Ending Neglect The Elimination of Tuberculosis in the United States (2000) / Chapter Skim
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2 The Current Situation and How We Got Here
2 The Current Situation and How We Got Here
Pages 23-50
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From page 23... ...
As shown in Figure 2-1, mortality rates were of a similar magnitude and followed a similar time course in the United States and Europe, peaking at approximately 400 per 100,000 population in Boston, New York, and Philadelphia combined (Dubos and Dubos, 1952~. The discovery of the etiological agent of tuberculosis provided the fundamental scientific underpinning for programs designed to prevent and control the disease.
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From page 25... ...
This program required that all cattle herds be systematically tuberculin skin tested, that herds with infected cattle be slaughtered (with an indemnity paid to the owner) , and that the premises be cleaned and disinfected after the infected animals were removed.
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26 ENDING NEGLECT 250 200 150 50¢ ~'200 _ m a ~5 150 _ Q . _ ~ 100 _ .~ 200 150 _ 100 _ 50 _ 1 1 1 1 1 1 I - - -United States \ -- Switzerland ~ _ , ~ \ 1 1 1 -- England ~j', and Wales | |l '~~ Prussia An.
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Tuberculosis morbidity data were also available for the entire continental United States beginning in 1933, when the National Tuberculosis Association (now the American Lung Association) began annual surveys.
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tuberculosis within institutions including hospitals, correctional facilities, residential care facilities, and shelters for the homeless population (Daley et al., 1992; Edlin et al., 1992~. Since then, improvements in the screening of new entrants to these facilities, more rapid diagnosis, the use of directly observed therapy to decrease infectiousness more rapidly, and more effective use of preventive therapy worked in combination to decrease the number of infec
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From page 30... ...
However, nearly every state in the union has reported at least one case of multidrug-resistant tuberculosis, and it is likely that even if no new cases of multidrug-resistant tuberculosis occur, cases will continue to occur for decades when individuals with latent infection with multidrug-resistant tuberculosis bacilli develop active tuberculosis. Multidrug-resistant tuberculosis is also a serious problem internationally.
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From page 31... ...
The same survey estimated the rate of multidrug resistance among previously treated cases to be 11.1 percent. Given these rates of multidrugresistant tuberculosis throughout the world and the relatively poor state of global tuberculosis control programs, it is highly likely that there will be continued increases in the proportions and a more widespread distribution of multidrug-resistant cases.
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............... 68 70 72 74 76 78 80 82 84 86 88 90 92 94 96 98 20 Year FIGURE 2-5 Reported tuberculosis cases, by county, 1998.
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In some instances conventional epidemiological analyses can be supplemented by molecular epidemiological analyses to develop an even more precise picture of the local epidemiological circumstances (Hopewell and Small, 1996~. Tuberculosis Control amid Worldwide Complacency The complacency that was a major factor underlying the resurgence of tuberculosis in the United States, and in many other low-incidence
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From page 34... ...
In the past the frequency of tuberculosis and, thus, the familiarity that physicians and public health officials have had with the disease have led them to conclude that all that needed to be known about tuberculosis was already known. This was explicitly described by Keers (1978)
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The defeatism was perhaps best expressed by Walsh and Warren (1979) who, in an analysis of "appropriate" primary health care interventions, concluded that tuberculosis control was too complex and costly to deserve being included as a high-priority activity.
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, to block grants to the states for control of communicable diseases as a whole, and the states were not required to direct any of the federal funding to tuberculosis (U.S. Congress, Office of Technology Assessment, 1993~.
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From page 37... ...
Given that the 1991 cost estimates were derived in part from actual data, if relative activity levels have not changed, it would appear that federal funding has largely been used to offset, not to add to, state and local support. However, it is likely that the costs relative to the total number of cases have increased because of the increased use of directly observed therapy, more active screening programs, broader contact investigations, and wider use of treatment of latent infection, all of which are more labor-intensive and, therefore, more costly interventions.
