Tuberculosis: Costly and Preventable Cases Continue in Five Cities
(Letter Report, 03/16/95, GAO/HEHS-95-11).

Pursuant to a congressional request, GAO assessed the ability of public
health authorities to contain the spread of tuberculosis (TB), focusing
on: (1) the possibilities of containing or reversing rising TB rates;
(2) federal efforts to aid state and local TB control programs; and (3)
how the federal budget process will be affected by rising TB rates.

GAO found that: (1) costly and preventable TB cases are occurring
nationwide and are predominantly impacting poor, urban, racial, and
ethnic minorities; (2) according to the Centers for Disease Control and
Prevention (CDC), the highest priority of a TB control program is to
detect persons with active TB and treat them with antibiotic drugs; (3)
four of the cities reviewed reported that staffing shortages caused by
hiring freezes, attrition, and resource limitations have affected their
ability to provide TB services; (4) in many instances, local TB control
programs could not ensure that TB patients would complete appropriate
treatment; (5) although the federal government has increased its
assistance to states and localities, state and local budgets for TB
control activities have not kept pace with the need for treatment and
preventive services; and (6) recent increases in cooperative agreements
have increased TB funding, helped improve the number of patients who
completed the full TB treatment, and increased the speed and accuracy of
TB diagnoses.

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

 REPORTNUM:  HEHS-95-11
     TITLE:  Tuberculosis: Costly and Preventable Cases Continue in Five 
             Cities
      DATE:  03/16/95
   SUBJECT:  Tuberculosis
             Acquired immunodeficiency syndrome
             Minorities
             Infectious diseases
             Health care services
             State/local relations
             Health services administration
             Federal aid to localities
             Disease detection or diagnosis
IDENTIFIER:  Atlanta (GA)
             Chicago (IL)
             El Paso (TX)
             Los Angeles (CA)
             Newark (NJ)
             Fulton County (GA)
             Mexico
             Juarez (MX)
             Tuberculosis Information Management System
             Medicare Program
             Medicaid Program
             National Tuberculosis Training Initiative
             AIDS
             
**************************************************************************
* This file contains an ASCII representation of the text of a GAO        *
* report.  Delineations within the text indicating chapter titles,       *
* headings, and bullets are preserved.  Major divisions and subdivisions *
* of the text, such as Chapters, Sections, and Appendixes, are           *
* identified by double and single lines.  The numbers on the right end   *
* of these lines indicate the position of each of the subsections in the *
* document outline.  These numbers do NOT correspond with the page       *
* numbers of the printed product.                                        *
*                                                                        *
* No attempt has been made to display graphic images, although figure    *
* captions are reproduced. Tables are included, but may not resemble     *
* those in the printed version.                                          *
*                                                                        *
* A printed copy of this report may be obtained from the GAO Document    *
* Distribution Facility by calling (202) 512-6000, by faxing your        *
* request to (301) 258-4066, or by writing to P.O. Box 6015,             *
* Gaithersburg, MD 20884-6015. We are unable to accept electronic orders *
* for printed documents at this time.                                    *
**************************************************************************


Cover
================================================================ COVER


Report to the Ranking Minority Member, Committee on Commerce, House
of Representatives

March 1995

TUBERCULOSIS - COSTLY AND
PREVENTABLE CASES CONTINUE IN FIVE
CITIES

GAO/HEHS-95-11

Tuberculosis Cases in Five Cities


Abbreviations
=============================================================== ABBREV

  AIDS - acquired human immunodeficiency syndrome
  CDC - Centers for Disease Control and Prevention
  CDOH - Chicago Department of Health
  CPI - consumer price index
  CPI-U - consumer price index-urban
  HIV - human immunodeficiency virus
  INH - isoniazid
  MDR-TB - multiple drug resistant tuberculosis
  PAHO - Pan American Health Organization
  PHA - public health adviser
  RIF - rifampin
  TB - tuberculosis
  TIMS - Tuberculosis Information Management System

Letter
=============================================================== LETTER


B-251306

Letter Date Goes Here

The Honorable John D.  Dingell
Ranking Minority Member
Committee on Commerce
House of Representatives

Dear Mr.  Dingell: 

After a period of substantial decline, the incidence of tuberculosis
(TB) has risen in the United States.  An estimated 10 to 15 million
Americans are currently infected with tuberculosis.\1

In 90 percent of these persons, the infection will remain latent, or
inactive, for life, and they will never develop TB.  In the remaining
10 percent of cases, those infected are at risk of developing active
TB sometime in their life.  For those living in crowded and unhealthy
conditions and those more susceptible to disease due to age or
illness, the risk of reactivation may be significantly higher. 

Since 1985, the number of new TB cases reported annually has risen to
over 25,000, with much of this increase occurring between 1990 and
1992.  The national case rate is now almost 10 per 100,000 persons. 
In some cities the case rate is higher.  For example, in 1992 in
Newark, Chicago, and Los Angeles, some neighborhood case rates were
from 10 to 15 times the national average. 

Concerned about containing the spread of TB, you asked us to assess
the ability of public health authorities to do so.  This report
discusses (1) the TB epidemic, nationally and in five hard-hit
cities; (2) the ability of local TB control programs to contain and
reverse rising TB rates; (3) federal efforts to aid state and local
TB control programs; and (4) the budgetary implications for the
federal government of a continuing TB problem. 


--------------------
\1 The cause of TB is a bacterium known as Mycobacterium
tuberculosis. 


