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TB in the United States – Elimination & drug resistance

The aim with TB in the United States is still the elimination of the disease, although the path towards this has not been as straightforward as was expected. For decades deaths from TB in the United States had declined, only for there to be a sudden resurgence in the 1980s alongside the AIDS epidemic.

TB in the United States

TB in the United States

From 1953 to 1984 the number of reported TB cases in the United States had declined at a rate of approximately 5% a year, from greater then 84,000 in 1953 to approximately 22,000 in 1984. However, from 1985 to 1992 reported TB cases increased 20%.

The surge in TB cases was particularly pronounced in New York where by 1992 there were 3,811 TB patients and 40 percent of them were also infected with HIV 1Shure, Natalie, “How New York Beat Its TB Epidemic, 2016, www.thedailybeast.com/articles/2015/03/23/how-new-york-beat-its-tb-epidemic.html. In addition, out of the thousands of cases in New York City at the peak of the epidemic 441 cases were of MDR-TB, which the standard TB drugs don’t cure.

A call for the elimination of TB in the United States

In 1989 the Advisory Committee for the Elimination of Tuberculosis (ACET) had published a strategic plan for the Elimination of Tuberculosis in the United States by 2010. Eliminating TB was defined as achieving a case rate of less than 1 per million population. However the plan was never fully implemented and the number of TB cases reported in the United States increased.

A further call for the elimination of TB in the United States

In 2000 when the case rate was 58 per million, the Institute of Medicine published a report, “Ending Neglect: The Elimination of Tuberculosis in the United States”. 2Institute of Medicine. Ending neglect: the elimination of tuberculosis in the United States. Washington, DC: National Academy Press; 2000 This was both a reminder of the threat posed by TB and a reaffirmation of the national goal of elimination.

Despite the fact that there had been a return to an annual decline of 4 to 8% in the national TB rate, the “Ending Neglect” report predicted that the goal of TB elimination set by ACET in 1987 would not be achieved by 2010. This was quite correct and in fact the 2010 rate with 11,182 TB cases was 36 fold higher than the elimination goal. It was proposed that there should be a new target date of 2035.

Incidence of TB cases by state and national average during 2014.

Incidence of TB cases by state and national average United States 2014.

TB cases by state

Four states (California, Texas, New York and Florida) representing approximately one third of the U.S. population accounted for half of all TB cases reported in 2014. The national TB incidence rate in 2014 was 3.0 cases per 100,000 people, ranging by state from 0.3 in Vermont to 9.6 in Hawaii. Twenty nine states and DC had lower rates in 2014 than in 2013; 21 states had higher rates.

Ten states and DC had higher rates than the national average. In 2014, as in 2013, four states (California, Florida, New York and Texas) reported more than 500 cases each. Combined these four states accounted for 4,795 TB cases, or 50.9% of all U.S. cases in 2014. There are more figures for the number of TB cases per state.

Foreign born and U.S. born people

Foreign born people continued to be disproportionately affected. In 2014, 66% of TB cases in the United States occurred in foreign born people. The top five countries of origin of foreign born persons with TB were Mexico, the Philippines, India, Vietnam and China.

The majority of TB cases among foreign born people, are believed to occur as a result of reactivation of TB infection previously acquired. The rate of TB cases reflects the level of TB in people’s country of origin. If the goal of elimination is to be achieved, then it is considered by the CDC that there will need to be additional interventions aimed at diagnosing and treating latent TB infection among foreign born people.3Negar Alami, CDC, Trends in Tuberculosis – United States, 2013, MMWR 2014;63:229-233 www.cdc.gov/mmwr/preview/mmwrhtml/mm6311a2.htm

Racial and ethnic minorities

In 2014 Asians had the highest TB case rate at 17.8 cases per 100,000, this was a slight decrease from 18.5 in 2013. Native Hawaiians or Other Pacific Islanders had the second highest TB case rate at 16.9 cases per 100,000 which is an increase compared to 11.4 cases per 100,000 reported in 2013.

Blacks or African Americans born in the United States represented 37% of TB cases in US born persons, and accounted for 13% of the national total.

Is progress now being made towards elimination?

In 2009 it was projected that at the rate of decline of 3.8% in annual cases that was achieved from 2000 to 2008, TB elimination would not be achieved until 2017 for the nation as a whole. A number of different reports concluded that the failure to progress towards the elimination goal, was not due to a faulty plan or an inappropriate goal, but a failure to fully implement a number of key components of the plan.

The latest preliminary TB statistics for the United States show that in 2015 there were 9,563 TB cases reported.4Salinas JL, Mindra G, Haddad MB, Pratt R, Price SF, Langer AJ. “Leveling of Tuberculosis Incidence — United States, 2013–2015.” MMWR Morb Mortal Wkly Rep 2016;65:273–278. DOI: http://dx.doi.org/10.15585/mmwr.mm6511a2

In 2014 there were 9,412 new cases of active TB disease. This was a 2.2% decline from 2013, but it was clear that:

“If your goal is elimination, there’s going to need to be a much greater rate of decline.”

So how could a greater rate of decline be achieved? What needs to be done?

It is not just that there needs to be a decline. It is also essential that there isn’t an increase in the number of people with TB, and it is from drug resistant TB that an increase could come.

Drug resistant TB in the United States

Although drug resistant TB is relatively rare in the United States, the treatment is very expensive, takes a long time to complete, disrupts lives and has potentially life threatening side effects. MDR TB is when the TB bacteria that a person is infected with are resistant to isoniazid and rifampin, two of the most potent TB drugs. XDR TB is when the bacteria are in addition resistant to several other drugs.

