Public Health: Trends in Tuberculosis in the United States (Letter
Report, 10/31/2000, GAO/GAO-01-82).

The number of Tuberculosis (TB) and multidrug-resistant TB cases in the
United States has steadily declined since 1992, although continued
vigilance is needed to further reduce TB. A relaxation of TB control
efforts are associated with the disease's resurgence in the late 1980s
and early 1990s. Centers for Disease Control and Prevention and World
Health Organization data suggest that the presence of TB as a major
public health problem in other countries has likely been a key
contributor to the number of new cases in the United States. As a
result, the United States has undertaken several activities to control
global TB, including providing funding and technical assistance for TB
control programs.

--------------------------- Indexing Terms -----------------------------

 REPORTNUM:  GAO-01-82
     TITLE:  Public Health: Trends in Tuberculosis in the United States
      DATE:  10/31/2000
   SUBJECT:  Tuberculosis
	     Health statistics
	     Disease detection or diagnosis
	     International cooperation

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GAO-01-82

A Report to Congressional Requesters

October 2000 PUBLIC HEALTH Trends in Tuberculosis in the United States

GAO- 01- 82

Letter 3 Appendixes Appendix I: State TB and MDR- TB Cases and Case Rate,
1999 20

Appendix II: Comments From CDC 22 Figures Figure 1: CDC Funding for TB and
Case Rate, United States, 1980- 99 8

Figure 2: TB Case Rates, 1999 11 Figure 3: New MDR- TB Cases, United States,
1993- 99 12 Figure 4: New MDR- TB Cases, New York City and Other U. S. Areas
13 Figure 5: Number of New MDR- TB and TB Cases, 1993- 99 15 Figure 6:
Country of Origin for New Foreign- Born TB Cases, 1999 16

Abbreviations

CDC Centers for Disease Control and Prevention HIV human immunodeficiency
virus HHS Department of Health and Human Services IUATLD International Union
Against Tuberculosis and Lung Disease MDR- TB multidrug- resistant
tuberculosis USAID U. S. Agency for International Development WHO World
Health Organization

Lett er

October 31, 2000 The Honorable Tom Bliley Chairman, Committee on Commerce
House of Representatives

The Honorable Fred Upton Chairman, Subcommittee on Oversight and
Investigations Committee on Commerce House of Representatives

The World Health Organization (WHO) estimates that about 2 million people
die each year from tuberculosis (TB), making it one of the leading
infectious killers worldwide. In recent years, global public health efforts
to combat TB have been complicated by the emergence of multidrug- resistant
tuberculosis (MDR- TB), which is resistant to the two primary drugs used to
treat this disease. Recent media reports have raised concern that the global
prevalence of TB and the emergence of MDR- TB have increased the public
health risk to the U. S. population. Accordingly, you asked that we review
available data on the incidence and characteristics of TB cases in the
United States. We analyzed the available data to determine answers to these
questions:

What are the trends in TB cases in the United States? What are the trends in
MDR- TB in the United States? How are these trends affected by the
prevalence of TB in other

countries? To respond to your request, we analyzed data from the TB
surveillance system of the Department of Health and Human Services' (HHS)
Centers for Disease Control and Prevention (CDC). This system includes data
routinely reported by all states on the demographics of newly diagnosed
cases of TB. 1 We also reviewed studies by WHO and other research, and
interviewed public health researchers and officials from CDC, state and
local TB prevention programs, the Advisory Council for the Elimination of
Tuberculosis, and the National Tuberculosis Controllers Association. We

1 We did not review the reliability of the CDC surveillance data. However,
CDC checks for completeness and consistency in the data and relies on states
and other reporting areas to conduct validation and completeness- of-
reporting studies as part of their CDC funding.

conducted this work from July 2000 to September 2000 in accordance with
generally accepted government auditing standards.

Results in Brief Following more than 3 decades of decline, the number of
reported TB cases in the United States began to increase in the late 1980s
and early

1990s, peaking at 26, 673 new cases in 1992. Since that time, the number of
new cases has steadily decreased. The rise in new TB cases in the late 1980s
and early 1990s has been associated with several factors, including the
emergence of the human immunodeficiency virus (HIV, the cause of AIDS),
transmission in institutions such as hospitals, jails, and homeless
shelters, cutbacks in TB programs, and MDR- TB outbreaks. Following an
increase in TB control and prevention activities, the number of reported TB
cases declined to 17,531 new cases in 1999- a 34 percent decrease from 1992.
Despite this progress the United States has not reached the HHS year 2000
goal to reduce TB to 3. 5 new cases per 100, 000 population (the current
rate is 6.4 cases per 100,000 population).

