Tuberculosis, caused by bacteria, usually affects the lung. Being airborne, TB has been one of the world’s deadliest communicable diseases. In spite of being curable and preventable, the disease has always been a continuous threat to human population. Moreover, there are cases of multidrug resistant, extremely drug resistant as well as HIV associated forms. Recognizing this grave threat, the World Health Organization urged every country to have a national program for tuberculosis prevention and control. After incidences of involuntary (...) detentions of people with suspected TB in some places, WHO also recommended that national TB prevention programs should incorporate ethical considerations in them. Specifically, it prescribed that human rights and social justice issues should be given due considerations. Studies suggest that India, following the international recommendations, has rolled down a national program to prevent and control TB cases in the country. However, neither is there much consideration of ethics in it, nor there is any pronounced effort to include social justice issues. The present paper investigates how the inclusion of elements from social justice theory can actually help India’s TB program to address the issue of equitable protection. Specifically, it shows how insights from JP Ruger’s ‘Health Capability Paradigm’ can help India’s TB strategies to render equitable protection by addressing health inequities. (shrink)

Tuberculosis is caused by bacillus Mycobacterium tuberculosis. In this study, a mathematical model of tuberculosis is analyzed. The numerical behaviour of the considered model is analyzed including basic reproduction number and stability. We applied three numerical techniques to this model, i.e., nonstandard finite difference scheme, Runge–Kutta method of order 4, and forward Euler scheme. NSFD scheme preserves all the essential properties of the model. Acquired results corroborate that NSFD scheme converges for each step size. While the other (...) two schemes failed to preserve some properties of the model such as positivity and convergence. A graphical comparison presented in this study confirms the numerical stability of the NSFD technique shown here is maintained over a large area. (shrink)

MDR-TB and admission to isolation can induce a situation in which individuals are normless, unable to achieve the social goals that they have learned to pursue. Described as anomie, this situation can induce deviant behaviour. Addressing the psychosocial ethics of MDR-TB and isolation, this paper responds to the call for consideration of resource allocation and liberty.

Tuberculosis (TB) is theTuberculosis (TB) second leading infectious cause of mortality worldwide and arguably the most important neglected topic in bioethics. This chapter: (1) explains the ethical importance of TB, (2) documents its neglect in bioethics discourse, (3) maps the terrain of ethical issues associated with TBTuberculosis (TB), and (4) advocates a moderate pluralistic approach to ethical issues associated with TB.

The stigmatisation of the gecekondu in post-1945 Turkey is a common theme in the literature. However, these studies have drawn little connection with health issues, even though these are known to be important in the mechanisms of stigmatisation. Policies for tuberculosis (TB) control—then Turkey's “number one health issue”—have tended to focus on individual and biological factors, to the detriment of social or environmental ones that could contribute to making TB a matter of politics and not only of policies. A (...) close study of the practices of the numerous TB-control actors nevertheless reveals an entanglement of the social, the environmental, and the medical questions. Through the emblematic but unknown case study of the TB-control pilot area created in Zeytinburnu in 1961, this article studies discourses, but also graphic representations, portraying the gecekondu as unhealthy, revealing an underlying environmental conception of TB among Turkish public health actors. The choice of Istanbul's biggest gecekondu neighbourhood to be a pilot area originated from a common conception of the gecekondu areas as pathogenic, but also contributed to reinforcing this vision and adding it to the very definition of the gecekondu. It thus participated in the stigmatisation of these areas and their inhabitants, even if some of the study's conclusions undermined the common vision of the gecekondu as populated by poor, rural migrants. However, the pilot project was also conceived as a way to integrate the inhabitants into the modern city. The “pilot” character of the area, if characteristic of the vocabulary of the 1960s, which were also the time of the attempt to “socialise the health services” in Turkey, is questionable. The project displayed a desire to know and control this specific territory rather than a genuine promotion of broader environmental changes to be replicated on a national scale. (shrink)

Tuberculosis (TB) is a potentially fatal infectious disease that, in Aotearoa New Zealand (NZ), inequitably affects Asian, Pacific, Middle Eastern, Latin American, and African (MELAA), and Māori people. Medical research involving genome sequencing of TB samples enables more nuanced understanding of disease strains and their transmission. This could inform highly specific health interventions. However, the collection and management of TB isolate samples for research are currently informed by monocultural biomedical models often lacking key ethical considerations. Drawing on a qualitative (...) kaupapa Māori–consistent study, this paper reports on preliminary discussions with groups of Māori, Pacific, and Afghan people in NZ, whose communities have been harmed by TB and TB stigma. Participants’ discussions highlight key concerns and meanings that ought to inform the development of guidelines and a more robust consultative process for the governance of how TB isolate samples are collected and used both retrospectively and in future research. We argue for ethical processes to be culturally nuanced and community-generated, flexible and meaningful, and situated in relation to the physical and symbolic effects of TB. We discuss the significance of Indigenous data sovereignty, rights, and kāwanatanga (governorship) in shaping a multicultural data sovereignty model. (shrink)

Prominent tuberculosis (TB) actors are invoking solidarity to motivate and justify collective action to address TB, including through intensified development and implementation (D&I) of technologies such as drugs and diagnostics. We characterize the ethical challenges associated with D&I of new TB technologies by drawing on stakeholder perspectives from 23 key informant interviews and we articulate the ethical implications of solidarity for TB technology D&I. The fundamental ethical issue facing TB technological D&I is a failure within and beyond the TB (...) community to stand in solidarity with persons with TB in addressing the complex sociopolitical contexts of technological D&I. The failure in solidarity relates to two further ethical challenges raised by respondents: skewed power dynamics that hinder D&I and uncertainties around weighing risks and benefits associated with new technologies. Respondents identified advocacy and participatory research practices as necessary to address such challenges and to motivate sustained collective action to accelerate toward TB elimination. We present the first empirical examination of bioethical accounts of solidarity in public and global health. Our study suggests that solidarity allows us better to understand and address the ethical challenges that arrest the D&I of new TB technologies. Solidarity lends credence to policies and practices that address the relational nature of illness and health through collective action. (shrink)

