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Just how low can infrastructure (and case rates) go?
The road to elimination is starting to look like a bumpy ride, at least for TB experts charged with drafting a plan for TB elimination in low-incidence states. Doubters should check with members of the Advisory Council for the Elimination of Tuberculosis (ACET), still dusting themselves off after their latest wrangle over the contentious subject.
As became clear at the last ACET meeting in Atlanta in February, regionalization is by far the biggest pothole looming in the elimination highway. "Oh, boy, that’s the real hot-potato issue," says Charles Nolan, MD, TB controller for Seattle/King County in Washington and head of ACET. To many TB administrators, the "R" word conjures up specters of funding streams dwindled to a parched trickle; jobs blowing away in the wind; SWAT teams of outsiders, tone-deaf to the nuances of local ways, swooping down on outbreaks; and cultures lost on the shelf of some faraway, faceless laboratory.
What, exactly, does elimination’ mean?
At the recent meeting, some even asked why ACET is bothering to talk about "elimination" in the first place. For one thing, they argued, many problems (as well as solutions) are the same no matter where you look — the same high-risk groups, the same programs stretched too thin. Plus, they add, "low-incidence" is hardly an all-or-nothing proposition, because even the highest-incidence states have pockets, or even vast tracts, that meet the definition of low incidence.
Hardly anyone would deny that the concept of "elimination" sounds a lot less plausible now than it did a decade ago. Since 1989, Nolan notes, the pool of low-incidence states (defined as states with TB rates of less than 3.5 per 100,000) has been virtually stagnant, with little movement of jurisdictions into or out of the pool. Among the 18 states that qualify, there’s been scant downward progress in their incidence rates. "The question is whether this as good as it gets," says Nolan. "Or, with good advice and better use of tools, can these low-incidence states move their incidence even lower?"
Some members of the ACET working group charged with producing a position paper on
the subject say it’s easier to tackle the question of "why bother?" than to unravel the knot of regionalization.
"We don’t want this document to read, We want you to have zero cases,’" notes Ruth Vogel, CPH, former state TB controller of North Dakota and now bureau chief for the Baltimore Division of Communicable Diseases. That doesn’t mean low-incidence states should settle for a 3.5 glass floor, either, she adds. "Sometimes people need to be willing to take a chance; they need to step out and say We can do this.’"
Other members of the working group are chomping at the bit. "In the 10 years I’ve spent
on ACET, there’s been a real change in emphasis," says Kathleen Gensheimer, MD, TB controller of Maine. "We’ve gone from fighting fires, which as a public health practitioner I’ve never found rewarding, to talking about prevention. If we just keep waiting to respond to outbreaks, we’ll never eliminate TB in this country. I think it’s time to move."
Fine; but what, exactly, does "elimination" mean? "Maybe it means some very low case rate, with no local transmission," suggests Jim McAuley, MD, MPH, medical director for Cook County Jail in Chicago and a member of the working group. "If 10,000 Laotian refugees arrive in your district, then yes, you may have
a case. But you don’t want to see your indigenous population develop TB."
Squeezing a dollar, North Dakota-style
To Vogel, low-incidence living teaches lessons that high-incidence states would do well to study. Upon moving to Baltimore, she discovered her survival skills learned in bare-budget North Dakota seemed just as much in demand in the cash-strapped Baltimore program.
Scrambling to find a way to keep providers in North Dakota sharp, for example, Vogel says she forged a partnership in North Dakota between
TB control and the University of North Dakota School of Medicine. The school was more than happy to put on twice-yearly regional workshops, with lunch thrown into the bargain, she found.
The local branch of the North Dakota American Medical Association also was persuaded to put TB on the agenda, and Vogel succeeded in getting a TB physician to join the AMA board. In Baltimore, Vogel has scarcely missed a beat and is already talking to area schools about possible partnerships.
The same spirit should pay off in Maine, Gensheimer says. There, a chicken-processing plant that’s added foreign-born workers to its work force has recently experienced three TB cases, along with an onslaught of bad publicity. Setting up a permanent screening program for the 34 nationalities represented in the chicken plant’s work force would be impossibly costly for TB controllers to undertake on their own; but with the recent headlines, "we’ve got what amounts to a captive audience [in plant management] right now," Vogel adds. What better time to join forces with plant management, she notes, maybe creating a model that could be used in other industries in the state where foreign-born workers have made inroads?