Consistent with the overall trends in TB cases, the number of new MDR- TB
cases has also steadily declined since CDC began tracking them in 1993. In
1993, nearly 500 new MDR- TB cases were reported; in 1999 the number dropped
to 154. Major reductions in MDR- TB cases resulted from a significant
decline in such cases in New York City, where a considerable number of MDR-
TB cases occurred in 1993. While the number of new MDRTB cases is dropping,
MDR- TB cases are no longer largely confined to New York City and a few
other areas. Between 1993 and 1999, all but five states reported at least
one case of MDR- TB.

Surveillance data suggest that further progress in reducing TB, including
MDR- TB, in the United States will depend largely on progress made in
addressing this disease in other countries, where WHO regards it as part of
a growing global epidemic. While the numbers of TB and MDR- TB cases in the
United States have declined overall, the numbers of cases in the United
States involving foreign- born persons have remained relatively stable. As a
result, the proportion of cases involving foreign- born persons has
increased, more than doubling for MDR- TB between 1993 and 1997- from about
3 to more than 7 of every 10 new MDR- TB cases. Recognizing the effect of
global TB on U. S. TB control efforts, the United States has undertaken
several activities, such as providing technical assistance to set up
international TB control programs and authorizing new funding for global TB
prevention and control activities. In commenting on this report, CDC
generally concurred with our findings.

Background TB Infection and Disease TB is a leading infectious killer of
youth and adults worldwide. Each year, 8

million people around the world develop active TB, and about 2 million
people die from it. TB is spread from person to person through the air and
usually infects the lungs, although other organs are sometimes involved.

WHO estimates that about one- third of the world's population is infected
with TB. However, most people infected with TB never develop an active case-
their immune system stops the bacteria from growing. A skin test can
determine if someone is infected with TB, even if they do not have an active
case. If they are infected and are at high risk for developing an active
case, health officials can give them preventive therapy to kill the TB
bacteria before the disease becomes active.

People who have prolonged, frequent, or intense contact with a person with
active and infectious TB- such as family members, roommates, and coworkers-
are at highest risk of becoming infected. Casual contact with an infectious
person- someone with active, untreated TB in the lungs- in a public place
such as a movie theater or subway is unlikely to lead to infection, although
the risk is not zero. The disease is not likely to be transmitted through
personal belongings, such as clothing, bedding, or other items an infected
person has touched. Once infected with TB, people with weakened immune
systems, especially those infected with HIV, are at higher risk of
developing active TB. In the United States, a culture test is generally used
to determine whether someone has an active case of TB. 2

When the TB bacteria become active, the disease can generally be cured with
multidrug therapy administered for 6 to 9 months. People who have been
treated with appropriate drugs for at least 2 to 3 weeks are usually not
infectious. However, treatment regimens must be followed vigilantly. Failure
to follow the regimen for the full course of treatment will cause the
patient to remain sick, and the bacteria may become resistant to the drugs
being taken. Patients may stop taking their anti- TB drugs because they may
feel better after only 2 to 4 weeks of treatment or because these drugs
often have unpleasant side effects. To help ensure completion of therapy,
CDC

2 Approximately 20 percent of active TB cases in the United States are
diagnosed clinically using other confirmation criteria.

recommends the use of directly observed therapy, in which a health care
worker or caseworker watches the patient swallow each dose of TB medication.
3

Multidrug- Resistant TB A TB case is considered to be MDR- TB if the
bacteria are resistant to the

Infection and Treatment two primary drugs- isoniazid and rifampin- used to
treat TB. While some

cases of MDR- TB develop in patients who have had prior TB treatment, other
cases occur in people who have not been treated for TB in the past. These
individuals become infected with MDR- TB from contact with people who have
active MDR- TB.

