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Insititute of Medicine (IOM) Report

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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.

Ending Neglect: The Elimination of Tuberculosis in the United States

Fact Sheet

"The question now confronting the United States is whether another cycle of neglect will be allowed to begin or whether, instead, decisive action will be taken to eliminate the disease."
 

The Institute of Medicine Report

The Centers for Disease Control and Prevention (CDC) has long recognized the moral obligation as well as the public health benefit of eliminating tuberculosis (TB) in this country. However, the conflicting evidence of declining TB rates in the general population against the increasing rates in certain high-risk groups led CDC to commission a study by the Institute of Medicine (IOM) to determine the feasibility of TB elimination as a national goal. If feasible, then the IOM was asked to provide specific recommendations as to how to make elimination of TB in the United States a reality.

The IOM determined that, yes, TB elimination in the U.S. was feasible, but stated that "to meet this goal, aggressive and decisive action beyond what is now in effect will be required." Furthermore, "elimination of TB is not possible with the tools we currently have available. An effective elimination campaign will require additional financial resources and a strong, durable commitment by policy makers."

CDC is encouraged by the IOM’s conclusion that TB can be eliminated in the United States. In fact, the IOM report supports the plan of the Advisory Council for the Elimination of Tuberculosis (ACET), an external advisory group to CDC, of committing to the goal of eliminating TB in the United States. Elimination was defined as less than 1 case per 1 million persons per year in "A Strategic Plan for the Elimination of Tuberculosis in the United States," Morbidity and Mortality Weekly Report, 1989; 38, No. S-3.

Key Message from the IOM Report

"We are now at a critical juncture. On the one hand, control of tuberculosis in the United States has been regained and we are at an all-time low in the number of new cases. On the other hand, we are particularly vulnerable again to the complacency and neglect that comes with declining numbers of cases. Now is the time to commit to the abolition of the recurrent cycles of neglect followed by resurgence that have been the history of tuberculosis. ... But to meet this goal, aggressive and decisive action beyond what is now in effect will be required." p. viii

The recommendations in the IOM report center around five areas of decisive action that will be needed to eliminate TB in the United States:

  1. Maintaining control of TB
  2. Speeding the rate of decline
  3. Developing new tools for diagnosing and treating TB
  4. Increasing involvement in global efforts
  5. Mobilizing and sustaining public support

Key Areas of Decisive Action

Maintaining Control of TB

"... without question the major reason for the resurgence of tuberculosis was the deterioration of the public health infrastructure essential for the control of tuberculosis." p. 2

In the 1970s and early 1980s, the nation let its guard down and TB came back with a vengeance. The country became complacent about TB, and many states and cities redirected TB prevention and control funds to other programs. Consequently, the trend toward elimination was reversed and the nation experienced a resurgence of TB, with a 20% increase in TB cases reported between 1985 and 1992. Many of these had drug-resistant TB. To maintain control of TB, the IOM recommends:

  • Mandating - by states - completion of therapy (treatment to cure) for all patients with active TB
  • Evaluating case management systems used in TB control efforts in new ways
  • Regionalizing TB control activities through federal and state efforts to share and better utilize clinical, epidemiological, and other technical services
  • Retaining federal categorical funding for TB control
  • Educating the public, and training health care providers in order to maintain excellence in TB services

Speeding the Decline

"At the current rate of decline, approximately 6 percent per year, it will take more than 70 years to reach the target for elimination of tuberculosis of 1 case of tuberculosis per million population." p. 122

Maintaining control of TB is not enough to eliminate it. People can unknowingly carry the bacteria that cause TB for years without getting sick (latent TB infection). In fact, an estimated 10 - 15 million Americans have latent TB infection. The infection can suddenly turn active and infectious when the immune system is compromised by changes in health, such as being infected with HIV or developing diabetes or cancer. Finding and treating people with latent TB infection before they become sick - and infectious - is absolutely essential to eliminating TB. To speed the decline of TB, the IOM recommends:

  • Developing better ways to find people who have been in close contact with someone with infectious TB, and if needed, treat them for latent TB infection

  • Performing TB skin testing as part of the medical evaluation for immigrants from countries with high rates of tuberculosis
  • TB skin testing inmates of correctional facilities
  • Increasing targeted TB skin testing and treatment of latent TB infection programs for high-risk groups

Developing New Tools

"... the greatest needs in the United States are new diagnostic tools for the more accurate identification of individuals who are truly infected and who are also at risk of developing tuberculosis." p. 122

The goal of TB elimination cannot be reached with the tools that are currently available. State-of-the-art tools will be needed, such as:

  • Effective tests for latent TB infection (the current skin test takes 2 days, is difficult to read, is often inaccurate, and is easily misread)
  • Tests to distinguish who will progress from latent TB infection to TB disease (more cost-effective and avoids unnecessary therapy)
  • Effective behavioral-change models to influence both persons at risk and their health care providers
  • An effective vaccine to prevent infection and active disease

Increasing Involvement in Global Efforts

"Although an altruistic argument for promoting the global control of tuberculosis can easily be advanced, worldwide control of this disease is also in the nation’s self-interest." p. 149

The U.S. will never be able to eliminate TB until this global epidemic is brought under control and the "reservoir" of infection is reduced. The IOM recommends:

Mobilizing and Sustaining Public Support

"Only an aggressive effort aimed at building political commitment can prevent the elimination of funding for tuberculosis research ... before the elimination of the disease, leading to yet another period of neglect." p. 4

Underlying all these actions, there must be a concerted effort to educate the public that TB elimination is achievable, promote scientific consensus on what needs to be done to achieve TB elimination, partner with leaders of high-risk groups to inform their communities that TB elimination is achievable, and use the media to create public interest in TB elimination. The IOM recommends:

  • Increasing resources for activities to secure and sustain public understanding and support for TB elimination efforts
  • Securing the participation of nontraditional public health partners, with this effort being led by the National Coalition for the Elimination of Tuberculosis (NCET) and CDC
  • Measuring and reporting progress toward the elimination of TB

Where to Get Information About TB

Centers for Disease Control and Prevention (CDC)

Division of TB Elimination Web Site
CDC Voice Information System
HIV, STD, and TB Information
1-888-232-3228

CDC National Prevention Information Network
Address:
P.O. Box 6003
Rockville, MD 20849-6003
Telephone: 1-800-458-5231

TTY: 1-800-243-7012
fax: 1-888-282-7681

E-mail News Service
A free electronic subscription to summaries of HIV, STD, and TB news articles can be obtained by sending a blank message to: preventionews-subscribe@cdcnpin.org. Allow 48 hours for subscription to become effective.

American Lung Association
1726 M Street NW
Suite 902
Washington, D.C. 20036

Telephone: 1-202-785-3355
Fax: 1-202-452-1805

DTBE Fact Sheet
IOM PowerPoint file
 
Contact Us:
  • Centers for Disease Control and Prevention
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    TTY: (888) 232-6348
  • Contact CDC–INFO
USA.gov: The U.S. Government's Official Web PortalDepartment of Health and Human Services
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800-CDC-INFO (800-232-4636) TTY: (888) 232-6348 - Contact CDC–INFO
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