Have you heard about "MILETEFOSINE", the drug that treats the brain infection caused by brain eating amoeba called Primary Amebic meningeocephalitis "PAM"?

CDC supplies drug to treat teen with brain-eating amoeba

By Ilene Manacher
CBS News

A drug that has been successful in treating a rare, deadly parasitic infection has been made available to a Houston teen who is battling the brain-eating amoeba, the Centers for Disease Control and Prevention confirmed.
The teenager, 14-year-old Michael Riley Jr., remains hospitalized with primary amebic meningeoencephalitis (PAM), a brain infection caused by the amoeba Naegleria fowleri. The condition is nearly always fatal.

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Brain-eating amoeba attacks Texas teen

Doctors treating Riley obtained the drug, miltefosine, which is normally used to treat another parasitic disease found in the tropics called leishmaniasis. Researchers found that it also showed promise in the lab for treating other free-living amoeba (FLA) infections, including those caused by Naegleria fowleri.
The Centers for Disease Control and Prevention has been providing the drug to doctors, with permission from the FDA, since 2009.
The CDC says miltefosine, along with other medications and therapies, helped save Kali Hardig, a 12-year-old Arkansas girl who was diagnosed with PAM in 2013. Hardig was the first patient since 1979 to survive the infection.
That same summer, a second child who was treated with miltefosine also survived, but suffered brain damage.
But experts warn the drug is not a magic bullet.
"That summer that we had the two survivors, including the girl from Arkansas, we very closely analyzed what happened there," Dr. Jennifer Cope, a medical epidemiologist with the CDC, told CBS News. "In the end we think it was probably a multifactorial 'perfect storm' of everything that happened to come together and have that perfect outcome."
Cope noted that miltefosine is not the only drug that's given to treat this type of infection.
"It's actually a full cocktail of drugs that are recommended, and miltefosine - the one that we have in Atlanta - is just one part of that. So the other drugs can be given as soon as they can be ordered from the hospital pharmacy," said Cope. "And then this one ... they make contact with us and order it here from Atlanta and we get it out as quickly as we can."
Until recently, miltefosine was only available from Germany. It is now one of several drugs used to treat rare diseases that the CDC keeps onsite in Atlanta.
A CDC blog notes that in 2014, the CDC sent 14 shipments of miltefosine to doctors treating possible FLA infections. The drug remains under an FDA investigational treatment program for FLA infections.
The amoeba Naegleria fowleri is found in warm freshwater like lakes and rivers, and can cause infections when it gets into a person's nose and travels to the brain. In Michael Riley's case, he's believed to have contracted the illness after swimming with friends at a lake in Sam Houston National Forest on August 13.
Riley is reported to be in a medically induced coma at Texas Children's Hospital, where doctors recognized the infection from having recently treated another case in the area. That patient died.

A Harvard expert puts us through on how to overcome choking in stressful situation.

 

A Harvard Psychiatrist explains why we 'choke in stressful situations - and how to stop.

By Srini Pillay, Contributor

A brain wired for survival is useful for finding food and shelter. But in the workplace, that kind of wiring won’t get you far.
Fighting for survival can have two effects: high adrenaline or undesired passivity. Ultimately, both can lead to burnout and stress.
So what’s the solution?
Striving to thrive — not necessarily survive — is ideal, but only if you’re well-equipped to withstand the pressure associated with it.
High-pressure situations often cause people to choke or miss out on valuable opportunities. Worse, people can lose serious professional momentum.
To prevent failure, it’s important to understand what happens in our brains when we choke.

What Causes Our Self-Sabotage?

There are three main reasons we choke under pressure:
We’re distracted from the big picture. When we’re overly focused on short-term problems and concerns, we lose sight of our long-term excellence. This is called “distraction theory” — our short-term memory is taken over by immediate concerns. As a result, we are consumed by our fear of failure, become overly impulsive, and lose control of our performance and priorities.
We turn off our autopilot. While on cruise control, our brains optimize our performance, allowing us to zip through tasks to hit home runs. But when we get nervous, we start making conscious, step-by-step efforts rather than automatic ones — our brains don’t work as efficiently. This is called “explicit monitoring,” and it can be disastrous.
We become overly stimulated. In the face of pressure, overstimulation can lead to overcompensation and, ultimately, choking. This is a phenomenon that affects everyone from experienced basketball players to people with high-stakes jobs. A 2009 study revealed people performed better in low-reward situations; high-reward situations caused test subjects’ brains to overcompensate and make mistakes.
That means it’s crucial to recognize the warning signs before they, well, choke you up.