MDR- TB cases are more difficult and significantly more costly to treat than
other TB cases. When a person has MDR- TB, the treatment takes 2 to 4 times
longer, the medication has more severe side effects, and the cure rate
decreases from nearly 100 percent for drug- susceptible TB to 60 percent or
less. WHO reports that treatment for an MDR- TB case- which requires
expensive medications for 18 to 24 months and may involve costly
hospitalizations- is often more than 100 times more expensive than treatment
for drug- susceptible TB. While no comprehensive studies have been conducted
on the average cost to treat a single case of MDR- TB in the United States,
one referral hospital reported that treatment of one MDR- TB patient can
cost more than $200,000. 4 This is significantly higher than the cost for
treating and monitoring contacts of a patient with drug- susceptible TB,
which the Institute of Medicine reported to be $16,391. 5

Federally Supported TB The United States currently has an extensive TB
prevention and control

Prevention and Control program administered at the federal, state, and local
levels. CDC and other

Activities researchers conduct clinical, epidemiological, behavioral, and
operational

research to enhance TB prevention and control efforts and conduct ongoing
surveys to evaluate the effectiveness of prevention efforts. CDC

3 WHO recommends directly observed treatment for at least the intensive
phase of treatment, which is the first 2 months. 4 MD Iseman, DL Cohn, and
JA Sbarbaro, “Directly Observed Treatment of Tuberculosis- We Can't
Afford Not to Try It,” New England Journal of Medicine, Vol. 328, No.
8 (1993), pp. 57678.

5 Institute of Medicine, Ending Neglect: The Elimination of Tuberculosis in
the United States (Washington, D. C.: National Academy Press, 2000), p. 73.

supports TB prevention and control efforts, including surveillance
activities to collect and report data on TB cases to CDC, in all 50 states,
the District of Columbia, and other U. S. jurisdictions. In response to the
emergence of drug- resistant TB in the early 1990s, CDC expanded the TB
surveillance system to include information on drug- resistant cases in 1993.
In 1999, information on drug resistance was reported for about 9 of every 10
TB cases that had been confirmed with a positive culture. 6

Number of TB Cases Is TB reemerged as a public health concern in the late
1980s and early 1990s,

when the number of new TB cases in the United States increased following
Again Declining

3 decades of steady decline. 7 Several factors, including the emergence of
MDR- TB as a public health concern, contributed to this resurgence. In
response, CDC funding for TB prevention and control activities increased
appreciably in the 1990s. This funding increase has been associated with
more- effective TB control and prevention programs and the subsequent
decline in the number of new TB cases and TB case rate (number of new cases
per 100,000 population). 8 Figure 1 shows CDC TB funding and the case rate
for 1980- 99.

6 Drug susceptibility testing is only performed for TB cases confirmed with
a positive culture. In 1999, 13,997 of the 17, 531 new cases of active TB
were confirmed with a positive culture. Results of susceptibility testing
for at least isoniazid and rifampin were reported for 12, 854 of these
confirmed cases.

7 The numbers of cases and case rates in this report refer to new cases
identified in the year in question. From 1953 to 1985 the number of TB cases
reported annually in the United States dropped 74 percent- from 84,304 to
22,201.

8 See CDC, “Tuberculosis Elimination Revisited: Obstacles,
Opportunities and a Renewed Commitment- Advisory Council for the Elimination
of Tuberculosis (ACET),” Morbidity and Mortality Weekly Report, Vol.
48, No. RR09 (Aug. 13, 1999), pp. 1- 13; and American Lung

Association, Epidemiology and Statistics Unit, Trends in Tuberculosis
Morbidity and Mortality( New York: American Lung Association, 2000).

Figure 1: CDC Funding for TB and Case Rate, United States, 1980- 99

14 New cases per 100,000 Constant 1999 dollars (millions)

180 160 12

140 10

120 8

100 6

80 60 4

40 2

20 0

0 1980 1985 1990 1995

Case Rate Funding (in 1999 dollars)

Source: CDC data, including CDC HIV appropriations used for TB in HIV
populations.

