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Very few of the employees understood that individuals on preventive therapy only were not a source of infection for others and education was needed in this area to make work-site preventive therapy feasible.

The final meeting took place at the Maine Medical Center in Portland with Kathleen Gensheimer, M.D., M.P.H., William Williams, M.D.; Maryann Weston, P.H.N.; and Diane Fanning, R.N. This is the largest TB clinic in Maine and is open weekly. Besides treating active cases the TB clinic works with the international clinic to conduct TB screening for refugees. About 50% of the refugees are tuberculin skin-test positive but completion of therapy rates is difficult and public health nurses make frequent home visits. Again, the problem of maintaining adherence with treatment for latent infection was a major concern. Where the medical consultants we met with in Augusta felt that community knowledge of TB was very low, Dr. Williams felt that it was very high in Portland and that he encountered few problems with poor diagnosis, treatment, or referral in Portland. This may be a residual effect of the outbreak at the ironworks and all of the attention it brought. Summary and Conclusions

In general, the tuberculosis program seemed to be functioning extremely well and the system of contact consultants seemed well designed to provide quality care for a widely dispersed population. With the treatment of cases progressing well, there have been a number of efforts to focus on tuberculin testing and treatment of latent infection but adherence and completion of therapy are major problems. The problems the program faces are not medical but rather deal with resources. A large portion of the public health budget is going to tuberculosis and the support for this spending probably is a legacy of the outbreak at the iron works. As the memory of that outbreak recedes, the funding for the program may begin to suffer. Also, resources to expand the program from treatment to prevention of the disease are not available now and will likely be very difficult to come by.



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