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Timothy F. Brewer, MD, MPH; S. Jody Heymann, MD, PhD; Graham A. Colditz, MB, DrPH; Mary E. Wilson, MD; Kenneth Auerbach, MS; David Kane; Harvey V. Fineberg, MD, PhD

JAMA. 1996;276(23):1898-1903.

Abstract
Objective.
—To develop more effective methods to assess tuberculosis (TB) control strategies so we can meet national goals for the elimination of TB in the United States.

Design.
—Using a semi-Markov model that divided the US population into 3 age groups and 18 clinical states based on disease status and risk for TB and human immunodeficiency virus (HIV) infection, we measured the effects of 5 changes in TB policy, introduced singly and in combination: (1) increased coverage and (2) improved efficacy of preventive therapy, (3) increased coverage and (4) improved efficacy of treatment, and (5) introduction of BCG vaccination.

Results.
—A BCG vaccination program that reached 10% of eligible children and 1% of eligible adults each year would produce a 17% reduction in cases and an 11% decline in deaths over 10 years. Preventive therapy programs among the general population would have little effect on the number of TB cases, but a program targeting HIV-infected patients would reduce HIV-associated TB cases and deaths 14% to 20%. A 10% improvement in the coverage and efficacy of both preventive therapy and treatment, coupled with the BCG vaccination program, would lead to a 47% decline in TB cases and a 50% decline in TB deaths relative to baseline over 10 years.

Conclusions.
—Improvements in treatment coverage or effectiveness alone are unlikely to reach established national goals for the elimination of TB. These goals can be achieved through a combination of improvements in current programs with targeted preventive therapy and BCG vaccination programs.

Author Affiliations
From the Channing Laboratory, Brigham and Women's Hospital, Boston, Mass (Drs Brewer and Colditz); Departments of Medicine (Drs Brewer, Colditz, and Wilson) and Health Care Policy (Dr Heymann), Harvard Medical School, Boston; Kennedy School of Government, Harvard University, Boston (Dr Heymann and Mr Kane); Departments of Epidemiology (Drs Colditz and Wilson) and Population and International Health (Dr Wilson) and the Technology Assessment Group (Drs Colditz and Fineberg and Mr Auerbach), Harvard School of Public Health, Boston; and Division of Infectious Diseases, Mount Auburn Hospital, Cambridge, Mass (Dr Wilson). Dr Heymann is now with the Department of Health and Social Behavior, Harvard School of Public Health.

Footnotes
Reprints: Timothy F. Brewer, MD, MPH, Channing Laboratory, 181 Longwood Ave, Boston, MA 02115.

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