Comment
at any given time. Are the number of cases reported
truly reliable, or should additional resources be made
available to search for the missing millions of cases—ie,
people who might be living with undiagnosed leprosy,
developing disability, and spreading disease?8 Unless
bold strategies are developed and supported by health
ministries in those endemic countries most affected by
leprosy, the NCDR might continue to stagnate or even
increase to numbers seen in the pre-elimination era.
Our experience in active case finding in hyperendemic
areas of Brazil shows that one needs only to actively
search to find the extent of hidden cases of leprosy,
revealing the true numbers.9,10
*Claudio Guedes Salgado, Josafá Gonçalves Barreto,
Moisés Batista da Silva, Isabela Maria Bernardes Goulart,
Jaison Antônio Barreto, Nesio Fernandes de Medeiros Junior,
José Augusto Nery, Marco Andrey Cipriani Frade,
John Stewart Spencer
Laboratório de Dermato-Imunologia, Instituto de Ciências
Biológicas, Marituba (CGS, JGB, MBdS), Campus Castanhal (JGB),
Universidade Federal do Pará, Pará 67200-000, Brazil; Centro de
Referência Nacional em Dermatologia Sanitária/Hanseníase do
Hospital de Clínicas da Universidade Federal de Uberlândia,
Uberlândia, Brazil (IMBG); Instituto Lauro de Souza Lima,
São Paulo, Brazil (JAB); Secretaria de Saúde do Município de
Palmas, Tocantins, Palmas, Brazil (NFdMJ); Fundação Oswaldo
Cruz, Rio de Janeiro, Brazil (JAN); Departamento de Dermatologia,
A roadmap for zoonotic tuberculosis: a One Health approach
to ending tuberculosis
1·8 million people die annually of tuberculosis, making
it the leading cause of death worldwide due to an
infectious disease. Most cases of tuberculosis in human
beings are caused by Mycobacterium tuberculosis.
Zoonotic tuberculosis is a neglected form of the disease
predominantly caused by a closely related species,
Mycobacterium bovis, which belongs to the M tuberculosis
complex.
In 2016, WHO estimated that there were 14 700 new
cases of zoonotic tuberculosis and 1200 deaths due to
the disease.1 Zoonotic tuberculosis poses challenges
for effective patient care and recovery. Clinical
differentiation of infections caused by M tuberculosis
and M bovis is not possible. Furthermore, M bovis is
www.thelancet.com/infection Vol 18 February 2018 137
Faculdade de Medicina da Universidade de São Paulo em Ribeirão
Preto, São Paulo, Brazil (MACF); and Department of Microbiology,
Immunology and Pathology, Colorado State University, Fort
Collins, CO, USA (JSS)
csalgado@ufpa.br
We declare no competing interests. We acknowledge funding from the
National Council for Scientific and Technological Development (CNPq),
Capes Pro-Amazonia, Pará State Health Secretary, Pará Federal University,
Ribeirão Preto Faculty of Medicine at University of São Paulo, Order of Malta,
the Fulbright Scholar Program, and the Heiser Fund of the New York Community
Trust. The funders had no role in the writing of the manuscript.
1 WHO. Global leprosy update, 2016: accelerating reduction of disease
burden. Wkly Epidemiol Rec 2017; 92: 501–20.
2 WHO. Leprosy. Global situation. Wkly Epidemiol Rec 2002; 77: 1–8.
3 WHO, Regional Office for the Eastern Mediterranean. Report on the
regional seminar on future trends in leprosy elimination. Alexandria: World
Health Organization, Regional Office for the Eastern Mediterranean, 2000.
4 WHO, Regional Office for Africa. Progress towards the reduction of the
burden of leprosy 2000–2011. Brazzaville: World Health Organization,
Regional Office for Africa, 2012.
5 Frade MAC, de Paula NA, Gomes CM, et al. Unexpectedly high leprosy
seroprevalence detected using a random surveillance strategy in
midwestern Brazil: a comparison of ELISA and a rapid diagnostic test.
PLoS Negl Trop Dis 2017; 11: e0005375.
6 Filho FB, Paula NA De, Leite MN, et al. Evidence of hidden leprosy in a
supposedly low endemic area of Brazil. Mem Inst Oswaldo Cruz 2017; 112: 1–7.
7 WHO. India’s massive leprosy case detection campaign reaches 320 million
people. Oct 18, 2016. http://www.who.int/neglected_diseases/news/
India_massive_leprosy_case_detection_campaign_reaches_320_mill/en/
(accessed Sept 25, 2017).
8 Smith WC, van Brakel W, Gillis T, Saunderson P, Richardus JH. The missing
millions: a threat to the elimination of leprosy. PLoS Negl Trop Dis 2015;
published online April 23. DOI:10·1371/journal.pntd.0003658.
9 Barreto JG, Guimarães L de S, Frade MAC, Rosa PS, Salgado CG. High rates
of undiagnosed leprosy and subclinical infection amongst school children
in the Amazon Region. Memórias do Inst Oswaldo Cruz 2012; 107: 60–67.
10 Salgado CG, Barreto JG, da Silva MB, Frade MAC, Spencer JS. What do we
actually know about leprosy worldwide? Lancet Infect Dis 2016; 16: 778.
naturally resistant to pyrazinamide, one of the four
essential medications used in the standard first-line
anti-tuberculosis treatment regimen.
The impact of zoonotic tuberculosis extends beyond
human health. M bovis is host-adapted to cattle, in
which the disease is referred to as bovine tuberculosis.
