scope:

Preface

It must be a matter of concern that 20 years after it was realized that tuberculosis was out of control across much of the developing world, the tide of tuberculosis shows no sign of being controlled. As a race, human kind is still losing the fight against tuberculosis. The main reason for an apparent peaking of the incidence is a peaking of HIV incidence. There is still an annual increase in the total number of cases globally.

Though there have been some encouraging developments particularly in the area of new diagnostics for tuberculosis, the minimum of 6 months of treatment is unlikely to be modified by the introduction of new drugs in the next 5 years. New vaccine development takes time and though there are some encouraging signs of new developments, it seems unlikely that we can replace BCG for at least 10 years. In that time another 20 million people will die and 80 million be affected by what should be a preventable and treatable disease.

The setting up of such global organizations as the Global Fund to Fight AIDS, Tuberculosis and Malaria, the Global Alliance for TB Drug Development and the Green Light Committee, which oversees help with MDR-TB, are steps in the right direction.

However, despite these developments, funding for tuberculosis drug, vaccine and diagnostic development is still woefully short of requirements.

The contribution to the fight against tuberculosis by developing countries is also a matter for concern. India, for example, with the highest burden of disease from tuberculosis, has decreased the annual proportion of its GDP spending on health from 1.4 per cent in the 1950s to 0.9 per cent currently.

In the preface to the last edition, I said that the English contribution to the International Union against Tuberculosis and Lung disease was assured. I was mistaken. Unfortunately, the British Lung Foundation decided to stop its share of the funding in 2005. The British Thoracic Society membership then voted as to whether it should take over the full contribution and despite a clear bias by its officers against the contribution voted only narrowly against continuing the contribution, currently running at 25 000 Euros a year. The Department of Health is currently funding on a year by year basis.

Though disappointing for the present, I feel the up and coming generation of chest physicians may be more sympathetic to the needs of the developing world than their predecessors.

The fourth edition of Clinical Tuberculosis is therefore published against a rather depressing background of a disease which is proving incredibly difficult to control, partly because it is not yet perceived as a national or international priority. The principal reason for this is co-infection with HIV, which renders the host uniquely susceptible to infection with tuberculosis and progression to disease. In parts of Africa where HIV infection is endemic, rates of tuberculosis have tripled over 15 years. Other factors are important to overcome if TB is to be controlled. In particular, poor medical infrastructures linked to poverty of individuals and communities render management almost impossible as it is difficult to get drugs to patients.

Even in well-resourced settings, tuberculosis does not always receive the priority it deserves and control is compromised.

As with previous editions, Clinical Tuberculosis is designed to provide the TB worker, whether in public health, laboratory science or clinical practice with a synoptic and definitive account of the latest methods and practice in its control.

The book is intended to be relatively short so that it is affordable to resource-poor concerns. For this reason, we have also excluded colour prints.

For the fourth edition, the main changes are in the area of laboratory-based diagnosis and management of disease. The gamma interferon-based blood tests make their appearance for the first time. The molecular techniques for diagnosing the species of mycobacterium and rifampicin resistance gene are now in first-line service provision in well-resourced settings. New developments, such as the microscopic observation for drug sensitivity (MODS), are detailed. Over the four editions of the book, the evolution of diagnostic methods has progressed so that what is being researched in one edition becomes of service use in the next. Unfortunately, the same cannot be said of drug or vaccine development.

A new chapter on the human immune response to the tubercle bacillus is included.

Increasing organization of what should be standard practice for all medical staff managing tuberculosis has resulted in clear guidelines being published on both side of the Atlantic. A new chapter on standards of care is there-fore also included. However, tuberculosis cannot be controlled anywhere until it is controlled everywhere. Central co-ordination by WHO and the International Union against Tuberculosis and Chest Diseases are required. To outline this task, a new chapter on the Global Plan to Stop TB has been added.

Finally, more in hope than expectation of a change before another edition is published, a separate chapter from the standard treatment regimens is now given over to new drugs and their likely place in regimens which may become standard practice in bringing down the length of treatment in the future.

The new charity for tuberculosis in the UK, TB Alert, continues to raise the profile of tuberculosis in the UK and the founding of an interparty TB committee in the House of Commons this year is a cause for hope.

In turning to the dedication of this book I felt it was time to honour those who had given the most to the fight against tuberculosis in the UK and across the world: my former teacher and mentor Wallace Fox, his partner in the MRC TB Units sadly closed in the 1980s, Denny Mitcheson and my good friend Sir John Crofton.