Health Care Delivery

Better use of available TB prevention strategies will be needed to eliminate the disease by the year 2010

Tuberculosis (TB) rates rose dramatically in the United States from 1985 to 1992 due to several factors. These include a rise in the number of people infected with the human immunodeficiency virus (HIV), which increases susceptibility to TB, and lack of effective TB control in certain regions of the country. Federal support to control TB led to a steady decline in the number of TB cases in the United States to an all-time low rate of 6.8 per 100,000 in 1998. However, better use of available TB prevention techniques must be made for the national goal of TB elimination (1 case per million people) by the year 2010 to be achieved, concludes a commentary by Timothy F. Brewer, M.D., M.P.H., formerly of Harvard Medical School and now with the London School of Hygiene and Tropical Medicine. Dr. Brewer's work was supported in part by the Agency for Healthcare Research and Quality (National Research Service Award fellowship F32 HS00079).

Dr. Brewer and his colleagues recommend using several available strategies. Prevention should be targeted at populations in which TB remains a threat: children born to HIV-infected mothers, injection drug users, the homeless, and health workers and others exposed to TB patients. TB skin testing and preventive therapy should be expanded for people infected with HIV. Foreign-born individuals who arrive in the country with noninfectious TB should receive followup preventive therapy or treatment, since foreigners accounted for 42 percent of all reported TB cases in the United States in 1998.

Bacille Calmette-Guerin (BCG) vaccine should be considered for HIV-negative people who are at increased risk of TB, including children of HIV-infected mothers. BCG vaccine should also be considered for homeless people and substance abusers. Skin testing and use of preventive therapy are problematic in these groups because of noncompliance or liver toxicity (due to already damaged livers from alcohol or drug abuse) from isoniazid, a key drug for treating TB. A goal should be to increase treatment completion rates from a low of 11 percent in some States to 90 percent. Finally, more costly but cost effective rapid TB culture and identification tests should be used to improve diagnostic accuracy and reduce the time to diagnosis and treatment.

See "New approaches to preventing and eliminating tuberculosis in the United States," by Dr. Brewer, S. Jody Heymann, M.D., Ph.D., and Jennifer P. Stevens, in the January 2000 Infections in Medicine 17, pp. 57-62.

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