Disease Control Planning Research Articles

Mortality patterns and the effect of socioeconomic factors on mortality in rural Tamil Nadu, south India: a community-based cohort study

The importance of mortality data for assessing the health status of any population and for planning disease control and health promotional interventions is well established. A population-based cohort study was conducted in Kaniyambadi Block, a rural block in North Arcot District in Tamil Nadu, India, with a population of approximately 120,000 people living in 88 villages. The mortality rates, patterns and effect of socioeconomic factors on mortality were studied. The overall incidence of mortality in the study cohort was 7.3/1000 person-years, with higher rates of mortality among men than women. People with low socioeconomic status (SES) had almost two-fold higher mortality rates across all age groups compared with people with high SES. Deaths due to injuries and other external causes contributed 23.0% of all deaths, among which the low socioeconomic group had 56% excess cause-specific mortality compared with the high socioeconomic group. Standardised mortality ratios indicated that the low socioeconomic group had 25% excess mortality compared with the overall standard mortality. This study clearly shows that the low SES group had a significantly higher incidence of mortality due to all causes and among all age groups.

Using the SaTScan method to detect local malaria clusters for guiding malaria control programmes.

BackgroundMpumalanga Province, South Africa is a low malaria transmission area that is subject to malaria epidemics. SaTScan methodology was used by the malaria control programme to detect local malaria clusters to assist disease control planning. The third season for case cluster identification overlapped with the first season of implementing an outbreak identification and response system in the area.MethodsSaTScan™ software using the Kulldorf method of retrospective space-time permutation and the Bernoulli purely spatial model was used to identify malaria clusters using definitively confirmed individual cases in seven towns over three malaria seasons. Following passive case reporting at health facilities during the 2002 to 2005 seasons, active case detection was carried out in the communities, this assisted with determining the probable source of infection. The distribution and statistical significance of the clusters were explored by means of Monte Carlo replication of data sets under the null hypothesis with replications greater than 999 to ensure adequate power for defining clusters.Results and discussionSaTScan detected five space-clusters and two space-time clusters during the study period. There was strong concordance between recognized local clustering of cases and outbreak declaration in specific towns. Both Albertsnek and Thambokulu reported malaria outbreaks in the same season as space-time clusters. This synergy may allow mutual validation of the two systems in confirming outbreaks demanding additional resources and cluster identification at local level to better target resources.ConclusionExploring the clustering of cases assisted with the planning of public health activities, including mobilizing health workers and resources. Where appropriate additional indoor residual spraying, focal larviciding and health promotion activities, were all also carried out.

Epidemiologic investigation of the re-emergence of infectious salmon anemia virus in Chile

Reports from surveillance activities were analyzed to determine the epidemiology of the re-emergence of infectious salmon anemia virus (ISAV) in Atlantic salmon farms in Chile. The epidemic and spatial and spatiotemporal patterns were described, taking into account commercial compartmentalization of the farms. During the 64 wk study period, 76 ISAV-infected salmon farms, representing 17 companies, were reported in 65% of the management geographic zones of the 10th region in southern Chile. Approximately 20% of the farms at risk became infected, with the incidence rate increasing slightly over time. Results from epidemic analyses and observed spatial and spatiotemporal patterns suggested an initial dispersal and subsequent clustering of cases around the index case (IC) in a propagated epidemic mode. Results suggested that delayed depopulation may have been a key factor in the spread and persistence of ISAV. Clustering of cases supported the assumption that passive transmission in seawater from ISAV-infected farms (proximity) is a critical factor in controlling disease. The re-emergence of ISAV in Chile has resulted in one of the largest ISAV epidemics reported in the world and this study generates new hypotheses and provides useful information for spatial disease control planning in salmon farming areas.

Syndromic Surveillances based on the Emergency Department

Due to heightened concerns regarding possible bioterrorist attacks, the Korea Center for Disease Control and Prevention introduced syndromic surveillance systems, which have been run by emergency departments in hospitals throughout Korea since 2002. These systems are designed to identify illness clusters before diagnoses are confirmed and reported to public health agencies, to mobilize a rapid response, and thereby to reduce morbidity and mortality. The Korea Center for Disease Control and Prevention performed drop-in syndromic surveillance successfully during the World Cup Football Games in 2002, the Universiad games in 2004, and the Asian Pacific Economic Cooperation meeting in 2005. In addition, sustainable syndromic surveillance system involving the collaborative efforts of 125 sentinel hospitals has been in operation nationwide since 2002. Because active data collection can bias decisions a physician makes, there is a need to generate an automatic and passive data collection system. Therefore, the Korea Center for Disease Control and Prevention plans to establish computerized automatic data collection systems in the near future. These systems will be used not only for the early detection of bioterrorism but also for more effective public health responses to disease.

