Recent IOM report could result in more funding for TB
New superbill’ to outline ambitious goals, projects
Construction has begun on a new TB "super-bill," which, if approved, would substantially increase funding and powers for TB control in the United States. The Omnibus TB Control Act, as the bill has been dubbed temporarily, is expected to lay ambitious groundwork that should cover everything from more money for a new vaccine to secure and separate funding for targeted testing activities.
Architects of the superbill — namely, members of the newly revitalized National Coalition to Eliminate Tuberculosis (NCET) — say a recently released report from the prestigious Institute of Medicine (IOM) should provide the impetus the measure will need to pass congressional muster.
"The IOM report has put TB on the front burner, and NCET has been designated as the report’s point-person," notes Lee B. Reichman, MD, MPH, executive director of the National Tuberculosis Center at the New Jersey School of Medicine in Newark. "This bill will address TB control as a specific issue, not as just something that’s funded through the Centers for Disease Control and Prevention."
The hope, of course, is to grab more attention for TB and more resources, as well. "We’ve had level funding since 1995, and the IOM report gives us a chance to re-focus," says Fran DuMelle, executive director of the American Lung Association (ALA), and a longtime adviser to NCET. "The IOM is a very credible institution. This is quite different from NCET going to Congress and saying, Hey. We need more money for TB.’"
It’s much too soon to talk specific dollar amounts or to predict to whom or exactly how the dollars would flow, DuMelle says. She also declines to predict who might sponsor such a bill, although she and other architects of the new bill likely will huddle with Sen. Henry A. Waxman (D-CA) or another of TB’s "angels" on the Hill. "Obviously, a lot of what happens will depend on the outcome of the fall elections," she adds.
For now, there’s the hard work of figuring out what money is already being spent, and where, and then estimating and adding sums to fill in existing gaps. "We’ve got to add up all the new pieces, plus look at the funding of all the current stuff," she explains. At least some of those "new pieces" will include some or all of these elements:
• more money for research for the "new tools" the IOM report identified as crucial for eliminating TB, particularly for a better vaccine;
• a demonstration project or projects for immigrant screening, in response to the IOM’s recommendation that immigrants get a tuberculin skin test overseas and then complete treatment for latent TB infection (LTBI) here as a precondition for receiving their green cards;
• demonstration projects in low-incidence parts of the country that incorporate a regionalized approach to TB control;
• TB "information centers" that can relay TB controllers’ messages effectively to the public, probably modeled along the lines of successful centers for other diseases such as diabetes and Alzheimer’s;
• other information centers charged with communicating effectively with high-risk populations;
• new funding for targeted testing of high-risk populations, established as a source that’s separate from money allotted for regular TB control activities.
Clearly, devising a bill of such scope will take time. In the meantime, Hill-watchers say TB funding for next year probably will take a hit, albeit not a fatal one. The latest word is that TB control will get only $127.6 million for the next fiscal year, which equals a reduction of about $56,000 from the current fiscal year, says Gary Ewert, legislative director for the ALA.
"We did successfully reverse the trend of level funding we’d seen for the past five years by getting a $10 million increase this year, so I guess I’m not terribly surprised this happened," adds Ewert. "But I am disappointed."
DuMelle remains optimistic, even about TB’s immediate funding prospects. "Maybe we can create enough noise [with the Omnibus bill] so that appropriators start adding some new money," she says. "All I know for certain at this point is that it’s an endgame strategy. I also know that September will be a frantic month for us."
Regardless of what happens in Congress, many questions in the Omnibus bill remain to be answered. Not the least of them is how many details, exactly, the bill should contain, says DuMelle. At an initial meeting in the NCET office in Washington in late July, some argued the more details, the better. Others warned against overwhelming Congress with too many nuts and bolts. DuMelle says she fell into the second camp. "I found myself in a roomful of people who are basically more comfortable thinking about details, and I tried to convince them that it’s us, not Congress, who need to know all the details."
Prickly issues related to screening
That’s not to say the nuts and bolts are trivial. Take the issue of new funding for vaccine studies. Almost a half-dozen big domestic agencies (among them, the Centers for Disease Control and Prevention, the National Institutes for Health, and USAID) have vaccine programs up and running; just figuring out what’s already out there will be a major headache. "There’s a substantial amount of work in just figuring out where all the current pieces are and how they fit together," says DuMelle.
Then there’s the prickly issue of immigrant screening. The IOM report proposals have met with a chilly reception, to put it mildly, at the Immigration and Naturalization Service. Some officials there say the proposals aren’t even legal. Meanwhile, technical experts warn that implementing the proposed changes will be tricky. To resolve just the legal knots, Congress probably will need to create a new "B-4" category for immigrants, she says.
As for the stateside portion of the immigrant-screening issue, which treats reactors for latent infection, how exactly would that work? "There are eight immigration entry points," DuMelle says. "Do you just pick one place that has lots of traffic? If so, which one? Do you pick a particular country? Do you do a piece here and a piece in the country of origin?"
Finally, there’s the well-known dictum about being careful of what you ask for, says DuMelle. As a federal employee at the July NCET meeting put it, "Congress can be a double-edged sword, and you never know which edge you’re going to get."
For example, asking Congress for more money for targeted testing could foster the illusion that the whole country is on track for elimination. "You don’t want to set this up so you wind up pitting one goal against another or making people think that, in some places, you no longer need lots of funding just to keep even," says DuMelle.
Last but not least, there’s the matter of nomenclature. "I’m not really sure we’re going to stick with Omnibus TB Control Act,’" DuMelle muses. "We may have to come up with some cute new name or happy acronym. Plus, the name needs to suggest elimination, not just control."
Just a little more than a year ago, few could have predicted NCET would be the torch-carrier for such an undertaking. In recent years, the organization has seen its influence steadily wane to the point that its head was on the chopping block, with TB policy-makers contemplating disbanding the entity altogether.
Then, a poll of ALA members showed a majority favored keeping NCET. A stay of execution was granted; in short order, the agency found itself with a new office and more staff.
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