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736 BritishJournalofNursing,2012,Vol21,No12

AbstractTuberculosis (TB) is a multi-faceted illness associated with a

long and fascinating history. Although much has changed in the

diagnosis, treatment and prevention of TB over the past six decades,

many of the challenges remain remarkably similar. In developing

solutions to these challenges, key stakeholders and politicians

would do well to learn from some of the more effective strategies

from the pre-chemotherapy era. Despite working with insufficient

resources, nurses have historically contributed significantly to

the work of the multidisciplinary teams in delivering care to

patients and families, as well as in implementing national TB

control and prevention programmes. The current resurgence of

TB in the UK makes it imperative to achieve consistently and

appropriately-funded TB services across the country. Whether NHS

commissioners and politicians will engage with nurses and others in

the reconfigured NHS to achieve this, however, remains to be seen.

Key words: Tuberculosis n History n Sanatorian Hard-to-reach groups

n Nursing role

ThereisgreatanticipationintheairasLondonprepares

tohostthe2012OlympicGamesforthefirsttime

since1948.TheGamesin1948werestagedonashoe-stringbudgetof just760000, incredibly, returning

a 29000 profit (Hampton, 2011). Taking into account

requiredsecuritymeasures,the2012Gamesarelookingata

costof11billion(HouseofCommonsCommitteeofPublic

Accounts,2012).However,theGameshaveinjectedsignificant

investmentintotheLondonBoroughofNewham,oneofthe

most deprivedareasin thecountry(Department ofHealth

(DH), 2011). Moreover, a London Health Commission/

LondonDevelopmentAgency commissioned report (2004)

suggeststhattheOlympiclegacywillincludelong-termand

wide-ranginghealthandsocialbenefitsforthecommunities

ofEastLondonandbeyond.

KelvinKarimisTBClinicalNurseSpecialist,SheffieldTeachingHospitalsNHSFoundation

Trust,Sheffield.

Accepted for publication: June 2012

Coincidentally,July2012willseeLondonhostingtheSixth

Conference of the Union Europe Region/International

Union Against Tuberculosis and Lung Disease entitled

TuberculosisandLungDisease:ThreatsandPromises.That

London should host such a major international scientific

conference is both timely and apt. London is facing a

tuberculosis (TB) threat with the highestTB rate of any

capitalcityinWesternEurope(LondonHealthProgrammes,

2011)andNewhamhas the highestTB rate inLondonat

128per100000(HealthProtectionAgency(HPA),2011a).TheresurgenceofTBinLondonandotherUKcitiesover

thepastfewdecadeshasbeenwelldocumentedbutdespite

promises of action from theGovernment to dealwith its

risingincidence,thereisstillalackofpoliticalwilltofund

thenecessarymeasures.

ThisarticlecomparesandcontraststhenatureofTBcare

and treatment in 1948 with that of today. Contemporary

issuesinTBcontrolandpreventionarediscussedaswellas

theroleofthenurseinmeetingtheassociatedchallenges.

TB epidemiology in 1948 and 2012In1948,therewasgoodreasontofearbeingdiagnosedwith

TB.TheepidemiologyofTBinthaterameantyoungadults

werelargelyaffected,particularlyinthe2535yearagegroup(Davies,2005).Womeninthisagegroupwerealsothought

tobe susceptibletoTB,possiblyowingto anincreasedr isk

duringpregnancy(Springett,1950).Asignificantnumberof

childrenwouldalsohaveacquiredlatentTBinfectionandthe

youngestwereathighest risk ofdevelopingfrequently fatal

formsofthediseasesuchasmiliaryTBandTBmeningitis

(Davies, 2005). Inolder agegroups,males seemed tobeat

highest risk (Wilkins, 1956). The increased prevalence of

smoking,especiallyamongmalesinthisperiod,mayhavealso

contributedtothisheightenedrisk(Lowe,1956).

Withtheexceptionoftheinterwaryears,theTBratehad

beensteadilyfallinginEnglandandWalesfromthebeginning

ofthetwentiethcentury.In1948,43971casesofrespiratory

TB and 8605 cases of non-respiratoryTB were reported.

There were also15600TBdeaths resultingin amortality

rateof36.5per100000(HPA,2011b;2011c).Althoughthe

post-warperiodsawadramaticfallinTBchildmortalityin

Tuberculosis care:Olympics 1948 vs 2012

Kelvin Karim

the countdown continues...

