II-A.6 Tuberculosis Total Program Funding (Dollars in thousands) Funding for FY 2003, FY 2002, and FY 2001 are included in the HIV/AIDS funding table Mandate CDC is responsible for administering and promoting a national program for the prevention, control, and elimination of tuberculosis (TB) in the United States. CDC also works to eliminate the spread of TB globally. Health Burden Many people think that tuberculosis is a disease of the past. One reason for this belief is that the United States is currently seeing a decline in TB and is at an all-time low in the number of new cases. However, that very success makes the nation vulnerable to the complacency and neglect that come with declining visibility. This success also gives the nation an opportunity to eliminate TB. There is reason for concern, as the nation has felt the ill effects of complacency and neglect of TB before. Once one of the leading causes of death in the U.S., TB had declined steadily after the introduction of effective chemotherapy in 1953. In the 1970s and early 1980s, TB control efforts were scaled back 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 cases were difficult-to-treat, drug-resistant TB. The nation's mobilization of additional resources to combat the resurgence in the 1990s has, however, paid off; in 2000 the nation achieved the eighth consecutive year of decline and an all-time low in reported TB cases. Regaining control of TB has clearly been one of the major public health success stories of the last decade and has put the nation back on track toward TB elimination. Still, TB continues to pose considerable challenges. All 50 states and District of Columbia continue to report TB cases each year and more than 16,000 cases of TB disease occurred in the U.S. during 2000. Every new TB case has the potential to spread if not promptly recognized and treated. An estimated 10 to 15 million persons in the U.S. have been infected with the TB bacteria (latent TB infection). At some point in their lives, about 10% of infected persons will develop TB disease that can be transmitted to others. A much higher proportion will develop TB disease if they are co-infected with HIV. An increasing proportion of cases in the U.S. are among persons born outside the country. Foreign-bom persons now account for nearly half of all U.S. TB cases. These trends reflect the potential impact of the global magnitude of TB on the health of people in the U.S. and elsewhere. Drug-resistant TB also poses a continuing threat. If persons with TB disease do not complete their full course of treatment, they can develop and spread strains of TB that are resistant to available drugs. One case of multidrug-resistant (MDR) TB can cost up to $1 million to treat. Some U.S. areas are also having increasing difficulty in ensuring proficiency among healthcare providers in diagnosing and treating TB disease and latent TB infection. Diagnosis of infectious cases may be delayed because of their lack of experience, resulting in unnecessary disease transmission to others. Strategies, Activities, and Resources In 1989, CDC set a goal to eliminate TB in the United States, with elimination defined as less than 1 case per 1,000,000 persons. This goal was reaffirmed by the Advisory Council for the Elimination of Tuberculosis (ACET) in 1999 and by the Institute of Medicine (IOM) in 2000. In its report. Ending Neglect: The Elimination of Tuberculosis in the United States, the IOM called for a renewed commitment to TB elimination. CDC and the Federal TB Task Force are outlining a plan to accomplish this goal. Central to this plan are strategies to: . Strengthen domestic TB control programs to ensure the prompt identification of persons with TB and offer appropriate treatment; Provide examination and treatment to persons who have latent TB infection and who are at high risk for developing infectious TB disease; Support the development of improved tools for TB prevention, such as a better vaccine, new diagnostic tests and improved drugs; Work in partnership with the countries that contribute most to TB morbidity in the U.S. In addition, CDC is working to address the global TB epidemic (8 million new cases and 2 million deaths annually). CDC provides technical assistance and leadership to global efforts and participates in global and country-specific TB prevention initiatives. Links to DHHS Strategic Plan Tuberculosis performance measures relate to DHHS Goal 1: Reduce major threats to the health and productivity of all Americans, and Objective 1.7: Reduce the incidence and impact of infectious diseases. Partnerships CDC works with state, large city, and territorial health departments to deliver TB prevention and intervention activities designed to reduce the incidence of TB and eventually eliminate the disease. CDC works with the HHS Advisory Council for the Elimination of Tuberculosis (ACET), the National TB Controllers Association, American Lung Association, and American Thoracic Society (ATS) to set guidelines, recommendations, and policies related to TB prevention, control, and elimination. CDC is working with the Federal TB Task Force to develop a federal action plan in response to the IOM report, Ending Neglect: The Elimination of Tuberculosis in the United States. CDC works with NIH and FDA to develop new diagnostic and treatment tools and better vaccines. Through contracts with academic institutions and public health departments and interagency agreements (with the Veterans Health Administration), CDC formed a consortium for clinical trials research (currently evaluating the new TB drug, rifapentine). Internationally, CDC collaborates with USAID, WHO, and others through efforts such as the Stop TB Initiative and through assistance to specific countries. Presentation of Performance Protecting Health and Promoting Partnerships Performance Summary Success in achieving TB elimination ultimately depends on treating infectious patients quickly and completely, treating