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Chapter 34 : Issues in Operational, Social, and Economic Research on Tuberculosis

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Abstract:

This chapter is organized into four sections: the burden of tuberculosis, BCG immunization, chemoprophylaxis, and case identification and treatment. In each section, the emphasis is on briefly reviewing relevant past work, identifying key constraints for effective tuberculosis control, and suggesting ways that operational research may provide answers. Of the four topics, the most important is case identification and cure. A reasonable estimate of prevalence can be derived by assuming that all purified protein derivative (PPD) responses with an induration size greater than the mode indicate true infections. To demonstrate the burden of tuberculosis in terms comparable to those used for other health problems, it was essential to estimate the number of cases and deaths due to tuberculosis in various regions of the world. The success of BCG vaccination programs is largely attributable to the organizational, financial, and technical success of the Expanded Program of Immunization. Treatment of individuals who are known to be infected with on the basis of 12 months of skin tests with isoniazid is effective in preventing subsequent breakdown to clinical tuberculosis. One of the fundamental tenets of tuberculosis control is the primary importance of diagnosing and treating pulmonary sputum smear-positive tuberculosis.

Citation: Murray C. 1994. Issues in Operational, Social, and Economic Research on Tuberculosis, p 583-622. In Bloom B (ed), Tuberculosis. ASM Press, Washington, DC. doi: 10.1128/9781555818357.ch34
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Image of Figure 1.
Figure 1.

Frequency distributions of induration sizes: general patterns for three frequencies of atypical mycobacterial cross-reactivity. Source: Bleiker et al. (1989).

Citation: Murray C. 1994. Issues in Operational, Social, and Economic Research on Tuberculosis, p 583-622. In Bloom B (ed), Tuberculosis. ASM Press, Washington, DC. doi: 10.1128/9781555818357.ch34
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Image of Figure 2.
Figure 2.

Estimated prevalence of tuberculosis infection by age and sex in 11 sub-Saharan African regions. Basutoland is present-day Lesotho, and Bechuanaland is present-day Botswana. Reprinted with permission from Roelsgaard et al. (1964).

Citation: Murray C. 1994. Issues in Operational, Social, and Economic Research on Tuberculosis, p 583-622. In Bloom B (ed), Tuberculosis. ASM Press, Washington, DC. doi: 10.1128/9781555818357.ch34
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Image of Figure 3.
Figure 3.

Age-distribution of smear-positive tuberculosis in four developing country programs. Sources: for Tanzania, Chum et al. (1988); for other countries, government registry data.

Citation: Murray C. 1994. Issues in Operational, Social, and Economic Research on Tuberculosis, p 583-622. In Bloom B (ed), Tuberculosis. ASM Press, Washington, DC. doi: 10.1128/9781555818357.ch34
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Image of Figure 4.
Figure 4.

Estimated numbers of cases of tuberculosis in the United States from 1978 to 1991 disaggregated into cases expected on the basis of trends in the risk of infection, cases of HIV and tuberculosis coinfection, and excess cases. Source: Bloom and Murray (1992).

Citation: Murray C. 1994. Issues in Operational, Social, and Economic Research on Tuberculosis, p 583-622. In Bloom B (ed), Tuberculosis. ASM Press, Washington, DC. doi: 10.1128/9781555818357.ch34
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Image of Figure 5.
Figure 5.

Numbers of pulmonary tuberculosis cases detected in The Netherlands, 1951.

Citation: Murray C. 1994. Issues in Operational, Social, and Economic Research on Tuberculosis, p 583-622. In Bloom B (ed), Tuberculosis. ASM Press, Washington, DC. doi: 10.1128/9781555818357.ch34
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Image of Figure 6.
Figure 6.

Numbers of smear-positive tuberculosis cases detected in Nicaragua, 1989.

Citation: Murray C. 1994. Issues in Operational, Social, and Economic Research on Tuberculosis, p 583-622. In Bloom B (ed), Tuberculosis. ASM Press, Washington, DC. doi: 10.1128/9781555818357.ch34
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Image of Figure 7.
Figure 7.

Variations in BCG protective efficacy at different times after vaccination in controlled trials. Reprinted with permission from Rodrigues and Smith (1990).

Citation: Murray C. 1994. Issues in Operational, Social, and Economic Research on Tuberculosis, p 583-622. In Bloom B (ed), Tuberculosis. ASM Press, Washington, DC. doi: 10.1128/9781555818357.ch34
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Image of Figure 8.
Figure 8.

