IOM says major changes necessary to wipe out TB
IOM says major changes necessary to wipe out TB
Study urges INS revamp, triple research funding
A new report on how to eliminate TB in the United States recommends major changes in U.S. immigration policies, says TB control programs in low-prevalence areas need to be restructured, and calls on the federal government to triple its support for biomedical research.
"We know making these changes won’t be easy," says Sue Etkind, RN, MS, director of the TB control program of the Massachusetts Department of Public Health and a member of the committee that wrote the report. "But we decided that if the goal is truly to eliminate TB, this is what it’s going to take."
Ernest P. Franck, head of the American Lung Association, says the report’s May 4 publication signals "our last chance to win the battle against tuberculosis."
Prepared by the National Academy of Sciences’ Institute of Medicine (IOM), the report is titled "Ending Neglect: The Elimination of Tuberculosis in the United States." It was commissioned and funded by the Centers for Disease Control and Prevention.
Proposed changes in immigration policy — perhaps the most striking part of the report — include how immigrants are screened for TB prior to their arrival in the United States. Instead of just getting a chest X-ray, the report says, they should have a tuberculin skin test as well; once here, they should complete treatment for latent TB infection as a condition of receiving permanent residency status.
Committee says testing not discriminatory
In the past, TB experts at the CDC have defended the existing system of immigrant screening, arguing that many developing foreign countries lack expertise and resources needed to do more than what they’re doing. (See TB Monitor, January 2000, p. 2 of TB Monitor International supplement.)
Putting the two recommendations into effect will mean 250,000 people will need treatment for latent TB infection (LTBI) each year at a cost of $23 million, the report says.
"What we’re asking for will take a major commitment of time and money, and at both ends of the process," says Etkind. "But if we really want to address TB elimination among these populations, this is what it will take."
Changes to the immigration system would need to be implemented gradually, not all at once, Etkind points out. In the United States, an attempt to treat the extra volume of cases of LTBI would be piloted before implementation on a wider basis. Three or four years later, "the idea is to revisit the changes and see if they’re doing what we intended," Etkind adds.
The IOM committee heard testimony from lawyers and advocates for immigrant communities who argued the proposals would discriminate unfairly against the foreign-born, says Etkind. "But we concluded that if we can offer a mechanism that will get immigrants into the health care system, that will benefit them, as well as benefit the community," she says.
Exempted from the proposed changes would be current U.S. residents who are foreign-born, visitors, students, and others who come here for only short periods of time.
Other IOM recommendations look at a different problem — not the pools of latently infected foreign-born, but the trickle of cases in low-prevalence regions. Here, the report says, the challenge is how to keep TB control programs sharp enough to recognize TB when a case or two dribbles in while ensuring Congress doesn’t dismantle the whole plumbing system.
That means massive restructuring, the report says. In one suggested configuration, TB control departments contract services from the private sector in arrangements designed to keep the private sector responsive and accountable to public health. "What we saw in Tacoma/Pierce County, WA, is the classic example," says John Sbarbaro, MD, MPH, medical director of University Physicians Inc. of the University of Colorado Health Sciences Center’s school of medicine in Denver.
"There, TB control functions have been contracted out to a private group of infectious disease specialists," says Sbarbaro. "But to maintain accountability and uphold quality of care, the ID [infectious diseases] clinic is accountable to a TB expert from the health department." At the same time, the ID group has established close ties to other private physicians at the community clinics who treat most of the area’s foreign-born patients.
The result, he adds, "is a great, three-way partnership that saves money and keeps the standard of care high."
U.S. needs $280M annually to fight global TB
In a second scenario, TB control programs in low-prevalence regions consolidate diminishing resources by forming a single specialized team of experts responsible for several states. Doing so will keep individual state programs from being scaled back so much that they are no longer able to function effectively, the report notes.
"Let’s say you have four sparsely populated Western states," Sbarbaro says. "Why not contract with someone who’ll be on call for all of them?" The IOM committee envisions a team of experts that monitors "what’s happening in correctional systems and native and immigrant populations; creates quality-assurance standards; and carries out surveillance and epidemiology."
Patrick Chaulk, MD, MPH, senior associate for health at the Annie E. Casey Foundation in Baltimore, likens the arrangement to a TB "SWAT team."
Finally, to combat the global epidemic more effectively, the United States should do a better job of supporting TB control in developing countries, the report says. In addition, the federal government needs to triple its investment in biomedical research that would lead to better diagnostics, therapeutics, and vaccines for TB. That price tag would come to at least $280 million a year, the report says.
Committee members who wrote the report include:
• Morton Swartz, MD, committee chair and professor of medicine at Harvard Medical School in Boston;
• Ronald Bayer, PhD, professor of the division of sociomedical sciences at Columbia University in New York City;
• Patrick Chaulk, MD, MPH, senior associate for health at the Annie E. Casey Foundation in Baltimore;
• Fran DuMelle, RN, MS, deputy managing director of the American Lung Association and director of government relations at the American Thoracic Society in Washington, DC;
• Sue Etkind, RN, MS, director of the division of TB prevention and control at the Massachusetts Department of Public Health in Boston;
• David Fleming, MD, assistant administrator and state epidemiologist at the Center for Disease Prevention and Epidemiology of the Oregon Health Division in Portland;
• Audrey R. Gotsch, DrPH, professor and vice-chair of environmental and community medicine at Johnson Medical School in Piscataway, NJ;
• Philip Hopewell, MD, associate dean and attending physician at the division of pulmonary and critical care medicine at San Francisco General Hospital;
• Donald R. Hopkins, MD, MPH, associate executive director of the Carter Presidential Center in Atlanta;
• John Sbarbaro, MD, MPH, medical director of University Physicians Inc. at the University of Colorado Health Sciences Center’s school of medicine in Denver;
• Peter M. Small, MD, director of the Stanford Center for Tuberculosis Research and assistant professor of medicine in the division of infectious diseases and geographic medicine at Stanford (CA) Medical Center;
• Mary Wilson, MD, chief of infectious diseases and director of the Travel Resource Center at Mount Auburn Hospital in Cambridge, MA;
• Lester Wright, MD, MPH, associate commissioner and chief medical officer of the New York State Department of Correctional Services in Albany, NY;
• Lawrence Geiter, PhD, study director and member of the Institute of Medicine in Washington, DC.
To view a copy of the IOM report, "Ending Neglect: The Elimination of Tuberculosis in the United States," go to www.nas.edu. To order a copy, call (202) 334-3313 or (800) 624-6242. The cost is $45.
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