India's "startling" rate of confirmed tuberculosis (TB) infection and the worst TB epidemic in Africa since the advent of antibiotics are highlighted in two articles in the New England Journal of Medicine.
In Africa, say Richard E. Chaisson and Neil A. Martinson, coexistence with HIV plays a large role, and TB detection relies on a sputum analysis technique that is particularly ill-suited to detection in HIV-infected patients.
As a result, many people remain ill and contagious for long periods before the disease is detected and thousands die without receiving a diagnosis. The average rate of successful treatment is also below the WHO target.
The declaration of a "TB emergency" by African health ministers in 2005 offered a glimmer of hope, but this requires enormous commitment, particularly regarding the development of new biomedical tools.
While research into new treatments is underway, African healthcare systems could adopt new strategies, including better use of existing culture techniques and WHO-standard treatment programmes, the authors add.
In India, says Vikram Paralkar in the second article, treatment of latent tuberculosis with nine months of single-drug therapy — the norm in the United States — is a concept found only in textbooks: were it implemented, nearly a tenth of the population would require treatment.
Progress has been made, and the WHO has reported that India's TB control programme had expanded to cover the whole country. But corruption complicated the situation, with officials recording fictional patients in order to meet government quotas.
"We must remember that statistics are only as good as the village-level data on which they are based," he says. "Many people continue to slip through the net and into jostling crowds, with at most a thin handkerchief to stifle their incessant cough."