By Tara Perti, MD, MPH, Assistant Health Officer and Tuberculosis Controller at the Santa Clara County Public Health Department
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.