Bovine tuberculosis threatens communities that rely
on livestock for their livelihoods, particularly those in
less-developed, rural areas. The disease has important
implications for animal health and welfare, as well as on
productivity through reduced meat and milk production
and condemnation of carcasses or affected parts that
are classified as unfit for human consumption during
meat inspection. Bovine tuberculosis also creates
 Comment
For more on SDGs see http://
www.un.org/sustainabledevel-
opment/sustainable-develop-
ment-goals/
For more on End TB Strategy
see http://www.who.int/tb/
strategy/en/
For more on Stop TB
Partnership’s Global Plan to
End TB see http://www.stoptb.
org/global/plan/plan2/
138 www.thelancet.com/infection Vol 18 February 2018
barriers to the international trade of animals and
animal products. This disease can become endemic in
wildlife populations, threatening conservation efforts,
and serving as a reservoir of infection for livestock and
people.
The most common route of transmission of M bovis
to people is through the consumption of contaminated
dairy products that have not been heat-treated, or raw
or improperly cooked meat from diseased animals. Thus,
strategies to prevent zoonotic tuberculosis in people
are different to those targeting tuberculosis caused by
M tuberculosis. In January, 2017, leading international
human health and animal health organisations called on
all stakeholders to improve the diagnosis and treatment
of zoonotic tuberculosis, control the disease at its
animal source, and prevent transmission to people.2
The launch of the multi-sectoral roadmap for zoonotic
tuberculosis in October, 2017, marks an important
milestone in the fight to end the global tuberculosis
epidemic.3 This roadmap calls for concerted action
through broad engagement across political, financial,
and technical levels, including government agencies,
donors, academia, non-governmental organisations,
and private stakeholders. Its development has been
co-led by WHO, the World Organization for Animal
Health, the Food and Agricultural Organization of the
United Nations, and the International Union Against
Tuberculosis and Lung Disease.
The human burden of disease cannot be reduced
without improvement of standards of food safety and
the reduction of bovine tuberculosis in animals. A One
Health approach recognises the interdependence of the
health of people, animals, and the environment. The
declaration made by the leaders of the G20 forum in
July, 2017,4 highlights the importance of a One Health
approach to tackle the spread of antimicrobial resistance
and address the need to foster tuberculosis research and
development.
The roadmap highlights ten priorities for addressing
zoonotic tuberculosis, underpinned by three core
themes. These are improve the scientific evidence
base by collecting and reporting more complete and
accurate data, improving diagnosis in people, and
addressing research gaps; reduce transmission at
the animal–human interface by ensuring safer food,
improving animal health, and reducing the risk to
people; and strengthen intersectoral and collaborative
approaches by increasing awareness, engagement,
and collaboration, developing policies and guidelines,
implementing joint interventions, and advocating for
investment.
These ten priorities are framed within the multi-
sectoral United Nations’ Sustainable Development
Goals 2016–30, which include a target for tuberculosis
under goal 3, and WHO’s End TB Strategy, which seeks
to end the global tuberculosis epidemic by 2030. This
strategy calls for diagnosis and treatment of every
person with tuberculosis, including those affected by
zoonotic tuberculosis, and is supported by the Stop
TB Partnership’s Global Plan to End TB 2016–20 (The
Paradigm Shift). This plan identifies people at risk
of zoonotic tuberculosis as a neglected population
deserving greater attention.
To end the global tuberculosis epidemic by 2030,
we need to act today. The time is right for a bold
and concerted effort to collectively address zoonotic
and bovine tuberculosis. Together, we can save lives and
secure livelihoods.
*Anna S Dean, Simona Forcella, Francisco Olea-Popelka,
Ahmed El Idrissi, Philippe Glaziou, Amina Benyahia,
Elizabeth Mumford, Elisabeth Erlacher-Vindel, Glen Gifford,
Juan Lubroth, Mario Raviglione, Paula Fujiwara
Global Tuberculosis Programme (ASD, PG, MR), Department of
Food Safety and Zoonoses (AB), Country Health Emergency
Preparedness and IHR (EM), World Health Organization, Geneva
1211, Switzerland; Status Department (SF), and Science and New
Technologies Department (EE-V, GG), World Organisation for
Animal Health, Paris, France; College of Veterinary Medicine and
Biological Sciences, Colorado State University, Fort Collins, CO,
USA (FO-P); Animal Production and Health Division, Food and
Agricultural Organization of the United Nations, Rome, Italy
(AEI, JL); and International Union Against Tuberculosis and Lung
Disease, Paris, France (PF)
deanan@who.int
We declare no competing interests.
1 WHO. Global tuberculosis report 2017. Geneva: World Health Organization,
2017.
2 Olea-Popelka F, Muwonge A, Perera A, et al. Zoonotic tuberculosis
in human beings caused by Mycobacterium bovis—a call for action.
Lancet Infect Dis 2016; 17: e21–e25.
3 WHO, World Organisation for Animal Health, Food and Agricultural
Organization of the United Nations, The International Union Against TB
and Lung Disease. A roadmap for zoonotic tuberculosis. Geneva: World
Health Organization, 2017.
4 G20 Germany 2017. G20 Leaders’ declaration: shaping an interconnected
world. https://www.g20.org/profiles/g20/modules/custom/g20_beverly/
img/timeline/Germany/G20-leaders-declaration.pdf (accessed
Sept 13, 2017).