Bovine tuberculosis is the most important animal health and welfare policy issue in Britain. Badgers are a wildlife reservoir of disease, although the eight-year Independent Scientific Group Randomised Badger Culling Trial concluded with a recommendation against culling. The report advised government that bovine TB could be controlled, and ultimately eradicated, by cattle-based measures alone. Despite the ISG recommendation against culling, the farming and veterinary industries continued to lobby government for a badger cull. The 2005–2010 Labour government followed the ISG (...) advice and decided against a cull. The 2010–2015 Coalition and the 2015-present Conservative governments have followed a badger culling policy. This paper investigates whether a virtuous government would cull badgers. It provides an overview of virtue theory in the context of government animal health and welfare policy. Bovine TB and badger control policy options are then analysed in the context of the virtues of justice, wisdom, integrity, loyalty, curiosity, trust, empathy, compassion and aesthetics. Justice is the first virtue of government, and badger culling is seriously problematic from a virtue perspective given that five badgers are culled per cow that avoids slaughter as a result. Analysis based on other virtues strongly suggests that government should not cull badgers. The paper concludes that a virtuous government would not cull badgers as part of policy to control bovine TB in cattle. (shrink)

Bovine tuberculosis is the most economically important animal health policy issue in Britain. The problem of what to do about badgers has plagued successive governments since a dead badger was discovered with bovine TB in 1971. Successive Labour governments oversaw the Randomised Badger Culling Trial from 1998 to 2006. Despite the RBCT recommendation against culling, the 2010–2015 Coalition government implemented pilot badger culls. This paper provides an account of the evolution of bovine TB and badger control policy, focusing on (...) the 1997–2010 Labour, the 2010–2015 Coalition and the 2015-present Conservative governments. Interviews with bovine TB policy stakeholders supplement discussion of the development of bovine TB policy. The paper discusses the science and politics of bovine TB policy, in which there are different badger control policies in Westminster, Welsh and Scottish governments. Badger control is a highly polarised issue, and the Coalition and Conservative governments have been heavily criticised for a culling policy opposed by the independent scientific community. Recent governments have defended badger culling on the basis of veterinary advice and experience in countries such as New Zealand. The paper concludes with two key recommendations to inform controversial animal health and welfare policy issues such as bovine TB. First, mandatory Animal Welfare Impact Assessment provides objective data on the impacts of policy options on cows and badgers. Second, robust ethical analysis, conducted by independent experts using established moral frameworks, should be applied to animal health and welfare issues for the benefit of decision makers. (shrink)

Tuberculosis (TB) is one of the world’s leading causes of death due to infection and efforts to control TB would be substantially aided by the availability of an improved TB vaccine. There are currently nine new TB vaccines in clinical development, and the first efficacy trials are due to commence in 2009. There are many complex ethical issues which arise at all stages of TB vaccine development, from the need to conduct trials in developing countries to informed consent and (...) the process of ethical review. While it is important that these issues are discussed, it may also be timely to consider the challenges which may arise if a vaccine in clinical development proves to be highly effective. We examine a number of scenarios where decisions on the deployment of a new TB vaccine may impact on the rights and liberty of the individual. (shrink)

We extend recent conversation about the ethics of human challenge trials to tuberculosis (TB). TB challenge studies could accelerate vaccine development, but ethical concerns regarding risks to trial participants and third parties have been a limiting factor. We analyse the expected social value and risks of different challenge models, concluding that if a TB challenge trial has between a 10% and a 50% chance of leading to the authorisation and near-universal delivery of a more effective vaccine 3–5 years earlier, (...) then the trial would save between 26 400 and 1 100 000 lives over the next 10 years. We also identify five important ethical considerations that differentiate TB from recent human challenge trials: an exceptionally high disease burden with no highly effective vaccine; heightened third party risk following the trial, and, partly for that reason, uniquely stringent biosafety requirements for the trial; risks associated with best available TB treatments; and difficulties with TB disease detection. We argue that there is good reason to consider conducting challenge trials with attenuated strains like Bacillus Calmette-Guérin or attenuatedMycobacterium tuberculosis. (shrink)

Bovine tuberculosis is an important animal health policy issue in Britain, which impacts farmers, the public, domestic farmed cattle and the wild badger population. The Westminster government’s badger culling policy in England, which began in 2013, has caused considerable controversy. This is in part because the Independent Scientific Group advised against culling, based on the Randomised Badger Culling Trial. Those opposed to badger culling support more stringent cattle-based measures and the vaccination of badgers. This paper argues for ethical analysis (...) of public policy options which impact sentient species. It provides a summary Animal Welfare Impact Assessment of a do-nothing approach, badger culling, and badger vaccination. A utilitarian analysis is then applied to these policy options considering human wellbeing and animal welfare. The analysis compares a badger culling policy that achieves a 19% reduction in bovine TB incidence, a badger vaccination model achieving a 12.5% reduction, and a do-nothing approach. Policy options are assessed over 9 years and a longer timeframe, and uncertainty is considered. The analysis finds that non-culling approaches, particularly badger vaccination, result in greater total utility, compared to badger culling. Badger culling causes 30% reduction in the badger population in England as well as substantial harms due to the culling process. Culling is opposed by public opinion and is associated with considerable risks and uncertainty. In contrast, non-culling approaches, such as cattle-based measures and badger vaccination, are supported by public opinion and are not associated with such risks. (shrink)

Bovine tuberculosis is an important and controversial animal health policy issue in England, which impacts humans, cattle and badgers. The government policy of badger culling has led to widespread opposition, in part due to the conclusions of a large field trial recommending against culling, and in part because badgers are a cherished wildlife species. Animal rights theorists argue that sentient nonhumans should be accorded fundamental rights against killing and suffering. In bovine TB policy, however, pro-culling actors claim that badgers (...) must be culled to avoid the slaughter of cattle. The first part of the paper compares AR theories of Regan, Francione, Cochrane, Garner and Donaldson and Kymlicka in the context of wildlife species. The second part of the paper applies these AR theories to bovine TB and badger control. AR theories are applied to badger control policy options of do nothing, badger culling, and badger vaccination. We conclude that AR theories are strongly opposed to badger culling. In general, culling is prohibited due to a badger’s right to life and its rights against suffering. The AR theories support a do-nothing, i.e. non-culling, non-vaccination approach to badger control. In the case of the AR theories of Regan and Francione, this is based on abolitionist positions with respect to farming. For Cochrane, Garner, and Donaldson and Kymlicka, the do-nothing policy option is preferred because badger vaccination causes a degree of suffering which generally is not for the individual’s benefit. (shrink)

