Ending Neglect The Elimination of Tuberculosis in the United States (2000) / Chapter Skim
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Executive Summary
Executive Summary
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in foreign-born persons; and review the current state of research and development in the United States on new diagnostics and therapeutics for TB prevention, control, and elimination; review the extent of multidrug-resistant tuberculosis and analyze factors that contribute to its development; and examine the role of the United States in international efforts at tuberculosis control. The committee will develop conclusions and recommendations regarding: a framework to guide a national campaign to eliminate TB in the United States; region-specific action steps required to work towards that goal; research needs and priorities for national TB elimination; information for health care providers and the public regarding the importance of vigilant and continued attention to TB control; health plan (fee-for-service and managed care)
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At a minimum, strategies for tuberculosis control will have to adapt to a declining incidence and the changing health care environment. For example, the private sector is becoming increasingly involved in both tuberculosis treatment and tuberculosis prevention, which will require effective programs of training and education for private sector clinicians, patients, and targeted segments of the general public.
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cases among individuals in this group is steadily increasing, and soon more than half of all cases of tuberculosis in the United States will be among foreign-born individuals. To address the disease among some foreign-born individuals with tuberculosis, those applying for immigrant visas could be required to undergo tuberculin skin testing as part of the medical examination already required for immigrants to the United States and could be required to complete examination and treatment for tuberculosis or latent tuberculosis infection (when indicated)
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The United States must increase its engagement in the global effort to control tuberculosis through participation in multilateral efforts, such as the Stop TB Initiative, and through bilateral initiatives with countries where the rates of tuberculosis are high and that present special circumstances, such as Mexico, which shares a large land border with the United States. The key to achieving tuberculosis elimination will be through social mobilization and maintaining the public interest and commitment necessary to provide sufficient resources for the effort.
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Those with tuberculosis are eligible for Medicaid, and many health departments are taking advantage of this to fund a variety of services, including directly observed therapy. In addition, tuberculin skin testing and treatment of latent infection are eligible for Medicaid reimbursement.
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Recommendation 3.2 To ensure the most efficient application of existing resources, the committee recommends that · New program standards be developed and used by CDC and state and local health departments to evaluate program performance. · Standardized, flexible case management systems be developed to provide the information needed for the evaluation measurements.
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· State and local health departments develop case management plans to ensure a uniform high quality of care for patients with tuberculosis and tuberculosis infection in their jurisdictions. Recommendation 3.4 To maintain quality in tuberculosis care and control services in an era of increased use of managed care systems and privatization of services, the committee recommends that · When it is determined that tuberculosis diagnosis and treatment services can be provided more efficiently outside of the public health department, the delivery of such services be governed by well-designed contracts that specify performance measures and responsibilities.
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Recent guidelines from CDC have emphasized the importance of identifying immigrants from high-incidence countries as soon as possible after their arrival in the United States and providing them with tuberculin skin testing and treatment for latent infection, when indicated. The addition of tuberculin skin testing to the medical evaluation for immigrant visa applicants from countries with high rates of tuberculosis and linking of evaluation and treatment for tuberculosis to receipt of permanent residency status could facilitate this process.
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Recommendation 4.2 To prevent the development of tuberculosis among individuals with latent tuberculosis infection, the committee recommends that · Tuberculin skin testing be required as part of the medical evaluation for immigrant visa applicants from countries with high rates of tuberculosis, a Class B4 immigration waiver designation be created for persons with normal chest radiographs and positive tuberculin skin tests, and all tuberculin-positive Class B immigrants be required to undergo an evaluation for tuberculosis and, when indicated, complete an approved course of treatment for latent infection before receiving a permanent residency card ("green carded. Implementation should be in a stepwise fashion and pilot programs should evaluate strategies and assess costs.
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Recommendation 5.2 To advance the development of diagnostic tests and new drugs for both latent infection and active disease, action plans should be developed and implemented. CDC should then exploit its expertise in population-based research to evaluate and define the role of promising products.
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Recommendation 6.1 To decrease the number of foreign-born individuals with tuberculosis in the United States, to minimize the spread and impact of multidrug-resistant tuberculosis, and to improve global health, the committee recommends that · The United States expand and strengthen its role in global tuberculosis control efforts, contributing to these efforts in a substantial manner through bilateral and multilateral international efforts. · The United States contribute to global tuberculosis control efforts through targeted use of financial, technical, and human resources and research, all guided by a carefully considered strategic plan.
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Recommendation 7.2 To increase the effectiveness of mobilization efforts the committee recommends that the National Coalition for the Elimination of Tuberculosis continue to provide leadership and oversight and that CDC continue to work in collaboration with the coalition to secure the support and participation of nontraditional public health partners, ensure the development of state and local coalitions, and evaluate public understanding and support for tuberculosis elimination efforts with the assistance of public opinion research experts. Recommendation 7.3 To assess the impacts of these recommendations and to measure progress toward accomplishing the elimination of tuberculosis, the committee recommends that, 3 years after the publication of this report and periodically thereafter, the Office of the Secretary of Health and Human Services conduct an evaluation of the actions taken in response to the recommendations in this report.
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