Perspectives in Disease Prevention and Health Promotion
A Strategic Plan for the Elimination of Tuberculosis in the United
States
In 1987, the Department of Health and Human Services (DHHS)
established
the Advisory Committee for the Elimination of Tuberculosis (ACET)
to
"provide recommendations for the development of new technology,
application of prevention and control methods, and management of
state
and local tuberculosis programs targeted toward the elimination of
tuberculosis as a public health problem." In response to this
charge,
the ACET completed a strategic plan for the elimination of
tuberculosis
(TB) in the United States with advice and consultation from a large
number of persons and organizations. The following is a summary of
the
plan. The complete plan has been published as an MMWR supplement
(1).
The plan urges the establishment of a national goal of TB
elimination
(an incidence of less than 1 case per million population) by the
year
2010, with an interim target of an incidence of 3.5 cases per
100,000
population by the year 2000. The plan cites three factors that
favor
the achievement of this goal: 1) TB is retreating into focal
geographic
areas and demographically well-defined groups; 2) biotechnology can
potentially generate better diagnostic, therapeutic, and preventive
modalities; and 3) new computer, telecommunications, and other
technologies will enhance the transfer of these new biotechnologies
into clinical and public health practice. A three-step plan of
action
is proposed:
Step 1. More effective use of existing prevention and control
methods,
especially in high-risk populations;
Step 2.The development and evaluation of new technologies for
diagnosis, treatment, and prevention; and
Step 3.The rapid assessment and transfer of newly developed
technologies into clinical and public health practice.
Current problems cited in the plan include deficiencies in
identifying
and reporting TB cases and contacts, the failure to fully use
prevention interventions, the failure of many patients to complete
prescribed therapy, and the failure to adequately assess the
effectiveness of community prevention and control programs.
Recommended priorities for action include 1) identifying and
screening
high-risk population groups within each health jurisdiction and 2)
making adequate and appropriate treatment and prophylaxis more
widely
available. Elimination of TB in the United States depends on the
identification of groups at high risk for infection and disease.
These
groups vary through time, by place, and by personal
characteristics. In
1987, the identifiable groups at high risk included HIV-infected
persons, the homeless, immigrants and refugees from high-prevalence
countries, intravenous-drug abusers, and residents of correctional
institutions and nursing homes. Blacks, Hispanics, and Native
Americans
are also at high risk; the higher risk in these minority
populations
appears to be primarily related to socioeconomic status (2).
However,
because the epidemiology of TB changes, populations now at high
risk
may decline in risk over time, and groups not currently identified
to
be at risk may become at risk. Therefore, the plan urges CDC and
state
and local health departments to continue and to strengthen TB
surveillance activities and to further improve their ability to
define
groups at high risk for TB.
In addition to identifying high-risk populations, health-care
providers
must extend TB screening, treatment, and prevention programs to
these
groups. For such programs to be optimally effective, high-risk
groups
and health-care providers for these groups should be involved in
designing, implementing, and promoting these programs.
To increase the proportion of patients who complete therapy, the
plan
recommends several actions, including the more widespread use of
the
newer short-course treatment regimens (3). In addition, for each
new
case of TB, a specific health-care provider should be responsible
for
assuring that patients and their contacts are educated about TB and
its
treatment, that therapy is continued and completed, and that
appropriate contact examination and preventive treatment are
conducted.
The use of directly observed therapy is strongly encouraged.
Quarantine
measures, including temporary institutionalization, are recommended
only in those rare instances when an infectious patient refuses to
comply with self-administered or directly observed therapy.
The implementation of these recommendations will require an
increase in
the number of health department outreach staff who are members of
the
populations they serve. During the past few years, this approach
has
proven successful in public health practice and is more
cost-effective
than alternative approaches such as long-term hospitalization (CDC,
unpublished data).
Intensified use of existing technologies as outlined above is
essential
in moving the nation toward elimination; however, this strategy
alone
will not be sufficient to reach the goal. It is crucial that new
technologies be developed. The plan points out that recent
developments
in biotechnology are revolutionizing the diagnosis, treatment, and
prevention of other infectious diseases and that, by applying these
new
techniques to TB, it should be possible to develop the new tools
needed
to eliminate TB (4).
The highest priorities for new technology development are 1) the
development of alternative approaches to prevention of disease
among
persons already infected and 2) the development of a more rapid and
effective test for identifying persons infected with living
tubercle
bacilli. Research efforts directed toward developing a more
reliably
effective TB vaccine, more rapid and accurate diagnostic tests, and
more effective and rapidly-acting drugs are also needed.
Finally, new technologies must be assessed and put into clinical
and
public health practice in a timely fashion. The plan points out
that
federal agencies; professional societies; and schools of medicine,
nursing, and public health all have a role in assessing and
implementing new technologies and that both public and private
funds
will be needed to support demonstration projects for technology
assessment and implementation.
