To compare alternative methods to ensure completion of treatment and preventive therapy for
tuberculosis (TB) in inner cities, and to identify the most cost-effective methods to
accomplish that. The basis for comparison included adherence rates and cost savings as
primary outcomes, and other parameters such as patient satisfaction, development of social
networks, and participation in support programs as secondary outcomes.
Two clinical trials were conducted with patients from Harlem. Among those with active
disease, a clinic-based surrogate family model was compared to traditional community-based
directly observed therapy (DOT). Among those eligible for preventive therapy, a
community-based intervention conducted by trained graduates of a TB DOT program (peer
workers) was compared to traditional self-administered preventive treatment.
Tuberculosis was on the decline from the mid 1950s until the mid 1980s; however, the United
States is now experiencing a resurgence of tuberculosis. In 1992, approximately 27,000 new
cases were reported, an increase of about 20 percent from 1985 to 1992. Not only are
tuberculosis cases on the increase, but a serious aspect of the problem is the recent
occurence of outbreaks of multidrug resistant (MDR) tuberculosis, which poses an urgent
public health problem and requires rapid intervention.
Control programs involve two major components. First, and of highest priority, is to detect
persons with active tuberculosis and treat them with effective antituberculosis drugs, which
prevents death from tuberculosis and stops the transmission of infection to other persons.
Treatment of active tuberculosis involves taking multiple antituberculosis drugs daily or
several times weekly for at least six months. Failure to take the medications for the full
treatment period may mean that the disease is not cured and may recur. If sufficient
medications are not prescribed early and taken regularly, the tuberculosis organism can
become resistant to the drugs, and the drug resistant tuberculosis then may be transmitted
to other persons. Drug resistant disease is difficult and expensive to treat, and in some
cases, cannot be treated with available medications.
The second major goal of control efforts is the detection and treatment of persons who do
not have active tuberculosis, but who have latent tuberculosis infection. These people may
be at high risk of developing active tuberculosis. The only approved treatment modality for
preventive therapy requires treatment daily or twice weekly for a minimum of six months, and
many patients do not complete the full course of therapy. Public and patient programs are
needed to increase the awareness of the problems associated with tuberculosis control.
The study is part of the NHLBI initiative "Behavioral Interventions for Control of
Tuberculosis" . The concept for the initiative originated from the National Institutes of
Health Working Group on Health and Behavior. The Request for Applications was released in
-Patients with suspected and confirmed TB
-Patients that are not a part of the therapy program established at Harlem Hospital, New
Wafaa El-Sadr, MD
University Professor; Director, ICAP, Department of Epidemiology