||Beyond four drugs. Public health policy and the treatment
of the individual patient with tuberculosis.
||AME REV RESPIR DIS 1993, 148, 2-5.
Two extremes of the TB propagation cycle taking
place simultaneously in different areas of the United States are
illustrated. One illustration represents hypothetical, ideal epidemiological
conditions wherein the applied TB control measures bring about the
desired cure in the expected timeframe. Actual conditions prevalent
in the US, over the past several decades until recently and still
existent in many areas, have been similar to this scenario. The
other, more complicated diagram illustrates some of the factors
responsible for the current TB resurgence and for the emergence
and transmission of multi-drug resistant organisms in the US. Under
these conditions, lack of health insurance and other barriers to
primary health care often delay the diagnosis of active TB, allowing
longer-term transmission. After diagnosis, many potential barriers
exist to successful therapy including homelessness, financial and
cultural barriers. Patients, not on effective treatment, often transmit
multi-drug resistant TB (MDR-TB) in a variety of settings including
hospitals and clinics, homeless shelters, jails, chronic care facilities
etc. Based on different studies, it was found that among patients
with AIDS under treatment for TB, the time period between infection
and active disease was so short as to preclude treatment. Studies
using genetic finger-printing showed new drug-resistant disease
could result from exogenous infection. Vastly different strategies
and resources are suggested to achieve control in the two different
The TB situation in Massachusetts and two features
of the control efforts are described in detail. The article by Graves
et al (1993) on drug-resistant TB in Puerto Rico is also elaborated.
Based on these two sources, it is urged that four-drug (Isoniazid,
Rifampicin, Ethambutol and Pyrazinamide) initial therapy and universal
drug susceptibility testing be given for all patients. DOT is recommended
for previously treated persons and those living outside Puerto Rico
and the US mainland. A progressive, step-wise, case management approach
to TB treatment, from least to most restrictive, is listed.
|KEYWORDS: HEALTH POLICY; USA.