Fighting TB in San Jose: New Urgency with Federal Funding at Risk

By Tara Perti, MD, MPH

What is tuberculosis (TB) and is it a problem here - in the U.S.?

Tuberculosis (TB) remains an enormous global problem and is one of the top ten causes of death in the world.  As we live in a global community, infectious diseases common in other countries also affect the United States.  In the United States, in 2015, 9,557 patients were diagnosed with TB disease.  TB is a communicable disease that most often affects the lungs, but it can affect any part of the body including lymph nodes, bones, kidneys, and the brain.  TB can cause very severe illness, and in 10% of cases, it is fatal.  Over 1/5th of patients with TB in the U.S. live in California, which has more cases of TB than any state in the country.  Among the 61 counties in California, Santa Clara County (the location of Big Cities Health Coalition member, San Jose) has the fourth highest number of TB cases.  The rate of TB in Santa Clara County is almost three times as high as the national rate.  We also have a higher percentage of Multi-Drug Resistant (MDR) TB, which requires treatment with a much more complicated regimen and can take 18-24 months to treat.  In 2015, only 1.2% of reported cases in the U.S. were MDR, compared with 2% of cases in SCC.  This year in SCC, 5% of cases were MDR.  

How does Public Health fight TB?

As all Local Health Departments who work on the frontlines of TB Prevention & Control in the U.S., the Santa Clara County Public Health Department investigates all reports of persons with confirmed or suspected TB disease.  A Public Health Nurse is assigned to every patient during their treatment to provide individualized case management, providing education and support, helping to ensure that TB is not spread further, addressing barriers to treatment adherence, and ensuring treatment completion.  Public Health Nurses also investigate close contacts to patients with infectious TB to identify any other individuals with TB infection and refer for appropriate treatment.  When individuals are infected with Mycobacterium tuberculosis, the bacteria that causes TB, but they do not yet have symptoms or evidence of TB disease, this is called latent TB infection (LTBI), which is not contagious.  When the body’s immune system can no longer contain the infection, the bacteria multiply and cause disease.  Individuals with LTBI may become sick with TB disease within weeks to many years after becoming infected.  When people develop TB disease, the TB bacteria can then be spread through the air from person to person when an individual with TB involving the lungs coughs, sneezes, or speaks.  Fortunately, individuals with LTBI can be treated to prevent developing TB disease in the future.  Treatment of LTBI can decrease the risk of becoming sick due to TB disease by over 90% when medications are taken as prescribed.  

In addition to providing case management, the TB Prevention & Control Program also serves as a community resource.  We provide clinical consultation to medical providers regarding diagnosis and treatment of patients with suspected or confirmed TB disease as well as LTBI, and provide outreach in the community for providers, and populations at increased risk for infection.

Path to TB Elimination

Defending Public Health Department Funding

Congress is currently considering repealing the Affordable Care Act, which would phase out a major source of resources used to fight infectious diseases by Public Health programs across the country called the Prevention and Public Health Fund.  While the Prevention and Public Health Fund does not directly support TB prevention and control activities, in Santa Clara County, 79% of the TB Prevention & Control budget is funded by the county.  If public health funding is cut on the federal level, it could substantially decrease local resources available for TB prevention and control. 

In the not-so-distant past of the early 1990s, decreases in public health funding, coupled with the HIV epidemic, contributed to a resurgence of TB nationwide.  In 1992, the rate of TB in the U.S. was 3.5 times the rate today, with over 1700 deaths.  Since then, we have made great strides in TB prevention and control - now is not the time to go backwards.   

Increasing Equitable Distribution of Federal Dollars for TB Prevention & Control Programs

Currently, federal funding for TB prevention and control is provided through Cooperative Agreements between the Centers for Disease Control and Prevention and the 50 States, two U.S. territories, and nine cities that have historically received direct federal funding to fight the disease.  Our County, despite having the 6th highest number of cases as compared with all counties in the United States in 2015, has never received direct federal funding.  To maximize the effectiveness of TB prevention and control, it is important that federal funding is equitably distributed, so that funding is proportionate to the burden of disease and the cost of TB Prevention & Control activities in local jurisdictions. 

