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Perspectives in Disease Prevention and Health Promotion A Strategic Plan for the Elimination of Tuberculosis in the United States

In 1987, the Department of Health and Human Services (DHHS) established the Advisory Committee for the Elimination of Tuberculosis (ACET) to "provide recommendations for the development of new technology, application of prevention and control methods, and management of state and local tuberculosis programs targeted toward the elimination of tuberculosis as a public health problem." In response to this charge, the ACET completed a strategic plan for the elimination of tuberculosis (TB) in the United States with advice and consultation from a large number of persons and organizations. The following is a summary of the plan. The complete plan has been published as an MMWR supplement (1). The plan urges the establishment of a national goal of TB elimination (an incidence of less than 1 case per million population) by the year 2010, with an interim target of an incidence of 3.5 cases per 100,000 population by the year 2000. The plan cites three factors that favor the achievement of this goal: 1) TB is retreating into focal geographic areas and demographically well-defined groups; 2) biotechnology can potentially generate better diagnostic, therapeutic, and preventive modalities; and 3) new computer, telecommunications, and other technologies will enhance the transfer of these new biotechnologies into clinical and public health practice. A three-step plan of action is proposed: Step 1. More effective use of existing prevention and control methods, especially in high-risk populations; Step 2.The development and evaluation of new technologies for diagnosis, treatment, and prevention; and Step 3.The rapid assessment and transfer of newly developed technologies into clinical and public health practice. Current problems cited in the plan include deficiencies in identifying and reporting TB cases and contacts, the failure to fully use prevention interventions, the failure of many patients to complete prescribed therapy, and the failure to adequately assess the effectiveness of community prevention and control programs. Recommended priorities for action include 1) identifying and screening high-risk population groups within each health jurisdiction and 2) making adequate and appropriate treatment and prophylaxis more widely available. Elimination of TB in the United States depends on the identification of groups at high risk for infection and disease. These groups vary through time, by place, and by personal characteristics. In 1987, the identifiable groups at high risk included HIV-infected persons, the homeless, immigrants and refugees from high-prevalence countries, intravenous-drug abusers, and residents of correctional institutions and nursing homes. Blacks, Hispanics, and Native Americans are also at high risk; the higher risk in these minority populations appears to be primarily related to socioeconomic status (2). However, because the epidemiology of TB changes, populations now at high risk may decline in risk over time, and groups not currently identified to be at risk may become at risk. Therefore, the plan urges CDC and state and local health departments to continue and to strengthen TB surveillance activities and to further improve their ability to define groups at high risk for TB. In addition to identifying high-risk populations, health-care providers must extend TB screening, treatment, and prevention programs to these groups. For such programs to be optimally effective, high-risk groups and health-care providers for these groups should be involved in designing, implementing, and promoting these programs. To increase the proportion of patients who complete therapy, the plan recommends several actions, including the more widespread use of the newer short-course treatment regimens (3). In addition, for each new case of TB, a specific health-care provider should be responsible for assuring that patients and their contacts are educated about TB and its treatment, that therapy is continued and completed, and that appropriate contact examination and preventive treatment are conducted. The use of directly observed therapy is strongly encouraged. Quarantine measures, including temporary institutionalization, are recommended only in those rare instances when an infectious patient refuses to comply with self-administered or directly observed therapy. The implementation of these recommendations will require an increase in the number of health department outreach staff who are members of the populations they serve. During the past few years, this approach has proven successful in public health practice and is more cost-effective than alternative approaches such as long-term hospitalization (CDC, unpublished data). Intensified use of existing technologies as outlined above is essential in moving the nation toward elimination; however, this strategy alone will not be sufficient to reach the goal. It is crucial that new technologies be developed. The plan points out that recent developments in biotechnology are revolutionizing the diagnosis, treatment, and prevention of other infectious diseases and that, by applying these new techniques to TB, it should be possible to develop the new tools needed to eliminate TB (4). The highest priorities for new technology development are 1) the development of alternative approaches to prevention of disease among persons already infected and 2) the development of a more rapid and effective test for identifying persons infected with living tubercle bacilli. Research efforts directed toward developing a more reliably effective TB vaccine, more rapid and accurate diagnostic tests, and more effective and rapidly-acting drugs are also needed. Finally, new technologies must be assessed and put into clinical and public health practice in a timely fashion. The plan points out that federal agencies; professional societies; and schools of medicine, nursing, and public health all have a role in assessing and implementing new technologies and that both public and private funds will be needed to support demonstration projects for technology assessment and implementation. Health departments, medical and nursing schools, schools of public health, voluntary agencies, professional societies, and minority advocacy groups share responsibilities for educating health-care providers and high-risk groups about the manifestations, methods of diagnosis, treatment, and prevention of tuberculosis. The plan recommends national, regional, and state conferences for health-care professionals to focus attention on TB and to teach modern approaches to its control and eventual elimination. The plan suggests that advisory committees be established in the states and major metropolitan areas to develop more specific strategies and tactics for TB elimination in each health jurisdiction and to review progress toward elimination. These reviews should include evaluations of morbidity and mortality data, the adequacy of case reporting and casefinding procedures, and the quality of treatment and prevention activities. Interested constituencies, such as lung associations, minority organizations, and professional societies, should be represented on these advisory committees. The ACET states that it is bringing this plan to the attention of the medical community and the public to stimulate positive and constructive discussion and action, to increase the level of TB awareness, and to encourage a commitment toward the elimination of TB. Reported by: Div of Tuberculosis Control, Center for Prevention Svcs, CDC.

