American Thoracic Society Medical Section of the American Lung Association----------Discharge of Tuberculosis Patients from Medical Surveillance*

THIS IS AN OFFICIAL STATEMENT OF ATS ADOPTED BY CoUNCIL IN OCTOBER 1975. One of the most striking features of the natural history of untreated pulmonary tuberculosis is the frequency with which relapse of the disease occurs after a period of clinical quiescence. For this reason, longterm (often lifelong) follow-up consisting of periodic evaluations including chest roentgenograms and bacteriologic examination of pulmonary secretions has been a part of the standard medical management of patients with tuberculosis. These evaluations are usually conducted at arbitrarily set time intervals and are independent of the patient's symptoms. Such surveillance has been considered to be the responsibility of public health authorities or of tuberculosis specialists who have the facilities and the knowledge to supervise appropriately this phase of management. With the advent of specific, potent antituberculosis chemotherapy, concepts of the management of the disease have changed dramatically. There is now more than 20 years' experience with drug therapy. The evidence convincingly indicates that if adequate antituberculosis chemotherapy is administered, tubercle bacilli are rapidly eradicated from the sputum (1-3). After completion of chemotherapy, relapse is uncommon (4-6). Thus, the reasons for the long-term surveillance policies designed and utilized in the pre-chemotherapy era and even into the 1970s are no longer applicable for tuberculosis patients who have completed adequate drug treatment. Moreover, several reviews of the productivity of long-term follow-up indicate that the majority of relapses are not detected by routine surveillance procedures (68). Because of the efficacy of chemotherapy and the poor yield from routine surveillance, long-term follow-up is in ·most instances an inappropriate use of health care resources. The critical determinant of the course that will be followed by the patient with recently diagnosed tuberculosis is the adequacy of the initial chemotherapy. Thus, major emphasis must be placed on this phase of management. Patient education and his or her understanding of the objectives of therapy are essential. Programs should be individualized and "Reprints may be requested from your state or local Lung Association.

tailored, not only to the disease process but to the patients' life-styles as well. In addition, methods of assessment and recording of compliance with drug regimens should be utilized to provide more precise quantification of the amount of drug ingested. This aspect of management may require considerable ingenuity and tenacity on the part of various health workers but is of sufficient importance to justify the efforts. There is enough evidence to indicate that the therapy listed below is adequate for the initial treatment of pulmonary tuberculosis as categorized in the American Thoracic Society (A TS) Diagnostic Standards and Classification of Tuberculosis (9). 0-No therapy indicated. I-No therapy or isoniazid as indicated by the ATS Statement on Preventive Therapy (10). 11-Isoniazid as indicated by the ATS Statement on Preventive Therapy (10). III-Usually, 18 months of multi-drug therapy (2 or more drugs), one of which is isoniazid. Patients in this classification who have stable roentgenograms and negative bacteriology but who have not been adequately treated in the past should be managed as Class II patients. Before discharge from the treatment program, patients in Classes II and III should be instructed as to what symptoms might be associated with activity of the tuberculous process and of the importance of prompt evaluation of these symptoms. "They should also be referred to an appropriate source of continuing general health care, making sure that a history of successfully treated pulmonary tuberculosis is transferred to the patient's medical record. Class II and Class III patients who have completed adequate therapy but who, because of coexistent disease (either pulmonary or nonpulmonary, such as silicosis or Hodgkin's disease), may be at increased risk of acti· vating or reactivating tuberculosis should as a part of the management of the concurrent disease have periodic re-evaluations for tuberculosis. Routine periodic surveillance, which is not a part

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of either an appropriate treatment program or comprehensive medical care, has only a very limited role in the management of tuberculous infection and disease. The following are examples of situations in which continued surveillance may be indicated: (1) Class III patients who did not respond to what should have been adequate chemotherapy. This would include patients who, because of the emergence of bacterial resistance to therapeutic agents or other undefined reasons, remain bacteriologically positive after the first 6 months of treatment. (2) Class III patients who have sustained one or more relapses during or after chemotherapy. (3) Class II patients for whom preventive therapy is strongly indicated because of risk to themselves or others but who either refuse or cannot take isoniazid. (4) Patients in Class III who have received a short-course regimen (isoniazid-rifampin daily for 6 months). It is likely that this regimen will prove to be quite effective; however, at this time the followup data are not sufficient to allow specific recommendations to be made. In these situations the frequency and duration of follow-up must be determined on an individual basis and related particularly to the risk of reactivation. All the recommendations of this statement apply regardless of social or occupational situations.

Acknowledgment The preparation of this Statement was supported in part by a grant from the Pittsfield Anti-Tuberculosis Association of Pittsfield, Massachusetts. This statement was prepared by the Ad Hoc Committee on the Discharge of Patients from Medical Surveillance. The committee members are as follows:

PHILIP

D.

HOPEWELL,

Chairman

WILLIAM BUCKINGHAM ROBERT WILHELM

F.

C.

ELLIOTT

RosENBLATT

KATHERINE H. K. Hsu

References I. Fox, W.: The John Barnwell Lecture: Changing concepts in the chemotherapy of tuberculosis, Am Rev Respir Dis, 1968, 97, 767. 2. Doster, B., Murray, F. J., Newman, R., and Woolpert, S. F.: Ethambutol in the initial treatment of pulmonary tuberculosis, Am Rev Respir Dis, 1974,107, 177. 3. Newman, R., Doster, B., Murray, F. J., and Woolpert, S. F.: Rifampin in the initial treatment of pulmonary tuberculosis, Am Rev Respir Dis, 1974, 109,216. 4. Grzybowski, S., McKinnon, N. E., Tuters, L., Pinkus, G., and Philipps, R.: Reactivations in inactive pulmonary tuberculosis, Am Rev Respir Dis, 1966,93,352. 5. Research Committee Southeast Metropolitan Regional Thoracic Society: Relapse in tuberculosis, Br J Dis Chest, 1973,67, 33. 6. Stead, W. W., and Jurgens, G. H.: Productivity of prolonged follow-up after chemotherapy for tuberculosis, Am Rev Respir Dis, 1973, 108, 314. 7. Bailey, W. C., Thompson, D. H., Jacobs, S., Ziskind, M., and Greenberg, H. B.: Evaluating the need for periodic recall and re-examination of patients with inactive pulmonary tuberculosis, Am Rev Respir Dis, 1973,107, 854. 8. Edsall, J., and Collins, G.: Routine follow-up of inactive tuberculosis: A practice to be abandoned, Am Rev Respir Dis, 1973,107,851. 9. Diagnostic Standards and Classification of Tuberculosis and Other Mycobacterial Diseases, American Thoracic Society, 1974. 10. Preventive therapy of tuberculosis infection, An official statement of the American Thoracic Society, Am Rev Respir Dis, 1974,110,371.