Even with deep-pocketed partners, the costs per case eliminated continue to rise as total cases go down, Gensheimer points out. At the same time, flashier diseases like West Nile virus clamor for dollars and public attention. An elimination plan can actually serve as a magnet for support, the Maine TB expert thinks. "It’s something to get TB back on the screen and something to rally around," she points out.
Sharing of services already under way
When it comes to the cloud known as regionalization looming over the horizon, consensus among members of the working group erodes a bit. "I see it as a relatively simple question," says Cook County’s McAuley. "How do we deal with TB once it becomes a relatively rare disease? On one hand, that means making sure doctors, nurses, and other health care providers still have TB on their radar screens when someone presents with symptoms. And it means making sure the health department can mobilize [during an outbreak]." Like it or not, the twin demands translate to at least some elements of regionalization, McAuley maintains. "At some point, it begins to makes so much sense that it becomes almost a requirement," he says.
In the Northeast, lab services have already begun to regionalize, he points out. Other labs routinely pick and choose which services to provide; the state lab in Illinois, for example, has opted out of doing tests for hepatitis C.
Other segments of health care where sharing of lab services is already practiced aren’t seeing the sky fall, he adds. "Those of us in private medicine send our labs all over the country," he says. "When I worked in a private hospital [in Chicago], we used a SmithKline lab in St. Louis." Cultures that needed second-line testing were shipped to a lab in New Jersey, he adds.
Gensheimer agrees, but with some reservations. "It’s tough to maintain [laboratory] competence with just a couple of cases a year," she concedes. "There’s also the expense of equipment. But if you send your labs out, you’ve really got to set the system up right, with a special courier service for rapid turnaround and a laboratory system that’s up and running seven days a week."
Finally, there’s the issue of shared medical expertise. No one’s suggesting bulldozing local programs in wholesale fashion, but TB controllers of the future, at least in low-incidence areas, should keep a hat-rack handy, because they’ll be wearing lots of different headgear, McAuley says.
"Look at Ruth Vogel," he points out. "In North Dakota, she had to do multiple things — STDs, HIV, TB, and immunization. In a state with 500,000 people, you simply can’t have six different people, with each doing just one task." Gensheimer bristles at the notion of replacing local TB docs with big-city hot shots. "Cross-training at the state level is one thing; you probably can’t have people saying, I only do HIV,’" she says. "But a SWAT team from Boston can’t handle everything."
Don’t let the knife cut too close
When the paring knife goes to work on local public health infrastructure, there are two kinds of dangers, adds Charles Wallace, Texas’ state TB control officer and another working-group member. One is the so-called "U-shaped curve of concern" — the pernicious dynamic whereby fewer cases lead to less funding, which leads in turn to more cases. "You have to keep in place strong TB programs, whatever morbidity level you have," Wallace says. "If you lose readiness to respond at the local level, it’s a death sentence for TB control." Plus, a program that’s been cut too close to the bone risks losing its integrity, Wallace warns. "If you’re constantly upsizing and downsizing, I think you risk losing a certain dynamic," he adds.
Though McAuley gently pooh-poohs the notion that "outside" experts can’t come in and do effective crisis control - after all, he points out, that’s what Center for Disease Control and Prevention teams are already doing - he does agree that somebody’s got to stay home and mind the store. "The biggest problem [with regionalization] is follow-through," he says. "Who makes sure people take their meds? You’ve got to maintain [adequate] presence at the local level."
Listening to Gensheimer and Vogel talk about the pick-and-shovel work of screening and administering prophylaxis to high-risk groups, it’s hard to believe that TB control is at imminent risk of disappearing into a generic vapor of public-health functions.
"It’d be nice to think we [low-incidence] states got to where we are now by dint of our great programs," says Gensheimer. "The truth is that Maine and other low-incidence states have been lucky. We’ve never had large populations of the foreign-born, prisoners, IV drug users, the HIV-infected, or the homeless. We’re low-incidence merely by coincidence and by good luck." Now, she adds, it’s time to get to work: "We need to leave the honeymoon period and target the remaining pools of infected individuals."
After all, McAuley points out, "elimination" by whatever definition means that TB controllers in some parts of the country will embark on a road to working themselves out of a job. "Understandably, plenty of folks are ambivalent about all this," he concedes. "For the short term, it’s a big resource shift; eventually, we may get to the point where we have to retool, and there may some job loss."
But, he adds, "I’m of the somewhat Pollyanna-ish view that we should just go for it."