During the resurgence in TB cases, the number of new cases reported per
100,000 population peaked at 10. 5 in 1992. Researchers and CDC officials
have identified several factors associated with the resurgence in the late
1980s and early 1990s. These include the following:

The HIV epidemic. Among people who are infected with TB, those who are also
infected with HIV are more than 40 times more likely to develop active cases
and become infectious than people not infected with HIV. Transmission in
institutions. Transmission within institutions such as

hospitals, correctional facilities, residential care facilities, and
shelters for homeless populations was a major factor in the TB resurgence.
Cutbacks in TB programs. Because TB was no longer perceived to be a

threat and because of other budget priorities, funding for TB prevention

and control activities was relatively low at all levels of government before
the resurgence, leading to cutbacks in many TB control programs. As a
result, health departments reported that they did not have adequate
resources to deal with all potentially noncompliant patients or to bring
outbreaks under control. The emergence of MDR- TB. MDR- TB emerged in
outbreaks in

institutional settings such as hospitals where HIV- infected persons
received care. Because drug- resistant cases were not recognized promptly,
initiation of effective treatment was delayed, and the infectiousness of
these cases was prolonged.

The resurgence of TB prompted increased CDC funding for TB prevention and
control activities including monitoring the disease, improving laboratory
capacity, expanding the use of health care workers to help ensure patients
take their medication, and expediting investigations of close contacts of TB
patients. CDC funding for TB prevention and control increased from about $25
million in fiscal year 1991 to more than $140 million each year since fiscal
year 1994. 9 In many areas, TB screening and preventive therapy services
directed toward high- risk groups, especially persons at risk for HIV
infection and persons in correctional facilities, have expanded
substantially. In fiscal year 1999, CDC funding for TB prevention and
control activities totaled $141.9 million and supported over 1, 100 outreach
workers. 10

Most CDC funding for TB prevention and control activities is provided to
states and localities. 11 In fiscal year 1999, CDC awarded $124. 5 million
to 50 states, 10 localities, such as the District of Columbia and New York
City, and 8 other jurisdictions, such as Puerto Rico. 12 In fiscal year
2000, the

9 CDC funding is only part of the total funding devoted to TB control;
comparable data on state and local TB funding are not available. Since 1988,
a portion of CDC funding for TB was appropriated as HIV funds and used for
TB activities in HIV populations.

10 Of this total, $22 million was appropriated as HIV funds and used for TB
activities in HIV populations. 11 CDC funds may be used for activities such
as keeping clinics open longer hours; however, CDC does not permit funds to
be used to procure pharmaceuticals to treat TB. 12 In addition to the
District of Columbia and New York City, other cities are Baltimore, Chicago,
Detroit, Houston, Los Angeles, Philadelphia, San Diego, and San Francisco.
In addition to Puerto Rico, jurisdictions are American Samoa, Guam, Marshall
Islands, Micronesia, the Commonwealth of the Northern Mariana Islands,
Republic of Palau, and the U. S. Virgin Islands.

funding mechanisms- cooperative agreements between the federal government
and state or local governments- included funding for core activities and
separate targeted testing and treatment of patients in highrisk groups with
inactive TB infection. Core activities include the direct observation of
patients taking their medication to better ensure completion of therapy,
contact investigations, surveillance and reporting of all newly diagnosed
cases of TB, and laboratory activities.

Since the substantial increase in CDC funding for TB prevention and control
activities, the TB case rate and number of newly reported TB cases have
decreased. In 1999 the TB case rate was 6.4 new cases per 100, 000
population- a nearly 40 percent decline from the peak of 10.5 new cases per
100, 000 population in 1992. Also during the same period, the total number
of new cases reported each year decreased by about one- third- from 26,673
in 1992 to 17,531 in 1999. 13

Despite the decline the national TB case rate in 1999 was higher than
targets set by HHS. The HHS Healthy People 2000 initiative set a target of
3.5 cases per 100, 000 population for 2000. Seventeen states had case rates
at or below this target in 1999 (see fig. 2). For 2010, HHS set an even more
ambitious target of 1 case per 100,000 population in its Healthy People 2010
initiative. 14

13 Cases reported from all 50 states and the District of Columbia. 14
Department of Health and Human Services, “Immunization and Infectious
Diseases,” Healthy People 2010, Conference Edition, data as of Nov.
30, 1999.

