Ambulatory Treatment in Tuberculosis Control

The Experience of Puerto Rico

Tuberculosis mortality declined in Puerto Rico from a rate of 333 deaths per 100,000 population in 1933, to 29.5 in 1959. This remarkable improvement was due largely to an intensive campaign which consisted of case-finding, education and early treatment of new cases. Since facilities for the hospitalization of open cases were very inadequate, it was decided in 1934 to treat most cases in dispensaries, using artificial pneumothorax as the main therapeutic procedure.

Pneumothorax (used since 1935) was effective in closing cavities and converting the sputum in 33 to 40 per cent of all the ambulatory patients selected for this treatment. Among those who took the treatment for six months or longer, the proportion of arrested cases was higher than 50 per cent. Since thousands of cases were treated, the total effect on the prevention of contagion was important.

Antimicrobial therapy has been used extensively since 1949. Streptomycin and PAS were the first drugs used. Practically every case of tuberculosis attending the public health dispensaries is now given antituberculous drugs (streptomycin and isoniazid) as soon as the diagnosis is made. In most cases the treatment has been continued for periods of six months or longer. Evaluation of the results obtained with these mass treatments have not been done on a large scale, but the limited studies made seem to indicate that about one half of the cases treated receive lasting benefit. Since the number of cases treated with drugs averages over 8,000 per year, the total effect of the program on the prevention of contagion has been of great importance. Reorganization of administrative procedures now being planned will undoubtedly improve results.

Plans of the Health Department for next year include tuberculin testing of all children under two, and treatment of reactors with isoniazid for one year; also tuberculin testing and treatment with isoniazid for one year of all contacts under 12 who live in conditions that facilitate contagion.

BCG vaccination research done in Puerto Rico and other parts of the Union under the auspices of the United States Public Health Service has shown that mass vaccination with BCG is ineffective and undesirable as a procedure for tuberculosis control. Well known public health measures that have stood the test of time, such as intensive case finding, prompt treatment of new cases and education, continue to be the pillars of the tuberculosis campaign. In the years to come, the treatment campaign will probably begin with the tuberculin reactor. It seems quite probable that the prompt treatment of tuberculin reactors with antimicrobial drugs will replace BCG vaccination in many countries.