Health departments, medical and nursing schools, schools of public
health, voluntary agencies, professional societies, and minority
advocacy groups share responsibilities for educating health-care
providers and high-risk groups about the manifestations, methods of
diagnosis, treatment, and prevention of tuberculosis. The plan
recommends national, regional, and state conferences for
health-care
professionals to focus attention on TB and to teach modern
approaches
to its control and eventual elimination.
The plan suggests that advisory committees be established in the
states
and major metropolitan areas to develop more specific strategies
and
tactics for TB elimination in each health jurisdiction and to
review
progress toward elimination. These reviews should include
evaluations
of morbidity and mortality data, the adequacy of case reporting and
casefinding procedures, and the quality of treatment and prevention
activities. Interested constituencies, such as lung associations,
minority organizations, and professional societies, should be
represented on these advisory committees.
The ACET states that it is bringing this plan to the attention of
the
medical community and the public to stimulate positive and
constructive
discussion and action, to increase the level of TB awareness, and
to
encourage a commitment toward the elimination of TB.
Reported by: Div of Tuberculosis Control, Center for Prevention
Svcs,
CDC.
Editorial Note
Editorial Note: The TB elimination plan developed by the ACET
provides
a roadmap to guide the TB elimination effort for the next 2
decades.
Consequently, the plan is being distributed to a wide variety of
public, private, and voluntary groups with the request that they
actively join in identifying and supporting steps essential to
eliminating this disease within their respective jurisdictions.
Although the occurrence of TB in the United States has declined
during
the past 35 years, the disease persists as a public health problem
in
this country. From 1953 through 1987, the number of reported cases
decreased from 84,517 to 22,255, and the annual incidence of TB
decreased from 53.0 to 9.3 cases per 100,000 population (5). The
reduction has been substantially greater among whites than among
other
races; as a result, the proportion of cases occurring in nonwhites
has
risen from 24% in 1953 to 49% in 1987 (6). Today, TB among
non-Hispanic
whites is predominantly a disease of the elderly; among minorities,
it
is primarily concentrated in young adults. In 1987, the median age
of
non-Hispanic whites with TB was 62 years; for minority patients,
the
median age was 39 years (6).
Foreign-born persons constituted 24% of patients in 1987, and the
risk
among immigrants from Asia is especially high, particularly in the
first years after arrival in the United States (5). The risk for
immigrants serves as a reminder that TB persists as a global health
problem of enormous dimension. Throughout the world, approximately
7-9
million new cases are diagnosed each year, and the disease is
estimated
to cause approximately 3 million deaths annually (7). An estimated
2
billion persons in the world have latent tuberculous infection
(International Union Against Tuberculosis, Paris, personal
communication, 1988), making it one of the most prevalent
infections in
the world. Through the development of new technology, the TB
elimination effort in the United States can potentially contribute
to
the solution of the global TB problem.
In the United States, new cases occur primarily among persons with
longstanding Mycobacterium tuberculosis infection rather than among
persons with recent infection. An estimated 10 million persons have
longstanding tuberculous infection (CDC, unpublished data). Major
progress toward elimination can be achieved by targeting TB
screening
and preventive therapy programs toward groups of persons with M.
tuberculosis infection who are at high risk for developing clinical
disease.
To accomplish this objective, health department TB-control programs
must be maintained, strengthened, and continually evaluated to
assure
the most beneficial use of available resources. CDC will continue
to
assist health departments by providing technical and financial
assistance, training and educational resources, and surveillance
and
epidemiologic assistance and by conducting applied and operational
research. CDC will continue to work with advisory groups, other
federal
agencies, state and local health departments, minority
organizations,
and other organizations to develop more specific strategies and
tactics
for implementing the plan.
References
CDC. A strategic plan for the elimination of tuberculosis in the
United States. MMWR 1989;38(suppl S-3).
2.Hinman AR, Judd JM, Kolnick JP, Daitch PB. Changing risks in TB.
Am J
Epidemiol 1976; 103:486-97.
3.American Thoracic Society/CDC. Treatment of tuberculosis and
tuberculosis infection in adults and children. Am Rev Respir Dis
1986;134:355-63.
4.American Thoracic Society/CDC/National Institutes of
Health/Pittsfield (Massachusetts) Antituberculosis Association.
Supplement on future research in tuberculosis: prospects and
priorities
for elimination. Am Rev Respir Dis 1986;134:401-20.
5.Rieder HL, Cauthen GM, Kelly GD, Bloch AB, Snider DE.
Tuberculosis in
the United States. JAMA (in press).
6.Bloch AB, Rieder HL, Kelly GD, Cauthen GM, Hayden CH, Snider DE.
The
epidemiology of tuberculosis in the United States: implications for
diagnosis and treatment. Clin Chest Med 1989 (in press).
7.Styblo K, Rouillon A. Estimated global incidence of
smear-positive
pulmonary tuberculosis: unreliability of officially reported
figures on
tuberculosis. Bull Int Union Tuberc 1981; 56:118-26.
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