Increased Targeted Testing and Treatment for Latent Tuberculosis Infection

While the number of cases in our county decreased from 197 cases in 2015 to 160 cases in 2016, the California Department of Public Health has estimated that, of our 1.9 million county residents, 8.5%, or over 160,000 people, have latent tuberculosis infection. This represents a very large reservoir of individuals from which future cases of TB disease will develop.  Consequently, in order to significantly decrease the number of patients with TB disease in Santa Clara County, it requires that more individuals with risk factors for TB are tested and treated for LTBI.  In September 2016, the U.S. Preventive Services Task Force (USPSTF) issued new recommendations for screening asymptomatic adults at increased risk for LTBI.  This underscores the need for primary care providers to conduct targeted testing and treatment for LTBI as part of routine preventive care or health maintenance, similar to providing diabetes screening for overweight adults and use of low-dose aspirin for primary prevention of cardiovascular disease in persons at increased risk.  While we have worked to notify community providers of these recommendations, it will require continued outreach and resources for outreach to implement these recommendations. 

Tara Perti is the Assistant Health Officer and Tuberculosis Controller at the Santa Clara County Public Health Department.

The ACA Replacement Would Devastate America’s Health

By Leana Wen

This blog originally appeared on statnews.com. 

As a physician who has treated patients in the emergency department before and after the Affordable Care Act was instituted, I have seen firsthand how it has transformed the lives of many of my patients. And as the health commissioner for Baltimore city, I have seen how it has safeguarded the lives of more than 40,000 residents in my city, and millions more around the country, who would otherwise be uninsured.

ACA Repeal Would Mean Massive Cuts To Public Health, Leaving Cities And States At Risk

By Chrissie Juliano

This blog was originally posted in Health Affairs.

When the Affordable Care Act (ACA) was passed a little over six years ago, it brought with it the promise of health insurance for all Americans. It also sought to begin to shift the paradigm for health care in this country, emphasizing value over volume, and recognizing the importance of prevention coupled with appropriate access to care.

Repeal of ACA would imperil a little-known part with a huge impact

By GRETCHEN MUSICANT

The debate about the future of the Affordable Care Act (ACA) is in full swing, and many know that repealing the ACA would leave almost 20 million Americans without health care coverage. This is of great concern.

But the fact that repealing the law would also decimate the already-fragile public health system in America is not known to many policymakers or members of the public.

To End HIV/AIDS, Cities like Ours are Leading the Way by Setting Bold Goals

By Anthony Stamper, Denver Department of Environmental Health

This was originally published as an op-ed in The Hill newspaper.

On December 1st, communities across the nation will commemorate World AIDS Day. First memorialized in 1988, World AIDS Day offers the opportunity for people worldwide to unite in the fight against HIV, show support for people living with HIV, and remember those who have died. We know that in the U.S. the number of people living with HIV and AIDS is concentrated in cities, and that cities are also the most ambitious leaders in the fight against the disease. This World AIDS Day, Denver can report some major victories in fighting the disease that policy makers at every level should study carefully.

Live Today: The Big Cities Health Inventory 2.0 – Success and Challenges

By Chrissie Juliano, MPP, Director of the Big Cities Health Coalition

Today we launch version 2.0 of our Big Cities Health Inventory (BCHI), an online, open access data platform that allows the public health field, media, researchers, the public, and policymakers to look across more than 50 health and socio-demographic indicators from 28 cities – in total more than 17,000 data points. We also have a number of case studies available, highlighting innovative work in our member cities.

