Epidemiological mess?

398

Tubercle and Lung Disease

BK strains isolated in our unit have had a similar antibiogram pattern. Chronological data supported the hypothesis that our 2 index cases had acquired tuberculosis in New York. An epidemiological report on nosocomial outbreaks of multidrug-resistant tuberculosis which occurred in New York at the same time further confirms the possibility of nosocomial contamination for them as we11.3 The 2 index cases were confined to their room as soon as the results of the search for acid-fast bacilli at direct examination were obtained. In view of the results of antibiograms, more strict precautions were adopted, including mask wearing for the index patients and nursing staff and strict limitation of visits. During the period over which any 1 of the 3 patients had positive sputum cultures, 53 AIDS patients were hospitalized in the same part of the unit. So far, no newly acquired tuberculosis has developed, either in these patients or among the 20 health care workers exposed. Tuberculin test was not systematically performed because BCG vaccine is universally used in France. Contact in overcrowded inpatient and outpatient facilities and the emergence of multiresistant BK may play an important role in the recent dramatic increase of tuberculosis.’ Tuberculosis is also the main infection that can be transmitted from immunocompromised hosts to health care workers.‘92 The only ways to prevent such a dissemination are early diagnosis, rapid antibiogram results and respiratory isolation precautions. Isoniazid preventive therapy should be promptly implemented among contact subjects, but its efficacy is limited by resistance and by the accelerated progression of newly acquired tuberculosis in immunocompromised patients. Prevention of multidrug-resistant tuberculosis dissemination in AIDS and non-AIDS patients should become a matter of utmost priority for the immediate future. L. Cotte Hepatology and AIDS unit H6pital de 1 ‘H&el-Dieu 1, place de 1 ‘H&pita1 69288 Lyon Cedex 02 France F. Fougerat Mycobacteria Laboratory IiastitutPasteur Lyon France C. Trepo Hepatology and AIDS unit H6pital de 1 ‘Hhel-Dleu and INSERM U 271 Lyon France

References 1. Daley C L, Small P M, Schecter G F et al. An outbreak of tuberculosis

with accelerated

progression

among persons infected

with the human immunodeficiency virus. N Engl. 3 Med 1991; 326: 231-235. 2. Di Perri G, Cruciani M, Danzi M C et al. Nosocomial epidemic of active tuberculosis among HIV-infected patients. Lancet 1989; ii: 1502-1504. 3. Centers for Disease Control. Nosocomial transmission of multidrug-resistant tuberculosis among HIV-infected persons. Florida and New York, 1989-1991. MMWR 1991; 40: 585-591.

Epidemiological mess? Grzybowski’s comment on the treatment aspect of BCG trial in his article ‘Natural history of tuberculosis epidemiology’ as ‘epidemiological mess’, stimulates me to react.‘.’ Being associated with the study as a supervisor of field operations, it is my privilege to share with you my experience of the treatment activity in the study. As is well known, the objective of the study was to find the efficacy of BCG vaccination in prevention of pulmonary tuberculosis. For ethical reasons, it was also decided to put all cases diagnosed in the study on antituberculosis treatment. To provide treatment for the cases nearer to their doors, the existing health infrastructure in the form of the District Tuberculosis Programme (DTP) had to be the only machinery, since it would not have been possible for the BCG project to run parallel specialized centres throughout the area without substantially diluting its resources. Moreover, the exclusively set up project centres for treatment would also have been largely unknown units, not otherwise frequented by the patients. However, it was realized that the additional caseload on the DTP, as a consequence of the project operations, could throw the existing system out of gear, especially in terms of drug supply. Also, its ability to motivate such a large number of patients for treatment could only, in any case, be limited. The Project therefore formulated a special treatment advisory team consisting of a leader and three to four health workers. This team called on each of the diagnosed cases, initially motivated him and gave him a referral slip. He was advised to report to nearest health centre with the slip to receive treatment. A copy of the referral slip containing identification particulars and details of diagnosis was personally handed over by the team to the medical officer concerned, with a request to treat the case on his attending the centre. The project team had also established a good rapport with the community by paying repeated visits to villages. This enabled patients having difficulty in getting treatment to approach the project staff for redressal. Such cases were attended to in priority by the project treatment team. Thus, four important prerequisites for active casefinding and treatment were met under the project, as follows: 1. 2. 3.

Identifying cases at their doorsteps. Arranging treatment nearer their homes. Initial motivation by the project team.

Correspondence

4.

Maintaining a constant respective centres.

supply

of drugs

at the

If in spite of these efforts old diagnosed cases still continued to form two-thirds of the prevalence cases at the survey conducted 12; years later, it could only be attributed to the serious imponderable, i.e. ‘treatment compliance by patients’ affecting treatment efficiency! We now know that only around 30-40% of patients take more than 80% of the treatment prescribed under the DTP. Advocates of specialized programmes often seem not to take into account this aspect of patients’ behaviour which could thwart many a well-intentioned activity! No interventionist approach could bring about a dramatic change in this situation. Long-term socioeconomic evolutions need to take place with time and the gradual emergence of a different pattern! M. S. Krishna Murthy Team Leader Covt of India National Tuberculosis Directorate

Institute

General of Health Services No 8, Bellary Road Bangalore

560 003 India

References I. Tuberculosis Prevention Trial, Madras: Trial of BCG vaccines in South India for tuberculosis prevention, Indian J Med Res 1980; 72 (suppl): l-74. 2. Grzybowski S. Natural history of tuberculosis: epidemiology. Bull Int Union Tuberc Lung Dis 1991; 66: 193-194.

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Reply I am grateful to Mr Krishna Murthy for describing the activities of the epidemiological team in trying to secure treatment for all cases of tuberculosis discovered in the course of the BCG trial in South India. 1 would like to assure him that I consider this epidemiological team to be the best I have ever seen anywhere in the world, and that I realize that their primary task was to assess the efficacy of the BCG vaccine. They have incidentally answered the unasked question of what happens to tuberculosis in the community, if the case-finding is perfect or almost perfect, but the treatment programme is weaker following the National Tuberculosis Programme routine of the time. I agree with him that lack of patients’ compliance was the main reason for the ‘epidemiological mess’ - there were more sources of infection left as the result of treatment than there would have been if nothing had been done. I do not agree with Mr Krishna Murthy, however. that we need to wait for the results of the ‘long-term socioeconomic evolution’ before we can achieve better results; surely adoption of short-course regimens, of intermittent supervised treatment and judicious use of incentives could result in immediate improvement.

Doctor Stefan Grzybowski UBCNGH

Respiratory Division 2775 He&her

Street

Vancouver-BC Canada V5Z3 J.5