From the mid nineteenth to mid twentieth century sanatoria loomed large in the popular consciousness as the space for the treatment of tuberculosis (TB). A review of the historiography of sanatoria at the beginning of this paper shows that the nursing contribution to the care of TB patients is at best ignored and at worst attracts negative comment. Added to this TB nursing was not viewed as prestigious by contemporaries, leading to problems attracting recruits. Using a case study approach (...) based on surviving archival material, this paper sets out to provide a glimpse of the work of TB nurses in a rural sanatorium at Westwood, Queensland, Australia. For the nurses geographical isolation was compounded by professional stagnation, which created a working environment influenced by friction and discord among the staff. It reveals how despite this, nurses coped with working in hostile conditions, to make the long stay of their patients, separated from their families and familiar life style more bearable. (shrink)

CAPPE LPO Box 8260 ANU Canberra ACT 2601 Australia Tel: +61 (0)2 6125 4355, Fax: +61 (0)2 6125 6579; Email: michael.selgelid{at}anu.edu.au ' + u + '@' + d + ' '//--> Abstract This article reviews ethically relevant history of tuberculosis and recent developments regarding extensively drug resistant tuberculosis (XDR-TB). It argues that tuberculosis is one of the most important neglected topics in bioethics. With an emphasis on XDR-TB, it examines a range of the more challenging ethical issues (...) associated with tuberculosis: individual obligations to avoid infecting others, coercive social distancing measures, third-party notification, health workers' duty to treat contagious patients, and international justice. In each of these cases, key philosophical questions are highlighted and the need for empirical research/information is demonstrated. CiteULike Connotea Del.icio.us What's this? (shrink)

Reconstructing some of the experiences of people living with tuberculosis in Argentina in the first half of the twentieth century, as reflected not only in written and oral accounts but also in individual and collective actions, this article explores the ways in which patients came to grips with medical expertise in times of biomedical uncertainty. These negotiations, which inevitably included adaptations as well as confrontations, highlight a much less passive and submissive patient–physician relationship than is often assumed. Though patients (...) were certainly subordinate to medical doctors’ knowledge and practices, that subordination, far from absolute, was limited and often overthrown. The article focuses on patients’ demands to gain access to a vaccine not approved by the medical establishment. By engaging with media organizations, the sick invoked their “right to health” in order to obtain access to experimental treatments when biomedicine was unable to deliver efficient therapies. (shrink)

This paper explores the notion of reciprocity in the context of active pulmonary and laryngeal tuberculosis treatment and related control policies and practices. We seek to do three things: First, we sketch the background to contemporary global TB care and suggest that poverty is a key feature when considering the treatment of TB patients. We use two examples from TB care to explore the role of reciprocity: isolation and the use of novel TB drugs. Second, we explore alternative means (...) of justifying the use of reciprocity through appeal to different moral and political theoretical traditions. We suggest that each theory can be used to provide reasons to take reciprocity seriously as an independent moral concept, despite any other differences. Third, we explore general meanings and uses of the concept of reciprocity, with the primary intention of demonstrating that it cannot be simply reduced to other more frequently invoked moral concepts such as beneficence or justice. We argue that reciprocity can function as a mid-level principle in public health, and generally, captures a core social obligation arising once an individual or group is burdened as a result of acting for the benefit of others. We conclude that while more needs to be explored in relation to the theoretical justification and application of reciprocity, sufficient arguments can be made for it to be taken more seriously as a key principle within public health ethics and bioethics more generally. (shrink)

During the mid-nineteenth century the annual tuberculosis mortality in the penitentiaries at Auburn, N.Y., Boston, and Philadelphia exceeded 10 percent of the inmate population. At the beginning of the sanatorium era, 80 percent of the prison deaths were attributed to TB. As the mountain air was “commonly known” to be healthful, the first prison sanatorium was opened in the mountains near Dannemora, N.Y. in 1904. It served to isolate contagious prison inmates until the advent of effective chemotherapy for the (...) disease in the 1950’s. Early antibiotic therapy for TB was such a great success that the public health aspects of TB in prisons remained dormant for the next 40 years.In 1991, a correctional officer from Auburn Correctional Facility in Auburn, New York died as a result of multidrug-resistant TB. He had been posted to care for hospitalized patients, from whom he acquired his disease. This death, and the transmission of TB infection to health care workers in the same hospital, brought the nature and extent of modern inmate medical care into finer focus. (shrink)

During the mid-nineteenth century the annual tuberculosis mortality in the penitentiaries at Auburn, N.Y., Boston, and Philadelphia exceeded 10 percent of the inmate population. At the beginning of the sanatorium era, 80 percent of the prison deaths were attributed to TB. As the mountain air was “commonly known” to be healthful, the first prison sanatorium was opened in the mountains near Dannemora, N.Y. in 1904. It served to isolate contagious prison inmates until the advent of effective chemotherapy for the (...) disease in the 1950’s. Early antibiotic therapy for TB was such a great success that the public health aspects of TB in prisons remained dormant for the next 40 years.In 1991, a correctional officer from Auburn Correctional Facility in Auburn, New York died as a result of multidrug-resistant TB. He had been posted to care for hospitalized patients, from whom he acquired his disease. This death, and the transmission of TB infection to health care workers in the same hospital, brought the nature and extent of modern inmate medical care into finer focus. (shrink)

ObjectiveTo identify the ethical challenges associated with the development and implementation of new tuberculosis drugs and diagnostics.MethodsTwenty-three semi-structured qualitative interviews conducted between December 2015 and September 2016 with programme administrators, healthcare workers, advocates, policymakers, and funders based in the Americas, Europe, and Africa. Interviews were analysed using thematic analysis.ResultsDivergent interests and responsibilities, coupled with power imbalances, are a primary source of ethical challenges; the uncertain risk profiles of new drugs present an additional one. Although this challenge can be partially (...) mitigated through stringent pharmacovigilance, respondents highlighted that high-burden countries tend to lack the resources to facilitate safe implementation. Increased advocacy and community engagement are considered an ethical imperative for future TB development and implementation.ConclusionsThis project helps identify some of the ethical challenges of new TB technologies. It demonstrates that investigating ethical challenges through qualitative research is one way to apprehend the difficulty of implementing new TB technologies. Addressing this difficulty will require that those in positions of power reconsider their interests in relation to disempowered communities.Policy implicationsEfforts to build consensus regarding what values should underpin the global governance of TB research, prevention, and care are essential to facilitate the ethical implementation of new TB technologies. (shrink)

