During the emergency phase of a refugee relief operation, TB activities should be limited to the treatment of patients who present themselves to the health-care system and in whom tubercle bacilli have been demonstrated by sputum smear examination.
Case identification. Passive case-finding will be most efficient in the refugee setting. Patients with respiratory symptoms (chest pain, cough) of greater than 3 weeks' duration, hemoptysis of any duration, or significant weight loss should have a direct microscopic examination of their sputum for AFB. If the sputum smear is negative for AFB but pulmonary TB is still suspected, the patient should be given a 10-day course of antibiotics and then be re-examined after 2-4 weeks. Specific anti-TB chemotherapy should not begin unless the presence of AFB has been confirmed. Symptomatic family members of an identified patient should also have sputum specimens examined.
Children who show signs and symptoms compatible with TB and who are either: a) a close contact of a patient with a confirmed case of TB, or b) tuberculin skin-test positive (in the absence of a BCG vaccination scar) should undergo a full course of anti-TB treatment if they do not respond to an appropriate regimen of alternative antibiotics.
Case management. The selection of a first-line chemotherapy regimen should generally be consistent with the national policy set forth by the host country MOH. However, it should be recognized that the crowded conditions of a refugee camp may foster an abnormally high rate of transmission. Additionally, uncertainty exists regarding the duration of stay in the country of asylum, and it may be more difficult to maintain adherence to an extended therapy regimen. Short-course therapy (6 months) should be considered for use in a refugee camp even when the national policy prescribes a longer course of treatment, provided the additional expense is not prohibitive.
Before enrolling refugees in a TB treatment program, consideration should be given to the stability of the populations and the capacity of the health-care program to supervise therapy and to follow-up patients who do not adhere to treatment. Administration of anti-TB drugs to persons in whom adherence is likely to be sporadic will foster increased drug resistance in that population.
The following drugs are used for the treatment of TB with chemotherapy: isoniazid, rifampin, pyrazinamide, streptomycin, ethambutol, and thiacetazone. The selection of a particular treatment regimen must take into consideration the organism susceptibility, cost, and duration of therapy. The decision regarding implementation of a specific therapeutic regimen will generally be made by the UNHCR in consultation with the MOH of the host government.
Case-holding. Whenever possible, chemotherapy should be observed by a health-care provider, especially during the first 2-3 months of treatment. Treatment efficacy should be assessed through a series of sputum smears. Patients participating in observed therapy who do not respond to treatment and whose sputum smears remain positive for AFB after 2 months should be reviewed by a physician and should begin a second-line treatment regimen.
Enrolling TB patients in a SFP may improve adherence to the treatment regimen and acts as a point of contact for follow-up.
The success of a TB control program depends on good management and close supervision. The responsibilities of staff assigned to the program need to be clearly defined, adequate records of patient progress should be maintained, and a system to follow-up patients who do not adhere to treatment should be established. The cooperation of the community is essential for success. A community education program should be established to help ensure adherence.
BCG vaccination should be administered as part of the comprehensive immunization schedule and not as a separate TB control activity. BCG vaccination is contraindicated for persons with symptomatic HIV infection, but can be administered to asymptomatic persons.
Selected Reading
Rieder HL, Snider DE, Toole MJ, et al. Tuberculosis control in refugee settlements. Tubercle 1989;70:127-4.
Davis CE, Allegra DT, Buhrer M. Tuberculosis control programs, Sakaeo and Khao I-Dang. In: Allegra DT, Nieburg P, Grabe M, eds. Emergency refugee health care -- a chronicle of the Khmer refugee-assistance operation 1979-1980. Atlanta GA: CDC;1983:61-4.