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38 ENDING NEGLECT It is clear that as the number of tuberculosis cases decreases, the costs per case will increase, as long as an adequate infrastructure is maintained. The fixed costs of tuberculosis control are not sensitive to the numbers of cases.
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From page 39... ...
Maintenance of Control amid Decreased Incidence A major challenge that needs to be addressed now is how to maintain effective tuberculosis control as the incidence of the disease decreases. This is especially true in parts of the United States where, currently, there are very few cases and a comparably low prevalence of infection.
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From page 40... ...
It was on the basis of such developments in mental health law, rather than as a result of challenges to the actions of public health officials in responding to tuberculosis cases, that it became possible to assert successfully that tuberculosis patients be accorded the procedural protections guaranteed by the Constitution. In 1980, in an appellate court decision
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From page 41... ...
In 1993, when the Advisory Council for the Elimination of Tuberculosis (ACET) recommended changes in state tuberculosis control laws, it declared As in commitment proceedings under state mental health laws, any law under which a person may be examined, isolated, detained, committed and/or treated for TB [tuberculosis]
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From page 42... ...
During the hearing process that preceded the adoption of the amended code, civil liberties advocates claimed that the proposed new regulations were unconstitutional because they did not require the city to "exhaust" all less restrictive alternatives before seeking the involuntary confinement of a persistently noncompliant tuberculosis patient. This broad interpretation of the least restrictive alternative doctrine formed the basis for a constitutional challenge brought against New York City's Health Department in early 1994 (In re Application of the City of New York v.
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From page 43... ...
On the other hand, they could find compelling a public health finding that the elimination of tuberculosis justified the compulsory treatment of latent infection just as the threat of multidrug-resistant tuberculosis justified the imposition of the requirement that those with tuberculosis complete their therapy even though they no longer posed an immediate public health threat. In commenting on this tension, Lawrence Gostin has noted While traditional public health law inquiries focus principally on present infectiousness, there is no reason to limit the direct threat doctrine in this way....
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From page 44... ...
. Elimination of infection was defined as "reduction to zero of the incidence of infection caused by a specific agent in a defined geographic area as a result of deliberate efforts; continued measures to prevent the reestablishment of transmission are required." Eradication was defined to indicate "permanent reduction to zero of the worldwide incidence of infection caused by a specific agent as a result of deliberate efforts," whereas control referred to "reduction of disease incidence, prevalence, morbidity or mortality to a locally acceptable level as a result of deliberate efforts" (Dowdle and Hopkins, 1998~.
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From page 45... ...
only after about 60 more years. If the current rate of reduction in annual incidence were doubled, which is imaginable by use of current tuberculosis control tools, it would still take about 27 years to reach the target of "elimination." Achievement of the current target of 1 case per 1 million population in the United States by the target year of 2010 would require an average annual rate of decline of 32 percent.
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From page 46... ...
The development of these indicators will require a better understanding of the epidemiology as it approaches elimination. THE ETHICS OF TUBERCULOSIS ELIMINATION With the incidence and prevalence of tuberculosis declining to the lowest levels in history in the United States and with the burden of tuberculosis continuing to exact an enormous toll in less developed nations, the ethical challenges posed by the goal of tuberculosis elimination are neither simple nor straightforward.
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From page 47... ...
Are the constitutional doctrines that, since early in the 20th century, have recognized the authority of the state to impose vaccination requirements to prevent disease sufficiently robust to justify mandatory screening for those at risk for disease? Finally, there is the question of whether those who are identified to have latent infection should be encouraged to undergo treatment or should be required to do so.
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From page 48... ...
The issues of screening and treatment for latent infection compel society to address the questions of when, if ever, it is appropriate to use compulsory public health powers and how to balance the collective wellbeing against the right of the individual to be free of intrusions when the threat that he or she poses to others is only statistical. These issues take on special significance in the context of the goal of tuberculosis elimination.
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From page 49... ...
1993. Controlling the resurgent tuberculosis epidemic: A 50-state survey of TB statutes and proposals from reform.
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From page 50... ...
1979. Selective primary health care: An interim strategy for disease control in developing countries.
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