Case totals down in 1998 for sixth consecutive year
Long-term commitment is still necessary
For the sixth consecutive year, the number of TB cases has gone down, the Division of Tuberculosis Elimination (DTBE) at the Centers for Disease Control and Prevention (CDC) announced last month. Last year’s total of reported TB cases for the nation stood at 18,371, compared with 19,851 cases for 1997.
Last year also saw decreases in 39 of 53 reporting areas, which include all 50 states, plus Wash ington, DC, New York City, and Puerto Rico. That left 14 of the 53 areas reporting either increases or no change in case totals. In 1997, by comparison, 18 of 53 areas reported either increases or no change in cases.
As in years past, CDC experts seasoned their satisfaction with the good news with caution. "It’s good news, of course," says John Seggerson, associate director for external relations for the DTBE. "But the nature of TB control is that it has to be a long-term commitment. That means if you let up on control, you’re going to see a resurgence in disease."
That theme was echoed by Ken Castro, MD, director of the DTBE, in a speech on March 23 marking World TB Day. "With TB, it’s easy to become complacent," Castro warned. "We tend to have a very short attention span when it comes to this disease."
Two problems still loom large
He used the same occasion to note that two problems in particular continue to pose a threat to TB control in the United States; namely, the persistence of drug-resistant strains of the disease and the presence of foreign-born populations who have latent TB infection. The upsurge in resistant strains of TB, both globally and at home, means TB can no longer be regarded with complacency, Castro said. "There is a belief that TB is a disease of the past, that TB is our grandparents’ disease. Yet the TB we face today is often far more complex than what our grandparents faced. If we don’t stop TB today, the TB our grandchildren face will be even more difficult to cure."
By the CDC’s most recent estimates, 43 states now have reported instances of multidrug- resistant disease.
As for TB among the foreign-born, that probably will pose the biggest challenge to TB controllers in the United States in the future, Castro added. "In the U.S., we have only begun to scratch the surface of screening for latent disease. Increasingly, our ability to meet this challenge will be the measure of our success." The proportion of TB among the foreign-born, which stood at only 22% of the national total in 1986, at last count had edged up to 40% of the total.
DTBE experts are still analyzing 1998 data to see how last year’s numbers have modified trends in drug-resistant disease, the proportion of cases occurring among the foreign-born, and other facets of the U.S. epidemic.
The increase in the proportion of foreign-born cases holds two implications, Castro noted: First, it means new ways must be found to reach out to foreign-born populations. Second, it indicates America must take a more active role in global TB control. Castro also said last year’s success in driving down case totals masks problems confined to certain locales. "The status of the epidemic varies from community to community," he said. "Many communities lack the resources to reach out to high-risk populations, screen properly for cases, do necessary follow-up investigations, and provide DOTS [directly observed therapy, short-course]."
Castro and World Health Organization experts also pointed to continuing problems in global TB control, among them the epidemic of multidrug-resistant TB that menaces Eastern Europe and Russia, and low worldwide enrollment in the WHO-approved DOTS. With only 16% of infectious cases enrolled in DOTS programs, it is imperative to increase political commitment to implementation of DOTS, the experts said.
"The fundamentals of TB control are not complex," noted Castro. "But building and sustaining the commitment needed to carry them out are daunting."
The CDC is committed to helping the WHO in its effort to increase the necessary commitment, he added, and for good reason: "What we do globally will benefit us here at home."
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