TB: the leading infectious killer of adults ... and the single biggest killer of young women.

Over 900 million women and girls are infected with tuberculosis (TB) worldwide, 1 million would have died and 2.5 million would have contracted the disease in 1998. The World Health Organization (WHO) estimates they would be mainly between the ages of 15 and 44, making TB the leading cause of death among women of reproductive age. "Wives, mothers and wage earners are being cut down in their prime and the world is not noticing", said Dr. Paul Dolin of WHO's Tuberculosis Programme. "Yet the ripple effect on families, communities and economies will be felt long after a woman has died."

This occurrence of the disease counters perceptions in wealthy countries where the disease is most commonly found in elderly men. In industrialized countries, one quarter of all TB cases occur in the over-65s, compared with only 10 per cent in developing countries of Africa, Asia and Latin America. In the developing world, TB is predominantly a disease of young adults: 60 per cent of all cases are young men and women of reproductive age. TB accounts for 9 per cent of deaths worldwide among women aged between 15 and 44, compared with war at 4 per cent, human immunodeficiency virus (HIV) at 3 per cent and heart disease at 3 per cent. Women of reproductive age are more susceptible to fall sick once infected with TB than men of the same age. Women in this age group are also at greater risk from HIV infection. As a result, in parts of Africa, young women with TB outnumber men with the disease.

But there's hope.

Among leading threats to women's health, TB may be the most affordably controlled. Gender and TB experts have since been working on an agenda for research into biological, epidemiological, social and cultural differences in the occurrence of TB in men and women and their access to the TB treatment strategy DOTS (directly observed treatment), recommended by WHO, by which patients are observed and monitored while taking their medication. Specific areas of focus are TB and pregnancy, diagnosis of TB in women, adherence to treatment and patient education. WHO recommends improved access to DOTS, and ensuring its delivery by health systems in ways that remove rather than reinforce inequities, protecting the vulnerable group.

The "treatment" - DOTS - combines five elements: political commitment; case detection through sputum smear microscopy; directly observed short-course treatment; regular drug supplies; and monitoring systems with evaluation treatment outcome for each and every patient. Today, six countries that account for over 50 per cent of the world's TB epidemic are in Asia. According to WHO estimates, 4.5 million of the 8 million new cases that occur each year are in India, China, Bangladesh, Pakistan, Indonesia and the Philippines.

WHO is concerned that the problem will be compounded by three factors: multi-drug resistant TB, HIV and the economic crisis in Asia. Surveys in selected sites in Asia show high levels of multi-drug resistant TB that cannot be treated with the most powerful anti-TB drugs. Furthermore, experts predict an increase in TB cases as a result of HIV which weakens the immune system, increasing TB transmission to both HIV-positive and HIV-negative people. By the end of the century, HIV will cause three quarters of a million new TB cases globally that would otherwise not have occurred.

There is also concern that a decline in the standard of living in the region could increase the spread of communicable diseases and in a climate of changing health sector priorities in which some disease programmes lose critical funding. One of the biggest problems is that the high-burden countries are not implementing effective control, which includes the failure to invest in good quality TB drugs.

Standardized, short-course chemotherapy is recommended by WHO as the most effective and affordable way to detect and cure infectious TB patients. Over 100 countries are now using DOTS. In the last three years, 1 million TB patients have been treated with DOTS. In some areas where such treatment has been introduced, death rates have been reduced fivefold to less than 5 per cent. In at least one Asian country, Thailand, the Government has taken the initiative in 1998 to increase coverage of the disease. It has committed to a five-year plan to ensure that every patient in Thailand has access to DOTS.