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EnglandandWales,therewerestill1562childdeathsin1948

(Lorber,1953).However,thesamedownwardtrendwasnot

seen inScotland wherethe number ofcases continued to

escalate (McDonald and Springett, 1954). For reasons that

werenotentirelyclear,theTBrateinScotlandhadrisento

66per100000by1948(Elliot,1949)andGlasgowhadthe

highestTBdeathrateinBritain(Stein,1950).

AlthoughTB mortalityin theUK in 2012 is very low,TBmorbidityhasbeenconsistentlyrising,saveforasmall

reduction in the number ofTB cases reported nationally

in 2010. Latest available figures from the HPA (2011d)

show that there were8483TB cases reported in theUK

in2010,anationalrateof13.6casesper100000.London

accountsforthelionsshare ofcases(39%) ata rateof 42

per 100000. Parts of London have particularly high TB

rates, including Newham, Brent and Hounslow (HPA,

2011a),withcomparableratestothoseinChina,Sudanand

Romania(WorldHealthOrganization(WHO),2012).

TBcontinuestoprimarilyaffectyoungadultsbetween15

and44 yearsofage(60%).Thoseover65andunder5 years

ofage accounted for 15% and 2%of casesrespectivelyin2010.Overall,TBaffectedslightlymoremalesthanfemales

(HPA,2011d).

Over70%ofTBcasesintheUKarepeoplebornoverseas,

particularlyin SouthAsiaand sub-SaharanAfrica, withthe

largestproportionbeingofIndian(25%),white(22%)and

blackAfrican(19%)ethnicity(HPA,2011d).

Fortunately,multidrug-resistantTB(MDR-TB),whichis

definedasbeingresistanttoatleastrifampicinandisoniazid,

remainslow.OftheTBcasesconfirmedmicrobiologicallyin

2010,only1.3%werereportedasmultidrugresistant.Thisis,

nevertheless,anincreaseonthe0.9%in2000(HPA,2011d).

TB treatment and care in 1948 and 2012

Although the first reasonably successful antibiotic,streptomycin, was discovered in the 1940s, it was not

availabletomostpeopleuntilmuchlater.Thedrugwasin

shortsupplyinBritainandneededtobeevaluatedforthe

treatmentofTBinhumans(Ryan,1992).Ryanobservesthat

millions of sufferers worldwidehad suffered the appalling

tormentofknowingthattherewasatreatmentavailablethat

mightcurethem,onlytobetoldbytheirdoctorsthatthey

couldnotgetholdofit(Ryan,1992:359).Author,George

Orwell,wasanotableexceptioninthathewasabletouse

hisconnectionstoobtainstreptomycinin1948/49(Holme,

1997).

The official chemotherapy era did not arrive until

the discovery of isoniazid in 1952. Professor Sir John

Croftonspioneeringworkinthe1950sdemonstratedthat

TB drugs used in combination brought more successful

outcomes.Treatment,therefore,consistedofstreptomycinby

intramuscularinjectionfor3 monthsandpara-aminosalicyclic

acid(PAS)andisoniazid orallyfor 1824 months (Medical

ResearchCouncil,1955;Davies,1999).

AsTB predominantlyaffected youngermen andwomen

ofworkingage,Europeangovernmentsbecameincreasingly

awareoftheeconomicimpact(Bryder,1988).Hardy(2003)

suggeststhat there was a post-war effortto controlTBby

ensuring that those with infectious disease were removed

from the community. Efforts were re-doubled to admitpatients to institutional settings such asTB hospitals and

sanatoria.However,evenafterthecreationoftheNHSin

1948,therewereinsufficientbedstomeetthedemand.In

December 1948, the Minister of Health, Aneurin Bevan,

concededthatsanatoriaadmissionwaitinglistswereseveral

monthslongandthatthiswasowingtoashortageoftrained

nursingstaff(Hansard,1948).

The nineteenth century German physician, Hermann

Brehmer, acknowledged to be the founding father ofTB

sanatoria, believedthat rest, appropriateexercise and good

nutritioncouldstrengthentheheart,improvethecirculation

and, therefore, heal the lungs (Warren, 2006). After 1859,

when Brehmer opened the first sanatoria in Germany,sanatoriasprangupalloverEuropeandNorthAmerica.The

BromptonHospitalSanatoriumat Frimley, perhaps oneof

themostfamoussanatoriainEngland,openeditsdoorsto

TBpatientsin1905(Bignall,1979).

