The UN Millennium Development Goals aim to halt and begin to reverse the TB incidence by 2015, and to halve the TB prevalence and mortality rates between 1990 and 2015. To achieve these goals, the WHO set targets in 1991 to be met by 2000: detection of 70% of all new sputum smear-positive cases arising each year, and successful treatment of 85% of these new cases. When those targets were not met by 2000, the target year was changed to 2005.73 Since then, improvements have been made: in 2004, the global detection rate of new sputum smear-positive cases reached 53% and treatment success was at 82%.74 In many regions, TB incidence has stabilized or declined; global prevalence is falling at about 5% per year. Yet global TB incidence increased from 1990 through 2003, and there has been no significant fall in the mortality rate. Indeed, based on the larger global population, more people died from TB in 2003 than in 1990. These trends suggest that the global TB incidence will increase further in the next decade, fueled in great part by failures to control TB in Africa and, to a lesser extent, in Eastern Europe. To avoid that prophecy, much work will need to be done. It is clear that targeted therapies including antibiotics and vaccines will be crucial to the effort, and ongoing work to expand the armamentarium is to be commended. Yet it is equally clear that the mere existence of such therapies will not be sufficient. A reduction in the world TB burden will require an increased dedication of resources to address both sensitive and drug-resistant TB in a sustained manner, a willingness to expand access to HIV therapy widely, and a readiness to adapt global solutions to local needs and circumstances. A lesser commitment, as history has shown, is no commitment at all.
KJ Cummings, NIOSH, Division of Respiratory Disease Studies, 1095 Willowdale Rd, MS 2800, Morgantown, WV 26505