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CDC's Response to Ending Neglect

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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

In collaboration with divisions in the National Center for Infectious Diseases, the Public Health Practice Program Office, and the National Institute for Occupational Safety and Health, the Division of Tuberculosis (TB) Elimination of the National Center for HIV, STD, and TB Prevention (NCHHSTP),* Centers for Disease Control and Prevention (CDC), is the functional equivalent of a national TB program in the United States. As such, CDC is the federal government’s lead agency for TB prevention, control, and elimination.

In 1989, CDC published A Strategic Plan for the Elimination of Tuberculosis in the United States. This plan had been developed by the Advisory Council for the Elimination of Tuberculosis (ACET) and proposed a national strategy for TB elimination by 2010. The implementation of this plan was set back by the TB resurgence that occurred in the late 1980s and early 1990s. This rekindling of TB disease was fueled by the onset of the human immunodeficiency virus (HIV) epidemic, increases in TB cases among foreign-born persons, outbreaks in congregate settings, and the appearance and transmission of deadly multidrugresistant (MDR) TB strains. These occurred at a time when decades of cuts in TB funding had resulted in the deterioration of TB control programs, and TB control officials had very few resources with which to fight back. CDC published the National Action Plan to Combat Multidrug-Resistant Tuberculosis in 1992 to complement the 1989 TB elimination document.

A renewed downturn in TB incidence since 1993 points to the successful implementation of these national plans over the past decade. Unprecedented low rates of TB disease now provide a historic opportunity to accelerate the decline in TB morbidity and the drive toward elimination. This opportunity is threatened, however, by several converging factors: 1) the retreat of TB into high-risk populations at the margins of society where it can resist detection, 2) the persistence and growth of the global TB epidemic, 3) the limitations of current control measures and recognition of the need for new tests and treatments, plus an improved vaccine, and 4) changes in the health care system that make the current context for TB elimination very different from that of a decade ago.

Given this altered landscape, in late 1998 CDC commissioned the Institute of Medicine (IOM) of the National Academy of Sciences to conduct a study and determine if TB elimination is still feasible as a national goal and, if so, to provide recommendations on how to make that goal a reality. The resulting report, Ending Neglect: The Elimination of Tuberculosis in the United States, concluded that TB elimination in the United States is indeed feasible but will require “aggressive and decisive action beyond what is now in effect.” To break the “cycle of neglect” that has characterized U.S. tuberculosis control efforts, the report recommended an aggressive strategy to 1) maintain control of TB, 2) speed the decline in TB incidence, 3) develop new tools for TB diagnosis, treatment, and prevention, 4) increase U.S. efforts to help fight the global epidemic, and 5) mobilize and sustain public support for TB elimination and track progress.

*NCHHSTP provides leadership in preventing and controlling human immunodeficiency virus (HIV) infection, other sexually transmitted diseases (STDs), and TB.

Rationale for TB Elimination

TB maintains its grim historical notoriety as one of the leading infectious causes of death worldwide. Ironically, it is preventable and, in most cases, treatable. Infection-control precautions can help reduce the risk of TB transmission. Medical treatment of persons with latent TB infection can prevent the subsequent development of active TB disease. TB disease can usually be cured with anti-TB drugs taken exactly as prescribed. Even persons with drugresistant strains can often be cured by alternative regimens of medications. The downturn in TB incidence that occurred between 1993 and 2001 is directly attributable to the resources used to strengthen TB control programs and implement these measures nationwide. The question now is whether this success will lead to waning interest and another cycle of neglect or provide the impetus for a final push toward TB elimination.

The continuing social, public health, and economic costs of TB provide a compelling rationale for TB elimination. Almost 16,000 new cases of TB disease occurred in 2001 in the United States, and an estimated 10 million to 15 million persons have latent TB infection with the attendant risk of future disease. Costly TB outbreaks continue to occur in the United States, and MDR TB continues to spread. TB-related costs approach $1 billion each year in this country.

Nonetheless, TB incidence is presently at an all-time low, and several factors strengthen the feasibility of and justification for elimination. TB is retreating into geographically and ethnographically distinct populations that, although hard to reach, can nonetheless be targeted for prevention and control interventions. Arguments based on social justice support increased efforts to combat a grave health problem that disproportionately affects disenfranchised persons. Finally, a U.S. initiative can stimulate other nations to seek the social and economic benefits to be derived from TB elimination.

CDC's Response to Ending Neglect: the Elimination of TB in the United States

This document is CDC’s response to the IOM’s TB elimination challenge. The plan reflects the scientific, programmatic, and health-sector developments of the last decade and supercedes the 1989 Strategic Plan for the Elimination of Tuberculosis in the United States. The goals, objectives, and action steps that comprise CDC’s contribution to TB elimination will serve as a guide for CDC’s work, in collaboration with its partners, to finally rid the nation of the human suffering and societal harm caused by TB disease.