ThemainstayofTBtreatmentinsanatoriawas,therefore,

a daily regimen of care based on improved dietary intake,

exposure to fresh air andsunshine, mental tranquillity, rest

andgradedexercise(Teller,1988).Suchtherapiesbecamea

thoroughlyestablishedritualinsanatoria(DuarteandLpez,

2009) and often formed the backdrop for many literary

works includingThomas Manns famous novel, The Magic

Mountain,andRichardYatessshortstory,No Pain Whatsoever.

Later in the nineteenth century, rest regimens were

supplemented with lung collapse procedures. Originallyinitiated by the Italian physician Carlo Forlanini in 1888,

collapse procedures sought to rest the diseased part of

the lung, thereby promoting closure of the tuberculous

cavities and healing by scar formation (Morlock, 1931).

Themostcommonprocedureinsanatoriainvolvedcreating

an artificial pneumothorax. Some of the other collapse

procedures used to treatTB were phrenic nerve cutting/

crushing, pneumoperitoneum, plombage and thoracoplasty

(Bignall,1979;Mehtaetal,2010).Collapseprocedureswere

notwithoutriskto patients.Whilesomepatientsmayhave

benefited, the evidence base for these interventions was

limited. Moreover, there wasalackof studiesto rigorously

testthelongertermbenefitstopatients(Pesanti,1995).

Historically,nurseshaveplayedasignificantroleinthecare

ofTBpatientsandthepreventionofthespreadofTB.Kirby

(2010) suggests that the value of the nursing contribution

in sanatoria has not always been recognised. Kirby argues

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thatsanatorianursesdemonstratedablendoftechnicaland

emotionalskillsthatenabledthemtodeliverindividualisedcare wherever possible, even if this meant their collusion

with patients to break sanatoria rules. Despite working in

hostileconditions,sanatorianursesoftenmadethepatients

stay bearable(Kirbyand Madsen, 2009). Box 1 summarises

someofthekeynursingskillsrequiredofnursesworkingin

sanatoria.

For patients beingcared for athome,TB health visitors

ordistrictnursesoftenvisited.Theirmainrolewastogive

adviceaboutinfectioncontrolinthehomesetting,toreduce

transmissionofdiseasetoothersandtosupportthepatient.

With the advent of chemotherapy, this role extended to

ensuring adherence to the treatment plan (Davies, 1999).

District nurses were also instrumental in ensuring that

patientsreceivedtheirstreptomycininjections(Hunt,2012).Although the modern treatment ofTB began with the

discovery of isoniazid, further breakthrough did not arrive

until the discovery of rifampicin in 1965. It then became

possibletoshortenTBtreatmentto6 monthsin mostcases

(Nuermbergeretal,2010).Bythe1970s,themodernshort-

courseTBtherapycameintoroutineuseinthedeveloped

world (Yew and Leung, 2005). Box 2 shows the current

standardTBtreatmentregimen.

The advent of curative treatment saw the demise of

sanatoria,surgeryforTBwasrarelyneededand,forthemost

part,TBcouldbetreatedathome(Davies,1999).Sincethe

1970s, TB has been a fully curable illness using standard

treatmentregimensexceptinthecaseofMDR-TBwhenthe

outcomeis lesscertain. Evidence-basedguidelinesfromthe

NationalInstituteforHealthandClinicalExcellence(NICE)

(2011)areavailabletoguidebestpracticeinthetreatment,

preventionandcontrolofTBandcliniciansarenowableto

access evidence-basedTB care pathways in a user-friendly

format(NICE,2012b).

Inthemodernera,hospitalnursesarelikelytoencounter

TBpatientslessfrequentlyandforshorterperiodsoftime.

Whilelessthan40%ofpatientshavetheirTBdiagnosedas

hospital inpatients (HPA, 2011d), the majority ofTB care

nowtakesplaceinthehomesetting.Inmostareas,individuals

willattendoutpatientclinicsforregularreviewthroughouttheir treatment with care case-managed at home byTB

specialistnurses.

The context of contemporary care and treatmentThenextpartofthisarticleaddressesthecontextinwhich

contemporaryTBcareandtreatmenttakesplaceintheUK.

Relevantcontextualfactorsincludemulticulturalism,poverty

andstigmatisation.

