take treatment as prescribed—simply do not hold in the homeless community. This can not only have catastrophic consequences for the individuals involved, but also means prolonged transmission in the community, and an increased incidence of acquired drug resistance.
Waiting in a hospital for the problem to come knocking on the door clearly does not work. But in New York City, a programme of active case finding, screening for latent disease, and access to intermediate care facilities that ensure treatment is adhered to, have helped to consistently reduce rates of active tuberculosis since the early 1990s. In London, the Find and Treat programme headed by Alistair Story has also made inroads. Since the programme started in 2005, Story and his team have screened over 60 000 people using their mobile radiography unit. That is 60 000 people who would otherwise have been invisible to health services. But funding for Find and Treat is precarious, and is likely to become even more so if the move to commissioning led by general practitioners goes ahead as planned. New York City has shown that where there is political will, there is a way to tackle tuberculosis in homeless communities. It is up to policy makers elsewhere to follow that lead.
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(11)60252-3/fulltext?rss=yes
The problems in Toronto are mirrored in many modern metropolises. Tuberculosis finds its niche in poverty and social exclusion, with rates of disease in the most vulnerable and marginalised communities orders of magnitude higher than those in the general population. Homeless people are the engines of transmission because the two assumptions that hold true for the general population—that people with symptoms will seek medical help, and that they will take treatment as prescribed—simply do not hold in the homeless community. This can not only have catastrophic consequences for the individuals involved, but also means prolonged transmission in the community, and an increased incidence of acquired drug resistance.
Waiting in a hospital for the problem to come knocking on the door clearly does not work. But in New York City, a programme of active case finding, screening for latent disease, and access to intermediate care facilities that ensure treatment is adhered to, have helped to consistently reduce rates of active tuberculosis since the early 1990s. In London, the Find and Treat programme headed by Alistair Story has also made inroads. Since the programme started in 2005, Story and his team have screened over 60 000 people using their mobile radiography unit. That is 60 000 people who would otherwise have been invisible to health services. But funding for Find and Treat is precarious, and is likely to become even more so if the move to commissioning led by general practitioners goes ahead as planned. New York City has shown that where there is political will, there is a way to tackle tuberculosis in homeless communities. It is up to policy makers elsewhere to follow that lead.
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(11)60252-3/fulltext?rss=yes
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