Tuberculosis as a major global health problem in the 21st century: a WHO perspective.

The World Health Organization, the Global Partnership to Stop TB, and the Millenium Development Project have all adopted the following 2005 targets for tuberculosis control: to detect at least 70% of all estimated sputum smear-positive cases and to treat successfully at least 85% of them. Although implementation of the DOTS strategy is the foundation for proper tuberculosis control, basic DOTS implementation may not be enough to reach these targets. Instead, evidence from several countries indicates that, although cure rates are approaching the global target, the case detection target may not be met, even with 100% DOTS implementation in designated public facilities. Thus, tuberculosis control must be critically examined to foster higher performance. In the context of an expanded framework for tuberculosis control, we present four strategic interventions through which cure and case detection rates may be significantly improved: (1) wider involvement of community workers, (2) engagement of private practitioners, (3) proper management of drug-resistant tuberculosis, and (4) efforts focused on controlling tuberculosis and human immunodeficiency virus. We conclude that, although country-based estimates need further refinement to ascertain the impact of each intervention, a fundamental shift in the approach to tuberculosis control is required if the global targets are to be reached rapidly.