Modelo agrometeorológico regional para estimativa da severidade da mancha de Phaeosphaeria em milho safrinha no Estado de São Paulo, Brasil

O milho safrinha, cultivado no outono-inverno, no Estado de São Paulo, tem apresentado com freqüência significativas reduções de produtividade devidas à mancha foliar de Phaeosphaeria. Como estratégia para minimizar esses danos, os modelos agrometeorológicos de previsão de doenças podem auxiliar no planejamento e na tomada de decisões para o controle da doença na cultura. Dessa forma, este trabalho tem como objetivo o desenvolvimento e teste de modelos agrometeorológicos para previsão da porcentagem da área foliar afetada pela doença (%AFA) em função do acúmulo diário de temperatura média e de chuva, em escala regional. Para tanto, foram utilizadas informações sobre a severidade da mancha de Phaeosphaeria em 158 cultivares de milho com diferentes níveis de resistência, durante a safrinha, em 14 diferentes localidades do Estado de São Paulo. Modelos foram desenvolvidos para cultivares suscetíveis, moderadamente resistentes e resistentes e os resultados indicaram haver boa performance na estimativa da %AFA, com altos valores de coeficiente de determinação (0,92; 0,81 e 0,83 respectivamente) e índice de concordância de Willmott (0,98; 0,87; 0,94 respectivamente), além de teste F significativo a 1% de probabilidade para todos os casos. Os resultados também permitiram sugerir que a chuva e a temperatura são os fatores preponderantes para a ocorrência da mancha de Phaeosphaeria no Estado de São Paulo. Esses modelos têm a vantagem de utilizar variáveis usualmente obtidas em estações meteorológicas e poderão ser empregados em sistemas de alerta fitossanitários para monitoramento da doença no Estado.

Mosquito Species (Diptera: Culicidae) and the Transmission of Ross River Virus in Brisbane, Australia

This study aimed to identify the major mosquito vectors of Ross River virus (family Togaviridae, genus Alphavirus, RRV) and to explore the threshold of mosquito abundance necessary for RRV transmission in Brisbane, Australia. Data on the monthly counts of RRV cases by statistical local areas from the Queensland Health and the monthly mosquito abundance in Brisbane between November 1998 and December 2001 from the Brisbane City Council were used to assess the pairwise relationship between mosquito abundance and the incidence of RRV disease over a range of time lags using cross-correlations. We used time series Poisson regression models to identify major mosquito species associated with incidence of RRV after adjusting for overdispersion, maximum temperature, autocorrelation, and seasonality. Our results show that Aedes vigilax (Skuse) (relative risk [RR] = 1.32; 95% CI = 1.01-1.74 per 100 mosquitoes per trap) and Culex annulirostris (Skuse) (RR = 1.14, 95% CI = 1.04-1.24 per 100 mosquitoes per trap) were most strongly associated with RRV transmission at a lag of 1 mo. Classification and regression tree (CART) analyses indicate that the occurrence of RRV was associated with an average monthly mosquito abundance ofAedes vigilax above 72 and Cx. annulirostris above 52. The validation analyses indicate that the crude agreement between predicted values and actual observations was 76% (sensitivity, 61%; specificity, 80%). The results may have applications as a decision support tool in planning disease control and risk-management programs.

Mosquito Species (Diptera: Culicidae) and the Transmission of Ross River Virus in Brisbane, Australia