November is National Diabetes Month: How We’re Fighting Diabetes in Long Beach, CA

By Kelly Colopy, Director, Long Beach Department of Health & Human Services

November marks National Diabetes Month in America, and it could not be more important for us to seize this chance to educate more Americans about the disease, and help them find out more about what they can do to fight it. More than 29 million U.S. adults have diabetes, and 25% of them don’t know it. Additionally, about 86 million adults—more than a third—have prediabetes, and 90% of them don’t know it. This wave of chronic disease costs money. More than 20% of health care spending is for people with diagnosed diabetes. A 2012 study estimates the total costs of diagnosed diabetes at $245 billion.

Congress Took 233 Days To Respond. Here’s How To Prepare For The Next Zika

Dr. Ferrer is a member of the Coalition's Alumni Council, as the Former Director of the Boston Public Health Commission. This blog originally appeared on HealthAffairs.com.

Barbara Ferrer

October 27, 2016

Congress recently passed federal funding for the nation’s response to the Zika virus, and the manner in which they provided those funds exposed a serious flaw in the way our nation handles disease outbreaks. In the time between the White House’s initial request for funding in February and the passage of the bill in September, the outbreak escalated dramatically, nearly unchecked by federal lawmakers. The entire process took a grand total of 233 days, which is simply far too long. It did not need to be this way.

Battling AIDS in Houston Latin-American communities

Note: this article was originally printed as an op-ed in The Hill newspaper.

By Chrissie Juliano, contributor

October 15 will mark National Latinx AIDS Day across America, which is an opportunity to take stock of the great strides made towards defeating the virus and eliminating the stigma it can create. (The term Latinx serves as a gender-neutral alternative to Latino/Latina).

Science has come a long way since HIV and AIDS became a part of the national consciousness in the early 1980’s, but as experts have learned, if those advances are not shared with everyday people, and if awareness about the disease and how to prevent it does not grow, then disease rates can continue to climb, despite breakthroughs in the laboratory.

New York Leading the Way with Paid Family Leave

Today is National Child Health Day. On this day, and every other day, we at the New York City Department of Health and Mental Hygiene are pursuing an ambitious child health agenda with the goal of advancing health equity by undoing injustice.  

For New York City’s children, inequities in social, environmental and economic conditions can determine health outcomes well before birth. Strong family relationships and community supports, however, can protect against toxic environments shaped by poverty and racism. Unfortunately, many working parents must choose between bonding with a new child and returning to work because their jobs fail to provide paid time off, making paid family leave a key policy for advancing child health equity.  

Congress Finally Funded the Zika Fight – Here’s How We Can Respond Quicker to the Next Outbreak

Before Congress left town this week for the end of this year’s campaign season, they provided funds to respond to the Zika outbreak – an exercise that took them far too long.

Since Zika emerged in the U.S., and the Administration first requested funds in February, the Zika virus has infected more than 3,300 Americans in the states and almost 20,000 in the U.S. territories, and those numbers continue to rise daily. In Puerto Rico alone, an estimated 50 pregnant women are infected each day, presenting daunting odds for their unborn children. Mosquito season is winding down in some parts of the country, and exists year round in others, but regardless, experts believe the worst is yet to come, as additional cases of Zika surface and the health system begins to care for these Zika-disabled children.

In Houston, Flood Response Success is about Taking the Long View

September is National Preparedness Month, so we asked the City of Houston, a Big Cities Health Coalition member, to share the lessons learned from their 2016 "Tax Day Day Flood." How did the public health department assist Houston residents, and did they consider their job done once the streets were dry?

by Raouf R Arafat, MD,MPH, Assistant Director, Houston Health Department

From April 16-18, 2016, the Houston area experienced widespread flooding.  First responders conducted 1,200 high-water rescues; over 6,700 houses were damaged in the region; overall property damage was estimated at $5 billion. Eight residents perished when their vehicles were trapped in high water. Four months later, Houston Health Department employees are still attempting to address the needs of flood victims through long-term case management.

