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TB Notes 1, 2000
CDC Funding for TB Prevention and Control
by Patricia Simone, MD
Chief, Field Services Branch, DTBE
and Paul Poppe
Deputy Director, DTBE
Federal fiscal support for TB control began with the passage of
the Public Health Service Act, which was created to assist states
in establishing and maintaining adequate measures for the prevention
and control of TB. To enhance case-finding activities, the 1955
Appropriation Act (Public Law 83-472) directed federal grants with
local matching funds to be used only for prevention and case-finding
activities. In 1961, Congress provided for project grants that were
to be used for improving services to known TB patients outside of
hospitals, examination of contacts, and diagnosis of suspects. In
December 1963, the Surgeon General's task force issued a report
recommending a 10-year plan to enhance the federal role in national
TB control through increased grants for services for unhospitalized
cases and inactive cases, contact investigations, school skin test
screening, and hospital radiograph screening programs. By 1967,
there were 82 TB control programs in the United States, with federal
appropriations of $3 million in formula grants and $14.95 million
in TB project grants.
However, in 1966 the Public Health Services Act was amended, changing
project grants to block grants. These new grants did not require
that any funds be used for TB control, and many health departments
eventually redistributed the funds to other programs. While categorical
TB appropriations were restored in 1982, there were very modest
amounts of federal funding (approximately $1 million to $9 million
per year) available for TB control until fiscal year 1992.
Despite an overall decline in funds being spent for TB control,
the number of reported TB cases continued to decline nationally
through 1984. However, from 1985, the number of cases began increasing
and continued to rise through 1992. Recognition of the outbreaks
of multidrug-resistant TB, the high mortality associated with TB
in HIV-infected persons, and transmission to health-care workers
resulted in strong recommendations for enhanced funding for TB prevention
and control programs and more stringent infection control practices.
In fiscal year 1992 the appropriation was increased to $15 million
from the previous year's funding of $9 million. It increased again
in 1993 to $73 million, when Congress appropriated $34 million for
the continuation and expansion of the TB cooperative agreements
and $39.2 million in emergency funds for use in the areas of the
country most heavily affected by the increased cases. Congress appropriated
yet another increase for categorical TB grants in 1994, and the
appropriation for TB project grants was increased to over $117 million.
In addition, approximately $25 million in redirected HIV funds have
been available for TB control activities each year since 1992, for
a total of over $142 million in funding for CDC for TB-related activities.
As a result of this infusion of funding, TB program infrastructures
have been rebuilt and the results are evident with six consecutive
annual decreases in the number of reported TB cases in the United
Image 1: TB Funding History vs. Reported Tuberculosis Cases, 1977-1996
Since 1994, however, CDC has received approximately level funding
for TB-related activities. The Tuberculosis Elimination and Laboratory
Cooperative Agreement was revised for FY2000 to ensure prioritization
of the core TB activities (completion of therapy, contact investigation,
surveillance, and laboratory) for all TB programs, with separate
funding provided on a competitive basis for targeted testing and
treatment of latent TB infection for high-risk groups in programs
demonstrating good performance on the core activities.
Federal funds are intended to supplement the state and local activities
for TB control and prevention, and in many states, federal funds
represent only a small fraction of the total funds available to
the TB program. However, in many other states, federal funds represent
the majority of TB funding available. Furthermore, some areas are
actually reporting a reduction in their state or local TB funding.
Yet the level of federal funding is expected to again remain the
same in fiscal year 2000 and 2001, which will result in a decreased
amount of available funds when inflation factors are applied. Although
cases have declined since 1993, the case rate of 6.8 per 100,000
in 1998 is still far short of the target of 3.5 per 100,000 by the
year 2000 set by CDC, and aggressive TB prevention and control efforts
must be sustained to continue on a successful course to elimination.
This will require the continuation of our current efforts and the
development of new or increased funding initiatives at every level,
including federal, state, and local.
The Advisory Council for the Elimination of Tuberculosis (ACET)
published "Tuberculosis elimination revisited: obstacles, opportunities,
and a renewed commitment" in the MMWR, August 13,
1999/Vol. 48/No. RR-9, and also stated the need for additional resources
to fully implement effective elimination strategies. In addition
to fiscal resources, ACET recommended building a stronger advocacy
at every level of government as well as engaging new partners at
the local level, and strengthening coalitions by revitalizing the
National Coalition for the Elimination of Tuberculosis (NCET) to
garner more private support, and strategically utilizing the media
to inform the general public and legislators regarding TB.