The NEW ENGLA ND JOURNAL of MEDICINE

Perspective September 21, 2017

Tuberculosis Elimination in the United States The Need

for Renewed Action
Ronald Bayer, Ph.D., and KennethG. Castro, M.D.

O
nce called the captain of all these men of
Tuberculosis Elimination in the United States

losis Report, the Southeast Asia

death, tuberculosis continues to kill 1.8 and Africa regions accounted for
most (71.8%) of the global tuber-
million people globally each year. In 2014, culosis cases (45.6% and 26.2%,
the World Health Assembly embraced an ambitious respectively). The remaining cases
occurred in the Western Pacific
resolution to reduce deaths from losis cases and 19,707 deaths were (15.3%), Eastern Mediterranean
tuberculosis by 95% by 2035. But reported in the United States (7.2%), Europe (3.1%), and Amer-
despite such global concern, tu- and the case rate was 52.6 per icas (2.6%) regions. In the United
berculosis has all but vanished 100,000. In 2016, the Centers for States, in addition to the cases
from the U.S. publics mind as a Disease Control and Prevention reported by the CDC, there are
perceived threat. Although this (CDC) reported 9287 new tuber- an estimated 13 million residents
lack of attention is understand- culosis cases, for a case rate of with latent tuberculosis infection,
able, given the substantial de- 2.9 per 100,000. But there con- including 20.5% of foreign-born
crease in disease burden over the tinue to be gross disparities in persons and 1.5% of U.S.-born
past several decades, it jeopar- rates of disease. A total of 68% persons.
dizes the prospect of tuberculo- of newly reported cases in 2016 Tuberculosis will ultimately de-
sis elimination in the United States were in foreign-born persons, who velop in an estimated 5 to 10%
a goal established by the De- had a case rate 14 times that of people with latent tuberculosis
partment of Health and Human among U.S.-born persons (see infection. The National Academy
Services in 1989. Critical ethical graph). of Medicine (formerly the Insti-
and policy questions must be ad- The case rate among foreign- tute of Medicine [IOM]), the CDC,
dressed if elimination is to be pur- born persons reflects the global and many state and local health
sued in earnest. distribution of tuberculosis. Ac- departments have long publicly
We have come a long way cording to the World Health Or- recognized the importance of tar-
since 1953, when 84,304 tubercu- ganization 2016 Global Tubercu- geting prevention efforts at peo-

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PERS PE C T IV E Tuberculosis Elimination in the United States

to act effectively to realize the

40
population-level promise of elim-
Rate of Tuberculosis Cases 35 ination.
(per 100,000 population)
30 Difficult policy questions re-
Foreign-born persons lated to the treatment of latent
25
tuberculosis infection were ad-
20 dressed in a landmark report
15 published by the IOM in 2000.
10
Overall The IOM committee, of which
one of us was a member, pro-
5
U.S.-born persons posed that immigrants applying
0 to enter the United States who
are found to have latent tubercu-
93

95

97

99

01

03

05

07

09

11

13

15
19

19

19

19

20

20

20

20

20

20

20

20
losis infection be permitted entry
Rates of Tuberculosis Cases among U.S.-Born versus Foreign-Born Persons, United under the condition that they un-
States, 1993-2015. dergo therapy and that inmates
Source: Tuberculosis in the United States: National Tuberculosis Surveillance System also be screened and treated for
highlights from 2015 (https://www.cdc.gov/tb/statistics/surv/surv2015/default.htm latent tuberculosis infection.4 The
[slide 17]). decision to release the report at a
time when there was still con-
ple with latent infection. As re- diagnosis of latent tuberculosis cern about the relative toxicity of
cently as last year, the second infection and shorter effective treatment for latent tuberculosis
priority of the New York City De- treatment courses should make it infection reflects a judgment by
partment of Health and Mental easier for these interventions to the IOM committee that what-
Hygiene Bureau of Tuberculosis be scaled up.3 Thus, the chal- ever clinical risks were posed by
Control was to ensure that indi- lenge for the public health com- intervention, the prospect of a
viduals at high risk for progres- munity in the United States is public health benefit should take
sion from latent TB infection to now how to more effectively iden- priority. In a cautionary note, the
TB disease complete treatment tify people with latent infection committee also concluded that
and do not develop disease. and ensure that they receive the in the absence of additional evi-
According to researchers at the recommended treatment. dence, dramatically enhancing out-
CDC, because approximately 93% The ethical and policy chal- reach to groups with high rates
of tuberculosis cases in foreign- lenges related to identifying and of latent tuberculosis infection
born persons in the United States treating asymptomatic latent tu- would fail; a heavy-handed re-
were attributable to the reactiva- berculosis infection are very dif- course to coercion was neither
tion of latent infection, targeted ferent from those involved in ethically justified nor strategical-
testing (and treatment) could be responding to infectious tubercu- ly wise.
an effective strategy for eliminat- losis disease, when the threat to But the kinds of public health
ing tuberculosis.1 This finding is people who are sick and others campaigns envisioned by the IOM
consistent with a 2016 review con- around them is immediate. There committee were never implement-
ducted by the U.S. Preventive Ser- will be legitimate concerns that ed. This failure is all the more
vices Task Force, which found screening programs targeted at remarkable given recent advances
adequate evidence that accurate people with the highest risk of in the diagnosis and treatment
screening tests for [latent tuber- latent infection will inadvertently of latent tuberculosis infection.
culosis infection] are available, stigmatize or unfairly burden im- Timidity and limited resources
treatment of [such infection] migrant populations and will fuel have hobbled efforts to reach and
provides a moderate health ben- xenophobic sentiments. Although treat people with latent infection.
efit in preventing progression to these potential harms must be The Comprehensive Tuberculosis
active disease, and the harms of addressed and efforts made to Elimination Act of 2008 author-
screening and treatment are minimize their occurrence we ized the appropriation of $200
small.2 Scientific advances in the believe they do not justify failing million in fiscal year 2009, in-