Get Out of Your Own Way

It’s easy to recognize when you’re beginning to choke under pressure — you’re overwhelmed, your quality of work is declining, and you feel more distracted, anxious, and exhausted than usual.
These are the first symptoms of an upcoming choke, and you’ll need to quickly take action. Here are five ways to nip a choke in the bud:
Remind yourself of the long term. If you’re feeling burned by the here and now, consider your long-term success. This will provide an important perspective to your current problems, give you confidence, and relieve some pressure from the situation.
Embrace and trust your autopilot. Too much conscious thinking and brain micromanagement will make you choke. Allow your instincts to complete low-risk tasks every once in a while. Learn to love and trust your autopilot.
Write out your concerns. Expressing your fears before major high-stress events will train your brain to manage these types of situations. Evict the fears from your head and force them to live on paper. One study showed students received better test grades when they took the time to write out their biggest worries beforehand.
Reappraise the situation. Adopt a different perspective, and reinterpret your situation’s meaning — and worst-case scenario. Ask yourself, “What’s the worst that can happen? Who is directly impacted by my situation?” Reappraisal can help you avoid overstimulation and maintain a positive outlook.
Understand your body’s reactions. The human body works in mysterious ways. Sweaty palms and racing hearts tend to make us even more anxious. Truly understanding why our bodies react can be tremendously helpful. In one study, simply explaining to students that they could learn from their bodies led to improved performance. It doesn’t matter whether it’s blood, sweat, or tears — your body’s changing reactions can always be positively leveraged.
Choking happens; that’s life. But these tools will help you perform more confidently and thrive in your office — not merely survive it.
Dr. Srini Pillay, founder and CEO of NeuroBusiness Group, is a pioneer in brain-based executive coaching. He also serves as assistant clinical professor of psychiatry at Harvard Medical School and teaches in the Executive Education Programs at Harvard Business School and Duke Corporate Education.

For some colon cancer patients, travel distance limits access to chemo

By Kathryn Doyle
Reuters Health 


(Reuters Health) - People who have been treated for colon cancer are less likely to get chemotherapy after surgery to reduce the risk of future cancer if they have to travel far for the appointments, according to a new study.
Preventive chemotherapy given after cancer surgery to reduce the risk of recurrence is called “adjuvant” chemotherapy, and guidelines recommend that stage III colon cancer patients start receiving adjuvant chemo within three months of surgery.
In some cases in the study, “travel distance to treatment was really a barrier for patients to receive treatment,” said lead author Chun Chieh Lin of the American Cancer Society in Atlanta, Georgia.
“We tried to understand how oncologist availability in the area could be another barrier, and we found that for patients without private insurance, oncologists do make a difference,” she told Reuters Health by phone.
Her team analyzed data from close to 35,000 patients with stage III colon cancer diagnosed between 2007 and 2010. Three-quarters of them received adjuvant chemo within 90 days of cancer surgery.
As distance to the chemotherapy center increased, the likelihood of getting the chemo decreased. Patients who had to travel more than 250 miles were about 60 percent less likely to get it than those who had to travel less than 12.5 miles.
In most cases, patients would be traveling back to the facility where they had their cancer surgery to have adjuvant chemo.
The number of oncologists in the immediate vicinity of the patient’s home was not associated with the odds of receiving chemo. But patients with no insurance, and those with public insurance, were less likely to get chemo if they lived in an area with few oncologists.
For people with private insurance, oncologist density did not make a difference, the authors reported in the Journal of Clinical Oncology.
Oncologist density ranged from zero oncologists per 100,000 residents in rural areas like west Texas, to more than seven oncologists per 100,000 residents in areas like central Florida.
Patients who cannot afford private insurance might have less ability to travel to get chemo, or to take the necessary days off of work to get it, Lin said.
Dr. Daniel G. Haller, professor of medicine emeritus at the Abramson Cancer Center at the University of Pennsylvania, who was not part of the new study, pointed out that often, patients cannot drive themselves home after a chemotherapy session.
“If they don’t have close family members to drive them or cannot take one day off every two weeks twelve times, for a typical regimen, they may not get the treatment,” Haller told Reuters Health by phone.
Travel distance likely affects treatment for many conditions, like cardiac follow-up or diabetes, Haller said.
Adjuvant chemo is highly recommended for some, but not all, colon cancers, Lin said.
In the U.S. the average age at colon cancer diagnosis is 70, and many older patients may have other health conditions which preclude chemotherapy, or make it less likely that the chemotherapy will benefit them, Haller said.
“How many of those people were recommended to get chemo? You don’t know what was said after their surgery,” based on the data in this study, he said. Some patients might have been told not to get adjuvant chemo, he added.
But in some cases, patients are told to get adjuvant chemo but refuse, or do not have the social support to get to their appointments, Lin said.
“For the travel barrier, there are several things we can do to help patients,” including the patient navigator service available in many major cancer centers, she said.
A patient navigator works one-on-one with a cancer patient and identifies barriers to their care and how they can be overcome, she said. Navigators can contact physicians available in the local area or make appointments or find transportation assistance.
Some nonprofit organizations offer travel assistance as well, Lin said.
SOURCE: bit.ly/1ERNt3Y Journal of Clinical Oncology, online August 24, 2015.

