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Am Fam Physician. 2006;74(2):230

to the editor: In the December 1, 2005, issue of American Family Physician, Drs. Potter, Rindfleisch, and Kraus provide a comprehensive summary of the management of active tuberculosis.1 Following the guidelines from their article, the family physician can adequately manage most cases of this disease in an outpatient setting with or without consultation with a pulmonary or infectious diseases specialist.

Although their article1 is directed toward the physician and thus focuses on the clinical issues pertinent to the individual patient, it is critical to view tuberculosis within a public health as well as a clinical framework. Specifically, the family physician should partner with the local public health department in the comprehensive management of this disease.

Physicians are obligated by law to report confirmed and suspected cases of tuberculosis to their local public health department as soon as possible to expeditiously activate public health communicable disease control measures. The health department has a public health mandate to assess the patient’s likelihood of contagiousness and to serve orders of isolation on individuals believed to represent a substantial possibility of disease transmission in the community. Usually these are patients with positive sputum smears. Another public health responsibility is to evaluate individuals potentially exposed to an active tuberculosis case. Most health departments have staff specifically trained to carry out contact investigation of tuberculosis patients’ family members, friends, and coworkers to identify and treat those at risk for the development of latent or active tuberculosis caused by exposure to the index case. This step is important in interrupting the chain of disease transmission, a critical function of public health. Finally, many health departments have case management services available whereby patients with active tuberculosis are closely monitored on a case-by-case basis to assist them with successfully completing the prolonged course of treatment necessary to cure the disease. Such case management may include direct-observed therapy in cases where compliance with treatment cannot otherwise be ensured. Case management also can assist patients with complex psychosocial needs such as homelessness by providing housing or food vouchers that not only assist directly with these needs but can serve as incentives for these patients to adhere to their tuberculosis treatment regimens.

Caring for patients with tuberculosis can be a gratifying experience for the family physician because most patients progressively improve throughout the course of treatment and are ultimately cured. To provide truly excellent care, remember to consider the public health implications of this disease for the patient’s family, friends, and the community in general. Involvement of the local health department will ensure that these public health matters are addressed in an effective manner while the physician is treating the individual patient.

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This series is coordinated by Kenny Lin, MD, MPH, deputy editor.

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