Prevention and Control

Prevention and Control - Without dismissing the importance of their efforts at case finding and treatment, public health workers interested in TB sought measures that might prevent this disease. With knowledge of Edward Jenner’s vaccinia prevention of smallpox and Louis Pasteur’s immunization treatment of rabies, Albert Calmette decided to turn his efforts at the Pasteur Institute in Lille, France, to developing a vaccine against TB. 

Prevention anda Control Tuberculosis

Together with his colleague, Camille Gue´rin, he began efforts to attenuate M. bovis by serial passage in 1902.15,38 During the devastating German siege of Lille in 1914 and the subsequent German occupation, they managed to maintain their cultures. In 1921 Calmette, now in Paris, was ready to try the vaccine known as Bacillus Calmette-Gue´rin (BCG) in a human subject. He approached Drs. Benjamin Weill-Halle´ and Raymond Turpin at the Hoˆ pital Charite´, and, on 18 July 1921, the new vaccine was administered to a 3-day-old infant whose mother had just died of TB and who would be raised by its tuberculous grandmother. 

The infant lived and thrived. During the next 4 years more than 100,000 doses of BCG were administered, and the TB death rate in vaccinated children was thought to be reduced by 10-fold. BCG came into widespread use in Europe following the Second World War, and in December 1973 the World Health Organization Expert Committee on Tuberculosis issued its NinthReport, in which it recommended that BCG should be used as widely as possible. Many trials of BCG efficacy have been conducted, some more rigorous than others. There is a striking disparity of results.39 This disparity is illustrated in Fig. 1.6, 

which is taken from a review by Paul Fine. Ultimately, an expert consensus emerged that BCG is useful in the prevention of miliary and meningeal TB in young children but has no epidemiological impact and no utility in prevention-oriented TB control programmes. Epidemiologists of the US Public Health Service never embraced BCG. Rather, they focused on prophylactic treatment of latent TB with isoniazid, an approach first suggested by Edith Lincoln.40 Large randomized control studies demonstrated the efficacy of this preventative measure in a variety of populations.41 Other countries have been slow to follow the American lead, however, and current control strategies in most nations emphasize treatment under direct observation using optimal.