Unlike their counterparts in 1948, modern nurses in

urban areas work with patients from a wide variety of

ethnicities and cultures. AsTB predominantly affects those

bornoverseas,itisimportantthatnursingcareandtreatment

takes account of an individual patients health and socialbeliefs.Thechallengefornursesinamulticulturalsocietyisto

striveforculturallycompetentpractice.Culturalcompetence

isamoremodernconceptthatrequirespractitionersnotonly

to be culturally awareand sensitive butto have the ability

and willingness to recognise and challenge discriminatory

practices(Papadopoulosetal,1998).

Similar to their counterparts in 1948, modern nurses

workwithpatientslivinginpoverty.In1948,andthepre-

chemotherapyeraingeneral,TBpatientsoftenexperienced

poor housing, lack of sanitation, overcrowding and harsh

workingconditions(WeissandAddington,1998).Ashousing,

working conditions and public health measures improved,

the numbers ofTB cases fell (Fairchild and Oppenheimer,

1998). Today, those living in poverty continue to bedisproportionatelyaffectedbyTB.Thosefrompoorersocio-

economic groups and marginalised communities areat the

highest risk (Siddiqiet al, 2001). Indeed,TBis increasingly

beingconfinedtoindividualswithoneormoresocialrisk

factors or behaviours.Therefore, those considered to be at

the highest risk include some migrants, those engaging in

alcoholand/ordrugmisuse,thehomelessorthoseinprison.

Box 1: Some of the care skills of the TBsanatoria nursesPhysical

n Personal care assistance for patients on bed rest, especially

after collapse procedures

n Expertise in assisting in technical procedures and post-

operative care of the patient including wound management

n Terminal care for dying patients

n Prevention of infection/hygiene advice to patients and families

n Administering TB drugs including streptomycin by

intramuscular injection

Psychological

n Communicating with patients with empathy

n Dealing with loss and bereavement

Social

n Measures to relieve patient boredom, including supporting

hobbies and interests

n Advice following discharge home taking account of stigma

attached to TB

Box 2: Standard recommended regimenfor respiratory tuberculosis(with drug discovery dates)Six-month course consisting of:

n Two months rifampicin (1965), isoniazid (1952),

pyrazinamide (1970) and ethambutol (1968)

n Further four months rifampicin and isoniazid

Source: National Institute for Health and Clinical Excellence, 2011; Yewand Leung, 2005

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Collectively, these individuals have been described as being

fromhard-to-reachgroups(HPA,2011d;Abubakaretal,2012).

TB nurses commonly deal with housing and welfare

benefits issues on behalf of patients. Many patients are

homeless,inpooraccommodation,haveinsufficientfoodand

areoftenunabletoaffordthefaresto/fromhospital.Although

NICE(2012a)hassuggestedtheuseoffinancialincentivesto

assistpatientsinadheringtotheirtreatmentplan,therearenoallocatedbudgetstofacilitatethisinpractice.Worsestill,

thereis evidenceto suggest thatsocialinequalities andthe

gapbetweenrichandpoorintheUKarewidening(National

EqualityPanel,2010).

Likenursesin1948,modernnursesalsohavetoworkwith

patientswhofeelstigmatisedbyaTBdiagnosis.Althoughthe

causesarecomplex,theconsequencesmaybesignificantasit

mayhinderaccesstoappropriateservicesbecauseindividuals

arelesslikelytobediagnosedpromptlyandtocompletetheir

treatment(CourtwrightandTurner,2010).Althoughstigma

seemstobeuniversal,itmaybeperceivedandexperienced

differentlyacrosscultures(WeissandRamakrishna,2004).

Modern TB nurses also encounter patients who areexperiencingadouble-stigmaasaresultofbeingco-infected

withTB and HIV. In 2008 co-infection was estimated to

be around 7% in the UK, although the precise number

of co-infected individuals is not known (HPA, 2010).

Co-infected individuals, especially women, are reported to

feelmorevulnerabletogreaterstigmatisation(Deribewetal,

2010;Daftary,2012).

Managing TB in hard-to-reach groupsIthasbeenknownforsomeyearsthatifTBratesaretobe

reversedintheUK,measuresneedtobetargetedatthoseat

highest risk (Anderson et al, 2007).The recentlypublished

NICE(2012a)guideline,Identifying and Managing Tuberculosis

Among Hard-to-Reach Groups,setsout16 recommendationstoachievebettertreatmentandpreventionandareductionof

TBtransmissioninthegeneralpopulation.

