TB officials re-examine goals in post-epidemic era
Greater emphasis on prevention, case management
After four years of steadily declining tuberculosis rates, this past year possibly the most pronounced, TB officials are having to redefine their mission. What began as the rallying cry to control a frightening epidemic of HIV-related and drug-resistant cases has now become the older and more basic goal of complete elimination.
"We are talking about a refocus now," says Walter Page, executive director of the National TB Controllers Association in Atlanta. "We got the increased epidemic’ under control and are doing well on the multiple drug-resistant TB and the HIV issue, and so now we need to work harder on TB elimination."
That evaluation was echoed by other public health officials across the country prior to the release of 1996 TB case rates during World TB Day on March 24.
"We are having to search and re-examine what our role is," says Jeffrey Stark, MD, associate professor of clinical pediatrics at Baylor University College of Medicine in Houston and chairman of the Advisory Council for the Elimination of TB. "I see our challenges as being different now and us being much smarter about who we really target, and it is not necessarily everyone with a positive skin test."
Less than a year after it consolidated with the AIDS division, the TB program at the Centers for Disease Control and Prevention also are re-evaluating what its priorities should be, now that both AIDS and TB are on the decline.
"We at the federal level and our partners at the local level must start focusing more attention now on preventive programs screening of high-risk populations and providing preventive therapy where indicated to keep future cases from developing," says Carl Schieffelbein, deputy director of the division of TB elimination for the Centers for Disease Control and Prevention in Atlanta. "Collectively, we probably have not been doing near as much in prevention as we really should have because we have been trying to deal with the infectious cases."
The success of TB programs in preventing infectious cases will be underscored once again as rates for 1996 show significant declines, predicted to be as high as 15% for New York City and in some cities, such as Newark, NJ, as high as 30%. Although the rates were not released at press time, Page and other TB experts anticipated a 5% to 7% decrease nationwide from the 1995 national rate. That would make it the fourth consecutive year that rates have dropped in the United States.
Schieffelbein could not release the figures but confirmed that the rate for the nation as a whole will be lower than last year. Inquiries by TB Monitor to selected cities indicate that the average decrease may be greater than the 5% decline in 1995. In Dade County, Florida, which covers hard-hit Miami, 274 cases were reported in 1996, compared with 379 the prior year a 27% decrease, says Joan Otten, RN, director of the office of TB control at Jackson Memorial Hospital. Cases at the hospital reflect a similar decrease 143 in 1996, compared with 178 in 1995 a 19% decrease. Only one case of multidrug-resistant TB was reported in 1996, compared with three in 1995, she added.
And in Houston, Stark says TB cases dropped to the mid 600s last year, down from more than 800 in 1995.
Still not out of the woods
"The good news is the rates are going down," Schieffelbein says. "The bad news is TB is one of these situations where you have to go for absolute victory. You can’t go for partial victory, and we have seen what has happened before, that when rates have gone down, the tendency is to assume that resources, both fiscal and human, can be pulled out."
As Stark points out, the TB problem in the United States is far from over.
"We have to pinch ourselves and remember that we still have over 20,000 cases of TB a year," he says. "That many cases of most other major contagious infectious diseases would still be considered a major league problem, so we have to maintain that perspective."
Lee Reichman, MD, MPH, director of the National Tuberculosis Center at the New Jersey Medical School in Newark, saw TB rates fall 30% in his city, mainly as a result of the model TB control implemented there several years ago. In nearby Jersey City, however, the rate actually increased last year. The center has agreed to implement its program, which emphasizes case management, into that city this year. (See case management story, p. 39.)
"If anyone says you are spending a lot of money on TB, the message is that the declining rates validate those expenditures. That is the proof," he says. "We made this major effort, and it works. The U-shaped curve of concern says that as soon as you take away the money, the rates will go up again, and I guarantee it will."
As in past years, TB officials are quick to bring up the U-shaped curve of concern. This time, however, there appears to be more hope that its lesson has been learned, having been paid for with the excessive morbidity and mortality rates of the past decade.
"Statistically we are back to where we were 10 years ago," says Stark. "If you take away the blip of the past decade, then I think we are pretty much back on track."
The destination of that track had been total elimination of new TB cases in the United States by 2010. But that projection was made prior to AIDS, managed care, and shifts in immigration, which accounts for the fact that cases in foreign-born residents have actually increased in the past several years.
"Whether we can meet it by then or shortly thereafter is a point of continued discussions because we have lost ground from when that goal was established," Schieffelbein says. "At the same time, the push toward elimination is indeed what we need to continue to do."
So far, the fear of deep federal cuts in TB funding has been unfounded. Although funding has leveled out from the large influxes in 1994, earmarked primarily for fighting multidrug-resistant cases and providing directly observed therapy, TB departments have avoided some of the deep cuts experienced in other public health sectors. As more control of funding is handed over to the states, however, the threat of funding cuts for TB programs will grow, Stark says.
On the other hand, TB programs have become more effective and efficient, primarily through using case management techniques and directly observed therapy. Indeed, the trend of declining cases cannot be attributed to the kind of scientific breakthroughs seen with the treatment of AIDS, says Stark, adding he is not sure exactly why the rates have gone down.
"I don’t think it’s because we are so smart. And it certainly is not because there have been any advances in the science of TB control, and globally we are worse off."
Beyond the widespread use of DOT, Schieffelbein also was reluctant to speculate reasons for the success. Reports that AIDS cases had decreased in the first six months of 1996 for the first time 13% less than the same period in 1995 have prompted some experts to make that connection. The impact of the AIDS case decline, however, would depend on what population is making up for the reduction, says Page.
"If it is decreasing among white middle-class homosexuals who don’t have TB, then it may be having no impact at all," he says. "But if it is in injection drug users who may be infected with TB, then that would be very helpful."
Reichman plays down the AIDS decline as a factor because it is so recent, while TB rates have declined in the four previous years.
Preventing disease in infected pool
With an estimated 10 to 15 million Americans infected with TB, the pool of potential TB cases is considerable. Add to that the increasing number of immigrants who have infection or active disease, and the goal of eradication in the United States seems farfetched based on present resources, says Stark. With managed care and welfare reform making it more difficult to seek out infectious cases in hard-to-reach populations, detection and treatment will have to depend more on the private community, Stark says, while health departments will focus more on surveillance, DOT, contact investigations, and prevention efforts that don’t fit well under the managed care system.
"The questions we need to address are how are we going to structure this, and what are we going to demand of managed care companies," he explains. "No one knows how to do this yet, but we all know we better start paying attention to it."
Perhaps a bigger barrier to eradication is the estimated 300,000 to 500,000 TB-infected immigrants who enter the country each year, he says. Improved screening of foreign-born residents must become a higher priority than it is now, he adds.
"At this point I don’t think we have the goals to really address that population of people, and frankly, I think we are just stupid if we don’t address that," he says. "For us to think we will really control TB in this country without attacking it globally is just incredibly naive."
Unlike the AIDS community, which has used its influence to push for the development of an HIV vaccine, the TB community has not been successful in galvanizing the resources and interest in developing a TB vaccine. Without an improvement over the BCG vaccine, TB will only continue to rise globally, Stark adds.
Barring any breakthroughs in drug development, Stark anticipates that TB cases in the United States will continue to drop but at a lesser rate of decline and then level out. Because eradicating the last remaining cases is the most expensive step, complete elimination will be difficult.
"As a public health official who has many masters to serve, you have to make decisions about what is going to be the biggest problem next year, and it may not be TB," he says. "The insidiousness of TB is that you can carry that damn thing for 50 years, and then it can come back to bite you."
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