Figure 2: TB Case Rates, 1999

D. C. Case Rate per 100,000 <3.5 (year 2000 target)

3.6- 6.4 >6.4 (national average)

MDR- TB Cases Are Similar to the trend for all TB cases, the number of new
MDR- TB cases in

Declining the United States has also declined since 1993, the first year CDC
collected

comprehensive data on them. According to CDC officials, improvements in the
TB infrastructure, infection control procedures in institutions, and

rapid laboratory techniques for identifying MDR- TB have contributed to the
success in controlling MDR- TB. Between 1993 and 1999, the percentage of new
TB cases that were MDR- TB declined from 2. 7 percent in 1993 to 1. 2
percent in 1999. 15 At the same time, the number of new MDR- TB cases in the
United States dropped nearly 70 percent- from nearly 500 to 154 cases (see
fig. 3).

Figure 3: New MDR- TB Cases, United States, 1993- 99

600 Number of New MDR- TB Cases

500 400 300 200 100

0 1993 1994 1995 1996 1997 1998 1999

The steady decrease in new MDR- TB cases was influenced by a substantial
decrease of the disease in New York City- the percentage of new TB cases in
New York City that were MDR- TB decreased from 9.1 percent in 1993 to 3.3
percent in 1999. At the same time, the percentage of new TB cases that were
MDR- TB in areas outside of New York City also decreased, from 1.7 percent
to 1 percent (see fig. 4).

15 Percentages of new TB cases that were MDR- TB are based on cases with
initial drug susceptibility testing performed.

Figure 4: New MDR- TB Cases, New York City and Other U. S. Areas

10 Percentage of TB Cases That Were MDR- TB

9 8 7 6 5 4 3 2 1 0

New York City Other U. S. Areas a

1993 1999

a Other U. S. Areas includes the 50 states and the District of Columbia,
excluding New York City.

Although the number of new MDR- TB cases has declined, these cases have been
reported across the country. When CDC conducted a special survey on MDR- TB
for the first quarter of 1991, only 13 states and New York City reported
MDR- TB cases. Since then, MDR- TB has been reported in additional states-
45 states and the District of Columbia reported at least one new case of
MDR- TB between 1993 and 1999. 16

16 App. I shows the number of TB cases and MDR- TB cases reported in 1999.

Progress Toward Foreign- born persons make up an increasing proportion of TB
and MDR- TB

cases in the United States. Research indicates that most foreign- born TB
Reducing TB in the

patients in the United States were probably infected before they arrived. 17
United States Is Linked

Therefore, trends in the number of reported new TB cases in the United to
Global TB Control

States that involve foreign- born individuals provide some insight on how
Efforts

the effectiveness of TB control efforts is linked internationally. One of
every 10 people in the U. S. population is foreign- born, but foreign- born
individuals accounted for more than 4 of every 10 new TB cases and 7 of
every 10 new MDR- TB cases in the United States in 1999. 18

The number of cases per year involving foreign- born persons has remained
relatively stable since 1993, despite the decline in the overall numbers of
new TB and MDR- TB cases in the United States. As a result, the proportion
of cases involving foreign- born persons has increased, particularly for
MDR- TB cases (see fig. 5).

17 See PLF Zuber, MT McKenna, NJ Binkin, IM Onorato, and KG Castro,
“Long- Term Risk of Tuberculosis Among Foreign- Born Persons in the
United States,” Journal of the American Medical Association, Vol. 278
(1997), pp. 304- 7. In addition, a CDC Working Group reported

that although some transmission is probably occurring in the United States,
most TB cases among foreign- born persons are likely the result of remotely
acquired infection. See CDC, “Recommendations for Prevention and
Control of Tuberculosis Among Foreign- Born Persons: Report of the Working
Group on Tuberculosis Among Foreign- Born Persons,” Morbidity and
Mortality Weekly Report, Vol. 47, No. RR16 (1998), pp. 1- 26.

18 In 1999, 26. 4 million foreign- born people resided in the United States,
representing 9.7 percent of the total U. S. population. See U. S. Census
Bureau, The Foreign- Born Population in the United States: Population
Characteristics, March 1999( Washington, D. C.: U. S.

Department of Commerce, Economics and Statistics Administration, U. S.
Census Bureau, 1999), p. 1. In developing statistics on foreign- born TB and
MDR- TB cases, CDC asks states and localities to report on those cases
receiving anti- TB therapy in the United States for at least 90 days. See
CDC, “Recommendations for Counting Reported Tuberculosis Cases”
(revised July 1997), Reported Tuberculosis in the United States, 1999(
Atlanta, Ga.: CDC), http:// www. cdc. gov/ nchstp/ tb/ surv/ surv99/
surv99pdf/ recom99. pdf (cited August 2000).