Abstract This study aimed to identify the major mosquito vectors of Ross River virus (family Togaviridae, genus Alphavirus, RRV) and to explore the threshold of mosquito abundance necessary for RRV transmission in Brisbane, Australia. Data on the monthly counts of RRV cases by statistical local areas from the Queensland Health and the monthly mosquito abundance in Brisbane between November 1998 and December 2001 from the Brisbane City Council were used to assess the pairwise relationship between mosquito abundance and the incidence of RRV disease over a range of time lags using cross-correlations. We used time series Poisson regression models to identify major mosquito species associated with incidence of RRV after adjusting for overdispersion, maximum temperature, autocorrelation, and seasonality. Our results show that Aedes vigilax (Skuse) (relative risk [RR] = 1.32; 95% CI = 1.01–1.74 per 100 mosquitoes per trap) and Culex annulirostris (Skuse) (RR = 1.14, 95% CI = 1.04–1.24 per 100 mosquitoes per trap) were most strongly associated with RRV transmission at a lag of 1 mo. Classification and regression tree (CART) analyses indicate that the occurrence of RRV was associated with an average monthly mosquito abundance of Aedes vigilax above 72 and Cx. annulirostris above 52. The validation analyses indicate that the crude agreement between predicted values and actual observations was 76% (sensitivity, 61%; specificity, 80%). The results may have applications as a decision support tool in planning disease control and risk-management programs.

Development of novel strategies to control foot-and-mouth disease: Marker vaccines and antivirals

Foot-and-mouth disease (FMD) is economically the most important viral-induced livestock disease worldwide. The disease is highly contagious and FMD virus (FMDV) replicates and spreads extremely rapidly. Outbreaks in previously FMD-free countries, including Taiwan, the United Kingdom, and Uruguay, and the potential use of FMDV by terrorist groups have demonstrated the vulnerability of countries and the need to develop control strategies that can rapidly inhibit or limit disease spread. The current vaccine, an inactivated whole virus preparation, has a number of limitations for use in outbreaks in disease-free countries. We have developed an alternative approach using a genetically engineered FMD subunit vaccine that only contains the portions of the viral genome required for virus capsid assembly and lacks the coding region for most of the viral nonstructural (NS) proteins including the highly immunogenic 3D protein. Thus, animals inoculated with this marker vaccine can readily be differentiated from infected animals using diagnostic assays employing the NS proteins not present in the vaccine and production of this vaccine, which does not contain infectious FMDV, does not require expensive high-containment manufacturing facilities. One inoculation of this subunit vaccine delivered in a replication-defective human adenovirus vector can induce rapid, within 7 days, and relatively long-lasting protection in swine. Similarly cattle inoculated with one dose of this recombinant vector are rapidly protected from direct and contact exposure to virulent virus. Furthermore, cattle given two doses of this vaccine developed high levels of FMDV-specific neutralizing antibodies, but did not develop antibodies against viral NS proteins demonstrating the ability of FMD subunit vaccinated animals to be differentiated from infected animals. To stimulate early protection prior to the vaccine-induced adaptive immune response we inoculated swine with the antiviral agent, type I interferon, and induced complete protection within 1 day. Protection can last for 3–5 days. The combination of the FMD marker vaccine and type I interferon can induce immediate, within 1 day, and long-lasting protection against FMD. Thus, this combination approach successfully addresses a number of concerns of FMD-free countries with the current disease control plan. By rapidly limiting virus replication and spread this strategy may reduce the number of animals that need to be slaughtered during an outbreak.

Implementing the World Health Organization Global Strategy on Diet, Physical Activity and Health

The World Health Organization (WHO) Global Strategy on Diet, Physical Activity and Health (DPAS) was adopted by the World Health Assembly in May 2004 (Resolution 57.17). Implementing DPAS is challenging because current investment in chronic disease prevention and control at national and international levels seriously lags behind what is required, and variable levels of political commitment lead to a limited capacity to respond effectively. Nevertheless, WHO Resolutions are valuable advocacy tools and, thus, DPAS presents a golden opportunity to develop national chronic disease prevention and control policies, plans and programmes where none exists, or to strengthen existing national responses where these are already in existence. WHO is also using the opportunity to engage all stakeholders in aligning their plans and activities with the objectives of DPAS. Non-governmental organizations, the Codex Alimentarius Commission, relevant WHO Collaborating Centres and the private sector (especially the food and non-alcoholic beverage drinks manufacturers and advertisers) are particularly important. Some activities are undertaken at the global level, e.g. interactions with Codex, and others are undertaken at the regional office level, e.g. providing technical support to countries. A critical aspect of the implementation process involves the production of suitable tools - guidelines, frameworks, protocols and good practice models - in a range of areas, to assist member states with the implementation of DPAS.