A polio-free world is in sight: what’s needed to wipe out the last 1%

By
Maureen Taylor
Professor of Virology at University of Pretoria.
The next three years are crucial in the global fight to eradicate the last 1% of polio cases and contain the virus across the world. But it will only become a reality with a combination of intensive vaccination campaigns and high-level surveillance to trace and monitor each polio case and circulating viruses.
Central to achieving this is the polio eradication and endgame strategic plan 2013 to 2018. The plan belongs to the World Health Assembly’s Global Polio Eradication Initiative. It was developed to eliminate and contain all wild, vaccine-related and sabin, which is a live but weakened strain, of the polioviruses by 2018.
Since the initiative was launched by the assembly in 1988, the number of polio cases have reduced by 99%. The remaining 1% of cases can be found in the two countries with endemic polio—Pakistan and Afghanistan. Nigeria was the third polio-endemic country until July 2015, when it recorded one full year with no new cases.
Polioviruses belong to the family of viruses that infect the human gastrointestinal tract and cause diseases of the nervous system. It is caused by one of three related wild polioviruses—poliovirus types 1, 2 and 3, or as a result of a poliovirus derived from a vaccine.
The vaccine-derived poliovirus develops when the weakened vaccine-virus given to a child during immunisation is excreted in areas with bad sanitation. It then circulates.
Although wild poliovirus type 2 was eradicated worldwide in 1999, the majority of reported cases are from vaccine-derived poliovirus outbreaks associated with type 2 wild poliovirus.
Challenges in the plan
Eliminating this last 1% of polio cases requires two main strategies in the plan: immunisation and surveillance. Its immunisation arm aims to achieve a high level of immunity across all populations while the surveillance arm picks up new cases.
To achieve the two elements, a combination of innovations may be required. The innovations need to be applied in the most challenging conditions and should be tailored for each country and its settings.
Currently, 2.5 billion children across the world have received vaccination against polio.
The challenges holding back immunisation include:
political unrest;
dealing with misinformation that the polio vaccine causes sterility and/or AIDS;
the banning of healthcare workers from vaccinating certain communities; or
attacks on healthcare workers distributing the vaccine, as has been the case in Nigeria and Pakistan.
In 2003, polio vaccination was stopped in parts of northern Nigeria. This caused a polio outbreak in six other countries. In Pakistan, the Taliban have launched several attacks on healthcare workers trying to vaccinate children.
Today, problems still persist in Pakistan. And recently, a church in Kenya started a misinformation campaign.
Why surveillance is important
Polioviruses replicate in the intestine of infected people and are shed in high numbers in faeces. As a result, the virus is found in sewage and faecally-contaminated water sources. Active surveillance is important to identify residual pockets of the poliovirus. These inform the areas where the supplementary immunisation campaigns are required.
Most people infected with polioviruses have inapparent or mild disease but a small percentage will develop polio. To successfully eliminate the disease, it is important that experts monitor both the virus’ transmission and the characteristics of people who have contracted the disease.
There are two aspects of surveillance. Within the global initiative, the gold standard for surveillance is the monitoring of cases of acute flaccid paralysis, or weakness in the limbs, in children under 15. Once this is picked up, further investigation needs to be done in the immediate community.
But in regions where surveillance for acute flaccid paralysis is either low or absent, alternate surveillance is needed. Here, environmental surveillance must be applied at sites where the virus is suspected to persistently circulate or can be reintroduced. This entails monitoring the sewage in high-density urban populations.
The benefit of this strategy was seen in 2013 when wild poliovirus was detected in the sewage in southern and central Israel and the West Bank. No cases of polio were reported but the poliovirus found was related to viruses present in Egypt and Pakistan. This early warning prompted an additional immunisation programme to prevent a potential outbreak of polio.
Towards the end goal
Until 2018, there will be continuous environmental surveillance of the poliovirus in the polio-endemic areas of Pakistan, Afghanistan and the recently-cleared Nigeria. Virologists will try to identify residual transmission and new importations. They will also monitor the switch from the vaccine that treats all three wild polioviruses to the one which treats only two. The third has been eradicated.
This strategy provides an important passive and non-invasive supplementary surveillance system to monitor circulating polioviruses in non-endemic countries and countries still using oral polio vaccines. This was shown in Israel.
Eliminating polio worldwide is achievable. But the success or failure of the global initiative depends on political and social will and adequate funding.
Since 1988, more than $9 billion has been invested into the global polio eradication initiative. Although more money is needed for the plan to be implemented until 2018, donor fatigue and anti-vaccine movements, such as those in Nigeria and Pakistan, could derail the process. This could cause a public health crisis.
But with adequate immunisation and the surveillance of both acute flaccid paralysis and the environmental factors, the polio-free status of the non-endemic countries can be maintained. This will also ensure that the transmission of polio in endemic countries is identified and interrupted.
--------------------------------------------------------------------------------
"Eradicating polio menace in Nigeria"
Written By
Eloke Onyebuchi.
Public Health Specialist.
http://www.vanguardngr.com/2013/03/eradicating-polio-menace-in-nigeria/