The View from Boston: As the World Gathers in Rio, It’s Time for All of Us to See Zika as a Global Outbreak

With the Olympics in Rio, a high-risk area for Zika infection, people around the world are thinking about taking precautions. While the games are occurring during the winter months in Brazil, when the risk of mosquito-borne diseases is lower, much of the buzz around the Zika virus has been focused on Rio, where the disease is transmitted locally because the main vector, the Aedes Aegypti mosquito, is plentiful. Although the disease burden is heaviest in hotter, climates, residents of Northern cities like Boston are not immune from this virus and have a role in stopping its spread.

What Does Health Equity in Action Look Like?

Public Health – Seattle and King County (PHSKC) serves over 2 million people with a staff of 1500 employees and is the 13th most populous county in the United States. In addition to the city of Seattle, our County includes 38 other cities, international air and seaports, and a diverse population that speaks about 150 different languages. We have an annual budget of about $318 million and are the largest health department in Washington State.

Philadelphia’s Historic Win-Win for Kids: Funding Poverty Reduction Programs with a New Tax on Sweetened Beverages

On June 16, 2016, 13 of the 17 members of Philadelphia’s City Council voted in favor of Bill No. 160176, the Sugar-Sweetened Beverage Tax. Cheers erupted from the groups that had rallied in favor of the tax: pre-K providers, city parks advocates, parents committed to better educational opportunities for their children, the public health community, and many more. And social media went wild.

Blanket Prescription: How Every Citizen in Baltimore Can Now Save a Life from Opioid Overdose

Every year, tens of thousands across our country die from a preventable illness. We have seen the number of people dying from overdose quadruple nationally and in Baltimore City, where I serve as Health Commissioner, we continue to see more people dying from overdose than from homicide. This is particularly tragic because there is a medication, naloxone, which can completely reverse the effect of an opioid overdose, and has been proven to save lives.

Reflecting on the Tragedy in Orlando Through a Public Health Lens

Only days ago, our nation experienced another mass shooting, the largest and most deadly to date. Forty-nine innocent, young people were murdered in a nightclub in Orlando, where they came together simply to hang out and dance. We as a nation experience these violent events far too often, and today, our Coalition stands in solidarity with the LGBTQ community, at whom this attack was directed; with the victims and their families of this latest event; and with all Americans who experience the trauma of gun violence each and every day. We stand committed to them no matter their race, ethnicity, religion, sexual orientation, gender identity, or place of birth. This is a time for our nation to come together to mourn the loss, find solutions, and discourage bigotry and hatred in all its forms.

Get real about minimizing risk of future Zika and Ebola cases

The debate over how to respond to the Zika virus has produced some of the most dramatic political theater seen in Congress since the Ebola outbreak in 2014. It’s an edge-of-your seat drama, and Washington, D.C.,’s media brain trust knows it: a mysterious, life-threatening virus with tropical origins, high stakes for American families and a national leadership at war over how to deal with it.

How the Windy City is Stopping Kids from Lighting Up

Today is World No Tobacco Day, a day dedicated to bringing attention to the devastating health risks associated with tobacco use and to build momentum for passing effective policies to reduce tobacco use across the globe. This year’s theme is “Get ready for plain packaging” – a bold approach from the WHO Framework Convention on Tobacco Control to reduce the promotional appeal of cigarette packs and communicate health information with graphic warnings.

Zika is Here. It’s Time for Congress to Catch Up to the Science

Congress left for recess last week without providing funding for the latest public health emergency, the Zika virus. Let’s give them the benefit of the doubt: until recently, the Zika virus was a moving target. The science was straining to catch up with the threat, and therefore, the costs of failing to prepare and respond were more vague. We weren’t 100% sure if Zika caused microcephaly in babies. We hadn’t seen the maps showing where the mosquito vectors lived. We didn’t know it could be sexual transmitted. Now, the facts are clear. Alexandra Phelan and Lawrence O. Gostin (Georgetown University public health/law professors), writing in Health Affairs last week, got it exactly right, saying “It is one thing to fail to prepare for an emerging infectious disease if the risks are uncertain. But it is quite another to fail to act when the facts are clear.” It is time for the U.S. Congress to allocate dollars to prepare for, and respond to, what could become a major public health disaster.