ONE HEALTH PRACTICE TO

STUDY THE EPIDEMIOLOGY AND

CONTROL OF TUBERCULOSIS

MURALIKRISHNA.P
PG SCHOLAR
DEPARTMENT OF VETERINARY PUBLIC HEALTH
ONE HEALTH PRACTICE TO STUDY THE EPIDEMIOLOGY AND
CONTROL OF TUBERCULOSIS

INTRODUCTION

Tuberculosis (TB) is one of the major public health threats, competing with the human
immunodeficiency virus (HIV) as the cause of death due to infectious diseases worldwide.
TB is a poverty-related disease which disproportionately affects the poorest, the most
vulnerable and susceptible population groups wherever it occurs. Improving access to
diagnosis and care, the basic requirements in the fight against TB, are particularly
challenging in these persons. Besides, TB control cannot be carried out without a proper
surveillance system in order to define the course of the epidemic and assess the impact of
control measures on the disease. Hence, TB national programs must devote significant
resources to the disease-specific recording and reporting system. Most control programs for
bovine tuberculosis include reporting to both veterinary and public health authorities, and
measures to prevent transmission from animals to humans. On the other hand, reporting of
human cases to veterinary authorities is rare, unless an animal source is suspected.
Exchange of data and strategic discussions between veterinary and public health authorities
would strengthen tuberculosis surveillance in both animal and human populations. A One
Health approach is clearly warranted for tuberculosis. The disease has similarly serious
consequences for humans and a broad range of animal species, and it has been strongly
advocated as a One Health issue. Yet, tuberculosis cases in humans and animals are
commonly treated as separate problems. Tuberculosis is caused by bacteria within the
Mycobacterium tuberculosis complex (MTBC). “Bovine tuberculosis” usually means
infection in cattle with Mycobacterium bovis. However, this definition may be too restrictive,
and the term bovine tuberculosis has been proposed to signify infection in cattle with any
bacteria in the MTBC. Similarly, “human tuberculosis” usually refers to infection in humans
with M. tuberculosis, while “zoonotic tuberculosis” refers to human infection with M. bovis.
However, for control and monitoring purposes, as well as a One Health approach, it would be
preferable to use the terms “human tuberculosis” and “bovine tuberculosis” for infection with
all bacteria within the MTBC in humans and cattle, respectively. Routine surveillance
systems represent the best method for drug resistance assessment and monitoring, though
high-quality data can be generated only by the allocation of significant resources. The
increasing number of detected multidrug-resistant forms is among the current most
frightening issues, requiring a strong and comprehensive commitment in terms of funds
allocation, research promotion and field implementation of new tools and protocols.