Implementing the World Health Organization Global Strategy on Diet, Physical Activity and Health

The World Health Organization (WHO) Global Strategy on Diet, Physical Activity and Health (DPAS) was adopted by the World Health Assembly in May 2004 (Resolution 57.17). Implementing DPAS is challenging because current investment in chronic disease prevention and control at national and international levels seriously lags behind what is required, and variable levels of political commitment lead to a limited capacity to respond effectively. Nevertheless, WHO Resolutions are valuable advocacy tools and, thus, DPAS presents a golden opportunity to develop national chronic disease prevention and control policies, plans and programmes where none exists, or to strengthen existing national responses where these are already in existence. WHO is also using the opportunity to engage all stakeholders in aligning their plans and activities with the objectives of DPAS. Non-governmental organizations, the Codex Alimentarius Commission, relevant WHO Collaborating Centres and the private sector (especially the food and non-alcoholic beverage drinks manufacturers and advertisers) are particularly important. Some activities are undertaken at the global level, e.g. interactions with Codex, and others are undertaken at the regional office level, e.g. providing technical support to countries. A critical aspect of the implementation process involves the production of suitable tools - guidelines, frameworks, protocols and good practice models - in a range of areas, to assist member states with the implementation of DPAS.

DEVELOPMENT OF A PREDICTIVE MODEL FOR ROSS RIVER VIRUS DISEASE IN BRISBANE, AUSTRALIA

This paper describes the development of an empirical model to forecast epidemics of Ross River virus (RRV) disease using the multivariate seasonal auto-regressive integrated moving average (SARIMA) technique in Brisbane, Australia. We obtained computerized data on notified RRV disease cases, climate, high tide, and population sizes in Brisbane for the period 1985-2001 from the Queensland Department of Health, the Australian Bureau of Meteorology, the Queensland Department of Transport, and Australian Bureau of Statistics, respectively. The SARIMA model was developed and validated by dividing the data file into two data sets: the data between January 1985 and December 2000 were used to construct a model, and those between January and December 2001 to validate it. The SARIMA models show that monthly precipitation (beta = 0.004, P = 0.031) was significantly associated with RRV transmission. However, there was no significant association between other climate variables (e.g., temperature, relative humidity, and high tides) and RRV transmission. The predictive values in the model were generally consistent with actual values (root mean square percentage error = 0.94%). Therefore, this model may have applications as a decision supportive tool in disease control and risk-management planning programs.

Planning a Mass Vaccination Exercise Using Influenza Vaccine in Grand Forks, North Dakota

ISSUE: Communities and healthcare organizations are preparing for bioterrorism and biological events. Plans include mass distribution of pharmaceuticals. The 2005 Joint Commission requirements include preparation to respond to epidemics or infections that can overwhelm organizational resources. PROJECT: A North Dakota Department of Health grant allowed the Northeast Biological Planning Coalition to adapt the Greater Grand Forks (GF) community's mass vaccination plan to an exercise administering free influenza vaccine to the public. Participating agencies included: GF Public Health, Altru Health System, Alerus Center, United Way, GF County Sheriff's Department, University of North Dakota, City of GF Public Information Office, GF Fire Department, GF Air Force Base, GF Police Department, GF County Social Services, UND Family Practice, Red Cross, and the Regional Bioterrorism Coordinator. The exercise was named MAXVAX. The Center for Disease Control and Prevention's (CDC) Smallpox Response Plan and Guideline was used to calculate the number of vaccinees and workers needed to simulate the scenario of immunizing 70,000 people in 10 days. The MAXVAX goal was to give 1750 people influenza vaccine in 4 hours. The venue was the 447,000-sq.-ft. Alerus Center. One-hundred-twenty volunteers were identified. A media campaign invited the public to be vaccinated. RESULTS: Although final plans were in place, the event was cancelled on short notice due to the unexpected shortage of flu vaccine in December 2003. LESSONS LEARNED: An exercise will identify weaknesses in written bioterrorism plans. Weaknesses that we identified include: event communication plans, volunteer management, security, and accommodating persons with special needs and homebound persons. Implementation of community emergency plans requires cooperation between many agencies.

Perspectives on emerging zoonotic disease research and capacity building in Canada.