BackgroundHuman biological materials are usually stored for possible future use in research because they preserve valuable biological information, save time and resources, which would have been spent on collection of fresh samples. However, use of these materials may pose ethical challenges such as unauthorized disclosure of genetic information, which can result in dire consequences for individuals or communities including discrimination, stigma, and psychological harm; has biosecurity implications; and loss of control or ownership of samples or data. To understand these problems (...) better, we evaluated the extent to which tuberculosis (TB) clinical research protocols that were used to collect and store biological materials for future use conform to the requirements stated in the Uganda national guidelines for research involving humans as participants.MethodsThis was a retrospective review of TB clinical research projects approved by the Uganda National Council for Science and Technology (UNCST) from 2011 to 2015, to examine whether they fulfilled the requirements for ethical collection and use of human materials. Data were abstracted through review of the project protocols using a template developed based on the informed consent and the Materials Transfer Agreement (MTA) requirements in the national guidelines.ResultsOut of 55 research protocols reviewed, most of the protocols 83.6% had been used to collect the stored samples (sputum, blood and sometimes urine), 28% had a section on specimen collection and 24% mentioned ownership of the biological materials. With respect to review of the consent forms used in the studies that stored materials for future use, only 9% of the protocols had a separate consent form for storage of materials, 4.5% of the consent forms explained the risks, 11.4% explained the purpose of the study while 6.8% mentioned the place of storage for the collected materials.ConclusionMany of the studies reviewed did not meet the requirements for collection and storage of biological materials contained in the national guidelines, which indicates a need to additional training on this topic. (shrink)

Indoleamine 2,3‐dioxygenase (IDO) is the rate‐limiting enzyme in conversion of tryptophan to kynurenines, feeding de novo nicotinamide synthesis. IDO orchestrates materno‐foetal tolerance, increasing human reproductive fitness. IDO mediates immune suppression through depletion of tryptophan required by T lymphocytes and other mechanisms. IDO is expressed by alternatively activated macrophages, suspected to play a key role in tuberculosis (TB) pathogenesis. Unlike its human host, Mycobacterium tuberculosis can synthesize tryptophan, suggesting possible benefit to the host from infection with the microbe. Intriguingly, (...) nicotinamide analogues are used to treat TB. In reviewing this field, it is postulated that flux through the nicotinamide synthesis pathway reflects switching between aerobic glycolysis and oxidative phosphorylation in M. tuberculosis‐infected macrophages. The evolutionary cause of such shifts may be ancient mitochondrial behavior related to reproductive fitness. Evolutionary perspectives on the IDO pathway may elucidate why, after centuries of co‐existence with the Tubercle bacillus, humans still remain susceptible to TB disease. (shrink)

With attention to the experiences, agency, and rights of tuberculosis patients, this symposium on TB and ethics brings together a range of different voices from the social sciences and humanities. To develop fresh insights and new approaches to TB care and prevention, it is important to incorporate diverse perspectives from outside the strictly biomedical model. In the articles presented in this issue of the Journal of Bioethical Inquiry, clinical experience is married with historical and cultural context, ethical concerns are (...) brought to bear on global health, and structural analyses shed light upon the lived experience of people living with TB. The relational and reciprocal dimensions of care feature strongly in these discussions, which serve as a poignant reminder that behind each of the yearly deaths from TB is a deeply personal story. No single discipline holds a monopoly on how to care for each of these people, but strong cases are made for support from mental health and social workers in addressing the kaleidoscope of needs in TB prevention. As the World Health Organization moves towards the goal of eliminating TB globally by 2050, attending to the needs of TB patients serves global interests to lower disease burden and to develop better integrated communities worldwide. (shrink)

Bovine tuberculosis is a controversial animal health policy issue in England, which impacts farmers, the public, cattle and badgers. Badgers act as a wildlife reservoir of disease. Policy options for badger control include do nothing, badger culling, and badger vaccination. This paper argues for mandatory Animal Welfare Impact Assessment for all policy that significantly affects sentient animals. AWIA includes species description, and AWIA analysis stages. In this paper, AWIA is applied to impacts of bovine TB policy options on cattle (...) and badgers. Over 4 years, 85,000 badgers will be culled to prevent the slaughter of ~17,750 cattle over 9 years. Hence, about five badgers are culled for every cow which avoids slaughter. The AWIA analyses the impact of badger vaccination on cows and badgers based on a set of stated assumptions. The AWIA estimates badger vaccination to reduce the number of cows slaughtered by 11,600, i.e. a 12.5% reduction. Additional to the harm of killing, culling has greater welfare impacts on badgers compared to non-culling options. Actors in animal health and welfare policy were interviewed about the concept of AWIA. Policy actors supported the idea of AWIA to provide objective data to feed into policy making. The paper concludes with the proposal that AWIA is a necessary stage of just policy making where sentient animals are impacted by government policy. (shrink)

Homelessness has existed in America since colonial times, and the attitudes, analyses and solutions offered through the succeeding centuries have evolved far less radically than recent media attention might suggest. From the building of the first poorhouse in Boston in 1664, to the conversion of massive armories into latter day poorhouses in New York City in the 1980s, our society has had ambivalent feelings towards the poor and the homeless. The outbreak and progression of tuberculosis in such settings—a seeming (...) mystery at best, a reality denied at worst—reflects both society’s ambivalence towards this population, as well as a misguided belief that modern medicine can be viewed in the abstract as curative and divorced from the social context to which all disease is inextricably bound. Unless and until these beliefs are addressed and altered, TB among the homeless will continue unabated. (shrink)

TB human challenge studies could accelerate TB vaccine development by reducing uncertainty in early-stage vaccine testing, selecting promising vaccine candidates for large-scale field trials, and identifying an immune correlate of protection. However, ethical concerns regarding the exposure of trial participants and bystanders to significant risk have been a limiting factor for TB human challenge models. We analyze the expected social value and risks of different types of TB human challenge models, and conclude that given the massive public health burden of (...) TB, challenge models with even scant probabilities of expediting TB vaccine authorization have enormous expected humanitarian value, saving between 33,000 and 1,375,000 lives over the next ten years. We argue that attenuated M.tb challenge trials can be conducted ethically, and discuss the benefits and drawbacks of conducting virulent M.tb challenge trials. (shrink)