EPIDEMIOLOGICAL STUDY OF TUBERCULOSIS AS ONE HEALTH

APPROACH

Epidemiological study of TB as one health study is highly essential as the disease is highly
zoonotic and is not reported properly as for example human TB is not reported to Veterinary
specialist who should be aware of person who has TB and should know the causative agent
and control measures. Infection by M. bovis has been reported in a wide range of
domesticated and wild animals. Although not as frequent a cause as M. tuberculosis, a
substantial number of humans with tuberculosis are infected with M. bovis. The prevalence of
M. bovis in human tuberculosis is generally higher in low-income regions with a high
prevalence in cattle. However, it has been proposed that the global prevalence of M. bovis in
humans is underestimated. In the absence of immunosuppression, human-to-human
transmission of M. bovis is rare but has been observed. Mycobacterium caprae, previously
regarded as a caprine subtype of M. bovis, has also been identified as the causative agent of
tuberculosis in domestic and wild animals, as well as humans. Mycobacterium tuberculosis is
most commonly isolated from people, but in regions with a high prevalence in the human
population, the infection may spill over to animals. Most animal isolates of M. tuberculosis
originate from cattle, pigs, dogs, and Indian elephants, but the infection has also been
demonstrated in captive and free-living wildlife. Molecular epidemiology has demonstrated
transmission between humans and animals, in both directions. Other MTBC species, such as
Mycobacterium microti, Mycobacterium pinnipedii, and Mycobacterium africanum, have
also been isolated from various host species. Infectious dose and route of infection are
important factors for the pathogenesis of the disease in individual hosts. Consequently,
population dynamics, spatial distribution, contact patterns, and population sizes influence
disease epidemiology. Efforts to categorize host species as “maintenance hosts” and “spill
over hosts” are sometimes contradictory, probably due to the fact that the populations of
these species differ between regions and ecological systems. The maintenance population
may consist of one or several host species, depending on how the effective critical
community size is achieved in different ecosystems. Detailed data, sufficient to demonstrate
the epidemiology of different MTBC species in different host populations, are difficult to
obtain. The epidemiology of the infection differs regionally as well as within different
populations in the same region. A crucial aspect of epidemiological data collection is case
definition. A case of human tuberculosis may be a patient with a smear-positive sputum
sample, a tuberculin reactor, a patient from whom M. tuberculosis has been isolated, or a
patient with samples positive for any bacteria within the MTBC. Similarly, animal cases may
be defined as tuberculin reactors, animals with visible lesions post mortem, animals with
histological lesions indicative of tuberculosis, or individuals with samples yielding M. bovis
(or MTBC) in culture. Furthermore, the tuberculin test in animals may be performed as a
single or comparative test in the skin of the neck or in the caudal fold, and the interpretation
may be different in different situations (e.g., regarding all inconclusive reactions as positive,
if a higher test sensitivity is prioritized above specificity). Different case definitions may be
used for different purposes, and this must be taken into account when drawing conclusions
from data.

GLOBAL EPIDEMIOLOGY
According to the World Health Organization (WHO), about 8.6 million cases (8.3–9.0
million) were estimated to have occurred in 2012, approximately 2.9 of whom were in
women. Most cases are estimated to be in Asia and Africa (58% and 27% respectively), with
the highest incidence in India (range 2.0–2.4 million) and China (0.9 −1.1 million), together
accounting for 38% of the total number of cases.

The global TB incidence rate slowly declined from 1997 to 2001, with an increase in 2001.
Subsequently, a 1.3% per year average reduction rate has been observed since 2002, reaching
2.2% between 2010 and 2011. Twelve million (11–13 million) prevalent cases of TB were
estimated in 2012, corresponding to about 169 cases per 100 000 population. TB mortality
was estimated at 1.3 million deaths (1.0–1.6 million) in 2012, including 320 000 (300 000 –
340 000) HIV-associated cases. A 45% drop in TB mortality rate has been observed globally
since 1990.

ONE HEALTH APPROACH IN CONTROL OF TUBERCULOSIS

Overall approach to control zoonotic TB is essential due to its rate of spread and proper
surveillance system should be evolved in order to report disease in both human and animal
side. The primary reason for tuberculosis control in animals is to protect public health. As
cattle infected with members of the MTBC can shed the bacteria in milk, unpasteurized dairy
products represent a public health risk. In many parts of the world, milk is heat-treated, but
other dairy products may be made with raw milk. While pasteurization of all dairy products is
crucial, tuberculosis control in cattle and other animals remain important for human and
animal health. However, all stakeholders may not support disease control efforts, which are
perceived as too costly and cumbersome, and therefore, not justifiable, when milk is
pasteurized anyway. There may be a risk that the progress of tuberculosis control in animals,
in combination with pasteurization of milk, has made professionals in human and veterinary
medicine less aware, or even ignorant, of the fact that tuberculosis does not restrict itself to
one host population. A stronger collaboration between veterinary and public health is often
called for, and this call for collaboration must be repeated until taken for granted, and fully
implemented in surveillance and control activities. Many of the most heavily infected regions
in the world lack the resources and infrastructure needed to control tuberculosis in animals
and humans, while the epidemiology may be entirely different from what has been seen in
countries where the disease has been eradicated from the animal population. This presents
new challenges.

