This ‘Commentary’ article published early online in the Lancet looks at the rising rates of tuberculosis (TB; the so-called ‘white plague’) in Britain, with an almost 50% increase in cases in London since 1999.

The death toll from TB began to fall in London at the start of the 20th century, as living standards improved; subsequent control of the disease was achieved by the introduction of antituberculosis drugs in the 1960s, improved health services, and BCG vaccination. By the early 1980s, TB was considered to be conquered in the UK and National Health Service (NHS) tuberculosis services were scaled down considerably. 

Travel and migration has allowed TB to resurface as a public health problem in all European countries.  In the UK there were over 14.6 cases of TB reported per 100,000 population in 2009; it is the only European country in which incidence rates continue to rise.  In London TB has returned ‘in force’ with 3450 cases diagnosed in 2009 (almost 40% of all UK cases), compared to 2309 in 1999.  This is likely to be an underestimate as sputum microscopy and culture only detects up to 70% of active cases.  Drug-resistant TB is also becoming a problem in the capital, with 172 isoniazid-resistant cases and a further 58 multi-drug resistant cases reported in 2009. 

In Britain, as in all European countries, the disease is mainly concentrated in high-risk groups such as migrants, refugees, homeless people, drug users, prisoners and people infected with HIV.  Although the increase in cases has largely been seen in non-UK born groups, the majority of these had lived in Britain for at least two years, indicating the disease is not being imported.  Poor housing, inadequate ventilation, and overcrowding are thought to be responsible for the higher incidence rates in certain London boroughs.

The authors note that a recent London TB service review assessment has made important recommendations, which (if implemented) will allow standardisation of clinical policy and practice and improve responsiveness.  They comment that “an immediate and serious long-term political and financial commitment is needed from the UK Government through the NHS if the tide is to be turned against the return of the white plague in London, and if tuberculosis is to be controlled. Such measures will erase London's reputation as the tuberculosis capital of Europe.”