Zoonoses are fundamental determinants of community health. Preventing, identifying and managing these infections must be a central public health focus. Most current zoonoses research focuses on the interface of the pathogen and the clinically ill person, emphasizing microbial detection, mechanisms of pathogenicity and clinical intervention strategies, rather than examining the causes of emergence, persistence and spread of new zoonoses. There are gaps in the understanding of the animal determinants of emergence and the capacity to train highly qualified individuals; these are major obstacles to preventing new disease threats. The ability to predict the emergence of zoonoses and their resulting public health and societal impacts are hindered when insufficient effort is devoted to understanding zoonotic disease epidemiology, and when zoonoses are not examined in a manner that yields fundamental insight into their origin and spread.EMERGING INFECTIOUS DISEASE RESEARCH SHOULD REST ON FOUR PILLARS: enhanced communications across disciplinary and agency boundaries; the assessment and development of surveillance and disease detection tools; the examination of linkages between animal health determinants of human health outcomes; and finally, cross-disciplinary training and research. A national strategy to predict, prevent and manage emerging diseases must have a prominent and explicit role for veterinary and biological researchers. An integrated health approach would provide decision makers with a firmer foundation from which to build evidence-based disease prevention and control plans that involve complex human/animal/environmental systems, and would serve as the foundation to train and support the new cadre of individuals ultimately needed to maintain and apply research capacity in this area.

A descriptive study of human Salmonella serotype typhimurium infections reported in Ontario from 1990 to 1998.

Salmonella infections cause gastrointestinal and systemic diseases worldwide and are the leading causes of food-borne illnesses in North America (1-4). Salmonella serotype typhimurium (ST), in particular, is increasingly becoming a major public health concern because of its ability to acquire multiple resistant genes (5,6). To describe demographic, temporal and geographical distributions, and reported risk factors of nonoutbreak cases of ST reported to a surveillance system in Ontario. Descriptive analyses were performed on data on salmonellosis cases reported in Ontario between 1990 and 1998. Direct age- and sex-standardized rates were computed, and temporal trend analyses were performed using simple linear regression and a general additive model with a locally weighted regression (LOESS) smoother. The mean annual rates of infections with all Salmonella serotypes and with ST were 27 cases per 100,000 persons and 3.7 cases per 100,000 persons, respectively. Males and children under five years of age had significantly higher rates of both ST and ST definitive type 104 (DT104) infections. There was also evidence of temporal clustering of all strains of Salmonella, with significantly more cases being reported during the summer. Significantly higher rates of ST DT104 were observed in urban areas compared with rural areas, suggesting potential differences in the geographical distribution of risk factors. Information on demographic, temporal and geographical distributions, and risk factors is critical in planning disease control strategies. Further prospective analytical observation studies are needed to gain a better understanding of the epidemiology of ST and ST DT104 in Ontario, which will better guide disease control decisions.

Raccoon and Skunk Population Models for Urban Disease Control Planning in Ontario, Canada

Population data on raccoon (Procyon lotor) and striped skunk (Mephitis mephitis), collected between 1987 and 1996 in the city of Scarborough (Ontario, Canada), were used to develop spatially explicit population models for use in disease control planning. The objective of model development was to: (1) provide a standard analytical method to identify areas of high-density raccoon and skunk subpopulations within cities, and (2) to identify those subpopulations predicted to function as sites of high dispersal (either into or out of subpopulations). These areas could be targeted in disease control programs. The models combined landscape map data with a stochastic, age-structured population model, which incorporated habitat-specific demographic data and functions relating to animal dispersal. Using this approach, the assemblage of raccoons and skunks inhabiting Scarborough was modeled as occupying discrete subpopulations linked by dispersal (i.e., a metapopulation). The landscape data used in this study were derived from classified LANDSAT satellite imagery data. Population data were derived from the literature and from trapping data collected within the Scarborough study area. The resulting models depicted metapopulations containing 7432 ± 1529 raccoons (mean ± 1 sd) distributed throughout eight subpopulations, and 533 ± 125 skunks distributed throughout 10 subpopulations. Raccoon density within subpopulations ranged from 37 to 94 animals/km2. Skunk density within subpopulations ranged from 6.4 to 12.6 animals/km2. Five raccoon subpopulations and one skunk subpopulation were predicted to stabilize at high relative population densities (>125% carrying capacity), implying that these subpopulations were functioning as net importers of dispersing animals. As such, these subpopulations were at higher risk of being sites of rabies outbreaks than surrounding subpopulations, owing to their high population densities and greater likelihood of receiving infected individuals. In contrast, one raccoon subpopulation stabilized at low relative population density and therefore appeared to be functioning as a net exporter of dispersing animals. The disease control implications of these findings are discussed.