Figure 5: Number of New MDR- TB and TB Cases, 1993- 99

Number of New MDR- TB Cases Number of New TB Cases

600 30,000

500 25,000

400 20,000

300 15,000

200 10,000

100 5,000

0 0

1993 1994 1995 1996 1997 1998 1999 1993 1994 1995 1996 1997 1998 1999

Unknown U. S.- born Foreign- born

About two- thirds of the new foreign- born TB and MDR- TB cases in 1999 were
from seven countries: China, Haiti, India, South Korea, Mexico, the
Philippines, and Vietnam. Figure 6 shows the distribution of new foreignborn
TB cases, which also generally approximates the distribution of new foreign-
born MDR- TB cases.

Figure 6: Country of Origin for New Foreign- Born TB Cases, 1999

South Korea Haiti 3% 4%

China 5%

7% India

36% 10%

Vietnam 12%

Philippines 23%

Mexico All others

Note: Total = 7, 553 foreign- born TB cases.

All seven countries have TB rates that are significantly higher than those
in the United States, according to data published by WHO. For example, WHO
estimates that India, the Philippines, and Vietnam had TB case rates that
were more than 25 times the U. S. rate in 1998, the most recent year for
which data are available. Similarly, based on available data for selected
locations in four of the seven countries- China, India, Korea, and Mexico-
WHO estimated that the proportion of TB cases that are MDR- TB in those
locations is significantly higher than in the United States. 19

While immigrants and certain other individuals seeking entry into the United
States are required to be screened for TB, this process cannot be

19 Based on available data for 1996- 99, WHO estimated the percentage of
MDR- TB among new TB cases in these countries ranged from 2.2 percent in
Korea to 10.8 percent in the Henan Province of China. In the United States,
1. 2 percent of new TB cases were MDR- TB. See WHO/ International Union
Against Tuberculosis and Lung Disease (IUATLD), Anti- tuberculosis Drug
Resistance in the World, Report No. 2 (Advance Printing) (WHO/ IUATLD

Global Project on Anti- tuberculosis Drug Resistance Surveillance, 2000), p.
95.

expected to fully protect against the spread of TB for two key reasons. 20
First, the process mainly identifies immigrants with active TB cases at the
time they apply for permanent residence, but active cases might not develop
until several years after infection. Second, the current screening process
misses millions of people, including tourists, students, and workers who are
in the United States temporarily and illegal immigrants.

Given these limitations, progress toward HHS' goals to reduce TB in the
United States will depend in part on TB control efforts in other countries.
Recognizing the effect of global TB on U. S. TB control efforts, the United
States is involved in various efforts to prevent and control TB in other
countries. Some of these efforts are aimed at providing grants for better TB
surveillance, providing technical support for developing and testing new
interventions, and funding CDC and WHO efforts to implement TB prevention
and control programs. The United States is involved in various TB programs
and initiatives undertaken by the U. S. Agency for International Development
(USAID), WHO, the World Bank, and nongovernmental organizations in countries
that have high rates of TB, such as India, the Philippines, and Russia. In
addition, Congress passed the Global AIDS and Tuberculosis Relief Act of
2000 (P. L. 106- 264). Signed into law on August 19, 2000, the act
authorizes $60 million for USAID for each of fiscal years 2001 and 2002 for
foreign assistance for tuberculosis prevention, treatment, control, and
elimination activities.

Conclusions While the number of TB cases, including MDR- TB cases, in the
United States has steadily declined since 1992, continued vigilance is
needed to

further reduce TB and MDR- TB in the United States. A relaxation of TB
control efforts has been associated with the disease's resurgence in the
late 1980s and early 1990s. Further, CDC and WHO data suggest that the
presence of TB as a major public health problem in other countries has
likely been a key contributor to the number of new TB and MDR- TB cases
identified each year in the United States. Given the growing proportion of
TB cases involving foreign- born persons, control of TB in other countries
will become increasingly important to meeting HHS' goals for reducing TB in
the United States.

20 Part 34 of Title 42 of the Code of Federal Regulationsrequires, among
other things, that immigrants and certain other individuals seeking entry
into the United States, as part of their application, receive a medical
examination, which may include a chest x- ray and a test for active TB.

