Prevention agency reassesses priorities
Prevention agency reassesses priorities
Cost-effective systems are needed
For a couple of days last fall, the National Cen ter for HIV, STD, and TB Prevention (NCHSTP) hit the pause button, convened about 30 experts from inside and outside the three disciplines the center oversees and considered whether researchers are doing what really needs to be done.
"We wanted to step back and make sure our research portfolio is addressing the big questions," says Jim Buehler, MD, associate director of science for NCHSTP. "This wasn’t a review of current work; it was to make sure we have a shared understanding of what our priorities are."
More emphasis on community programs
One benefit that emerged from the review exercise was a determination to look more closely at the systems that have an impact on public health.
"In the past when we’ve looked at behaviors, we’ve often emphasized individual behaviors," Buehler says. "There’s been less emphasis on community-level determinants. We need to figure out what is the nature of a community where there is strong prevention activity."
For example, along with focusing on providing messages to individuals about the dangers of sharing needles, what’s the impact of laws that prohibit someone from possessing a syringe?
Policy and structural factors such as physician behavior formed a second focus of discussion, says Buehler. "We spend a lot of time talking about patient behavior, but how do we do a better job of defining policy so it benefits health? And then how do we make sure policy is acted upon by health care providers?"
From the perspective of public health officers who deliver care to TB patients, there are four areas in which NCHSTP could help, notes Charles Nolan, MD, the TB control officer for Seattle/King County, director of the CDC’s Advisory Council to Eliminate Tuberculosis (ACET), and one of the featured speakers at the NCHSTP stock-taking event.
"For a variety of reasons, local and state TB programs exist in a constant budget crisis of one kind or another," says Nolan. "We need more research into the most cost-effective ways to do our business."
Diverse populations challenge systems
More work in the international arena also would help TB controllers, since most morbidity due to TB is found outside the United States. Here at home, patients at risk for TB increasingly are enrolled in managed care plans; learning how public health bureaucracies can navigate the shoals of managed care is certainly another challenge for research.
Finally, Nolan tells a story he says illustrates one last need:
"In Ukraine, everyone learns that you prevent TB by giving BCG. All schoolchildren get a BCG vaccination; to see whether the vaccination has worked, they give you a tuberculin skin test. People who test positive are told they are now protected from getting TB; those who test negative are told they need to be re-vaccinated.
Ukrainians who emigrate to the United States find matters are reversed, he continues. Here, they also get a tuberculin skin test. This time, though, those who test negative are told they have nothing to worry about, while those who test positive are told they must take six months of medication.
The moral, says Nolan, is that TB patients represent increasingly diverse populations, and more research into the nature of the diversity needs to be done if TB controllers of the future are to succeed in their jobs.
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