State-of-the-Art Tuberculosis Prevention

Abstract

Tuberculosis (TB) is a preventable and treatable disease. Institutions that diagnose and treat clinical cases are trying, by isolating their cases, to prevent transmission in order to assure safety in the workplace for their health-care workers and other patients. Cohen et al (see page 420) have shown in this issue of CHEST that by utilizing what could be called “a high index of suspicion” based on easily attainable clinical information on potential TB patients, one can, with a reasonable level of confidence make an informed prediction about the presence or absence of sputum positivity, and thus, infectivity. This schema along with recent recommendations from the CDC1Centers for Disease Control and Prevention. Guidelines for preventing the transmission of Mycobacterium tuberculosis in healthcare facilities 1994. MMWR 1994; 43(No. RR-13):1-132Google Scholar are designed to contribute to early diagnosis, early treatment, and thus prevention of transmission. Each published report of TB transmission, or study designed to reduce TB transmission, raises consciousness about this problem. The challenge is to continue to maintain this consciousness in a responsible manner. Hysteria about TB and its transmission is still pervasive, especially to health-care workers and their unions. TB transmission to a health-care worker is an age old problem, but when it occurs, it should not be considered the “end of the world” but an opportunity for a highly effective intervention. A conversion to a positive Mantoux test merely means that one has recently been infected with the tubercle bacillus, a situation which is, in the overwhelming majority of cases, amenable with a simple, well-characterized, benign treatment. TB infection is a state which is shared with one-third of the world's population.2Comstock GW Cauthen CM Epidemiology of tuberculosis.in: Reichman LB Hershfield ES Tuberculosis: a comprehensive international approach. Marcel Dekker Inc, New York1993: 23Google Scholar However with any documented new TB infection, an individual is, by definition, at preventable high risk for advancement to active TB. The CDC has presented guidelines1Centers for Disease Control and Prevention. Guidelines for preventing the transmission of Mycobacterium tuberculosis in healthcare facilities 1994. MMWR 1994; 43(No. RR-13):1-132Google Scholar designed to foment administrative, engineering, and respiratory protection control for prevention of TB transmission. However, institutional resolve to constructively deal with any employee who has been exposed and/or infected has been seriously lacking. Our colleagues, health-care workers, have presumably joined our profession because of concern for patients and clients. Furthermore, one might suspect that they might be somewhat more sophisticated than the population at large in matters of their own health. We should think that they would deserve, expect, and demand “state-of-the-art” medical care! The only unambiguously current “state-of-the-art” of TB prevention for documented new TB infection is isoniazid preventive therapy. Schemas like those of Cohen et al may be effective as far as they go but no schema can completely eliminate new TB infection in health-care workers. Recently Sorresso et al3Sorresso DJ Mehta JB Harvill LM et al.Underutilization of isoniazid chemoprophylaxis in tuberculosis contacts 50 years of age and older: a prospective analysis.Chest. 1995; 108: 706-711Abstract Full Text Full Text PDF PubMed Scopus (34) Google Scholar and Gonzalez-Rothi4Gonzalez-Rothi RJ Tuberculosis chemoprophylaxis and physicians.Chest. 1995; 108: 596-598Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar depicted the shocking lack of commitment of the medical profession to isoniazid preventive therapy in high risk new infections3Sorresso DJ Mehta JB Harvill LM et al.Underutilization of isoniazid chemoprophylaxis in tuberculosis contacts 50 years of age and older: a prospective analysis.Chest. 1995; 108: 706-711Abstract Full Text Full Text PDF PubMed Scopus (34) Google Scholar or even in themselves. Until we all accept and promote the fact that the control of TB consists of not only identifying, isolating, and treating the infectious case, but also very specific behavior relative to any newly exposed and infected individual (agreeing to take and then taking a full course of preventive therapy), we cannot ever hope to make a dent in TB, and TB will continue to strike fear and hysteria in the health-care worker and his or her community.