Date: May 4, 2000
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Aggressive Campaign Needed To Prevent Resurgence of Tuberculosis
WASHINGTON -- U.S. policy-makers need to intensify the fight against tuberculosis (TB) by finding and treating people with latent infections, and strengthening public health services, says a new report
from the Institute of Medicine of the National Academies. It recommends screening programs that would target high-risk communities in the United States and intensify the TB testing process for visa applicants from countries where the disease is most widespread.
Although the number of tuberculosis cases is dropping in the United States, action is needed because a global epidemic remains a potential source of new infections, the report says. Without testing, a person can unknowingly carry a latent infection for years before it becomes active and contagious.
"This country has entered a dangerous phase in which the disease has retreated to specific communities, where it can lie dormant and resist detection," says Morton N. Swartz, chief, James Jackson Firm of Medical Service, Massachusetts General Hospital, Boston, and chair of the committee that wrote the report. "Without decisive steps to identify and treat the undetected cases, the disease could come back with a vengeance and exact a heavy price."
To break this cycle, the report recommends the following multistep, aggressive strategy designed to eliminate tuberculosis in the United States:
> improve screening for latent infections among high-risk groups
> reorganize TB control systems to reflect the shifting patterns of the disease
> increase U.S. efforts to assist other countries in fighting the global epidemic
> develop better methods for detecting and treating latent infections
TB control in the United States has been marked by a pattern of neglect that should not be repeated, the report says. When medical advances led to a declining number of cases, Congress responded in 1972 by 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 took high-cost control measures to deal with the outbreak, and the disease is now at an all-time low in this country -- about 68 active cases per million -- with the rate dropping about 7 percent each year.
Eliminating TB entirely in the United States is a reasonable goal because it is preventable, treatable, and curable, the report says. Infection requires prolonged contact -- usually spending hours in a confined area with a person who has an active case of the disease. In the United States, TB deaths are rare. Even drug-resistant strains can be cured by a very strict regimen of antibiotics. Yet, each year TB claims 2 million to 3 million lives worldwide, mainly in countries with limited health facilities.
Active, contagious cases are the first priority in tuberculosis control, and all states should mandate the completion of treatment for anyone with an active infection, the report recommends. This will help interrupt the spread of the disease and prevent the emergence of drug-resistant strains. Screening Programs
Eliminating TB also will require aggressive new efforts aimed at latent infections, the report says. At present, more than 40 percent of all new cases of TB in the United States are among the foreign-born coming from nations with high rates of the disease. Risk of developing active tuberculosis is highest during their first five years in this country; of those who develop the disease, about a third will do so within one year. If current trends continue, such immigrants soon could account for the majority of new TB cases in the United States. For these reasons, it is imperative to require testing for latent infection prior to arrival in this country, the report urges. This would require a major restructuring of the current program.
"We understand that our recommendations may cause some alarm, and we want to allay any fears," says Swartz. "These latent infections do not pose an immediate health risk. But we want to be prudent and take the steps that can help prevent future outbreaks."
Under current U.S. procedures, prospective immigrants must get a chest X-ray to check for active cases of TB. If detected, an infectious case must be treated in the home country before a visa is granted. Others with a suspicious X-ray may enter the United States, but are required to report to the local health department.
To detect latent infections, skin testing should be required as part of the visa application process for permanent residency, the the committee said. Applicants who test positive but show no evidence of active infection would be allowed to enter the United States, but then would be required to undergo evaluation and therapy before they could receive a permanent residency card.
This requirement should extend to all immigrants from the highest risk countries, such as those where the infection rate is above the global average of 36 percent, the committee said. It also should apply to immigrants from Mexico, even though the disease is less prevalent there. This step is needed because Mexican immigrants account for nearly 25 percent of all cases in the United States among the foreign-born, the report says. In total, the report estimates that 250,000 potential immigrants per year would be included in this enhanced screening program, which could prevent an estimated 2,100 cases of TB.
People coming to the United States for temporary stays, as opposed to permanent residence -- such as students, workers, and their families -- would not undergo mandatory testing under the committee's recommendations. Currently, no health testing of any kind is required to get a temporary visa, and initiating a screening program would require further evaluation, the report says. But it does encourage schools and employers to provide testing.
Currently, about 7 million foreign-born individuals with latent TB infections 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. To succeed, they will have to involve the private sector, neighborhood health centers, and community-based organizations. A model program can be found in Seattle.