Intervals from conversion to onset of tuberculosis disease. Source: Styblo (1991).

Citation: Murray C. 1994. Issues in Operational, Social, and Economic Research on Tuberculosis, p 583-622. In Bloom B (ed), Tuberculosis. ASM Press, Washington, DC. doi: 10.1128/9781555818357.ch34
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Image of Figure 9.
Figure 9.

Alternative models of tuberculosis transmission.

Citation: Murray C. 1994. Issues in Operational, Social, and Economic Research on Tuberculosis, p 583-622. In Bloom B (ed), Tuberculosis. ASM Press, Washington, DC. doi: 10.1128/9781555818357.ch34
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Image of Figure 10.
Figure 10.

Progression of tuberculosis.

Citation: Murray C. 1994. Issues in Operational, Social, and Economic Research on Tuberculosis, p 583-622. In Bloom B (ed), Tuberculosis. ASM Press, Washington, DC. doi: 10.1128/9781555818357.ch34
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Image of Figure 11.
Figure 11.

Delay from symptoms to diagnosis in Chile, 1985 to 1986. Source: Tabilo et al. (1987).

Citation: Murray C. 1994. Issues in Operational, Social, and Economic Research on Tuberculosis, p 583-622. In Bloom B (ed), Tuberculosis. ASM Press, Washington, DC. doi: 10.1128/9781555818357.ch34
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Image of Figure 12.
Figure 12.

Delay from symptoms to diagnosis in Bolivia, 1988 to 1989. Source: Rojas and Lanza (1989).

Citation: Murray C. 1994. Issues in Operational, Social, and Economic Research on Tuberculosis, p 583-622. In Bloom B (ed), Tuberculosis. ASM Press, Washington, DC. doi: 10.1128/9781555818357.ch34
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Image of Figure 13.
Figure 13.

Probability of default for each 10-day period of treatment for pulmonary tuberculosis patients in four districts of Botswana, 1987 to 1990.

Citation: Murray C. 1994. Issues in Operational, Social, and Economic Research on Tuberculosis, p 583-622. In Bloom B (ed), Tuberculosis. ASM Press, Washington, DC. doi: 10.1128/9781555818357.ch34
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Tables

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Table 1.

Estimated risks of tuberculous infection and their trends in developing countries, 1985 to 1990

Citation: Murray C. 1994. Issues in Operational, Social, and Economic Research on Tuberculosis, p 583-622. In Bloom B (ed), Tuberculosis. ASM Press, Washington, DC. doi: 10.1128/9781555818357.ch34
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Table 2.

BCG coverage by region: percentage of children immunized by 12 months of age with BCG vaccine

Citation: Murray C. 1994. Issues in Operational, Social, and Economic Research on Tuberculosis, p 583-622. In Bloom B (ed), Tuberculosis. ASM Press, Washington, DC. doi: 10.1128/9781555818357.ch34
Generic image for table
Table 3.

Yield in cases from concurrent smear and culture examinations of eight consecutive sputum specimens from each of 194 persons with lung X-ray shadows and prolonged chest symptoms suggesting tuberculosis

Citation: Murray C. 1994. Issues in Operational, Social, and Economic Research on Tuberculosis, p 583-622. In Bloom B (ed), Tuberculosis. ASM Press, Washington, DC. doi: 10.1128/9781555818357.ch34
Generic image for table
Table 4.

Results of chemotherapy for smear-positives in three sub-Saharan African programs

Citation: Murray C. 1994. Issues in Operational, Social, and Economic Research on Tuberculosis, p 583-622. In Bloom B (ed), Tuberculosis. ASM Press, Washington, DC. doi: 10.1128/9781555818357.ch34
Generic image for table
Table 5.

Estimated average incremental cost per patient treated in low- and middle-income countries

Citation: Murray C. 1994. Issues in Operational, Social, and Economic Research on Tuberculosis, p 583-622. In Bloom B (ed), Tuberculosis. ASM Press, Washington, DC. doi: 10.1128/9781555818357.ch34
Generic image for table
Table 6.

Average incremental unit costs in the intensive phase for Malawi, Mozambique, and Tanzania

Citation: Murray C. 1994. Issues in Operational, Social, and Economic Research on Tuberculosis, p 583-622. In Bloom B (ed), Tuberculosis. ASM Press, Washington, DC. doi: 10.1128/9781555818357.ch34

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