CDC's Response to Ending Neglect
In collaboration with divisions in the National Center for Infectious
Diseases, the Public Health Practice Program Office, and the National
Institute for Occupational Safety and Health, the Division of Tuberculosis
(TB) Elimination of the National Center for HIV, STD, and TB Prevention
(NCHSTP),* Centers for Disease Control and Prevention (CDC), is
the functional equivalent of a national TB program in the United
States. As such, CDC is the federal government’s lead agency
for TB prevention, control, and elimination.
In 1989, CDC published A Strategic Plan for the Elimination
of Tuberculosis in the United States. This plan had been developed
by the Advisory Council for the Elimination of Tuberculosis (ACET)
and proposed a national strategy for TB elimination by 2010. The
implementation of this plan was set back by the TB resurgence that
occurred in the late 1980s and early 1990s. This rekindling of TB
disease was fueled by the onset of the human immunodeficiency virus
(HIV) epidemic, increases in TB cases among foreign-born persons,
outbreaks in congregate settings, and the appearance and transmission
of deadly multidrugresistant (MDR) TB strains. These occurred at
a time when decades of cuts in TB funding had resulted in the deterioration
of TB control programs, and TB control officials had very few resources
with which to fight back. CDC published the National Action Plan
to Combat Multidrug-Resistant Tuberculosis in 1992 to complement
the 1989 TB elimination document.
A renewed downturn in TB incidence since 1993 points to the successful
implementation of these national plans over the past decade. Unprecedented
low rates of TB disease now provide a historic opportunity to accelerate
the decline in TB morbidity and the drive toward elimination. This
opportunity is threatened, however, by several converging factors:
1) the retreat of TB into high-risk populations at the margins of
society where it can resist detection, 2) the persistence and growth
of the global TB epidemic, 3) the limitations of current control
measures and recognition of the need for new tests and treatments,
plus an improved vaccine, and 4) changes in the health care system
that make the current context for TB elimination very different
from that of a decade ago.
Given this altered landscape, in late 1998 CDC commissioned the
Institute of Medicine (IOM) of the National Academy of Sciences
to conduct a study and determine if TB elimination is still feasible
as a national goal and, if so, to provide recommendations on how
to make that goal a reality. The resulting report, Ending Neglect:
The Elimination of Tuberculosis in the United States, concluded
that TB elimination in the United States is indeed feasible but
will require “aggressive and decisive action beyond what is
now in effect.” To break the “cycle of neglect”
that has characterized U.S. tuberculosis control efforts, the report
recommended an aggressive strategy to 1) maintain control of TB,
2) speed the decline in TB incidence, 3) develop new tools for TB
diagnosis, treatment, and prevention, 4) increase U.S. efforts to
help fight the global epidemic, and 5) mobilize and sustain public
support for TB elimination and track progress.
*NCHSTP provides leadership in preventing and
controlling human immunodeficiency virus (HIV) infection, other
sexually transmitted diseases (STDs), and TB.
Rationale for TB Elimination
TB maintains its grim historical notoriety as one of the leading
infectious causes of death worldwide. Ironically, it is preventable
and, in most cases, treatable. Infection-control precautions can
help reduce the risk of TB transmission. Medical treatment of persons
with latent TB infection can prevent the subsequent development
of active TB disease. TB disease can usually be cured with anti-TB
drugs taken exactly as prescribed. Even persons with drugresistant
strains can often be cured by alternative regimens of medications.
The downturn in TB incidence that occurred between 1993 and 2001
is directly attributable to the resources used to strengthen TB
control programs and implement these measures nationwide. The question
now is whether this success will lead to waning interest and another
cycle of neglect or provide the impetus for a final push toward
The continuing social, public health, and economic costs of TB
provide a compelling rationale for TB elimination. Almost 16,000
new cases of TB disease occurred in 2001 in the United States, and
an estimated 10 million to 15 million persons have latent TB infection
with the attendant risk of future disease. Costly TB outbreaks continue
to occur in the United States, and MDR TB continues to spread. TB-related
costs approach $1 billion each year in this country.
Nonetheless, TB incidence is presently at an all-time low, and
several factors strengthen the feasibility of and justification
for elimination. TB is retreating into geographically and ethnographically
distinct populations that, although hard to reach, can nonetheless
be targeted for prevention and control interventions. Arguments
based on social justice support increased efforts to combat a grave
health problem that disproportionately affects disenfranchised persons.
Finally, a U.S. initiative can stimulate other nations to seek the
social and economic benefits to be derived from TB elimination.