BackgroundAfrica continues to bear a disproportionate share of the global HIV/AIDS, tuberculosis (TB) and malaria burden. The development and distribution of safe, effective and affordable vaccines is critical to reduce these epidemics. However, conducting HIV/AIDS, TB, and/or malaria vaccine trials simultaneously in developing countries, or in populations affected by all three diseases, is likely to result in numerous ethical challenges.MethodsIn order to explore convergent ethical issues in HIV/AIDS, TB and malaria vaccine trials in Africa, the Ethics, Law and Human (...) Rights Collaborating Centre of the WHO/UNAIDS African AIDS Vaccine Programme hosted a consultation on the Convergent Ethical Issues in HIV/AIDS, TB and Malaria Vaccine Trials in Africa in Durban, South Africa on the 10-11 February 2009.ResultsKey cross cutting ethical issues were prioritized during the consultation as community engagement; ancillary care obligations; care and treatment; informed consent; and resource sharing.ConclusionThe consultation revealed that while there have been few attempts to find convergence on ethical issues between HIV/AIDS, TB and malaria vaccine trial fields to date, there is much common ground and scope for convergence work between stakeholders in the three fields. (shrink)

Homelessness has existed in America since colonial times, and the attitudes, analyses and solutions offered through the succeeding centuries have evolved far less radically than recent media attention might suggest. From the building of the first poorhouse in Boston in 1664, to the conversion of massive armories into latter day poorhouses in New York City in the 1980s, our society has had ambivalent feelings towards the poor and the homeless. The outbreak and progression of tuberculosis in such settings—a seeming (...) mystery at best, a reality denied at worst—reflects both society’s ambivalence towards this population, as well as a misguided belief that modern medicine can be viewed in the abstract as curative and divorced from the social context to which all disease is inextricably bound. Unless and until these beliefs are addressed and altered, TB among the homeless will continue unabated. (shrink)

This article critically examines current responses to multi-drug resistant tuberculosis and argues that bioethics needs to be willing to engage in a more radical critique of the problem than is currently offered. In particular, we need to focus not simply on market-driven models of innovation and anti-microbial solutions to emergent and re-emergent infections such as TB. The global community also needs to address poverty and the structural factors that entrench inequalities—thus moving beyond the orthodox medical/public health frame of reference.

Controlling the movement of potentially infectious bodies has been central to Australian immigration law. Nowhere is this more evident than in relation to tuberculosis, which is named as a ground for refusal of a visa in the Australian context. In this paper, I critically examine the “will to knowledge” that this gives rise to. Drawing on a critical analysis of texts, including interviews with migrants diagnosed with TB and healthcare professionals engaged in their care, I argue that this focus (...) on border policing, rather than resettlement and the broader social determinants of health that drive current rates of TB, paradoxically renders migrants diagnosed with TB as liminal subjects in the post-arrival phase. This raises ethical issues about who “matters,” as well as dilemmas about what constitutes adequate care for the “Other,” both of which go to the heart of the political economy of migration. (shrink)

Contact investigation is an evidence-based intervention of multidrug-resistant tuberculosis (MDR-TB) to protect public health by interrupting the chain of transmission. In pursuit of contact investigation, patients’ MDR-TB status has to be disclosed to third parties (to the minimum necessary) for tracing the contacts. Nevertheless, disclosure to third parties often unintentionally leads the MDR-TB patients suffered from social discrimination and stigma. For this reason, patients are less inclined to reveal their MDR-TB status and becomes a significant issue in contact investigation. (...) This issue certainly turns into a negative impact on the public interest. Tension between keeping MDR-TB status confidential and safeguarding public health arises in relation to this issue. Regarding MDR-TB management, patient compliance with treatment and contact investigation are equally important. Patients might fail to comply with anti-TB therapy and be reluctant to seek healthcare due to disclosure concerns. In order to have treatment adherence, MDRTB patients should not live through social discrimination and stigma arising from disclosure and TB team has a duty to support them as a mean of reciprocity. However, implementation of contact investigation as a public health policy can still be challenging even with promising reciprocal support to the patients because MDR-TB patients are living in different contexts and situations. There can be no straight forward settlement but an appropriate justification for each distinct context is needed to strike a balance between individual confidentiality and public interest. (shrink)

Tuberculosis has continued to retain its title as “the captain among these men of death”. This is evident as it is the leading cause of death globally from a single infectious agent. TB as it is fondly called has become a major threat to the achievement of the sustainable development goals (SDG) and hence require inputs from different research disciplines. This work presents a mathematical model of tuberculosis. A compartmental model of seven classes was used in the model (...) formulation comprising of the susceptible S, vaccinated V, exposed E, undiagnosed infectious I1, diagnosed infectious I2, treated T and recovered R. The stability analysis of the model was established as well as the condition for the model to undergo backward bifurcation. With the existence of backward bifurcation, keeping the basic reproduction number less than unity $$({R_{0}}<1)$$ is no more sufficient to keep TB out of the community. Hence, it is shown by the analysis that vaccination program, diagnosis and treatment helps to control the TB dynamics. In furtherance to that, it is shown that preference should be given to diagnosis over treatment as diagnosis precedes treatment. It is as well shown that at lower vaccination rate (0–20%), TB would still be endemic in the population. As such, high vaccination rate is required to send TB out of the community. (shrink)

There is a nationwide resurgence of tuberculosis in the country’s urban centers; New York City stands at the forefront of this resurgence. The root causes are increased homelessness, drug addiction and poverty, all symbols of deteriorating social and economic conditions in the city. The inadequate level of public health resources devoted to TB has also contributed to its spread. Still, even with these factors, it is questionable whether the escalating number of TB cases in this country would have occurred (...) without the reservoir of immunosuppressed persons, who are less resistant to the disease, created by the AIDS epidemic. The fear and urgency of this public health crisis, which has been emerging since the beginning of the last decade, are fueled by the rise of TB strains resistant to the first-line drugs and by the disease’s contagiousness. (shrink)