1110 n engl j med 377;12 nejm.org September 21, 2017

The New England Journal of Medicine

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PE R S PE C T IV E Tuberculosis Elimination in the United States

creasing to $243 million in fiscal the burden of tuberculosis in the dence of tuberculosis domestical-
year 2013. However, the CDC Di- United States but we have not ly. The late George Comstock fa-
vision of Tuberculosis Elimination seen the type of mass movement mously stated that TB anywhere
received nearly 30 to 42% less that occurred when AIDS activists is TB everywhere. From the per-
funding than authorized during called on political, organiza- spective of an ethics of public
these years. tional, and financial resources to health, the lack of action to re-
duce rates of latent tuberculosis
infection in the United States
There will be legitimate concerns that represents both the governments
screening programs targeted at people failure to protect its people from
infectious threats and societys
with the highest risk of latent infection failure to provide care to its most
vulnerable.
will inadvertently stigmatize or unfairly
Disclosure forms provided by the authors
burden immigrant populations and fuel are available at NEJM.org.

xenophobic sentiments. From the Mailman School of Public Health,

Inadequate outreach is only
part of the problem. One study
found that 83% of people in the
United States and Canada who
tested positive for latent tubercu-
losis infection accepted treatment
but only 39% of those who
were offered the recommended
course of therapy completed it.5
What would it take
An audio interview
with Dr. Bayer is
to radically improve
available at NEJM.org rates of treatment
acceptance and com-
pletion? Would the public health
benefits justify the costs? It may
be inevitable that in tuberculosis-
elimination programs, the cost
per case averted increases as the
total number of cases decreases.
There are public health offi-
cials, health care providers, and
activists committed to reducing
correct what the IOM called a
woefully inadequate response.
Instead, we seem to be recapitu-
lating what Lee Reichman termed
the U-shaped curve of con-
cern: when investments in pub-
lic health that are sparked by a
sense of threat result in a decline
in disease incidence, thereby re-
ducing the perceived danger and
leading to lower investments
ultimately setting the stage for
disease resurgence.
To be sure, there are constraints
on what public health policy in
the United States can achieve as
long as the global burden of tu-
berculosis persists. But we believe
that there is no justification for
the continued failure to press for-
ward with interventions that could
have a marked effect on the inci-
Columbia University, New York (R.B.), and
the Rollins School of Public Health, Emory
University, Atlanta (K.G.C.).
1. Tsang CA, Langer AJ, Navin TR, Arm-
strong LR. Tuberculosis among foreign-born
persons diagnosed 10 years after arrival in
the United States, 20102015. MMWR Morb
Mortal Wkly Rep 2017;66:295-8.
2. U.S. Preventive Services Task Force, Bib-
bins-Domingo K, Grossman DC, et al. Screen-
ing for latent tuberculosis infection in adults:
US Preventive Services Task Force recom-
mendation statement. JAMA 2016;316:962-9.
3. Sterling TR, Villarino ME, Borisov AS, et
al. Three months of rifapentine and isonia-
zid for latent tuberculosis infection. N Engl
J Med 2011;365:2155-66.
4. Institute of Medicine. Ending neglect:
the elimination of tuberculosis in the Unit-
ed States. Washington, DC:National Acad-
emy Press, 2000 (https://www.nap.edu/catalog/
9837/ending-neglect-the-elimination-of
-tuberculosis-in-the-united-states).
5. Horsburgh CR Jr, Goldberg S, Bethel J,
et al. Latent TB infection treatment accep-
tance and completion in the United States
and Canada. Chest 2010;137:401-9.
DOI: 10.1056/NEJMp1707387
Copyright 2017 Massachusetts Medical Society.
Tuberculosis Elimination in the United States

A Nicotine-Focused Framework for Public Health

A Nicotine-Focused Framework for Public Health

Scott Gottlieb, M.D., and Mitchell Zeller, J.D.

D espite extraordinary progress

in tobacco control and preven-
tion, tobacco use remains the lead-
ing cause of preventable disease
and death in the United States.
Combustible cigarettes cause the
overwhelming majority of tobacco-
for more than 480,000 U.S. deaths
each year. Indeed, when used as
intended, combustible cigarettes
related disease and are responsible kill half of all long-term users.1

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The New England Journal of Medicine
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Copyright 2017 Massachusetts Medical Society. All rights reserved.