them with drugs that work, treating their close contacts, treating persons with latent infection who are at high risk of developing the disease, and maintaining timely, complete local, state, and national TB information systems to monitor elimination efforts. Key performance measures include the following: Percentage of infectious TB patients who complete treatment within 12 months. Because completion of TB treatment is the most effective way to reduce the spread of TB and prevent its complications, this objective is the highest priority for CDC's TB program. Its achievement is vital to the reduction of TB cases and the eventual elimination of this disease. By FY 2003, CDC anticipates that 88% of TB patients will complete therapy within 12 months. In 1998, 79.1% of patients were reported to complete therapy within 12 months, an increase from the 67.6% reported in 1994. Patients who do not complete therapy within 12 months are often difficult to treat and require numerous interventions. Significant new efforts must be made to achieve this objective. CDC supports outreach workers, hired from language, cultural, and ethnic groups with high TB incidence to help meet this objective. Outreach workers help patients complete treatment through directly observed therapy (DOT), incentives, and other adherence strategies. CDC and the CDC-funded Model TB Centers also design and implement training and educational aids for health department and healthcare provider staff to improve the skills needed to help achieve this objective. Percentage of TB patients with initial positive cultures who also have drug susceptibility tests done: Healthcare providers must know if a newly diagnosed infectious patient is infected with drug-sensitive or drug-resistant organisms so that appropriate drug therapy can be initiated. If this information is not known, patients may receive inadequate treatment leading to spread of drug-resistant organisms, additional morbidity, and even TB outbreaks and mortality. The performance for this measure in 2000 was 92.7%, up from 73.3% in 1993. With continued progress, CDC expects that programs will achieve the 95% target in FY 2003. Much of this progress is attributable to increased efforts of state and local health departments and hospital infection-control practitioners to address the resurgence of TB and to increased funding for health department laboratories to purchase state-of-the-art equipment needed to perform more accurate and rapid laboratory testing and confirmation for TB and MDR TB. Percentage of contacts of infectious cases who are placed on treatment for latent TB infection and complete a treatment regimen: Contacts of infectious TB patients are at high risk of developing TB and therefore must be screened for infection and offered and complete treatment if infected. This is critical in community efforts to control and prevent TB. The 1998 rate for this measure was 74%, up from 68.4% in 1993. Through cooperative agreements to state and local health departments, CDC supports a commitment to the identification and examination of contacts and the completion of treatment for contacts who have latent TB infection. Health departments are required to address this objective in their TB cooperative agreement applications. CDC is also designing training for health department TB staff to improve their skills in this area. Percentage of other high-risk persons who are placed on treatment for latent TB infection and complete a treatment regimen: Completion of treatment for latent TB infection is a cornerstone of U.S. efforts to reduce TB and eventually eliminate the disease. The 1998 rate for this objective was 62.9%; achieving future targets will require a great deal of effort by health departments and healthcare providers who serve persons at risk for TB. In recent years, many health departments have appropriately placed top priority on identifying and treating TB cases, reducing morbidity, and controlling outbreaks. With fewer TB cases, CDC is emphasizing activities related to completion of treatment for latent TB infection. In FY 2001, approximately 6% of TB cooperative agreement base award funds were devoted to targeted testing and completion of treatment for latent TB infection in groups at high risk for infectious TB. CDC is also working with HRSA and other federally funded programs serving groups at high risk for TB to facilitate testing and completion of treatment in high-risk persons. Recently, CDC and the American Thoracic Society issued new recommendations for the treatment of latent TB infection that permit 2month therapy for certain groups. These recommendations are an outcome of CDC- and NIH-supported research. CDC is assessing the implementation of these guidelines to examine the incidence of adverse events and has recently issued additional guidance to help providers more safely test persons who are latently infected. CDC believes these regimens will significantly increase the percentage of persons who complete treatment for latent TB infection. Percentage of TB case reports in which core data items are complete: To design and carry out community TB prevention and elimination efforts, public health officials and community leaders need to identify the unique and ever-changing characteristics of TB in their communities. Significant progress is being made on this front. States now report from 95% to 100% complete information on 19 of 22 targeted reporting variables. Progress can be attributed to CDC funding for TB surveillance activities and frequent telephone, electronic, and on-site communication between CDC and health department Surveillance staff. Two of the under-reported variables for this measure relate to information about the HIV status of TB patients. CDC is working with health department TB staff, state epidemiologists, HIV program staff, and others to resolve issues surrounding these items, many of which are related to HIV confidentiality issues. 80-950 D-19 |