After 20 Years of Decline, Tuberculosis Inches Up in U.S.

Marsha Mercer, Star Tribune, May 15, 2016

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The goal set by the CDC, in 1989, of eliminating TB by 2010–defined as less than one case in a million people–remains elusive. Even if the trend of declining cases had continued, the United States would not have eliminated TB by the end of this century, the CDC said.

“We are not yet certain why TB incidence has leveled off, but we do know it indicates the need for a new, expanded approach to TB elimination,” said Dr. Philip LoBue, director of the CDC’s Division of Tuberculosis Elimination, in an email.

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In the United States, Asians have the most cases and the highest rate of disease–17.9 out of 100,000 persons. The top five countries of origin for foreign-born TB patients are Mexico, the Philippines, Vietnam, India and China.

Immigrants and refugees are screened for TB and treated before entering the United States. Tourists, students and temporary workers are not screened. The CDC does not recommend across-the-board screening for everyone entering the United States, the CDC’s LoBue said.

Because TB hits some ethnic and racial groups harder than others, TB patients can face discrimination and social isolation. Public health officials worry about finding ways to target high-risk populations with TB education and treatment without stigmatizing those groups.

“Given the stigmatization of TB, our ability to do targeted interactions is limited,” said Dr. Jeffrey Starke, a pediatric tuberculosis physician at Texas Children’s Hospital in Houston. Starke is a member of the federal Advisory Council for the Elimination of Tuberculosis, which makes policy recommendations. “We’ve got to find a nonpejorative way to do it so others don’t perceive discrimination,” he said.

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Today four states–California, New York, Texas and Florida–have more than half the nation’s active TB cases, though they have only a third of the country’s population. The four states have the highest numbers of foreign-born residents. The number of cases in Texas rose 5 percent to 1,334 last year.

“We’re clearly going in the wrong direction,” Starke said.

He pointed out that TB is “a social disease with medical implications” because living conditions put someone at risk. TB is associated with poverty, overcrowding and being born outside the United States.

California, with 2,137 cases in 2015, has more than one in five of the new U.S. cases each year and a TB rate nearly twice the national average. Its TB prevention and control program is the nation’s largest–a $17.2 million annual budget split roughly in half between federal and state general funds, and a 40-person central office staff that works with TB contacts in the state’s 61 local health jurisdictions.

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About 2.5 million people are infected with TB in California, but most don’t know it, said Dr. Jennifer Flood, chief of California’s TB control program.

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Treating TB patients is labor intensive. To ensure that TB patients complete the course of drugs that lasts six months or longer, Directly Observed Therapy programs require a health care worker–not a family member–to watch patients with active TB swallow every dose. If a patient cannot get to a clinic, a health care worker goes to the person’s home. The worker monitors patients for side effects and other problems.

Care also involves communication and cultural challenges. In Michigan, where the number of active TB cases rose from 105 in 2014 to 130 last year, the health department reaches out to Detroit’s large Arab and Bangladeshi populations. In other parts of the state, Burmese immigrants have different needs, said Peter Davidson, Michigan TB control manager.

“Some local health departments have strong partnerships with translation services. Some rely on a less formal mechanism–a private physician or someone on staff at the hospital who speaks the language,” Davidson said.

The cost of treating an active TB case that is susceptible or responsive to drugs averages $17,000, according to the CDC. Care of patients with drug-resistant TB, which can result from taking antibiotics prescribed before TB was properly diagnosed, costs many times more: $134,000 for a multidrug-resistant patient and $430,000 for an extensively drug-resistant one.

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The federal Tuberculosis Elimination Act, the chief federal funding for TB programs, is authorized at $243 million a year but has received an appropriation of far less for the last several years–$142 million this year, for example.

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