Toman’s Tuberculosis. Case Detection, Treatment, and Monitoring. Questions and Answers. Second Edition.

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In 1964, the World Health Organization began promulgating standard approaches for national tuberculosis control programs based on the recommendations of its expert committees. Over the ensuing decades, these recommendations have evolved, following in the path of increasing knowledge applicable to tuberculosis control. The WHO recommendations were published in the form of succinct reports with recommendations that could be readily adopted. Lacking from these reports, however, was the evidence upon which the recommendations were based and a critical appraisal of that evidence. In 1979, the WHO published a book by Kurt Toman, one of its professional staff members, entitled Tuberculosis. Case Detection, Treatment, and Monitoring. Questions and Answers. In this book, Toman attempted to provide evidence-based, authoritative answers to questions that local health officers might have concerning the WHO tuberculosis control norms.

In Toman’s Tuberculosis. Case Detection, Treatment, and Monitoring. Questions and Answers, Second Edition, Thomas Frieden has updated the earlier edition to bring it into line with modern WHO recommendations. Frieden brings to this work an extensive background in tuberculosis control, both in New York City, where he spearheaded that city’s recovery from the disastrous resurgence of tuberculosis that occurred in the 1980s, and in India. He has enlisted the help of a large cadre of contributors, some drawn from the WHO, many from other venues; some leading experts, others more junior.

Toman adopted an unusual format for his work, and this format has been maintained in the current edition. The book is set out not in conventional chapters but as a series of questions that Toman and now Frieden believe a tuberculosis control officer or student might ask. There are 75 such questions in the current edition. They are arranged in three sections: case detection, treatment, and monitoring (the last was not included in Toman’s original edition). Each question is stated and followed by a text of several pages in which the answer is given and supporting data are reviewed. The result is a book that is readable but serves poorly as a reference work—there is no index—but draws one into browsing. With minimal effort, one can find the answer to a question one has, provided that question is one that Toman or Frieden has included. Browsing in the book leads one to acknowledge, “I really should have asked that question.” There is variability in the answers to the questions, as one might expect with a multi-authored work, but in general the answers are well done and appropriately referenced.

Much has changed since Toman’s first edition, and so there are new questions. Yet, some of Toman’s original questions remain relevant and have been retained, often with little or no change in Toman’s text. Given the enormous impact on tuberculosis of HIV infection, I was disappointed to find only three questions, one in each section, directed at HIV. Another omission is the entire question of vaccination with BCG. BCG was not included in Toman’s first edition, although at the time of its publication the vaccine was recommended for routine use by the WHO. Today, BCG is still recommended for newborns because of its efficacy in the prevention of miliary and meningeal tuberculosis in the very young. Admittedly, Frieden has defined the scope of the book so not to include vaccination as did Toman; that is a decision I would not have chosen to make. A final omission is the treatment of latent tuberculous infection, a practice promoted in the United States but not elsewhere. Even if it is not to be used in most of the areas served by the WHO, it is a modality that has been subjected to rigorous study, and I would have chosen to include it.

The current WHO-recommended tuberculosis control strategy is known by the acronym DOTS (directly observed therapy, short course). It is much more than simply providing for supervision of patient pill-taking. Many aspects of it are covered in the third section of this edition. However, I believe that the hard questions of what it is that makes this strategy succeed or fail and how much supervision of pill taking contributes to compliance have not been as critically assessed as they should have been. This book misses the opportunity to take a rigorous look at this aspect of DOTS and consider it in respect to the large literature on patient compliance.

In summary, I would like to see this book address a few issues that it omits. On the other hand, it is a readable work, and its format should be attractive to many persons responsible for aspects of tuberculosis control. It is not a reference work, but it is more apt to be read than a reference to me. It deserves widespread distribution to health care workers in the field of tuberculosis control.

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