the combined effect of the 2 epidemics is magnified” [34], and, thus, HIV could have a major impact on the TB epidemiology in current and future wars. This is confirmed in the comprehensive review of Kimbrough and associates on the burden of TB in crisis-affected populations, where the risk of excess mortality among HIV-positive individuals was substantially enlarged [6]. However, most of the studies were done before the era of widespread access to antiretroviral medicines that most likely will reduce the excess risk due to HIV in ongoing and forth coming crises.
The World Health Organization (WHO) postulates that more resources should be directed to screening, diagnosis, and treatment of HIV and TB drug resistance, monitoring early indicators of resistance and integrating HIV and TB prevention and intervention [43]. Kerridge et al. [44] regard these recommendations as even more critical in conflict-affected states with weakened public health infrastructure in which antiretroviral therapy programs can be destabilized, and treatment and supply chains interrupted.
TB Control Measures
The TB situation in the years before WWII varied considerably throughout the world. There were countries with a far developed TB control program and others with a poor program. Details are given in the country-specific chapters 5–19 in which the pre-war TB situation and its development during and after the war are described. Here we will list the various potential measures which existed before the war and which evolved during and after WWII as a response to the deterioration of the TB situation.
Pre-War Control Measures
The epidemiologic assessment of the TB situation is based mainly on mortality data. The notification of active TB cases for the assessment of TB morbidity was not yet commonly introduced.
TB control measures mainly aimed at preventing the transmission of the TB bacilli from infectious patients to their contacts. An important step for the isolation of infectious patients was to admit them to a TB sanatorium. Many TB sanatoria had been opened already in most countries. There, bed rest, provision of high-caloric food, and sunlight were the leading therapeutic approach; in selected cases treatment modalities such as artificial pneumothorax or more invasive surgical procedures were performed [46]. Compulsory isolation of “difficult” patients was allowed in Germany. Most countries had already introduced an ambulatory structure with dispensaries for special TB care, usually run under the responsibility of the local or national government.
The main diagnostic method was the microscopic examination of the expectorated sputum in suspicious cases. Radiography or fluoroscopy for diagnostic purposes had been introduced in the 1920s, but were not used for routine screening of the general population. X-ray screening was applied, however, in the military service of some countries. Tuberculin skin tests were usually not performed as a routine screening method, but sometimes for diagnosis of cases suspected of having TB.
The pasteurization of milk and the culling of infected (tuberculin-positive) cattle to prevent the transmission of bovine TB was not generally introduced. Only in few countries, BCG vaccination was established on a broad basis.
TB Control during War
During the war, medical services for the general population were frequently reduced or disrupted. In particular, a shortage of experienced TB personnel did result, many doctors and also nurses were drafted into the military service. TB sanatoria and hospitals were used for wounded soldiers, thus often substantially reducing the number of beds for TB patients. Patients had to be discharged, thus facilitating the spreading of the TB bacilli into the population. Transportation became difficult and was doubly injurious to TB care, preventing patients from going to clinics or dispensaries for diagnosis and treatment, and impeding TB nurses to visit the homes of patients to give advice and provide home care.
The governments often instituted committees composed of TB specialists who developed strategies to maintain TB services and to improve the condition of TB patients. Special attention – as far as possible – was devoted to providing adequate nutrition and accommodation. Educational information on precaution against TB was provided to the public, guidelines for doctors were developed, and teaching of TB in medical schools intensified. Directives against the spread of TB in schools, kindergarten, and similar institutions were decreed. In countries suffering from air raids, shelter conditions were improved to prevent droplet infection. If possible, separate bunkers and/or masks for TB patients were provided. Children (and TB patients) were evacuated from the cities to the countryside. For patients with an artificial pneumothorax, the refilling with air was ensured.
As often a shortage of workers developed during the war, even patients with active TB were used by the industry. This could have a negative impact on the course of the disease and limited the provision of medical care to the patients. In the Soviet Union, to secure care for patients, night sanatoria were established in which the patient received special supervision and treatment after finishing work.
Post-War TB Control
After the war, an almost catastrophic TB situation was present in many countries. The TB control programs were often almost completely disrupted, in particular in the most affected countries. Thus, it was necessary to restore or restructure the TB services.
In 1943, the United Nations Relief and Rehabilitation Administration (UNRRA) was founded, which became part of the United Nations in 1945. Its purpose was to “plan, co-ordinate, administer or arrange for the administration of measures for the relief of victims of war in any area under the control of any of the United Nations through the provision of food, fuel, clothing, shelter and other basic necessities, medical and other essential services.” UNRRA cooperated closely with dozens of volunteer charitable organizations, today called non-governmental organizations (NGOs). In Germany and Austria, these tasks were mainly organized by the military governments of the Allies.
One of the main and most urgent problems was the shortage of food. If possible, food supplements were provided to TB patients. The number of hospital and sanatorium beds for TB patients had to be substantially increased, and technical equipment for diagnostic and therapeutic purposes had to be supplied as radiographs, fluoroscopes, microscopes, pneumothorax apparatus, thoracoscopes, and other surgical instruments; doctors and nurses had to be trained, and case finding and case supervision by the local public health organizations had to be intensified to get reliable epidemiological statistics. Repeat mass radiography screening and tuberculin testing were introduced in some countries to find infected and diseased TB cases as was – for prevention – a BCG vaccination program (in some European countries with the help of Danish and Swedish Red Cross); the housing accommodation had to be improved; the pasteurization of milk and the culling of infected cattle was started or enhanced.
The International Union against Tuberculosis (IUAT) resumed its activities in 1946 [45], and became – after the founding of the WHO in 1946 – the first NGO to be officially recognised by WHO. National TB organizations and societies enhanced their activities, too, and improved international co-operation. Research in TB diagnostics, therapy, and prevention was essentially stimulated by the discovery of anti-tuberculosis agents. Almost simultaneously at the end of 1944 – only 3 weeks apart – the first para-aminosalicyclic acid was used successfully in Sweden and thereafter streptomycin in the USA for the treatment of active TB in each one patient [46]. Other cases with successful treatment soon followed, which started a new era in the fight against TB and contributed substantially to the further success of TB control after WWII.