Targeted screening programs also should be implemented for other high-risk groups, including mandatory skin tests for all inmates in correctional facilities, the report says. New infections can more easily be transmitted in the close setting of a jail or prison. For high-risk groups who are hard to reach, such as substance abusers and the homeless, a different approach is needed. Successful outreach efforts already provide various services for these populations, and nearly all involve close collaboration with community-based organizations, neighborhood health centers, and private providers. They should be enlisted to help identify undetected cases of TB.Additional Steps
Implementing these recommendations will be challenging, and will require substantial new funding from Congress to support the various federal, state, and local agencies involved, the report cautions. While the committee did not estimate the total cost of a program to eliminate TB in the United States, it did say the added expense of testing and treating new immigrants with suspected latent infections would total about $23 million per year -- slightly less than the costs of treating those same individuals if their disease became active. The savings would be far greater, however, compared to the costs if those same infections went untreated and spread to other individuals.
Control efforts need to be restructured, the report adds. For decades, specialized units in local public health departments have been at the center of the system, assuring local expertise. But in areas where the number of TB cases has declined steeply, these operations should be regionalized to maintain efficiency and quality. In some instances -- especially in areas where there are few new cases -- the most cost-efficient model may be to contract with private health providers.
Expanding screening efforts and reorganizing TB care will go a long way toward blocking the spread of the disease. However, better tests and treatments, including a vaccine, also will have to be developed, the report says. Preliminary research over the past several years has set the groundwork, but federal leadership and resources will be needed to complete the job. At least $280 million per year in federal research dollars -- triple the amount now spent -- would be necessary to make these advances.
Finally, the United States cannot eliminate TB until the global epidemic is brought under control, the report says. The United States should increase its contribution to the global tuberculosis control effort, particularly in those countries that are the source of most new cases. This should include financial, technical, and research support.
The study was funded by the Centers for Disease Control and Prevention. The Institute of Medicine is a private, nonprofit institution that provides health policy advice under a congressional charter granted to the National Academy of Sciences. A committee roster follows.
Read the full text of Ending Neglect: The Elimination of Tuberculosis in the United States
for free on the Web, as well as more than 1,800 other publications from the National Academies. Printed copies are available for purchase from the National Academy Press Web site
or at the mailing address in the letterhead; tel. (202) 334-3313 or 1-800-624-6242. Reporters may obtain a pre-publication copy from the Office of News and Public Information at the letterhead address (contacts listed above).
INSTITUTE OF MEDICINE
Division of Health Promotion and Disease PreventionCommittee on the Elimination of Tuberculosis in the United StatesMorton N. Swartz, M.D.* (chair)
Professor of Medicine
Harvard Medical School; and
Chief, James Jackson Firm of Medical Service, and Chief Emeritus, Infectious Disease Unit
Massachusetts General Hospital
BostonRonald Bayer, Ph.D.
Professor, Division of Sociomedical Sciences
Joseph L. Mailman School of Public Health
New York CityC. Patrick Chaulk, M.D., M.P.H.
Senior Associate for Health
Annie E. Casey Foundation
BaltimoreFran DuMelle, M.S.
Deputy Managing Director
American Lung Association, and
Director of Government Relations
American Thoracic Society
Washington, D.C.Sue C. Etkind, R.N., M.S.
Division of Tuberculosis Prevention and Control
Massachusetts Department of Public Health
BostonDavid W. Fleming, M.D.
Assistant Administrator and State Epidemiologist
Center for Disease Prevention and Epidemiology
Oregon Health Division
PortlandAudrey R. Gotsch, Dr.P.H., C.H.E.S.
Professor and Vice Chair
Department of Environmental and Community Medicine, and
University of Medicine and Dentistry of New Jersey - Robert Wood Johnson Medical School
PiscatawayPhilip C. Hopewell, M.D.
Associate Dean, and Attending Physician, Division of Pulmonary and Critical Care Medicine
San Francisco General Hospital, and
Medical Director, Francis J. Curry National Tuberculosis Center, and Professor of Medicine
University of California
San FranciscoDonald R. Hopkins, M.D., M.P.H.*
Associate Executive Director
The Carter Presidential Center
ChicagoJohn A. Sbarbaro, M.D., M.P.H.
University Physicians Inc.
School of Medicine
University of Colorado Health Sciences Center
DenverPeter M. Small, M.D.
Stanford Center for Tuberculosis Research, and
Assistant Professor of Medicine
Division of Infectious Diseases and Geographic Medicine
Stanford Medical Center
Stanford, Calif.Mary E. Wilson, M.D.
Chief of Infectious Disease, and
Travel Resource Center
Mount Auburn Hospital
Cambridge, Mass.Lester N. Wright, M.D., M.P.H.
Associate Commissioner and Chief Medical Officer
New York State Department of Correctional Services
INSTITUTE STAFFLawrence Geiter, Ph.D.
Member, Institute of Medicine