Tuberculosis: The things you need to know about the disease caused by a bacterium called Mycobacterium tuberculosis, very fatal as it usually attack the lungs.

 By

Eloke Onyebuchi

Public Health Specialist/Principal Consultant.

Description of Tuberculosis

Tuberculosis, often referred to as TB, is a curable infectious disease caused by the tubercle bacillus - also known as Mycobacterium tuberculosis or M. tuberculosis. 'Mycobacterium' means spore-like bacteria. TB bacilli have a thick waxy coat, are slow growing and can survive in the body for many years in a dormant or inactive state whereby people are infected but show no signs of TB disease. When the bacilli are awake and dividing people are said to have 'active TB'. TB can affect any part of the body but is most common in the lungs and lymph glands. People with active TB affecting the respiratory tract can infect others but not all people with respiratory TB are infectious. Other forms of TB e.g. lymph or bone are not infectious. The microscopic bacillus hitches a lift on an aerosol of tiny droplets of mucus and saliva produced when an infectious person talks, coughs or sneezes - others then inhale these droplets. In poorly ventilated areas the bacillus can remain suspended for several hours. Most people who get TB have had a prolonged exposure to an infectious person - usually someone in the same household. It is extremely rare for children with TB disease to be infectious - children get TB from adults with active respiratory TB (HPA).

The majority of TB contacts experience nothing. Studies have demonstrated that only about 30% of healthy people closely exposed to TB will get infected and of those only 5%-10% will go on to develop TB disease. Young children exposed to TB are more likely to develop disease than healthy adults. What happens to the TB bacilli once in the lung is largely determined by individual immune response - 70% of healthy TB contacts will completely eradicate the bacilli and show no signs of infection, the remainder will become infected and have a positive reaction to a skin test. For the 5%-10% who go on to develop TB disease the risk is greatest within the first 5 years following infection. A small number of people who become infected develop what is called primary disease, usually within 8 weeks of exposure. This can pass unnoticed and usually resolves without treatment leaving a small scar on the lung and surrounding lymph nodes that can be seen by chest X-ray. Children are more likely to develop primary disease than adults. If the immune system cannot kill or contain the bacilli they multiply resulting in damage to the surrounding tissues. TB bacilli can live in almost any part of the body so the effects are extremely varied depending on the site of disease (WHO; HPA).

