TB Notes Newsletter
No. 3, 2013
Healthy People 2020 Progress Review
The Burden of Tuberculosis and Infectious Diseases in the U.S. and Abroad
On Tuesday, July 30, 2013, Dr. Kenneth Castro, Director, DTBE, joined other public health leaders in a Healthy People 2020 progress review. This Healthy People progress review included, for the first time, a presentation by a nonfederal partner, Ed Zuroweste, MD, Chief Medical Officer, Migrant Clinicians’ Network. Howard Koh, MD, Department of Health and Human Services (HHS) Assistant Secretary for Health, served as moderator. Other participants included Irma Arispe, PhD, Associate Director, National Center for Health Statistics (NCHS); Tom Kenyon, MD, Director, CDC's Center for Global Health (CGH); and Craig Shapiro, MD, HHS Director, Office of the Americas, Office of Global Affairs (OGA). The review was conducted in Washington, DC, as a webinar, and had an estimated audience of 500 viewers. An underlying theme throughout the progress review was our need to continue to align domestic elimination efforts with the global fight against TB.
What Is Healthy People?
Healthy People is a collaborative U.S. initiative that provides science-based, 10-year national objectives for promoting health and preventing disease, to improve the health of all Americans. The project is managed overall by the HHS Office of Disease Prevention and Health Promotion (ODPHP). It consists of goals and objectives, with targets that are designed to guide national health promotion and disease prevention efforts. Healthy People 2020, the current version of this ongoing effort, covers 42 topic areas, and includes 1,200 objectives or measures.
Data Overview: National Center for Health Statistics
Dr. Irma Arispe (NCHS) reported that in an earlier era, TB was a leading cause of death—not just in other parts of the world, but in the United States as well. In 1900, TB was the second leading cause of death in this country. As recently as 1950, it was the seventh leading cause of death. Today we have pushed TB off the list of leading causes of death in this country. However, TB remains a serious challenge to global health. Worldwide, it is the leading cause of death among persons with HIV. It is also the second leading cause of death from a single infectious agent.
Global Leading Causes of Death, 2008
Dr. Arispe summarized her key points as follows: overall, U.S. TB rates are decreasing. However, disparities persist for racial and ethnic minorities and those born outside the United States. In addition, TB remains an urgent public health problem in Asia and Africa. Health issues abroad can directly impact health in the United States.
Tuberculosis: Domestic Overview
Speaking next, Dr. Castro described DTBE as the equivalent of the National TB Program for the United States. DTBE funds state and local TB programs, as well as two consortia that carry out program-relevant research: the TB Trials Consortium (TBTC) and the TB Epidemiologic Studies Consortium (TBESC). CDC also provides technical assistance in 22 countries, in partnership with the U.S. Agency for International Development (USAID), the World Health Organization (WHO), and others.
To explain recent trends, Dr. Castro discussed the 1985–1992 U.S. resurgence of TB following decades of decline. The causes: first, the dismantling of TB clinical services after funding disappeared in the late 1970s and early 1980s. Other causes included the emerging HIV epidemic, immigration from countries where TB was common, spread of TB in institutions, and emergence of multidrug-resistant (MDR) TB.
Excess TB Cases, U.S. 1985–1992
The resurgence, which caused an estimated 52,100 excess TB cases, prompted action. New resources were made available, and funds were quickly mobilized. These were used to hire staff and to focus on training and education. The funding increases also allowed the U.S. to improve the detection of TB cases, upgrade state laboratories for early diagnosis and recognition of drug resistance, update treatment and infection control recommendations, pay for the broad-scale use of directly observed therapy, and emphasize the need for ongoing program evaluation.
These steps paid off, and TB began decreasing in both U.S.-born and foreign-born persons in the United States. The decreases in TB in U.S.-born persons have been substantive. However, in comparison, TB decreases for the foreign-born persons have been so modest as to remain relatively stable; thus, the proportion of U.S. TB cases that they account for rose from 28% in 1991 to 62% by 2011. Rates in 2011 were nearly 12 times higher for foreign-born persons than for U.S.-born persons and were still above the Healthy People 2020 target of 14.0 per 100,000 population.
TB: Global Overview
Based on this changing epidemiology, the Institute of Medicine2 urged the U.S. to become directly engaged in the global fight against TB. CDC and other U.S. agencies now collaborate closely with many international partners in this global effort. Global TB control work here at CDC spans three Centers and four divisions; yet, it is highly collaborative and synergistic.
Investment Upfront Leads to Big Dividends for TB Control
Moreover, there is potential for enormous return on investment in TB control programs in countries from which most of our foreign-born TB patients originate. Dr. Castro shared the example that an investment in screening U.S.-bound immigrants and implementing directly observed therapy, short-course (DOTS) in Mexico could result in remarkable reductions in TB incidence among this population. A $35 million U.S. investment in Mexico's TB program would result in fewer cases of TB in the United States, fewer deaths from the disease, and net discounted savings of $108 million over 20 years.
Dr. Castro's key takeaway messages were as follows: there remain many challenges to U.S. elimination of TB. Funding gaps are again leading to inadequate human resources, limited access to diagnosis and treatment services, and limited surveillance to document burden and impact. Combating TB among foreign-born persons will remain the key to any progress toward elimination. MDR TB and HIV-associated TB, here and abroad, pose a threat to our ability to fight this disease. The complacency that comes with a successful program may ironically lead to the disinvestment in these programs, loss of clinical expertise and of capacity to respond to outbreaks, and concentration of the epidemic in the most vulnerable groups.
Yet there is good news: the trend of decreasing U.S. TB incidence as a result of concerted efforts provides a remarkable success story: cases have declined more than 60.5% from the 1992 peak. However, as with many other communicable diseases, TB prevention and control requires building the best international partnerships to help meet domestic needs. Recent research developments are yielding results that are being translated into program improvements.
Overview: Center for Global Health
Viewers next heard from Dr. Tom Kenyon (CGH). His key points were that there is a continuing need to strengthen public health systems worldwide and assure global health security. Efforts to address global TB control are underway, but they need to be enhanced—including providing technical support, strengthening surveillance and laboratory systems, building in-country capacity, and contributing to the evidence base for implementation of effective TB control strategies. He stated that TB elimination in the United States is not possible without addressing TB among foreign-born persons—both in their country of origin and here. Continued U.S. investment in TB control in other countries saves lives, protects Americans at home and abroad, and makes economic sense.
U.S.-Mexico Border Region Issues
Dr. Craig Shapiro followed with a talk about TB in the U.S.-Mexico border region. His key points were that TB rates are higher in the U.S.-Mexico border region than in other areas of United States. Major challenges in the area include continuity of care and harmonizing treatment protocols across state and national lines. Efforts of the U.S.-Mexico Border Health Commission are aimed at promoting binational collaboration (federal, state, and local levels) and cross-border sharing of information and resources for prevention and treatment.
Migrant Clinicians Network: Case Study
Dr. Ed Zuroweste reported on the Migrant Clinicians Network, whose physicians provide care for migrants and foreign-born workers in the Unites States. He gave an example of a complicated but ultimately successful case involving a migrant who traveled extensively across the U.S. but eventually completed treatment for TB.
Div of TB Elimination
- U.S. Department of Health and Human Services. Office of Disease Prevention and Health Promotion. Healthy People 2020. Washington, DC. Available at www.cdc.gov/nchs/healthy_people/hp2020/hp2020_IID_GH_progress_review.htm.
- Institute of Medicine. Ending Neglect: the Elimination of Tuberculosis in the United States. Washington, DC: National Academy Press; 2000.