CDC's Response to Ending Neglect: the Elimination of TB in the
This document is CDC’s response to the IOM’s TB elimination
challenge. The plan reflects the scientific, programmatic, and health-sector
developments of the last decade and supercedes the 1989 Strategic
Plan for the Elimination of Tuberculosis in the United States.
The goals, objectives, and action steps that comprise CDC’s
contribution to TB elimination will serve as a guide for CDC’s
work, in collaboration with its partners, to finally rid the nation
of the human suffering and societal harm caused by TB disease.
The plan is organized around six goals that frame TB elimination
efforts in the context of the IOM’s recommendations. The goals
and corresponding objectives are as follows:
- Goal I: Maintain control of TB
Maintain the decline in TB incidence through timely diagnosis
of active TB disease, appropriate treatment and management of
persons with active disease, investigation and appropriate evaluation
and treatment of contacts of infectious cases, and prevention
of transmission through infection control.
- Maintain and enhance local, state, and national public health
surveillance for TB.
- Support the infrastructure needed for laboratory-based identification
and treatment of TB.
- Ensure that patient-centered case management and monitoring
of treatment outcomes are the standard of care for all TB
- Develop community partnerships, and strengthen community
involvement in TB control.
- Improve the timely investigation and appropriate evaluation
and treatment of contacts with active TB disease and latent
- Ensure appropriate care for patients with MDR TB, and monitor
their response to treatment and their treatment outcomes.
- Ensure that health care facilities maintain infection-control
- Develop improved engineering and personal protective techniques
to prevent TB transmission.
- Improve TB control in foreign-born populations entering
or residing in the United States.
- Educate the public and train health care providers to maintain
excellence in TB services
- Goal II: Accelerate the decline
Advance toward TB elimination through targeted testing and treatment
of persons with latent TB infection, appropriate regionalization
of TB control activities, rapid recognition of TB transmission
using DNA fingerprinting methods, and rapid outbreak response.
- Increase the capacity of TB control programs to implement
targeted testing and treatment programs for high-risk persons.
- Explore the appropriateness of regionalizing TB control
activities in high, intermediate, and low TB-incidence areas
of the United States.
- Characterize circulating M. tuberculosis strains
using DNA fingerprinting methods.
- Develop national, state, and local capacity to respond to
outbreaks of TB.
- Goal III: Develop new tools
Develop and assess new tools for the diagnosis, treatment, and
prevention of TB.
- Develop a coordinated plan for TB research.
- Develop new methods for diagnosing persons with latent TB
infection and for identifying infected persons who are at
high risk for developing active TB.
- Develop and assess new drugs for improving TB treatment
- Develop a new and effective TB vaccine.
- Develop and implement a program of research on behavioral
factors related to TB treatment and prevention.
- Rapidly transfer findings from research studies into practice.
- Goal IV: Reduce the global burden of TB
Increase U.S. involvement in international TB control activities.
- Provide leadership in public health advocacy for TB prevention
- Provide technical support and build capacity for implementation
of the World Health Organization strategy for TB control (i.e.,
DOTS), especially in those countries that contribute significantly
to the U.S. TB burden.
- Develop models for the diagnosis and treatment of patients
with MDR TB.
- Provide technical, programmatic, and research support to
reduce the incidence of TB as an opportunistic disease in
high HIV-burden countries.
- Goal V: Mobilize and sustain public support
Mobilize and sustain support for TB elimination by engaging policy
and opinion leaders, health care providers, affected communities,
and the public. Implement a comprehensive health communication
campaign that supports TB elimination and ensures the development
and delivery of effective TB elimination messages. Improve communication
efforts through consistent monitoring and evaluation of the plan's
methods and strategies.
- Develop and implement a health communications effort focusing
on the achievable goal of eliminating TB, if both political
commitment and resources are made available.
- Help communities foster nontraditional, multisectoral, public-private
partnerships to improve the effectiveness of their communications
activities, with particular attention to culturally appropriate
- Support the development of state- or area-specific TB elimination
plans that contain communications activities designed to build
support for TB elimination.
- Goal VI: Track progress
Monitor progress toward the goal of TB elimination, and regularly
report on progress to all target audiences.
- Develop innovative analyses for examining surveillance data
to help focus elimination efforts.
- Develop novel indicators of progress toward elimination.
- Conduct periodic evaluations of TB program performance at
federal, state, and local levels.
- Conduct an annual progress review.
CDC's Response to Ending Neglect: The Elimination of Tuberculosis
in the United States complements a separate, more comprehensive,
coordinated federal response to the IOM's recommendations by providing
more detail on CDC's part of the federal strategy. Implementation
of these plans will set in motion the activities needed to eliminate
TB in the United States.