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 TB scenarios.

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.