Management of Tuberculosis: Special Considerations
The treatment and prevention of tuberculosis have gained importance as the number of cases continues to increase worldwide and the ability of the disease to pass from one area to another becomes progressively greater. Interventions used in the US to help control the disease include the identification of latently infected individuals through the use of skin testing, the use of chemoprophylaxis to prevent subsequent activation of latent disease, and the prompt identification and treatment of individuals with active disease. In other countries, the widespread use of Bacille Calmette Guerin (BCG) vaccination seems to be effective in preventing some serious forms of the disease: best estimates gauge its overall effectiveness at 50% in preventing active infection. Additional studies of the efficacy of BCG or an improved vaccine are much needed. The problems of compliance with treatment for active disease, even for short-course regimens, seem to be universal, and many experts have suggested the use of directly observed therapy. The process itself has not been rigorously studied, but there are a number of descriptive, comparative and modelling studies that seem to indicate its effectiveness. In particular, the studies including the use of lay community supervisors demonstrate possible cost effectiveness even in poorer countries. Given the scope of the problem of compliance and its impact on antibacterial resistance and transmission of infection, directly observed therapy seems to be a very reasonable approach and one that may be very cost effective from various perspectives.
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