TUBERCULOSIS-CONTROL POLICIES IN MAJOR METROPOLITAN HEALTH DEPARTMENTS IN THE UNITED-STATES .5. STANDARD OF PRACTICE IN 1992

Since 1978, we have surveyed the 28 metropolitan health departments in itially reporting > 250 cases of tuberculosis/yr to determine the stan dard of practice in the control of pulmonary tuberculosis and the fact ors affecting treatment policy. In this survey, results were compared with data obtained in 1978, 1980, 1984, and 1988. As in the previous y ears, all departments completed the survey. The predominant treatment regimen was 6 months of chemotherapy(64 +/- 1.33% of patients) involvi ng isoniazid (I), rifampin (R), and pyrazinamide (Z). Estimated durati on of treatment, which had decreased from 20.2 +/- 2.1 months in 1980 to 7.58 +/- 1.02 months in 1988, increased to 9.34 +/- 2.32 months in 1992 (p < 0.01). This was attributed to an increase in drug-resistant cases (17 of 25 programs) and to increased incidence of HIV infection during the previous 4 yr. In 1984, HIV infection was estimated to coin cide with tuberculosis in 2.54% of all patients, 7.72% in 1988, and 17 .42% in 1992. Several other major departures from prior perceived prac tices were reported. In 1980, 32.1% of all patients were hospitalized initially for tuberculosis treatment, and this number decreased progre ssively to 17.8% in 1988; in 1992, 34.2 +/- 1.32% of patients with tub erculosis were hospitalized for initial treatment. In 1988, no program reported regular use of alternative therapy to isoniazid for chemopro phylaxis; in 1992, 21 programs used alternative regimens (predominantl y R-containing). In 1992, nine programs reported increased funds for t reatment of tuberculosis (27.2 +/- 1.97% after inflation), whereas 16 reported a mean decrease of 14% after inflation. We find that tubercul osis treatment in the major metropolitan health departments in the Uni ted States consists predominantly of short-course chemotherapy utilizi ng I, R, and Z and that overall mortality is not reported to be greate r because of initially drug-resistant organisms. However, HIV-associat ed disease now is a major etiologic factor in tuberculosis, and the nu mber of hospitalizations has doubled in 4 yr. Despite diminished resou rces, incidence of hospitalization and duration of treatment have incr eased for the first time in 12 yr. In the absence of an increase in fu nds for treatment, we conclude that problems currently identified in t uberculosis control by major metropolitan health departments likely wi ll be exacerbated in the immediate future.