Ending Neglect:
The Elimination of Tuberculosis in the United States

Institute of Medicine

Telephone News Conference
May 4, 2000

Opening Statement
by

Morton N. Swartz

Chief, James Jackson Firm of Medical Service
Massachusetts General Hospital, Boston
and
Chair, Committee on the Elimination of Tuberculosis in the United States



Good morning, and thank you for joining us by telephone today for the public release of our report. We hope that our efforts will help put an end to a dangerous pattern in the nation's tuberculosis history -- a pattern of complacency and neglect.

Over the past seven years, the TB epidemic in the United States has gradually receded. TB rates here are now at an all-time low. Yet, globally the epidemic grows in strength. Parts of Europe where the disease was once thought to be under control now report the spread of deadly drug-resistant strains. TB remains a leading infectious killer in the world.

Despite the falling number of cases in the United States, this country has entered a dangerous phase in which the disease has retreated to specific communities where it can lie dormant and resist detection. Without decisive steps to identify and treat the undetected cases, the disease could come back with a vengeance and exact a heavy price. U.S. policy-makers cannot afford to relax their vigilance. Current efforts at TB control will not be sufficient, and doing less could be disastrous. We therefore urge an aggressive campaign designed to eliminate TB in the United States.

The resurgence of the epidemic that occurred in the late 1980s had its origins in the complacency of the early 1970s. As the number of cases dropped, Congress eliminated all funding dedicated to fighting the disease in 1972. Local control efforts collapsed in many parts of the country, and new outbreaks in the late 1980s quickly turned into an epidemic that cost billions of dollars to control. Hundreds of drug-resistant cases developed. A completely treatable and curable disease once again turned deadly. The United States cannot afford to let this happen again.

Bear in mind that the global epidemic keeps the stakes high. In some of the hardest hit countries -- mainly in Africa and Asia -- more than one-half of the population is infected. In this era of rapid transportation, what happens in the rest of the world is important to the United States. As the number of home-grown cases declines, more than 40 percent of all new TB cases in the United States come from these high-prevalence countries. This is especially worrisome because TB, in its early stages, can lie dormant and hidden. The infected individual can be carrying the seeds of a potential outbreak and not even know it.

To short-circuit the cycle of TB resurgence in the United States, our report recommends an aggressive, multistep strategy designed to eliminate tuberculosis. First we want to emphasize the need to strengthen the identification and full treatment of active cases. This is of the highest priority. In addition, the following steps are crucial:

> improve screening for latent infections among high-risk groups,
> reorganize TB control efforts to reflect the changing incidence of the disease,
> increase U.S. efforts to assist other countries in fighting the global epidemic, and
> bolster research to develop better methods for detecting and treating latent infections.

Improved screening for latent infections would stop the disease in its tracks before it becomes contagious. To do a better job of this, the committee recommends a targeted screening program for these early infections among high-risk groups, including potential immigrants from countries where the disease is most prevalent. Under current procedures, all immigrants are checked for active, contagious cases of TB. No one with this condition can be admitted to the United States until treated. If test results merely are suspicious, applicants are told to report to public health officials once they get to the United States for further testing and treatment.

To improve this process and make sure visa applicants for permanent residency are fully tested and treated, we recommend two changes. First, to detect latent infections, all potential immigrants from high-prevalence countries should be required to get a tuberculin skin test prior to entering this country. Second, to improve follow-up, we recommend that documents granting permanent residency be withheld until immigrants receive needed screening or treatment after arrival. While this may sound simple, it would require both a major shift in the current immigration program and additional funding from Congress. We estimate the cost at $23 million, although in the long run, this would be cheaper than the cost of treating the individuals and others they infect.

In the case of those coming from high-prevalence countries on temporary visas, there is still the risk of a person with a latent infection developing active tuberculosis. However, that risk may be lower, particularly if the stay is for a short period of time. No medical testing of any kind currently is required for individuals on a temporary visa, and it would take more evaluation to mandate TB testing. Therefore, we encourage employers and schools to consider providing screening and treatment for workers and students on temporary visas.

Currently, about 7 million foreign-born individuals with latent TB infections already reside in the United States. The committee did not call for mandatory screening or treatment for these individuals, but instead recommended expansion of culturally sensitive and foreign-language outreach programs. For example, public health officials in the Seattle area run a model program of this type.

For other high-risk groups, such as inmates in correctional facilities, we recommend mandatory skin tests and treatment. The confined conditions of prison are ideal for the transmission of this disease.

We understand that our recommendations may cause some alarm, and we want to allay any fears. Latent infections do not pose an immediate health risk. It would be prudent, however, to take the steps that can help prevent future outbreaks. The United States has an opportunity to stop this disease, and should take advantage of it.

Beyond screening, public health control efforts need to be restructured in the United States. As the number of cases rapidly declines in some areas and increases in others, reorganization becomes necessary. To maintain expertise and efficiency in those communities where the number of TB cases has declined steeply, control programs should be regionalized. It also may be most cost-efficient to contract with private providers.

Since a growing proportion of new cases is coming from other countries, the United States must do more to help control this global epidemic by providing financial and technical support in the nations where the disease thrives.

Finally, the United States needs to spend more on research. The committee calls for the federal government to triple its investment in TB research -- increasing it to at least $280 million per year. The money is needed to help develop better diagnostic tests and treatments, including a vaccine.

This four-step plan would be a good start toward eliminating tuberculosis in the United States. It will take decades to beat the disease, but now is the time to begin.

That concludes my opening remarks. My colleagues and I will now take questions from reporters. Because we are recording this news conference, please state your name and affiliation.