Thefollowingrecommendationsare,intheauthorsview,

crucialtoachievingthestatedobjectives.

Commissioning multidisciplinary TB supportfor hard-to-reach groupsAs we have seen from the pre-chemotherapy era, the

management ofTB has always required a multidisciplinary

approach. In recent years, the nursing contribution has

been increasingly recognised as integral to the work of

the multidisciplinary team (Bothamley et al, 2011). TB

nurseshaveforsometimeactedascasemanagersinrespect

of patients on their caseload. However, there is renewed

emphasisonenhancedcasemanagementinsituationswhere

thepatientsneedsareparticularlycomplex(RoyalCollegeof

Nursing,2012).Asenhancedcasemanagementdrawsupon

awiderrangeofnursingskills,ithasbeensuggestedthatthe

numberofpatientsonthecaseloadberestrictedto20as

opposedtothesuggestednumberof40(NICE,2012a).As

laudable as these aims are, the prospect of achieving this

nurse/patientratioconsistentlyacrossthecountrydoesnot

lookpromisinginthecurrentpoliticalandeconomicclimate.

Identifying active pulmonary TB among thoseusing homeless or substance misuse servicesContact investigation, aimed at detecting new cases and

preventing future cases has long been a part of TB and

prevention control programmes (Abubakar et al, 2012).

Nurses have played a central role in active case-finding.

This recommendation suggests that there is a need for

active case-finding using mobile digital radiography in

appropriate settings where homeless people and substance

misusers congregate.The idea is, of course, not new. Mass

miniature radiography (MMR) was used very successfully

for the detection of TB in the general UK population

betweenthe1940sand1960s(Hollandetal,2006).Sincethe

disbanding of MMR, very few programmes have been setup.OneexceptionistheLondonFindandTreatprogramme,

involvingtheuseofmobiledigitalradiography.Thisnurse-

ledmultidisciplinaryprojecthasevaluatedwellandhasbeen

foundtobecosteffective(Jitetal,2011).Thereare,however,

reportsinthepressthattheongoingfundingofthisproject

maybeunderthreat(Jack,2010).

Identifying and managing active and latent TB:vulnerable migrantsThere isevidence tosuggest that many migrants are from

deprived communities (Siddiqi et al, 2001) and some will

bevulnerableasaresultoflanguagebarriers(NICE,2012a).

Whilethereisevidencethattargetedscreeningofindividuals

fromhigherincidenceTBcountriesisparticularlyeffectivein identifying latent TB, there is considerable deviation

fromexistingnationalguidance(Pareeketal,2011).Nurses

are involved with migrant screening initiatives around the

countrybutthereisalackofconsistencyofservices,largely

owingtolackoffunding.

Rapid-access TB servicesAnimportant part ofTB controlis ensuring timely access

tohealthservices.Promptdiagnosisis,therefore,imperative.

In 1948, Stradling highlighted that GPs often delayed or

failed to refer their patients with suspectedTB (Stradling,

1948).ThereisevidencetosuggestthatmanyGPsstillhave

a low threshold for suspecting aTB diagnosis resulting in

delays and/or adverse outcomes for patients (Griffiths and

Martineau,2007).TheeducationroleofTBspecialistnurses

isanimportantadditionbutmoreneedstobedonetoensure

thatall GPs (and otherprimary care professionals)havean

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awarenessof thesymptomsthatmaysuggestaTBdiagnosis

and to undertake appropriate early investigations and/or

promptreferrals(LondonHealthProgrammes,2011).

Accommodation during treatmentInthesamewaythatsanatorianursesoncedid,TBspecialist

nurses regardensuring successful patient concordancewith

prescribedTB treatment as a core role. It is integral toachieving a cure and protecting public health. A goal of

achieving 85% completion rates has been set out in the

ChiefMedicalOfficersTBActionPlan(Donaldson,2004).

Thisisparticularlydifficulttoachieveinrespectofthemany

TBcasesinhard-to-reachgroups.Directlyobservedtherapy

(DOT)isonestrategythatmaybeusedtofacilitatesuccessful

completion of treatment and toprevent thepatient being

losttofollowup.However,providingDOTforanincreasing

numberofpatientsisstretchingcurrentresourcestothelimit.

