Liverpool (UK), Mar 9 (The Conversation) With one of the largest tuberculosis (TB) outbreaks in US history, Kansas has more to worry about than its recent Super Bowl defeat.

During the past year, 67 people with TB have been detected. This comes on the back of increasing rates of TB in the US year on year since the start of the COVID pandemic.

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Rather than a relic of the Victorian era, TB is the world's most enduring pandemic, killing more people each year than any other single infection.

While more common in low-income countries, TB continues to be found in more deprived communities, cities, prisons, homeless populations, and in black, Asian and Indigenous people, including in wealthy countries such as the US and UK.

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TB outbreaks in wealthy countries act as a canary in a coalmine, reflecting cracks in national public health systems. More broadly, TB outbreaks in any setting have deeper implications for the struggle to end TB globally.

TB is an airborne infection that doesn't respect borders. With increasing mass movement, including due to climate change and war, the maxim “TB anywhere is TB everywhere” is more resonant today than ever.

In the UK, TB rates consistently declined between 2011 and 2020. But, like the US, this decline reversed since COVID emerged in early 2020.

In 2023, there was a 13 per cent increase in the number of people who became unwell with TB in England, compared with 2022.

At 9.5 people with TB per 100,000 people per year, England is in jeopardy of losing its “low TB incidence” status (less than ten people with TB per 100,000 people per year).

Rates of TB in England have a stark social gradient, with the poorest 10 per cent of people having five times higher rates of TB than the richest 10 per cent.

In the UK, there is a cost of living crisis. Many people, especially the poorest, are struggling to put food on the table. TB is a social disease of poverty that thrives where there is overcrowding, undernutrition and poor working and living conditions.

But the increase in TB in the UK cannot be put down to greater risk of disease alone. The response of the health and social care system to prevent and cure TB is crucial.

The BCG vaccine, currently the only TB vaccine, is not nearly as effective as we would like at preventing disease. There is hope on the horizon with several vaccines under development, but their effect may be impeded by vaccine hesitancy driven by misinformation.

Other barriers to address include lack of TB awareness, continuing TB-related stigma, understaffing of vital TB community nursing teams, and a breach between health and social care sectors to support those vulnerable to TB.

For countries with lower incidence of TB across Europe and North America, many TB policies are targeted at identifying and treating TB in groups who are most at risk of being exposed to the disease, including people moving from regions of the world where TB is more common.

Patterns of migration to the UK changed significantly following Brexit. A need to expand the workforce, particularly in health and social care, has led to active recruitment and movement of people from higher TB burden countries.

This is relevant because, in England, four in five people with TB were born outside the UK, and rates among this group increased by 15 per cent between 2022 and 2023.

Screening migrant populations as part of their visa application process pre-entry is effective at identifying people with infectious TB. But prevention is better than cure, and there remains a gap in screening for TB infection or TB disease without symptoms.

Providing well-tolerated, preventive TB treatment can reduce the risk of developing active TB disease by 85 per cent in the future. Yet the screening programme in the UK is under-resourced, with just 11.5 per cent of eligible migrants screened for TB infection in 2023.

We should not overlook the fact that rates of TB also increased, although to a lesser extent (3.9 per cent), among people born in the UK – the first time this has happened for many years.

Among both UK-born and non-UK-born populations, often overlapping social risk factors such as homelessness, asylum seeker status, drug or alcohol misuse, incarceration and mental health disorders continue to drive TB.

These factors, which jumped by 27 per cent between 2022 and 2023, not only increase the likelihood of TB disease but are associated with much lower rates of cure.

Early diagnosis and treatment of TB are crucial to prevent long-term health issues or even death. The sooner someone starts effective treatment, the sooner they stop being infectious, helping to reduce the spread of TB. Improving access to diagnosis and care will lower TB transmission.

Unacceptable delays in treatment

Nearly a third of people with TB in the UK experience a delay of four months between the onset of their symptoms (commonly cough, fever, night sweats and weight loss) and taking their first anti-TB medicine.

This unacceptable delay is similar to (or even longer than) the treatment delays we have documented in low- and middle-income countries with much higher TB burdens, including Peru, Nepal and Mozambique.

In the UK, most people are entitled to free NHS care, and TB care and prevention is free to all. However, the NHS is overwhelmed and policies relating to healthcare recovery costs of visitors and migrants can prevent people with TB, wherever they are from, from getting timely care. This situation poses a public health threat to us all.

Effective TB prevention and care is possible. While current tools are imperfect, albeit with recent progress in diagnostics and treatment, researchers around the world are further advancing science and innovation in the fight against TB.

This includes the promise of nutritional supplementation, financial and social support, and a new TB vaccine. Providing timely support to everyone with TB remains fundamental to our response to this illness of poverty.

To end TB, whether in the US, UK, or globally, we would do well to remember and apply the old medical adage: treat the person, not the disease. (The Conversation)

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