Editorial Note

Editorial Note: The TB elimination plan developed by the ACET provides a roadmap to guide the TB elimination effort for the next 2 decades. Consequently, the plan is being distributed to a wide variety of public, private, and voluntary groups with the request that they actively join in identifying and supporting steps essential to eliminating this disease within their respective jurisdictions. Although the occurrence of TB in the United States has declined during the past 35 years, the disease persists as a public health problem in this country. From 1953 through 1987, the number of reported cases decreased from 84,517 to 22,255, and the annual incidence of TB decreased from 53.0 to 9.3 cases per 100,000 population (5). The reduction has been substantially greater among whites than among other races; as a result, the proportion of cases occurring in nonwhites has risen from 24% in 1953 to 49% in 1987 (6). Today, TB among non-Hispanic whites is predominantly a disease of the elderly; among minorities, it is primarily concentrated in young adults. In 1987, the median age of non-Hispanic whites with TB was 62 years; for minority patients, the median age was 39 years (6). Foreign-born persons constituted 24% of patients in 1987, and the risk among immigrants from Asia is especially high, particularly in the first years after arrival in the United States (5). The risk for immigrants serves as a reminder that TB persists as a global health problem of enormous dimension. Throughout the world, approximately 7-9 million new cases are diagnosed each year, and the disease is estimated to cause approximately 3 million deaths annually (7). An estimated 2 billion persons in the world have latent tuberculous infection (International Union Against Tuberculosis, Paris, personal communication, 1988), making it one of the most prevalent infections in the world. Through the development of new technology, the TB elimination effort in the United States can potentially contribute to the solution of the global TB problem. In the United States, new cases occur primarily among persons with longstanding Mycobacterium tuberculosis infection rather than among persons with recent infection. An estimated 10 million persons have longstanding tuberculous infection (CDC, unpublished data). Major progress toward elimination can be achieved by targeting TB screening and preventive therapy programs toward groups of persons with M. tuberculosis infection who are at high risk for developing clinical disease. To accomplish this objective, health department TB-control programs must be maintained, strengthened, and continually evaluated to assure the most beneficial use of available resources. CDC will continue to assist health departments by providing technical and financial assistance, training and educational resources, and surveillance and epidemiologic assistance and by conducting applied and operational research. CDC will continue to work with advisory groups, other federal agencies, state and local health departments, minority organizations, and other organizations to develop more specific strategies and tactics for implementing the plan.

References

  1. CDC. A strategic plan for the elimination of tuberculosis in the United States. MMWR 1989;38(suppl S-3). 2.Hinman AR, Judd JM, Kolnick JP, Daitch PB. Changing risks in TB. Am J Epidemiol 1976; 103:486-97. 3.American Thoracic Society/CDC. Treatment of tuberculosis and tuberculosis infection in adults and children. Am Rev Respir Dis 1986;134:355-63. 4.American Thoracic Society/CDC/National Institutes of Health/Pittsfield (Massachusetts) Antituberculosis Association. Supplement on future research in tuberculosis: prospects and priorities for elimination. Am Rev Respir Dis 1986;134:401-20. 5.Rieder HL, Cauthen GM, Kelly GD, Bloch AB, Snider DE. Tuberculosis in the United States. JAMA (in press). 6.Bloch AB, Rieder HL, Kelly GD, Cauthen GM, Hayden CH, Snider DE. The epidemiology of tuberculosis in the United States: implications for diagnosis and treatment. Clin Chest Med 1989 (in press). 7.Styblo K, Rouillon A. Estimated global incidence of smear-positive pulmonary tuberculosis: unreliability of officially reported figures on tuberculosis. Bull Int Union Tuberc 1981; 56:118-26.



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