ItisnotclearhowmanypatientsrequireDOTannuallybutit

islikelytoexceedthe11%ofcasesin2010highlightedbythe

HPA(2011d).DespitetheuseofDOT,anumberofpatients

stillfailtocompleteafullcourseofTBtreatment.Formanypatients,takingtheirTBtreatmentisnotahigh

priorityastheystrugglewithobtainingthebasicsofshelter

and food for their survival. The closure of sanatoria has

meantthatthereisnowhereforpatientstogoiftheyneed

inpatientcareandsupporttocompletetheirTBtreatment.

Whileitistruetosaythatthequestionofwhethersanatoria

were successful or not remains controversial (McFarlane,

1989;Condrau,2010),manyarguethattheirclosurewasa

bigmistake.TheRoyalCollegeofPhysiciansofEdinburgh,

forexample,suggeststhatwhatevertheirdeficiencies,these

institutionsat leastprovidedthedisciplineforadministering

regularly andmeticulously whatever therapywas on offer

(Holme,1997:31).

Intheauthorsview,therewasmuchtocommendsanatoriacare with the emphasis on fresh air, rest, exercise, good

nutrition andpsychologicalsupport.Thereis a compelling

argument for the reinstatement of similar facilities for the

management ofTB among the homeless and those from

other hard-to-reach groups. For an increasing number of

complexcases,theavailabilityofappropriateaccommodation

maybethekeyfactorindeterminingwhetherasuccessful

cureisachievedornot.

Conclusion

In the period since 1948, TB in the UK has shifted

from being an illness that frequently resulted in death to

one that is mostly curable. Although there have been a

number ofdevelopments innursing care over thepast six

decades, remarkable similarities remain. Like their 1948

counterparts, modernnurses areengaged in implementing

appropriate infection control measures aimed at reducing

diseasetransmission,promotingpatientconcordancewithTB

medications, educationaboutTBtreatmentandprevention,

aswell as supportingpatients commonlyexperiencing fear

and stigmatisation.There is alsomuch tobe learned from

the pre-chemotherapy era.While sanatoria have been the

subject of criticism, their demise has left a major gap in

serviceprovision,especiallyforthehomelessandotherswhoneedaccesstoaccommodation,careandsupporttofacilitate

successfulcompletionoftheirtreatment.

It has been clear for some time thatTB is increasingly

affecting those predominantly from hard-to-reach groups

suggesting a direct link with poverty and widening social

inequalities. Nevertheless, national recommendations to

overhaulTB control andprevention and tomitigate some

of the effects of povertyhave been in the public domain

for a number of years. Unfortunately, many of the key

recommendationshave not been implemented and funded

consistently across the UK. The present lack of funding

is reminiscent of the failure of health services to provide

inpatientTBcareandtreatmenttoallofthosewhoneededthem in 1948.To that extent,TB remains theCinderella

servicethatithasalwaysbeen.

TheGovernmenthasarguedthatthenewNHSreforms

focuson the needs of patients aswell as empower health

professionals (DH, 2010).The acid test for the success of

thesereformsiswhethertheservicesandmeasuresneeded

tosignificantlyreducetheincidenceofTBarecommissioned

and appropriately funded consistently across the UK.The

early signs arenotgood.ThemuchpublicisedPan-London

TB Plan (London Health Programmes, 2011), which had

beenscheduledtolaunchinApril2012,hasbeenderailedby

thecurrentNHSreorganisation.

Nurses have historically contributed greatly to TB

treatment, control andprevention in theUK.There is noreasontobelievethatthiswillchange.Contemporarynurses

do,however,haveanopportunitytodemonstrateleadership

byensuringthatTBisaccordedthepriorityitdeservesfrom

NHSservicecommissioners.The2012OlympicGamesmay

drawattentiontotherelativelyhighratesofurbanTBwhile

themediaspotlightisonLondon.However,whetherornot

thisultimatelyleadstoprogressinthe reconfiguredNHSis

anotherquestionentirely. BJN

Conflict of interest: none.

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Key POinTS

nModern treatment has rendered TB a largely curable illness

n TB is increasingly affecting those from hard-to-reach groups

n There is much to be learned from the pre-chemotherapy era

in the contemporary management and prevention of TB

n Increased funding and political commitment is required

to implement existing national TB management, control

and prevention guidelines consistently across the country

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