The plan is organized around six goals that frame TB elimination efforts in the context of the IOM’s recommendations. The goals and corresponding objectives are as follows:

  1. Goal I: Maintain control of TB

    Maintain the decline in TB incidence through timely diagnosis of active TB disease, appropriate treatment and management of persons with active disease, investigation and appropriate evaluation and treatment of contacts of infectious cases, and prevention of transmission through infection control.

    Objectives:

    1. Maintain and enhance local, state, and national public health surveillance for TB.
    2. Support the infrastructure needed for laboratory-based identification and treatment of TB.
    3. Ensure that patient-centered case management and monitoring of treatment outcomes are the standard of care for all TB patients.
    4. Develop community partnerships, and strengthen community involvement in TB control.
    5. Improve the timely investigation and appropriate evaluation and treatment of contacts with active TB disease and latent TB infection.
    6. Ensure appropriate care for patients with MDR TB, and monitor their response to treatment and their treatment outcomes.
    7. Ensure that health care facilities maintain infection-control precautions.
    8. Develop improved engineering and personal protective techniques to prevent TB transmission.
    9. Improve TB control in foreign-born populations entering or residing in the United States.
    10. Educate the public and train health care providers to maintain excellence in TB services

  2. Goal II: Accelerate the decline

    Advance toward TB elimination through targeted testing and treatment of persons with latent TB infection, appropriate regionalization of TB control activities, rapid recognition of TB transmission using DNA fingerprinting methods, and rapid outbreak response.

    Objectives:

    1. Increase the capacity of TB control programs to implement targeted testing and treatment programs for high-risk persons.
    2. Explore the appropriateness of regionalizing TB control activities in high, intermediate, and low TB-incidence areas of the United States.
    3. Characterize circulating M. tuberculosis strains using DNA fingerprinting methods.
    4. Develop national, state, and local capacity to respond to outbreaks of TB.

       
  3. Goal III: Develop new tools

    Develop and assess new tools for the diagnosis, treatment, and prevention of TB.

    Objectives:

    1. Develop a coordinated plan for TB research.
    2. Develop new methods for diagnosing persons with latent TB infection and for identifying infected persons who are at high risk for developing active TB.
    3. Develop and assess new drugs for improving TB treatment and prevention.
    4. Develop a new and effective TB vaccine.
    5. Develop and implement a program of research on behavioral factors related to TB treatment and prevention.
    6. Rapidly transfer findings from research studies into practice.

       
  4. Goal IV: Reduce the global burden of TB

    Increase U.S. involvement in international TB control activities.

    Objectives:

    1. Provide leadership in public health advocacy for TB prevention and control.
    2. Provide technical support and build capacity for implementation of the World Health Organization strategy for TB control (i.e., DOTS), especially in those countries that contribute significantly to the U.S. TB burden.
    3. Develop models for the diagnosis and treatment of patients with MDR TB.
    4. Provide technical, programmatic, and research support to reduce the incidence of TB as an opportunistic disease in high HIV-burden countries.

       
  5. Goal V: Mobilize and sustain public support

    Mobilize and sustain support for TB elimination by engaging policy and opinion leaders, health care providers, affected communities, and the public. Implement a comprehensive health communication campaign that supports TB elimination and ensures the development and delivery of effective TB elimination messages. Improve communication efforts through consistent monitoring and evaluation of the plan's methods and strategies.

    Objectives:

    1. Develop and implement a health communications effort focusing on the achievable goal of eliminating TB, if both political commitment and resources are made available.
    2. Help communities foster nontraditional, multisectoral, public-private partnerships to improve the effectiveness of their communications activities, with particular attention to culturally appropriate materials.
    3. Support the development of state- or area-specific TB elimination plans that contain communications activities designed to build support for TB elimination.

       
  6. Goal VI: Track progress

    Monitor progress toward the goal of TB elimination, and regularly report on progress to all target audiences.

    Objectives:

    1. Develop innovative analyses for examining surveillance data to help focus elimination efforts.
    2. Develop novel indicators of progress toward elimination.
    3. Conduct periodic evaluations of TB program performance at federal, state, and local levels.
    4. Conduct an annual progress review.

    CDC's Response to Ending Neglect: The Elimination of Tuberculosis in the United States complements a separate, more comprehensive, coordinated federal response to the IOM's recommendations by providing more detail on CDC's part of the federal strategy. Implementation of these plans will set in motion the activities needed to eliminate TB in the United States.

 
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