Agency Comments In commenting on this report, CDC generally concurred with
our findings. It stated that the need for the United States to combat
tuberculosis

internationally through financial and technical assistance measures is
burgeoning, and that it is developing strategic actions involving both
domestic and international agendas to eliminate tuberculosis in the United
States.

CDC also provided technical comments, which we incorporated where
appropriate. CDC's comments are included as appendix II.

As agreed with your offices, unless you publicly announce its contents
earlier, we plan no further distribution of this letter for 30 days. At that
time, we will send copies to the Honorable Donna E. Shalala, Secretary of
HHS; the Honorable Jeffrey P. Koplan, Director of CDC; and other interested
parties. We will also make copies available to others on request.

The information in this letter was developed by Frank Pasquier, Dominic
Nadarski, Kim Yamane, and Stan Stenersen. Please contact me at (202) 5127119
or Frank Pasquier at (206) 287- 4861 if you or your staffs have any
questions.

Janet Heinrich Director, Health Care- Public Health Issues

Appendi xes State TB and MDR- TB Cases and Case Rate,

Appendi xI

1999 All TB a Cases per

100, 000 MDR- TB cases

Cases population United States b 154 17, 531 6. 4

Alabama 0 314 7. 2 Alaska 0 61 9. 9 Arizona 2 262 5. 5 Arkansas 0 181 7. 1
California 33 3,606 10. 9 Colorado 0 88 2. 2 Connecticut 2 121 3. 7 Delaware
0 34 4. 5 District of Columbia 1 70 13.5 Florida 12 1, 277 8. 5 Georgia 4
665 8. 5 Hawaii 2 184 15. 5 Idaho c 16 1. 3 Illinois 9 825 6. 8 Indiana 1
150 2. 5 Iowa 1 58 2. 0 Kansas 0 69 2. 6 Kentucky 2 209 5. 3 Louisiana 0 357
8. 2 Maine 0 23 1.8 Maryland 3 294 5. 7 Massachusetts 0 270 4.4 Michigan 7
351 3. 6 Minnesota 4 201 4. 2 Mississippi 0 215 7. 8 Missouri 2 208 3.8
Montana 0 14 1. 6 Nebraska 0 18 1. 1 Nevada 0 93 5. 1 New Hampshire 0 19 1.
6 New Jersey 6 571 7. 0 New Mexico 0 64 3. 7

Continued from Previous Page

All TB a Cases per

100, 000 MDR- TB cases

Cases population

New York 35 d 1, 837 10.1 North Carolina 3 488 6. 4 North Dakota c 7 1. 1
Ohio 2 317 2.8 Oklahoma 0 208 6.2 Oregon 0 123 3. 7 Pennsylvania 4 454 3. 8
Rhode Island 1 53 5. 3 South Carolina 0 315 8. 1 South Dakota 0 21 2. 9
Tennessee 0 382 7. 0 Texas 10 1, 649 8. 2 Utah 0 40 1. 9 Vermont 0 3 0. 5
Virginia 4 334 4. 9 Washington 2 258 4. 5 West Virginia 0 41 2. 3 Wisconsin
2 110 2. 1 Wyoming 0 3 0. 6

Other U. S. jurisdictions

American Samoa c 4 6. 3 Federated States of

c c c Micronesia Guam 0 69 45.4 Northern Mariana Islands 0 66 95. 4 Puerto
Rico 1 200 5. 1 Republic of Palau 2 11 59. 7 U. S. Virgin Islands c c c a
Includes MDR- TB cases.

b Figures for the United States are based on data from 50 states and the
District of Columbia. c Data not available. d Thirty- four of the 35 MDR- TB
cases in New York were reported from New York City.

Source: CDC, Reported Tuberculosis in the United States, 1999( Atlanta, Ga.:
CDC, August 2000).

Appendi xII

Comments From CDC (201083) Lett er

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Page 1 GAO- 01- 82 Trends in Tuberculosis in the United States

Contents

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General Accounting Office

Washington, D. C. 20548 Page 3 GAO- 01- 82 Trends in Tuberculosis in the
United States

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Appendix I

Appendix I State TB and MDR- TB Cases and Case Rate, 1999

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Appendix II

United States General Accounting Office Washington, D. C. 20548- 0001

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