Why is TB in the United States important?
TB in the United States is important because the United States is one of the most significant low burden TB countries. Although much is written about the high burden TB countries there are also, going forward, things that can be learnt from the low burden countries. And even in low burden countries there are deaths that can be prevented and financial savings that can be made.
What are currently the main activities with TB in the United States?
TB in the United States
At a local level the current activities are the same as they have been for many years. For those people with TB disease, the aim is to provide effective treatment. For those people with latent TB, the aim is to provide preventative treatment, to prevent them from developing active TB disease.
But there is also a wider goal which is to eliminate TB in the United States by 2035. In 2010 it was estimated that if TB could be eliminated by 2035, then there would be:1Stop TB USA, Tuberculosis Elimination Plan for The United States, A Call for Action on the Tuberculosis Elimination Plan for the United States, 2010, Atlanta, https://stacks.cdc.gov/view/cdc/12076
- 15,200 fewer TB related deaths;
- 253,000 fewer cases of TB;
- $1.3 billion less in TB treatment costs.
There is currently a year by year decline in cases of TB. But the decline is very slow and at the current rate of progress the goal of elimination by 2035 is unlikely to be achieved. So when was the goal of elimination set, what progress is being made towards achieving it, and are there changes that need to be made?
TB control in the United States in the 20th century
In the early 1900s TB rates declined steadily from approximately 200 deaths per 100,000 people per year to less than 1 death per 100,000 people in 1985.2T Navin, The Continued Threat of Tuberculosis, 2002, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2738542/
Thanks to improved social and economic conditions and the development of effective drugs, TB experts in the United States believed that TB could be virtually eliminated by 2010.3https://tbfacts.org/history-of-tb-drugs/ 4CDC's response to Ending Neglect, 2002, https://www.heartlandntbc.org/assets/training/mini-fellowship/PediatricToolBox/CDC/ed_training/iom/iomresponse/intro.htm
But when medical advances led to a declining number of cases, Congress had responded in 1972 by:5Aggressive Campaign Needed to Prevent Resurgence of Tuberculosis, 2000, National Academies, https://www8.nationalacademies.org/onpinews/newsitem.aspx?RecordID=9837
eliminating all funding dedicated to fighting the disease. As a result TB public health systems collapsed, infection rates jumped during the late 1980s, and deadly drug resistant strains emerged".
It is estimated that this resurgence of TB required billions of dollars to be invested by federal, state and local governments to put the United States back on the path to TB elimination.6Tuberculosis An Opportunity to eliminate a disease in the United States, 2017, http://www.tbcontrollers.org/ntca-2/committees/advocacy/tb-elimination-statement/#.XsOfhcbTVBw It is estimated to have cost at least $1 billion in New York City alone.7T. R. Frieden, Tuberculosis in New York City - Turning the Tide, 1995, https://www.nejm.org/doi/10.1056/NEJM199507273330406?url_ver=Z39.88-2003&rfr_id=ori%3Arid%3Acrossref.org&rfr_dat=cr_pub%3Dwww.ncbi.nlm.nih.gov
The ongoing existence of drug resistant strains has also continued to be very expensive.
In 2018 in the United States for each patient:8The Costly Burden of Drug-Resistant TB Disease in the U.S., 2018, https://www.cdc.gov/tb/topic/drtb/default.htm
- the cost of treating drug sensitive TB was $49,000;
- treatment costs for MDR-TB averaged $393,000;
- treatment costs for XDR TB averaged $758,000.
There is more about the cost of TB treatment in different countries.