In 2014 1.0% of reported cases of TB in the United States were of primary MDR TB, which means that there is no previous history of TB disease and there is resistance to at least isoniazid and rifampicin, two of the main TB drugs. This percentage has remained stable fluctuating between 0.9% and 1.3% since 1996. Also in 2014 there were 2 cases reported of XDR TB, compared to 5 cases in 2013, 2 in 2012, 5 in 2011, and 1 in 2010. Of the 15 XDR TB cases reported since 2009, 11 have been among foreign born people.

The average cost of treating a person with TB disease increases with greater resistance. Direct costs average $17,000 to treat drug susceptible TB, $150,000 for MDR TB and $482,000 to treat XDR TB. There is then in addition productivity losses of $27,000 for treating drug susceptible TB, $132,000 for MDR TB and $182,000 for XDR TB. Of those people treated for drug resistant TB in the U.S. at present, 9% die during treatment, 27% stop working, 73% are hospitalized and 37% require home isolation. An increase in the number of patients with MDR-TB or XDR-TB could have a dramatic financial impact on both State and local health care systems.

National Action Plan for Combating Multidrug-Resistant TB

United States & drug resistant TB

United States & drug resistant TB

In December 2015 the National Plan for Combating Multi-drug Resistant Tuberculosis was launched. The National Action Plan identifies a number of critical actions that the U.S. Government would like to take over a 3 to 5 year period to contribute to the global fight against MDR-TB. It is designed to have an impact within the 3 to 5 year timescale, as well as serving as a call to action for the global community.

It has however been made clear that the National Action Plan is not a commitment to provide additional funds, and that the activities described in the action plan are subject to “budgetary constraints and other approvals”.

The National Plan has three main goals that aim to strengthen health-care services, public health, and academic and industrial research through collaborative action by the U.S. government in partnership with other nations, organisations and individuals.

Targets of the National Action Plan

If the objectives of each goal are successfully carried out, then this should result in the following National Action Plan targets being met. There are certain interim targets to be met by 2016, and 2018, with the aim of the following overall targets being met by 2020. Only the first of these is a domestic target with the rest being concerned with the global impact of TB.

  • To reduce by 15% the number of newly diagnosed MDR-TB cases;
  • To initiate treatment for 50% of patients with MDR-TB in the ten countries with the highest burdens of MDR-TB;
  • To successfully treat at least 16 million TB patients in high-burden countries;
  • To achieve and maintain treatment success rates of 90% for individuals in high burden countries with drug susceptible TB;
  • To reduce the global incidence of TB by 25% compared to 2015 levels.
 Isoniazid tablets

Isoniazid tablets

TB drug shortages

There are a number of cross cutting themes in the different program goals of the National Action Plan, and one of these is that of TB drug shortages.

Isoniazid is one of the first-line drugs used as part of a regimen to treat active TB disease and latent TB infection. In 2013 79% of State and local TB programs reported difficulties in procuring isoniazid. Second line drugs are used for the treatment of MDR-TB and in 2013 it was reported that 81% of U.S. TB programs that managed patients with MDR-TB had difficulty procuring second-line drugs. There have also been shortages of the diagnostic products used in TB skin tests. One of the significant outcomes of Goal 1 would include a National TB stockpile to prevent shortages of TB medicines and diagnostic tests.

Funding of the National Action Plan

After the launch of the National Action Plan, TB advocates raised questions about adequate funding for the plan’s implementation. This was partially because of the Obama Administration’s repeated attempts to cut USAID’s TB program over the past few years, only for this to be rejected by Congress. Advocates estimate that the program will require $412 million for the fiscal year 2017 to meet the targets laid out in the plan. A 1992 plan with the same name was not implemented due to a lack of funding. Will the 2015 National TB Action Plan end up the same way, or will there really be change?

Just two months after the launch of the National Action Plan, President Barack Obama proposed cutting the USAID’s funding to combat TB by 19%. This will be the fourth budget in a row from the Obama administration that calls for a 19% cut to TB funding at USAID. In each of the earlier years Congress rejected the reduction. If lawmakers approve the funding proposal, it would be the lowest level of spending on TB since the fiscal year 2009.5“Obama proposes less money to fight world’s top infectious killer”, Huffpost Politics, www.huffingtonpost.com/entry/tuberculosis-obama-budget_us

Rep. Eliot Engel, a longtime advocate for TB funding said:

If you don’t have money with the plan we can talk about pie in the sky all you want”, Engel said. “But if you don’t put your money where your mouth is, it’s worthless.”

Major Source

National Action Plan for Combating Multidrug Resistant Tuberculosis https://www.whitehouse.gov/blog/2015/12/22/national-action-plan-combat-multidrug-resistant-tuberculosis/

References

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1. Shure, Natalie, “How New York Beat Its TB Epidemic, 2016, www.thedailybeast.com/articles/2015/03/23/how-new-york-beat-its-tb-epidemic.html
2. Institute of Medicine. Ending neglect: the elimination of tuberculosis in the United States. Washington, DC: National Academy Press; 2000
3. Negar Alami, CDC, Trends in Tuberculosis – United States, 2013, MMWR 2014;63:229-233 www.cdc.gov/mmwr/preview/mmwrhtml/mm6311a2.htm
4. Salinas JL, Mindra G, Haddad MB, Pratt R, Price SF, Langer AJ. “Leveling of Tuberculosis Incidence — United States, 2013–2015.” MMWR Morb Mortal Wkly Rep 2016;65:273–278. DOI: http://dx.doi.org/10.15585/mmwr.mm6511a2
5. “Obama proposes less money to fight world’s top infectious killer”, Huffpost Politics, www.huffingtonpost.com/entry/tuberculosis-obama-budget_us