Background: The banking of biological samples raises a number of ethical issues in relation to the storage,export and re-use of samples. Whilst there is a growing body of literature exploringparticipant perspectives in North America and Europe, hardly any studies have been reportedin Africa. This is problematic in particular in light of the growing amount of research takingplace in Africa, and with the rise of biobanking practices also on the African continent. Inorder to investigate the perspectives of African research participants, we (...) conducted a studywith research participants in a TB study in the Western Cape, South Africa. Methods: Semi-structured interviews were conducted using an interview guide which drew on the mostprominent themes expressed in current literature on sample storage, re-use and exportation.Interviews were conducted in Afrikaans and subsequently translated into English by the sameinterviewer. Interviews were transcribed verbatim and analysed qualitatively. Results: The results of our study indicate that the majority of participants were supportive of givingone-time consent to the storage and re-use of their samples. The concept of research being fora "good cause" was a central prerequisite. Additionally, a significant minority requested thatthey be re-contacted if a future use was not stipulated on the original consent. There was alsoconsiderable variation in how participants understood the concept of a 'good cause', withparticipants describing three distinct categories of research, of which two were generallythought to constitute 'good cause' research. Research that was for-profit was considered tofall outside the spectrum of 'good cause' research. Participants displayed confidence in theabilities of the researchers to make future decisions regarding sample use, but seemedunaware of the role of ethics committees in either this process or more generally. Conclusions: Participants expressed a wide and complex range of views about issues of sample storage andre-use, and they showed a great deal of trust in researchers. Participants' willingness to havetheir samples stored and re-used is consistent with findings from existing studies. However,in contrast to existing literature, participants were generally not in favour of for-profitresearch. Further research needs to be done to explore these ideas in other communities, bothin South Africa and other countries. (shrink)

There is a nationwide resurgence of tuberculosis in the country’s urban centers; New York City stands at the forefront of this resurgence. The root causes are increased homelessness, drug addiction and poverty, all symbols of deteriorating social and economic conditions in the city. The inadequate level of public health resources devoted to TB has also contributed to its spread. Still, even with these factors, it is questionable whether the escalating number of TB cases in this country would have occurred (...) without the reservoir of immunosuppressed persons, who are less resistant to the disease, created by the AIDS epidemic. The fear and urgency of this public health crisis, which has been emerging since the beginning of the last decade, are fueled by the rise of TB strains resistant to the first-line drugs and by the disease’s contagiousness. (shrink)

The resurgence of tuberculosis in the United States is due, in part, to the dismantling of large-scale treatment systems that were a critical part of the disease control effort for the better part of the twentieth century. As the number of cases grows, clinicians, politicians, public health officials and community advocates have grappled with the difficult problem of building systems to care for infected people that are consonant with current knowledge and beliefs about quality care. As an example, the (...) United Hospital Fund’s 1992 report, The Tuberculosis Revival: Individual and Societal Obligations in a Time of AIDS, discussed policies to guarantee adequate treatment that protects patients’ civil rights, needs for special facilities for care of TB patients, and the special problems faced by infected prisoners. This thoughtful report highlighted many areas of social policy that require further examination. (shrink)

Emerging genomic technologies promise more efficient infectious disease control. Whole genome sequencing is increasingly being used in tuberculosis diagnosis, surveillance, and epidemiology. However, while the use of WGS by public health agencies may raise ethical, legal, and socio-political concerns, these challenges are poorly understood. Between November 2017 and April 2018, we conducted semi-structured interviews with 22 key stakeholders across the fields of governance and policy, public health, and laboratory sciences representing the major jurisdictions currently using WGS in national TB (...) programs. Thematic analysis of the interviews was conducted using NVivo 11. Respondents identified several ethical and practical challenges associated with WGS in TB care and surveillance, all related to issues of trust, including: 1) the power of public health; 2) data sharing and profits derived from surveillance efforts; and 3) concerns regarding who has access to, and can benefit from, the technology. Additional challenges included: the potential utility that WGS adds to a public health program, the risks associated with linking necessary epidemiological metadata to the genomic data, and challenges associated with jurisdictional capacity to implement the technology. Successful implementation of WGS is dependent on fostering relationships of trust between those working with genomics technology and those directly impacted by it, including clinicians. Building trust between the public and the public health agencies and within public health agencies themselves is critical due to the inherent complexity of WGS and its implementation for communicable disease control purposes. (shrink)

The resurgence of tuberculosis in the United States is due, in part, to the dismantling of large-scale treatment systems that were a critical part of the disease control effort for the better part of the twentieth century. As the number of cases grows, clinicians, politicians, public health officials and community advocates have grappled with the difficult problem of building systems to care for infected people that are consonant with current knowledge and beliefs about quality care. As an example, the (...) United Hospital Fund’s 1992 report, The Tuberculosis Revival: Individual and Societal Obligations in a Time of AIDS, discussed policies to guarantee adequate treatment that protects patients’ civil rights, needs for special facilities for care of TB patients, and the special problems faced by infected prisoners. This thoughtful report highlighted many areas of social policy that require further examination. (shrink)

The issue of detention as a tuberculosis control measure has resurfaced following the prolonged detention of a patient with an extensively drug-resistant strain of tuberculosis in a prison cell in Arizona, and the attempted detention in Italy and subsequent detention in Atlanta, Georgia of an American sufferer thought to have XDR-TB in May 2007. These cases have reignited the debate over the evidence that supports detention policy in the control of tuberculosis, and its associated legal and ethical (...) ramifications. This paper considers whether involuntary detention is justified where voluntary measures have failed or where a patient poses a danger, albeit uncertain, to the public, and discusses the need for strengthening evidencebased assessments of public health risk. (shrink)

