OHE’s 50th Celebration: Publications on Tuberculosis Show Constancy and Change

Between 1962 and 1998, OHE published more than 100 booklets on various diseases and conditions as part of a series on “current health problems”. The first and the last of the disease state papers were on the same illness: tuberculosis. The first paper, from 1962, was the OHE’s first publication; the second, the last in the series, was published in 1998. What is most remarkable in comparing these two is less the change in successful treatment than the context within which the disease exists.

Between 1962 and 1998, OHE published more than 100 booklets on various diseases and conditions as part of a series on “current health problems”.  Topics included public health issues and health systems challenges – and also ran the gamut of diseases, from heart disease to mental illness, cancers, migraine, Parkinson’s, obesity and more.  Some topics were examined more than once, occasionally decades apart.  These in particular highlight the changes that have occurred in approaches to health care during OHE’s 50 years of operation.

Appropriately, the first and the last of the disease state papers were on the same illness: tuberculosis.  The first paper, from 1962, was the OHE’s first publication; the second, the last in the series, was published in 1998.  What is most remarkable in comparing these two is less the change in successful treatment than the context within which the disease exists. 

The 1998 publication seems gloomy: “The [1962] booklet noted that  ‘ . . . the use of these drugs, combined with traditional methods of treatment, had opened up the possibility of the final defeat of TB in Britain within 15 years ‘. Thirty-five years on that optimism appears misplaced. Approximately 6,000 TB notifications and [5]00 deaths are still reported annually in the UK. . . . The 1990s have been a period when TB notifications have levelled out and, indeed have even increased.”

A broader view, however, still using only these two publications, shows progress between 1962 and 1998.  Much is due to the continuation and expansion of trends already underway in 1962, greatly aided by better science and new technology in medicine and in other areas.  For example:

1. Medical knowledge about TB — susceptibility, transmission and progression — expanded substantially between 1962 and 1998.
2. Epidemiology advanced, allowing screening to much more effectively target those groups at highest risk in the UK, and do so in a timely manner.
3. Prevention made more extensive use of vaccination, covering a large proportion of the UK population in a systematic manner.
4. Diagnostics leapt forward.  The 1962 publication called for better use of “miniature radiography” in the UK; by 1998, molecular diagnostics had appeared, allowing “more effective therapy and better patient outcome”.
5. New drug treatments replaced old approaches – both drug and non-drug — reducing overall costs to the NHS and minimising costs to society from work lost.  The threat of resistance, a key concern in 1962, was by 1998 still a concern (and remains so today). By 1998, that was addressed in the UK using the DOTS (directly-observed treatment, short-course) approach, whereby health care workers ensured the patient took the medication correctly for six months. No hospitalisation was required and patients could continue to work throughout the period of treatment.
6. Specific treatment guidelines, from the Joint Tuberculosis Committee of the British Thoracic Society, aided health care providers.  These were revised in 1994 “to take account of new evidence concerning contact tracing, drug-resistant disease and the relationship between HIV infection and TB”. (NICE issued guidance in 2006 and amended that in 2011.)

Progress clearly was made between 1962 and 1998. In 1962, new cases of TB were “down” to about 20,000 a year; by 1998, this was 6,000. Deaths were at 2,250 in 1962, 500 in 1998, and 300 in 2007[1].

By 1998, however, aspects of the context had changed, introducing some new concerns and intensifying old ones.  For example, the appearance and effects of HIV increased susceptibility to TB in that population. Although these cases accounted for a small portion in 1998, 2.3 per cent of new cases, they potentially could add to the spread of the disease.  Moreover, easier and more frequent travel from areas of the world with a greater incidence of TB made clear the importance of addressing TB at a global level, not just at home.  According to the 1998 publication: “the overall notification rate for previously untreated TB in England and Wales in 1993 was 9.2 per 100,000 population . . . Highest rates were recorded for people of Indian subcontinent ethnic origin (117.0 per 100,000) and black African origin (135.2 per 100,000). The rate for the white population was 4.7 per 100,000.  The rate of TB among people of black African and South Asian origin varied” with the highest rates being for those who had arrived in the UK most recently.  In addition, trips back to the country of origin carried clear risks of exposure: the 1998 publication notes that India had the highest number of prevalent TB cases in the world, accounting for as much as 30 per cent.

A clear difference in the two publications is in the approach to valuation.  The 1962 paper included rather rudimentary analyses of the cost savings to society from using drugs to treat TB.  “New drugs,” it states, “have shortened the duration of treatment and allowed many patients to be treated at home instead of in hospital. They have solved one of the most pressing problems besetting the Health Service in its early years”.  The paper assumed that 100,000 people would not only survive, but also be able to work, adding £400 million per year to the GNP.  Annual savings on hospital costs added another £15 million in savings.  “Thus, the anti-tubercular drugs would appear to provide an economic benefit to England and Wales alone of at least £55 million per year” (about £620 million in 1995, adjusted for inflation).

The 1998 publication focuses not on savings, but on costs, an indication of how perspectives changed.  Included in calculating the cost to the NHS were primary care, hospital care, pharmaceutical services and the vaccination program.  Total yearly cost of TB to the NHS was put at £25.6 million for 1994/5, with £1.86 million of that accounted for by pharmaceuticals.  Indirect costs, including lost productivity, were estimated at £42.8 million.  The total estimated burden of disease for TB, then, was £68.4 million, in 1995 figures (about £5 million in 1962 pounds).

Epilogue

Since the 1998 publication, the incidence of TB in the UK has increased from 11.4 per 100,000 population in 2000 to 14.4 in 2011.[2] The number of new cases reported in 2011 was 8,963. The majority of new cases, and the increase in the number of cases, still are attributable to people of African and South Asian origin. In 2011, for example, TB cases among the UK-born was 4.1 per 100,000 (slightly lower than in 1998), compared to 83.6 among the people born outside the UK. Continuing concern about TB led to the issuance of NICE guidelines in 2006 (amended in 2011) — CG117 Tuberculosis: Clinical diagnosis and management of tuberculosis, and measures for its prevention and control.

TB, and partial or complete resistance of some forms of TB to existing treatments, continue to be major issues globally. TB trails only HIV/AIDS as the world’s leading cause of death from a single infectious agent, although the death rate dropped by 40% from 1990 to 2010.[3] For TB and other deadly infectious diseases, encouraging treatment innovation is critical. Recent OHE research has focused on this important policy issue.