Tuberculosis is diagnosed by contact tracing, this is done by looking for source of contact; screening suspects with Monteux or heaf test or by passive method – clinical presentation. Most undeveloped countries with inadequate funds use sputum smear microscopy for diagnosis. This is because it is fast, cheap, realistic and receptive to patients with complex pulmonary TB, even though it is not receptive to those with early or extra pulmonary TB (Dines, etal., 2007). TB can be prevented by Bacillus Calmette Guerin (BCG) immunisation. This vaccine increases the body immunity and protects against the most severe forms of the disease known as TB meningitis. At extreme cases, TB can be treated with a chemoprophylaxis like Rifampin, Isoniazid, or Rifampin plus pyrazinamide depending on the immunity of the patients.

Global Epidemiology

Throughout the nineteenth and early twentieth century TB was rife in the cities of Europe and North America - London and New York were two of the worst affected cities. TB in the England, and other industrialised nations, declined rapidly last century but never went away. Today, an estimated one third of the world's population - nearly two billion people - is infected. Nine million people a year develop the active disease and nearly two million die - one TB death every twenty seconds.

TB was declared a global health emergency by the World Health Organization in 1993. Nearly all countries in the world are now affected by the global resurgence of TB caused primarily by increasing poverty and poor access to health services, migration and HIV, overcrowding (WHO; HPA; Walls, T., and Shingadia, D., 2003).

Evidence based studies show that about 15 million people infected with HIV also suffer from tuberculosis and out of the 3 million HIV deaths in 2003, 600,000 were traced to tuberculosis (WHO, 2005; Hernandez, etal., 2008).

           

                     Table 1.   TB case notification rates, 1990–2007

Region	1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007
Africa America Eastern Mediterranean Europe South East Asia Western Pacific	82    78      80   75     96     86      97       97      108   115   117   126   143   150   160     157     161  158  32    34      34  22     31      33     32        32       32     29     28     27     27     26     27       26      25     24 61     80      27  49     28      28     33        30       50     36     29     34     38     40      45        54     59     68 29     27      29  28     28      33      37       41        40     43     43     42     43     41     40         41     41     39 131  131     97  93     92      97    100       88         84     95     90     89     92     94    101       105  112  115 59    50      49  46     46       51      54        53        50     49      47     47     47     57     67        73    75     77
Global	71   69       57  55    56        59      63       60         61      63     61      62     65    69     75        79    82     84

Rates are per 100 000 population. From 1995 on, number shown is notification rate of new and relapse cases.                                 Source: WHO, 2009.

Data from WHO indicates an increase in TB cases from 9.3 million in 2007 to 9.4 million in 2008 as a result of poverty and increase in population. Out of the 9.4 million in 2008, 1.2 – 1.6 million were HIV/AIDS positive. 78% of the HIV – positive TB cases was in Africa and 13% were in South East Asia. In the same 2008, 11.1 million prevalent cases of TB were reported, comparable to 164 cases per 100,000 populations. The data indicated that majority of TB cases occurred in India (55%), Africa (30%), with significant but little size of the cases occurring in the Eastern Mediterranean Region (7%), European Region (5%), and Americans (3%). 22 Countries with high burden of TB cases ranked by WHO according to their high incidence of TB accounted 80% of all cases worldwide. The first five of these countries according to incident cases are India (1.6 – 2.4 million),China (1.0 – 1.6 million), South Africa (0.38 – 0.57 million) and Indonesia (0.34 – 0.52 million). The first two among the five countries accounted for 35% of cases globally (WHO, 2009).

Research has shown that three factors was responsible for re – emergence of tuberculosis and they are drug – resistant TB, co – infection with HIV and lack of appropriate access to medical care due to social and economic deprivation (Gandy, M., and Zumla, A., 2002). In 2007, 27 countries were reported to have accounted 85% of multidrug resistant tuberculosis (MDR – TB). 15 of the 27 countries were from the European countries and an estimate of 500,000 MDR – TB was reported globally with India (131,000), reporting the highest MDR – TB cases worldwide  and 57 countries reporting a case of XDR – TB (WHO, 2009).

