New Haemophilus influenzae type b control strategy: premature commitment to prophylaxis?

Recent promulgation of an official policy on prevention of secondary cases of Haemophilus influenzae type b disease illustrates the challenges and frustrations inherent in the policy-making process. Despite evidence that H influenzae type b disease is "contagious" in households and probably also in day care centers and despite demonstration that rifampin eradicates nasopharyngeal H influenzae type b carriage, the single field study of rifampin use to prevent secondary cases of H influenzae type b disease remains unpublished and has yet to receive broad critical scrutiny. Promulgation of the rifampin strategy prior to publication of this critical study is unfortunate, as public and private providers are now committed to a policy that will be difficult to evaluate or alter. Now that the strategy has been issued, the central question regarding rifampin prophylaxis has changed from "Is this strategy effective?" to "Can this strategy be shown to be ineffective?" When policies are issued prior to publication of key supporting data, or when such studies are either missing or highly controversial, the policy-making committee might publish, along with its recommendations, explicit criteria for continuation, modification, or withdrawal of the new policy. This structured reassessment approach could accommodate the critical need to proceed with disease control recommendations--even though based on incomplete information--yet underscore the policy's tentative nature and provide direction for future assessment and study.