TUBERCULOSIS: Middle East

Editor’s Page
www.thelancet.com   Vol 380   December 2012 1
Tuberculosis in the Middle East
The history of tuberculosis is probably as old as the
human race. Stone age skeletons unearthed in Europe
had signs of tuberculosis lesions, and tuberculosis
of the spine has been found in Egyptian mummies
dating from the third millennium BC. A mummified
body from the second century BC discovered in
China was also found to be afflicted by pulmonary
tuberculosis.
In the mid-1990s, WHO declared tuberculosis
to be a global emergency. The seriousness of the
situation was made clear in 1996 with estimates
that one in every three of the world’s people was
infected with  Mycobacterium tuberculosis, that
8000000 people were newly infected every year, and
that tuberculosis was killing some 3000000 people
every year. WHO reported that in 2011 the disease
caused almost 8800000 new infections, and killed
1 100000 people worldwide.
Tuberculosis was once well controlled in many parts
of the world. The lowest-income groups suffer most
from the disease, and industrialisation and consequent
improvements in health standards in many countries
have contributed to decreased tuberculosis rates. In
the Middle East, the prevalence rate of the disease was
as low as 6·2 per 100 000 people in 2010 in the United
Arab Emirates; the rate was 277 per 100 000 people
in 1990 in Yemen, dropping to 71 per 100 000 people
in 2010. Similar  decreasing trends occurred in many
countries in the region except Kuwait, where the rate
per 100 000 people increased from 19 in 1990 to 51 in
2010. The observed rise in prevalence is most probably
attributed to screening and surveillance programmes
established in Kuwait. The prevalence has been stable
since 1990 in Saudi Arabia, at 23 per 100 000 people.
It seems that in many parts of the Middle East,
expatriate workers from countries with a high prevalence of tuberculosis contribute to the occurrence of
new cases. In Saudi Arabia, for example, the incidence
of tuberculosis among expatriates is double that for
Saudi nationals. In Oman, the predominant strains of
M tuberculosis are similar to those commonly found in
the Indian subcontinent. The prevalence of the disease
in Iran was 23 per 100 000 people in 2012. Pulmonary
tuberculosis is the most common form of the disease
in the region. A recent WHO report indicates that, in
Iran, almost 52% of patients are smear-positive, 15%
are smear-negative, and 29% present with extrapulmonary involvement.
Although many efforts have been made to combat
tuberculosis, the emergence of HIV/AIDS, a disease that
acts in concert with tuberculosis, has exacerbated the
global burden. Many people afflicted by tuberculosis
are nowadays ravaged with poverty and also live with
with AIDS. In Iran, 27% of patients with tuberculosis
are also HIV-positive. What makes the situation
worse is the emergence of multidrug-resistant isolates
of tuberculosis.
Multidrug-resistant  M tuberculosis refers to isolates
that are not susceptible to isoniazid and rifampicin.
A  research study from seven regions of Saudi Arabia
revealed that, of 1505 isolates, 4·5% were multidrugresistant. Rates in the United Arab Emirates and
Kuwait are 4% and 1%, respectively. The prevalence
is 3% among newly treated and 9·4% of previously
treated patients in Yemen. Of new patients diagnosed
with the disease in Iran, 5% have multidrug-resistant
tuberculosis. As Tracy Dalton and colleagues show in
this issue of The Lancet Middle East, the prevalence of
extensively drug-resistant tuberculosis is on the rise,
associated with the increased use of second-line drugs
in patients with multidrug-resistant tuberculosis.
The necessary infrastructure to control tuberculosis
should be established in the Middle East. Appropriate
policies should be developed in every country in the
region to ensure prevention, early diagnosis, and
rational use of antibiotics for treatment of tuberculosis. Implementation of active surveillance and
reporting systems are also of paramount importance.
Developing standard laboratories for molecular
characterisation of isolates would help us better
understand the epidemiology of the disease and the
spread of isolates in the region. Because expatriates
and refugees are responsible for most transmission
of tuberculosis in the Middle East, developing policies
to monitor these individuals would also help control
the infection.
Farrokh Habibzadeh
The Lancet Middle East Edition, NIOC Medical Education and
Research Centre, Shiraz, Iran