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Federal Tuberculosis Task Force Plan in Response to the Institute of Medicine Report, Ending Neglect: The Elimination of Tuberculosis in the United States

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The documents listed below are historical, archived information. The information contained in these documents, while accurate at the time of release, may not be the most current available.

Executive Summary

Introduction

After years of decline in the United States, the number of reported tuberculosis (TB) cases increased 20% between 1985 and 1992. This resurgence was associated with a deterioration of the infrastructure for TB services; the human immunodeficiency virus (HIV) epidemic, which substantially increases the risk for active TB among persons with latent TB infection (LTBI); increased immigration of persons from countries where TB is endemic; TB transmission in congregate settings (e.g., hospitals and prisons); and development of multidrug-resistant TB (MDR TB). However, a renewed emphasis on TB control and prevention and a major commitment of resources in the mid- to late 1990s resulted in substantial declines in the disease. In 2000, the number of TB cases decreased for the eighth straight year to an all-time low of 16,377 cases, a 7% decrease over the 17,531 cases reported in 1999.

In the summer of 2000, the National Academy of Sciences’ Institute of Medicine (IOM) issued a report, Ending Neglect: The Elimination of Tuberculosis in the United States.1 The report states that the resurgence of TB in the United States was the price of neglect reflected in earlier funding reductions and concludes that, with proper funding, organization of prevention and control activities, and research for development of new tools, TB can be eliminated as a public health problem in the United States.

In response, the Federal TB Task Force developed this plan to implement the IOM recommendations. The plan is organized around the five areas of IOM recommendations and provides a blueprint for a significant reduction in the remaining U.S. TB cases. The plan includes domestic and global strategies — planned for implementation in partnership with global agencies such as the World Health Organization (WHO) and the International Organization of Migration — as well as detailed action steps and specific agency roles.

Chronology in the Development of This Report

In responding to the IOM report, members of the Federal TB Task Force met to develop a coordinated federal action plan. Two meetings were convened in Bethesda, Maryland, on December 6-7, 2000, and February 8-9, 2001, to initiate the development of this plan.

A consensus was reached in determining the lead agencies and collaborating agencies for each activity. Individual recommendations revolving around common activities were consolidated, and a consensus was reached on the resulting list by circulating drafts to the entire task force. In the next step, lead individuals were identified for the lead agencies. These persons worked with named co-leads and collaborating agencies to further develop the strategies by adding additional action steps where deemed necessary to implement the strategies. Subsequent drafts of the entire document were shared with the Federal TB Task Force participants who provided comments, where appropriate, for the next draft. The final draft was discussed at a Federal TB Task Force conference call in late August 2001, where remaining issues were resolved. This was followed by a series of additional participant reviews accomplished by circulation of the drafts to participants. Because of the unusual multiagency nature of this document, this final document went through high-level multiagency clearance before publication.

Strategies for Eliminating Tuberculosis

The IOM recommended five overarching strategies for eliminating TB. The first strategy, maintaining control of TB, is a necessary prerequisite to elimination of the disease and requires strengthening of labor-intensive activities that make optimal use of available tools to help find and cure all persons with active TB. The IOM’s second strategy is to accelerate the decline of TB. Maintaining control of TB is not sufficient to eliminate TB; individuals can unknowingly carry live bacteria that cause TB for years without getting sick (also known as latent TB infection). An estimated 10 to 15 million persons in the United States have latent TB infection, many of them in identifiable but hard-to-reach populations. Latent TB infection can suddenly turn active and contagious. Finding and treating high-risk persons with latent TB infection before they become sick — and infectious — is absolutely essential to eliminating TB. High-risk persons include those with recent infection, contacts of persons with infectious TB, persons with HIV or AIDS, substance abusers, persons who have immigrated to the United States from areas of the world with high rates of TB, prisoners, and the homeless. In addition, persons who reside or work in institutional settings (e.g., hospitals, homeless shelters, correctional facilities, nursing homes, and residential homes for patients with AIDS) may have an ongoing risk for acquiring TB infection and disease.

Thirdly, the IOM recommends the development of new tools. The goal of TB elimination cannot be reached with the tools that are currently available. TB elimination will require an increased investment in TB research to develop a more effective vaccine, as well as new tools and drugs to more rapidly and reliably diagnose and shorten treatment for all persons with latent and active TB, including those afflicted with MDR TB. The fourth IOM strategy calls for increased global United States actions. The IOM report notes that the proportion of foreign-born TB cases in the United States has been steadily increasing and says it benefits the United States to help strengthen TB control programs globally. Specifically, page 11 of the IOM report states that "Tuberculosis will not be eliminated in the United States until the worldwide pandemic is brought under control." Finally, the IOM recommends an assessment of the impact of actions taken in response to the IOM report. The Advisory Council for the Elimination of Tuberculosis (ACET) and the Federal TB Task Force will monitor the federal response to the IOM report.

In response to these recommendations, the Federal TB Task Force developed the action steps contained in this document. Specific tasks and projects are described, and agencies with the lead responsibility for each step, along with estimated start and completion dates, are provided.

Conclusion

While the strategies and action steps complement ongoing federal TB prevention, control, and research activities, they cannot all be implemented with current funding. Federal TB Task Force agencies will implement the strategies and action steps contained in this report as resources become available. Federal TB Task Force members continue to confer via teleconference on a quarterly basis and remain ready to provide a coordinated federal response to the IOM recommendations and to progress toward TB elimination in the United States.

 
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