Fifty years of success in controlling tuberculosis in Iran, the question is how?

To the Editor—Tuberculosis (TB) is one of the top 10 causes of death worldwide.¹ Despite efforts over the last two decades, control of the infection at a global level is still out of reach; however, decreasing trends in Mycobacterium tuberculosis incidence, outbreak, and mortality have been observed.² The best estimate for 2017 is 1.3 million TB deaths (range, 1.2–1.4 million) with an additional 300,000 deaths (range, 266,000–335,000) resulting from TB disease among HIV-positive people.³ Most cases are estimated to have occurred in Asia and Africa, with the highest incidence in China (1,410 million) and India (1,339 million) in 2017.³ According to the data,^{3, 4} Iran has a low TB mortality rate (1 case per 100,000 population, excluding cases of HIV plus TB), compared to most neighboring countries such as Afghanistan (29 per 100,000 population), Armenia (1.2 per 100,000 population), Azerbaijan (8.7 per 100,000 population), Iraq (2.9 per 100,000 population), Turkmenistan (9.9 per 100,000 population), and Pakistan (27 per 100,000 population). Moreover, according to a report by the Ministry of Health and Medical Education of Iran, from 1964 to 2016, the incidence of pulmonary TB with positive sputum smear in Iran decreased by >10 times to 5.7 per 100,000 population in 2016.⁵ But how has Iran succeeded in controlling TB in a region with high burden of tuberculosis and multidrug-resistant (MDR) tuberculosis?

Because Iran is located in a special geographical location, achieving this result requires huge financial cost, equipment, and time investment for Iran. The country is surrounded by 2 countries with a high burdens of TB (ie, Pakistan and Afghanistan) in the east as well as Iraq in the west (with which Iran is involved in external and internal wars). In addition, Azerbaijan to the north has a high prevalence of MDR-TB. Thus, the challenge to control this disease is substantial, and its success is admirable. There are several important reasons for Iran’s success. (1) Continuation of free treatment and diagnosis for TB patients plays a significant role in TB control. (2) Nine regional TB laboratories in big cities including Tabriz, Shiraz, Isfahan, Mashhad, Kermanshah, Zahedan, Gorgan, Ahvaz, and Tehran distribute alerts about all TB incidents. (3) Improved phenotypic and genotypic diagnosis, treatment, and follow-up have accompanied the increased quantity and quality of health care in Iran over 50 years, despite economic sanctions. (4) The addition of 3 multidrug-resistant TB treatment centers in Shiraz, Mashhad, and Tabriz cities in southern, eastern and western Iran, respectively, now cover all regions of Iran. (5) Cooperation with the international community has improved, especially with the World Health Organization. (6) The activities of university centers in TB control have improved through skilled personnel training and improving education for the poor regions and suburbs. (7) Quality control programs for TB microbiology laboratories have been implemented. (8) The number of private medical diagnostic labs in the cities and the villages has grown substantially. (9) Finally, the Ministry of Health and Medical Education on TB program includes follow-up and continuous monitoring. According to the policy objective of the Ministry of Health in Iran, by the year 2025, the detection rate of pulmonary TB will have increased to >85% and the rate of treatment will have increased to 90%.