Evidence from WHO indicate that out of the 1.3 million deaths occurred in 2008, 0.5 million deaths occurred in women with HIV negative incidence cases of TB. The same goes for HIV positive TB deaths which was estimated to be 0.5 million. The report shows that the addition of the number of deaths of both HIV – negative and positive people is liken to 28 deaths per 100,000 populations (WHO, 2009).

Statement of the problem in England

Tuberculosis resurgence in England over the last ten years swelled by 25% and is still growing as 1700 cases occur each year more than in the late eighties when the disease is at its lowest. Tuberculosis in England is more common among inner city inhabitants as evidence based studies show that every two out of five cases occur in London (DH, 2004). This is because most cases in England are as a result of high immigrants, overcrowding and homelessness. Evidence based studies show that most TB patients in England were born abroad (Crofts, etal., 1991; Breathnach, etal., 1998; HPA, 2003; DH, 2004; Ohkado, etal., 2004).This is because people are at risk of TB if they have lived in parts of the world where the disease is common. TB follows a pattern of migration and it is therefore more common in certain ethnic groups especially if they were born abroad. Research has shown that the burden of TB in England is concentrated on Multi – drug resistant tuberculosis, hard to reach population and innovations for new vaccines. Co – infection with HIV is found to be fairly small in England compared to other developing countries of the world like India. Evidence show that 3% of people with TB are HIV positive in England (DH, 2004). 

                                        Table 2: Tuberculosis case report in England, 2000 – 2008

Year	Number of cases	Rates (per 100,000)
2000	6075	12.3
2001	6296	12.7
2002	6296	12.7
2003	6691	13.4
2004	7011	14.0
2005	7763	15.4
2006	7828	15.4
2007	7736	15.1
2008	7970	15.5

                                                        Adapted from (HPA).

                   Figure 1. Tuberculosis case rates by place of birth and ethnic group, England, 2002-2008

                                                     Source: (HPA)

Hard to reach populations include the homeless (those without permanent accommodation, sofa surfers, hostel accommodation), mobile travellers, alcohol and drug users, migrants and those with minimal income or educational levels (NHS, 2010).These people are easily affected by the disease because of their inconsistency in adhering to TB screening, treatment and  loss to follow up. Evidence show that these factors increases risk of TB infection, discontinuation of regimen, chances of MDR – TB and co – infection with HIV. These factors underline the reasons why management of Tb in hard to reach populations are very difficult due to lack of basic information and history about them. A report from NHS quoted a survey in London which stated that hard to reach population estimates 17% of TB cases in London, half of MDR – TB and uncompleted regimen (NHS, 2010).

However, global research for a new vaccine is a good development to end the threat that tuberculosis poses to the world. Bacille Calmette – Guerin (BCG) has been effective in protecting people against tuberculosis as it is a live attenuation of mycobacterium bovis – a strain that causes Tuberculosis. Irrespective of the success that this vaccine has registered in the last century, it is also a threat to tuberculosis management. Studies have shown that long time usage of BCG vaccine against TB has proven successful (NHS 2010; Antas and Castello – Branco, 2008) and has been a platform for development of new vaccine after the discovery of the demographic factors that have affected BCG in the last century (Antas and Castello – Branco, 2008). Present innovation for new vaccine involves changing the widely used BCG vaccine with an improved recombinant version of cellular CD8+ T cell response or with the real strain of the causative organism itself and increasing the immunity with a virally vectored vaccine. An NHS evidence report stated that “Several such candidate vaccines are now being evaluated in clinical trials, including Modified Vaccinia virus Ankara (MVA) expressing Ag85A (MVA85A); Adenovirus expressing antigen 85A, B and TB10.4; and a fusion protein of two antigens, M72 with adjuvant. One of the factors most hampering TB vaccine developments is the lack of a validated immunological correlate of protection. A strong cell mediated immune response is required for protection, and certain cytokines such as interferon gamma and tumor necrosis factor alpha are essential. However simple measurement of the levels of these cytokines has not been found to correlate with protection. At present the only way the efficacy of the new generation of TB vaccines can be evaluated is in large, expensive and time consuming Phase Iib/ Phase III efficacy trials in high incidence populations within TB endemic countries. The first of these new generation vaccines has now entered into efficacy testing, and although there are many challenges in the development of a new TB vaccine, there is optimism within the field that considerable progress has been made over the last 10 - 15 years" (NHS, 2010).