Ethnicity and im/migrant classification systems and their constituent categories have a long history in the construction of public health knowledge on tuberculosis in the United Kingdom. This article critically examines the categories employed and the epidemiological discourses on TB, im/migrants, and ethnic minorities in health reporting between 1965 and 2015. We employ a Sociology of Knowledge Approach to Discourse Analysis to trace the continuities and changes in the categories used and in the discursive construction of im/migrants, ethnic minorities, and (...) TB. These continuities and disjunctures are analysed within their socio-historical context to demonstrate the historical contingency of epidemiological knowledge production. We outline two historical phases in knowledge construction. The first coincides with the period of decolonisation, which witnessed a change in discursive identity ascriptions from ‘immigrants’ to ‘ethnic groups’ in health reporting as the ‘other’. The second commenced after 1991, when the adoption of the census ethnicity categories as a standard in the collection of population statistics entrenched ethnicity categories in health reporting. We argue the health reporting discourse reveals that the ‘new’ public health exhibits continuities with the ‘old’ by targeting the immigrant ‘other’ through biosecuritisation practices. We contend that these categories originated within a postcolonial paradigm and that increasing immigration and new forms of mobility are creating the preconditions for new discourses on identity construction that have implications for the current collaborative TB strategy. (shrink)

Since 1986, we have seen a rise in the occurrence of tuberculosis in the United States. Long considered defeated in this country, the disease is returning with distressing vigor. Outbreaks of MDR-TB, tuberculosis resistant to more than one medication, have been reported around the country. This article analyzes the Centers for Disease Control and Prevention's National Action Plan to Combat Multidrug-Resistant Tuberculosis, with particular focus on the moral dimensions of mandatory directly observed treatment (DOT) and involuntary quarantine. (...) It is proposed that a moral response to the control of tuberculosis must be one which is sustainable and which can effectively curtail the spread of the disease at a minimal cost to individual rights. (shrink)

In contrast to the great majority of mycobacterial species that are harmless saprophytes, Mycobacterium tuberculosis and other closely related tubercle bacilli have evolved to be among the most important human and animal pathogens. The need to develop new strategies in the fight against tuberculosis (TB) and related diseases has fuelled research into the evolutionary success of the M. tuberculosis complex members. Amongst the various disciplines, genomics and functional genomics have been instrumental in improving our understanding of these (...) organisms. In this review we will present some of the recent key findings on molecular determinants of mycobacterial pathogenicity and attenuation, the evolution of M. tuberculosis, genome dynamics, antigen mining for improved diagnostic and subunit antigens, and finally the identification of novel drug targets. The genomics revolution has changed the landscape of TB research, and now underpins our renewed efforts to defeat this deadly pathogen. (shrink)

BackgroundInformed consent is an ethical and legal requirement for research involving human participants. However, few studies have evaluated the process, particularly in Africa.Participants in a case control study designed to identify correlates of immune protection against tuberculosis (TB) in South Africa. This study was in turn nested in a large TB vaccine efficacy trial.The aim of the study was to evaluate the quality of consent in the case control study, and to identify factors that may influence the quality of (...) consent.Cross-sectional study conducted over a 4 month period.MethodsConsent was obtained from parents of trial participants. These parents were asked to complete a questionnaire that contained questions about the key elements of informed consent (voluntary participation, confidentiality, the main risks and benefits, etc.). The recall (success in selecting the correct answers) and understanding (correctness of interpretation of statements presented) were measured.ResultsThe majority of the 192 subjects interviewed obtained scores greater than 75% for both the recall and understanding sections. The median score for recall was 66%; interquartile range (IQR) = 55%–77% and for understanding 75% (IQR = 50%–87%). Most (79%) were aware of the risks and 64% knew that they participated voluntarily. Participants who had completed Grade 7 at school and higher were more likely (OR = 4.94; 95% CI = 1.57 – 15.55) to obtain scores greater than 75% for recall than those who did not. Participants who were consented by professional nurses who had worked for more than two years in research were also more likely (OR = 2.62; 95% CI = 1.35–5.07) to obtain such scores for recall than those who were not.ConclusionNotwithstanding the constraints in a developing country, in a population with low levels of literacy and education, the quality of informed consent found in this study could be considered as building blocks for establishing acceptable standards for public health research. Education level of respondents and experience of research staff taking the consent were associated with good quality informed consent. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Closing the Gaps in Pediatric HIV/AIDS Care, One Step at a TimeLisa V. Adams, Helga Naburi, Goodluck Lyatuu, Paul Palumbo, and C. Fordham von ReynFatuma's* doctors were completely perplexed. It was 2003 and she had returned to the DARDAR clinic in her hometown of Dar es Salaam, Tanzania three times that week with vague complaints of various pains and aches. Her doctors were considering whether these symptoms were due (...) to the initiation of her recent treatment with antiretroviral medications for her HIV infection or related to the last administration of the investigational tuberculosis (TB) vaccine that the DARDAR Health Study was evaluating. Fatuma's doctor, Dr. Lillian Mtei, consulted with Dartmouth's chief of Infectious Disease, Dr. Ford von Reyn, who happened to be in Dar that week on a site visit. Neither physician could determine the basis for her symptoms. Dr. Mtei returned to the exam room once more and this time emerged with the answer: Fatuma had just learned that her three year old daughter was HIV-infected, likely contracted from Fatuma during or shortly after she gave birth to her daughter. Fatuma believed that her HIV diagnosis was a death sentence for her daughter since antiretroviral therapy was not widely available for children.Dr. von Reyn, Dartmouth's lead clinical researcher in Africa and a father, knew too well the harsh reality of inequities in a resource-limited country. He turned to Dr. Mtei and said decidedly, "we need to do something about this."Thus the DARDAR Pediatric Program was born.Pediatric HIV: A Neglected DiseaseThe need for HIV treatment among children in Tanzania, as in most of sub-Saharan Africa, is compelling. At the end of 2009, approximately 160,000 children aged zero to fourteen in Tanzania were living with HIV (Joint United Nations Programme on HIV/AIDS [UNAIDS], 2011). Even with successful roll out of prevention of mother to child transmission programs in Tanzania, there were nearly 29,000 perinatal infections in 2009. As of December 2010, only 18% of these were enrolled in HIV treatment programs (UNAIDS, 2011; World Health Organization [WHO], 2011). Without antiretroviral therapy (ART), one-half of HIV-infected children will die before their second birthday. Since clinical research to determine efficacy and safety of new medical treatments is conducted almost exclusively in adults, provision of new medical treatments to [End Page 75] children always lags behind advances for adults. Furthermore, children are often underrepresented in programs for antiretroviral drugs for the following reasons: 1) they are not prioritized for care; 2) facilities lack infant diagnostic capabilities; 3) there is limited pediatric HIV training and consequently, a shortage of pediatric providers; and 4) pediatric antiretroviral formulations are frequently unavailable. The unacceptable delays in pediatric HIV drug development and treatment access led the international organization Drugs for Neglected Diseases initiative to publish an editorial in which they referred to pediatric HIV as a "neglected disease" (Lallemant, Chang, Cohen, & Pecoul, 2011).The Tip of the Iceberg: More than Just MedicinesWith a grant from the New York-based Foundation for the Treatment of Children with AIDS, the DARDAR Pediatric Program, a joint collaboration between Geisel School of Medicine at Dartmouth and Muhimbili University of Health and Allied Sciences, began seeing patients in May 2006. It was the first dedicated pediatric HIV Care and Treatment Center in Tanzania and operates in accordance with Tanzania's National AIDS Control Programme's guidance. Testing for both children and infants (the latter of which requires a more sophisticated assay) is available.The day the clinic opened we celebrated this collaborative effort that would provide HIV-infected children in Dar es Salaam access to antiretroviral treatment. One of our first patients was a six-year-old boy whose mother, like Fatuma, was a participant in our TB vaccine trial. She had been advised to bring her son to us for HIV screening. Her son looked healthy so she was surprised and understandably distraught when his test results indicated that not only was he HIV-infected, but his CD4 percentage was very low. His mother was reluctant to have him started on antiretrovirals given his general appearance and young age—and that he was... (shrink)