RACCOON AND SKUNK POPULATION MODELS FOR URBAN DISEASE CONTROL PLANNING IN ONTARIO, CANADA

Population data on raccoon (Procyon lotor) and striped skunk (Mephitis mephitis), collected between 1987 and 1996 in the city of Scarborough (Ontario, Canada), were used to develop spatially explicit population models for use in disease control planning. The objective of model development was to: (1) provide a standard analytical method to identify areas of high-density raccoon and skunk subpopulations within cities, and (2) to identify those subpopulations predicted to function as sites of high dispersal (either into or out of subpopulations). These areas could be targeted in disease control programs. The models combined landscape map data with a stochastic, age-structured population model, which incorporated habitat-specific demographic data and functions relating to animal dispersal. Using this approach, the assemblage of raccoons and skunks inhabiting Scarborough was modeled as occupying discrete subpopulations linked by dispersal (i.e., a metapopulation). The landscape data used in this study were de...

A World Wide Web-Based Health Resource

Two hundred ninety-two school nurses in Missouri participated in a mailed survey to aid in the design of SchoolhealthLink, a World Wide Web (WWW)-based information service for Missouri school nurses and children. The nurses identified specific health information resources likely to benefit school nurses and school children and prioritized these resources. The school nurses assigned high priority to 11 types of health information resources: individualized health care plans, emergency care plans, communicable disease control plans, acute illness, injuries, communicable diseases, hotline numbers, medications in schools, immunization protocols and standards, community-based health care resources, and Department of Elementary and Secondary Education regulations that affect school nurse practice. The four most common health problems school nurses identified were asthma, attention deficit disorder, diabetes, and head lice. SchoolhealthLink will provide a one-stop WWW-based resource for school nurses and school children.

The study of human behavior and schistosomiasis transmission in an irrigated area in Morocco

This paper presents a research strategy for studying water contact, water use and schistosomiasis transmission in an irrigated area of Morocco. This setting, with many scattered water contact sites, many activities carried out at these sites, and the small number of people involved, was not appropriate for a conventional water contact study based on the observation of water contact sites, such as had been carried out in the Nile delta. The Moroccan study utilizes three related concepts: the household, time geography, and the gendered use of space. It seeks to understand processes and interrelationships underlying the daily mobility pattern of individual households, and seen as part of a larger system of organization and structure in time and space. The preliminary results of the study indicated the complexity and dynamism of water use and water contact, which need to be considered in planning disease control strategies especially in changing settings, such as those associated with environmental interventions in the study area.

Simulation of the transmission of Salmonella enteritidis phage type 4 in a flock of laying hens.

Simulation of disease transmission in laying flocks infected with Salmonella enteritidis phage type 4 over a 48-week egg-production period indicated that the maximum weekly incidence risk could range from 0.05 to 0.28, and the maximum proportion of culture-positive birds could range from 0.20 to 0.77 of the flock, depending on the effective contact rate. If the egg contamination proportion were 0.08, contaminated egg production could vary from a weekly maximum of 0.42 per cent to 2.24 per cent depending on the effective contact rate, but the actual rate of contamination was more important in determining the numbers of infected eggs produced. The results from previous studies suggest that this proportion could range from 0.075 to 0.25. The model produced levels of infected and immune birds similar to those reported in the literature, suggesting effective contact rates of between 2 and 4.5. There is insufficient information on transmission cycles to validate the model, but it does provide a mechanism for consolidating research findings, reviewing areas for further research, and aiding more effective planning for disease control.

Compliance, coercion, and compassion: moral dimensions of the return of tuberculosis.

Since 1986, we have seen a rise in the occurrence of tuberculosis in the United States. Long considered defeated in this country, the disease is returning with distressing vigor. Outbreaks of MDR-TB, tuberculosis resistant to more than one medication, have been reported around the country. This article analyzes the Centers for Disease Control and Prevention's National Action Plan to Combat Multidrug-Resistant Tuberculosis, with particular focus on the moral dimensions of mandatory directly observed treatment (DOT) and involuntary quarantine. It is proposed that a moral response to the control of tuberculosis must be one which is sustainable and which can effectively curtail the spread of the disease at a minimal cost to individual rights.