TUBERCULOSIS CONTROL- PAST AND FUTURE

After being neglected for two decades, in the early 1990s TB re-emerged in the global health
perspective due to outbreaks in high-income countries that promoted attention. Over the last
twenty years global strategies for TB control have been recommended for adoption and
adaptation in all countries. The first strategy DOTS, was launched in 1994–1995. It was
based on five key essential components of any sound response to TB:

1) Political commitment with increased and sustained financing

2) Case detection among people presenting with symptoms in clinics through quality-assured
bacteriology

3) Standardized and supervised treatment along with patient support

4) Effective drug supply and management system

5) A standard monitoring and evaluation system.

By adopting this strategy in as many as 180 countries, approximately 17 million patients were
started on effective treatment by 2003.

The launch of the first Global Plan to Stop TB 2001–2005 contributed to this achievement
by raising prominently the need to invest both domestically and internationally. The
establishment of the Global Fund in 2002, by favouring the access to international financing,
was an additional strong factor to strengthen national programmes.
In view of the need to accelerate efforts and reach the international targets set in the context
of the MDGs, in 2006 WHO launched an enhanced global strategy referred to as Stop TB
strategy. This new approach aimed to ensure universal access to high-quality health services
and patient-centred care for all individuals with TB, through additional efforts addressing the
challenges emerging in the new century. The principles of DOTS were incorporated as the
first component of the 2006 Stop-TB Strategy, together with five additional components:

1) Address TB/HIV, MDR-TB and the needs of vulnerable populations

2) Contribute to health system strengthening based on primary health care

3) Engage all care providers

4) Empower TB patients and encourage community engagement

5) Enable and promote research.

New Stop TB Strategy, the second Global Plan to Stop TB covered the period 2006–2015.
The scope of this plan was to address the MDG challenge and pursue the other international
targets in order to halve the 1990 TB prevalence and mortality rate by 2015 and eliminate
TB as a public health problem by 2050.

FUTURE PROSPECTIVES IN ONE HEALTH ASPECT:

The strategy stands on three pillars:

(1) Promote integrated patient-centred care and prevention

(2) Foster bold policies and supportive systems

(3) Encourage intensified research and innovation.

Crucially, the new strategy recognises fully the need for strong policies that go beyond those
of national programmes and engage the entire health system, such as rationalising the use of
medicines, ensuring their quality, establishing infection control measures etc. In addition, the
new strategy calls upon the institution of universal health coverage and social protection
schemes that facilitate access to care by poor people with TB while preventing catastrophic
expenditures due to their ill health.

Four principles underpin the three pillars:

1. Government stewardship and accountability

 2. Strong coalition with the civil society and communities

3. Protecting and promoting human rights, ethics and equity

4. Adaptation of the strategy and targets at country level with global collaboration.

The strategy is also designed to face the challenges of low-burden countries (namely, those
with an incidence below 10/100 000/year). In these countries TB tends to concentrate in
selected susceptible groups with limited transmission rates within the general population and
with most TB cases resulting from reactivation of latent TB infection (LTBI).

Among priorities in these countries, but also worldwide, a crucial importance was attributed
to the introduction and the routine application of new technologies for rapid detection of
drug-resistance and to the development of specific diagnostic algorithms, particularly useful
for high-risk patients and proper diagnosis procedures and treatment and culling policies in
animals should be enhanced.

CONCLUSIONS

A systematic collaboration between different professions and control systems, and a common
nomenclature clearly separating the name of the host species from the infecting bacterial
species are the first steps toward effective tuberculosis surveillance and control. We should
learn from history and not repeat the mistake of those who, upon Koch’s discovery of
different MTBC species, first assumed that bovine tuberculosis did not affect humans,
leading to the pasteurization of milk for calves long before it was applied to milk for human
consumption. The more careful attitude of some early scientists, proposing to omit the host
designation of the different bacterial species in order to anticipate assumptions that they are
limited to the host whose name they bear (32), should be remembered as we make scientific
progress. Understanding the complex ecosystem of the multi-host pathogens within the
MTBC is necessary for disease control. There is an urgent need for scientific advances in
order to meet the need for global tuberculosis control in all host populations, but this will
require a new thinking as regards the ecology of tuberculosis and a practical application of
the One Health concept.

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