Setting the aim of the elimination of TB in the United States
In 1984 Dr James Mason, the Director of the CDC, challenged the public health community to develop a strategy to eliminate TB from the United States.9A Strategic Plan for the Elimination of Tuberculosis in the United States, 1989, https://www.cdc.gov/MMWR/preview/MMWRhtml/00001375.htm
This challenge resulted in the formation of the Advisory Council for the Elimination of Tuberculosis (ACET) and the publication of a national TB elimination plan in 1989. The elimination of TB was defined as achieving a TB case rate of one per one million people a year.10R. Reves, Tuberculosis Elimination in the United States: An Achievable Goal or an Illusion?, 2012, https://www.atsjournals.org/doi/full/10.1164/rccm.201206-1039ED
Ending Neglect
In 1998 the Institute of Medicine (IOM) was commissioned to conduct a study to determine if TB elimination was still a feasible goal. If it was they should 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 was still feasible, but would require:11L. Geiter, Ending Neglect: The Elimination of Tuberculosis in the United States, 2000, National Academies Press, https://www.ncbi.nlm.nih.gov/pubmed/25077271
"agressive and decisive action beyond what is now in effect"
A new target date for elimination was set at 2035 and there were overall five main groups of steps that were identified as being needed in order to achieve elimination.
These steps included much greater attention being paid to the screening of "at risk" populations. And people with latent infection should be actively treated instead of society passively waiting for infected individuals to develop disease and then infecting others. It was also said that these ideas should be embraced by TB control staff and, in turn, promoted to public health policy makers.
But key components of the plan were never adequately funded or fully implemented.
What were and indeed are the "at risk" populations
There are two main groups of "at risk" populations for TB.12At-Risk Populations for Tuberculosis, State of Rhode Isladn, Department of Health, https://health.ri.gov/diseases/tuberculosis/about/atriskpopulations/
These are:
- People at high risk for TB exposure and infection and
- People at high risk for progression to TB disease once infected.
People at high risk for TB exposure and infection include:
- Close contacts of people exposed to infectious cases of TB i.e. people with TB disease;
- Foreign born people including children, who have immigrated within the last five years from parts of the world that have a high TB incidence;
- Residents and employees of high risk congregate settings (prisons, nursing homes, homeless shelters, drug treatment facilities and healthcare facilities);
- Health care workers who serve high risk clients;
- Some medically under served, low income populations as defined locally;
- High risk racial or ethnic minority populations defined locally as having an increased prevalence of TB;
- Infants, children and adolescents exposed to adults in high in high risk categories;
- People who inject illicit drugs or any other locally identified high risk substance users.
People at high risk for progression to TB disease once infected include:
- People with HIV infection;
- People who were infected with M. tuberculosis within the past 2 years, particularly infants and very young children;
- People who have underlying medical conditions known to increase the risk of progression to active TB disease;
- People who inject illicit drugs;
- People with a past history of inadequately treated TB.
The Call for Action Report in 2010
Nine years after the IOM report this "Call for Action on the Tuberculosis Elimination Plan for the United States", was an assessment of how and why the IOM's tuberculosis elimination plan had not been fully implemented.13Stop TB USA, Tuberculosis Elimination Plan for The United States, A Call for Action on the Tuberculosis Elimination Plan for the United States, 2010, Atlanta, https://stacks.cdc.gov/view/cdc/1207 It provided updated action plans on how there could be accelerated progress towards TB elimination in the United States. It also restated the benefits of elimination.
It identified the TB elimination effort as failing, not for want of the right goals or specific recommendations but rather because the IOM recommendations needed to achieve the goals had not been fully implemented.
Now more than 30 years after the goal of elimination was set, another report on the progress that has been made
This latest report summarised the situation in 2017 as follows:14Tuberculosis An Opportunity to eliminate a disease in the United States, 2017, http://www.tbcontrollers.org/ntca-2/committees/advocacy/tb-elimination-statement/#.XsOfhcbTVBw
"The implementation of the 1989 and 2000 recommendations has been far too slow and incomplete. Due mainly to lack of political will and monetary investmentment. We urge the current administration and Congress to galvanize sustained political and monetary investment towards eliminating TB in the United States. Such leadership would pay off, not only in protecting the health and well-being of the people, but would ensure an adequate public health infrastructure for addressing TB and other health security threats to the United States, while producing substantial cost savings."
It would in addition save many lives.
Not only is there still a need for the elimination of TB, but an improved public health infrastructure would surely have been of help at this time of coronavirus and covid-19.
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This page was last updated in May 2020.
Author Annabel Kanabus
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