AbstractWe propose an emerging conceptualization of “intervention hesitancy” to address a broad spectrum of hesitancy to disease prevention interventions among healthcare personnel (HCP) beyond vaccine hesitancy. To demonstrate this concept and its analytical benefits, we used a qualitative case-study methodology, identifying a “spectrum” of disease prevention interventions based on (1) the intervention’s effectiveness, (2) how the intervention is regulated among HCP in the Israeli healthcare system, and (3) uptake among HCP in the Israeli healthcare system. Our cases ultimately contribute to (...) a more nuanced conceptualization of hesitancy that HCP express towards disease prevention interventions. Our case interventions included the seasonal influenza vaccine, the Mantoux test, and the hepatitis B (HBV) vaccine. Influenza and HBV are vaccine-preventable diseases, though their respective vaccines vary significantly in effectiveness and uptake among HCP. The Mantoux test is a tuberculin skin test which provides a prevention benchmark for tuberculosis (TB), a non-vaccine preventable disease. We conducted semi-structured interviews with relevant stakeholders and analyzed them within Israeli and international policy context between 2016 and 2019, a period just prior to the COVID-19 pandemic. We propose the conceptualization of “intervention hesitancy”—beyond “vaccine hesitancy”—as “hesitancy towards a wide range of public health interventions, including but not limited to vaccines”. Results suggested that intervention hesitancy among HCP is rooted in weak trust in their employer, poor employment conditions, as well as mixed institutional guidelines and culture. Conceptualizing intervention hesitancy expands the ability of healthcare systems to understand the root of hesitancy and foster a supportive institutional culture and trust, cognizant of diverse disease prevention interventions beyond vaccination. (shrink)

BackgroundA requisite for ethical human subjects research is that participation should be informed and voluntary. Participation during the informed consent process by way of asking questions is an indicator of the extent to which consent is informed.AimsThe aims of this study were to assess the extent to which parents providing consent for children's participation in an observational tuberculosis (TB) research study in India actively participated during the informed consent discussion, and to identify correlates of that participation.MethodsIn an observational cohort (...) study of tuberculosis in infants in South India, field supervisors who were responsible for obtaining informed consent noted down questions asked during the informed consent discussions for 4,382 infants who were enrolled in the study. These questions were post-coded by topic. Bivariate and multivariate analysis was conducted to examine factors associated with asking at least one question during the informed consent process.ResultsIn total, 590 out of 4,382 (13.4%) parents/guardians asked any question during the informed consent process. We found that the likelihood of parents asking questions during the informed consent process was significantly associated with education level of either parent both parents being present, and location.ConclusionsThe findings have implications for planning the informed consent process in a largely rural setting with low levels of literacy. Greater effort needs to be directed towards developing simple participatory communication materials for the informed consent process. Furthermore, including both parents in a discussion about a child's participation in a research study may increase the extent to which consent is truly informed. Finally, continuing efforts need to be made to improve the communication skills of research workers with regard to explaining research processes and putting potential research participants at ease. (shrink)

If James has a latent tuberculosis infection , he is at risk of developing active tuberculosis disease but he is not yet sick. LTBI is a liminal space between health and illness. Diagnosed with LTBI, James could be conceptualised as having a liminal body. Treatments for LTBI are available, but why would a person seek treatment for a disease he does not yet have? One thing is definite: James needs to be educated about the symptoms and severity of (...) active tuberculosis disease. (shrink)

An international consensus emerged in the years between 1900 and 1910 regarding the need to refocus antituberculosis efforts away from treating tuberculosis in adults and toward preventing active disease in children. This paper uses social history as a framework to explore pediatric health experiments in France (foster placement of city children with rural farm families), Germany (open‐air schools), and the United States (preventorium) for children considered ‘pretubercular’. The scientific, social, and political variables that reshaped prevailing ideas and practice with (...) regard to TB prevention during those years are described. The creation of the first preventorium in the United States is explained and the way in which French and German pediatric prevention strategies were adapted to address a specific population considered at high risk in the United States, indigent immigrants, is detailed. For each of these three nations, nurses were central actors. Their efforts provide a unique vantage point to study the cultural dimensions of risk and prevention embedded in nursing care and the interplay between science, culture, nurses, and the state. (shrink)

Drug-resistant tuberculosis has a high mortality rate. Most medicines used to treat it are poorly tested and have terrible side effects. Activists have campaigned for patients with drug-resistant TB to have access to experimental drugs, particularly one called bedaquiline, before these have been approved by regulatory authorities such as the Food and Drug Administration in the United States and the Medicines Control Council in South Africa. Some activists have also campaigned for bedaquiline to be approved by regulatory authorities before (...) testing of the drug is completed. These campaigns raise ethical concerns about whether patients should be offered experimental, unapproved, medicines for the treatment of life-threatening illnesses, and if authorities should approve drugs for life-threatening illnesses when vital questions about safety and efficacy remain outstanding. (shrink)