New rules for new age in low-prevalence guide

ACET committee ponders funding, expertise

At a time when more and more parts of the country are watching their TB caseloads sink, experts are wondering whether it’s time for rules to be rewritten to take the changes into account.

One group of experts, the Centers for Disease Control and Prevention’s Advisory Council on Elimination of Tuberculosis (ACET), has started working on just such a project. "Historically, we’ve always focused on high-risk settings," says Charles Nolan, MD, head of TB control for Seattle/King County and chairman of ACET. "It’s invigorating to think about the next step toward elimination, which is how to reduce the burden of disease in low-incidence areas."

The challenges for low-prevalence settings differ, sometimes dramatically, from problems faced by public health in a high-prevalence environment, Nolan adds. The biggest issues are how to retain infrastructure and funding on the one hand, while on the other keeping interest and expertise from flagging.

Local TB control likely to succeed

Even trickier, perhaps, is how departments with shrinking budgets can build in enough elasticity to be able to respond to emergencies, developing the so-called "surge capacity" needed for times when an outbreak occurs.

Finally, theres the challenge of how to go about wiping out the last stubborn handful of cases, Nolan says. "Looking at states where there are very low numbers of cases year after year — the Dakotas, Wyoming, Maine — you get the sense that there may be a floor below which it’s going to be very difficult to go, at least with the tools we currently have," he says. "Can we change that dynamic, given the tools we have and the dynamic of TB itself?"

One member of an ACET committee that’s working to draft new guidelines for low-prevalence areas says the key is not to let go of the basics. "I’m arguing that no matter how few cases you get down to, you still need that basic public health infrastructure," explains Kathleen Gensheimer, MD, state epidemiologist for the Maine health department. She disputes the notion that, ultimately, public health functions might be replaced by a centralized or regionalized "SWAT team" ready to swoop down and handle outbreaks.

"The problem with that idea is that every state has its own unique epidemiology and its own issues," she points out. "Outsiders couldn’t have as clear an understanding as state people do." New Englanders, with their "less government is better" sentiments, also are more apt to cooperate with public health authorities from their own state than with experts from "the outside," she says.

Low prevalence could breed ignorance

The real issue is not whether a local public health infrastructure can ever be replaced completely, but how much it can be reduced and still continue to function effectively, Gensheimer adds. "We don’t have an outbreak’ team here," she says. "Everyone’s off doing their own thing; in fact, everyone’s pretty much overwhelmed by their job responsibilities."

When a crisis occurs, and people get pulled from one division of public health to help out in another, "that means that for those weeks, no one’s answering the phone." In an ideal world, she adds, a way would be found to build in more surge capacity, while drawing on those "outsiders" for expertise.

That leaves the issue of how to maintain expertise on the home front. "The medical community sees fewer and fewer cases of TB," she notes. "Many have never diagnosed a single case. But somehow, you’ve got to keep people thinking about it. You’ve got to find a way to keep the risk flag flying."

As TB cases go down, lack of familiarity may breed not just ignorance but also contempt, at least among the public, adds Gensheimer. "I think as TB becomes less common, we’ll see more stigmatization associated with the disease," she explains.

"Sometimes in a contact investigation, I’ll encounter that — the feeling that these foreigners’ bringing in TB have caused someone to have to take a medicine they don’t want to take, and that it’s all their fault," she says.

In a low-prevalence future, Gensheimer says, it will be more important than ever to guard against provoking a backlash against the foreign-born.