   RESULTS IN BRIEF
------------------------------------------------------------ Letter :1

Costly and preventable TB cases are occurring across the nation. 
Although the disease is found in all parts of society, it is
predominantly impacting the poor and urban racial and ethnic
minorities.  In the cities we visited--Atlanta, Chicago, El Paso, Los
Angeles, and Newark--TB rates are higher than the national average,
and TB cases are growing most rapidly among these vulnerable
populations, who often lack access to health services. 

The Centers for Disease Control and Prevention (CDC) and other TB
experts attribute recent TB case increases to more frequent
transmission in settings with inadequate infection control measures,
the effects of human immunodeficiency virus (HIV) infection, and the
introduction of TB infection and cases by persons from countries with
high TB rates.  In the cities we visited, high TB rates also result
from problems ensuring that TB patients complete a full course of
appropriate treatment and problems identifying those who have had
contact with TB patients. 

Although the federal government has increased its assistance to
states and localities, state and local budgets for TB control have
not increased at the same rate as the federal contribution.  Total
funding per TB case in constant dollars has generally declined in
each of the cities we visited. 

In addition to funding problems, a weakened TB control infrastructure
in health departments has reduced the ability of local TB programs to
find infected persons and successfully treat those with active TB so
that they do not spread the disease to others. 

While TB cases are growing most rapidly among vulnerable populations,
the health of the general population will continue to be compromised
by additional TB cases and drug- resistant TB infections.  We
estimate that, unless control efforts are improved, the total
national resources for treating TB annually could more than double to
$1.5 billion by the year 2000. 


   BACKGROUND
------------------------------------------------------------ Letter :2

Tuberculosis was once considered a disease that could be eliminated
in the United States.  After the discovery of antibiotics that could
kill the bacterium causing TB, the incidence of the disease markedly
declined.  Improvements in working conditions, housing, nutrition,
and sanitation also may have contributed to this decline.  As a
result, in the 1960s, the Public Health Service recommended that
states and local communities close their sanitoria and treat TB
patients in outpatient clinics.  Today, state and local health
departments are primarily responsible for designing and implementing
TB control services. 

Almost every TB case results from contact with a person with active,
contagious TB,\2 especially when such a person coughs; however, once
infection occurs, infection usually remains inactive for some time.\3
During this latent period, infected persons do not develop the active
disease and cannot spread TB to others.  Most healthy persons
infected with this bacterium will not develop active, contagious TB;
however, others may later do so if their bodies do not successfully
suppress the infection and they do not get treatment. 

Active TB can affect various parts of the human body.  In its most
common form, it causes progressive damage to lung tissue.  The
symptoms include persistent cough, night sweats, fever, and fatigue. 
Until recently, it was estimated that 90 percent of current TB cases
resulted from the reactivation of infection that occurred years or
decades ago.  However, recent research indicates that a higher
proportion, one-third or more, of new TB cases in two U.S.  cities
may have resulted from recent contact with a person with contagious
TB.\4 Immunosuppressed persons, such as those with acquired human
immunodeficiency syndrome (AIDS), are at particularly high risk for
developing active disease soon after contact with a contagious
person. 


--------------------
\2 TB disease is demonstrated by clinical, bacteriologic, or
radiographic evidence. 

\3 The immune system of a normally healthy person will usually
prevent the development of active TB. 

\4 David Alland and others, "Transmission of Tuberculosis in New York
City--An Analysis by DNA Fingerprinting and Conventional
Epidemiologic Methods," New England Journal of Medicine, Vol.  330
(1994), pp.  1710-1716 and Peter Small and others, "The Epidemiology
of Tuberculosis in San Francisco--A Population-Based Study Using
Conventional and Molecular Methods," New England Journal of Medicine,
Vol.  330 (1994), pp.  1703-1709. 


      FIRST PRIORITY:  DETECT AND
      TREAT ACTIVE TB
---------------------------------------------------------- Letter :2.1

According to CDC, the first and highest priority of a TB control
program is to detect persons with active disease and treat them with
antibiotic drugs.  Treatment plans usually include periodic
examinations and at least 6 to 9 months of daily or twice or three
times weekly treatment with multiple antibiotics.\5 If the disease is
sufficiently advanced before detection, the patient may require
hospitalization.  In some cases, health care workers must watch, or
directly observe, TB patients take their medication to ensure that
the antibiotics are taken as instructed.  If a patient takes the
medication for the full period, the disease is generally cured and
should not recur. 

When a patient with active TB does not get adequate treatment,
serious problems, including continuing transmission of infection,
increasing disability, and death, can result.  In addition, the
infecting TB bacterium can become resistant to the misused or
discontinued drugs.  The resulting single or multiple drug-resistant
tuberculosis (MDR-TB) can be transmitted directly to others and is
much more difficult and costly to treat.\6

MDR-TB treatment consists of at least 18 months of medication, which
includes a minimum of four drugs.  Lengthy and costly hospital stays
can be necessary and in some cases death can ensue.  According to
CDC, in nine MDR-TB outbreaks, from 43 percent to 93 percent of the
patients died.  The direct cost of treating a person with MDR-TB has
been estimated to be about 5 to 10 times that of treating a person
with nondrug-resistant TB.  The estimated cost of treating MDR
patients at a U.S.  hospital that specializes in treating such cases
ranges from $100,000 to $200,000 per patient.\7


--------------------
\5 Commonly used antituberculosis drugs include the antibiotics
rifampin (RIF), isoniazid (INH), ethambutol, pyrazinamide, and
streptomycin. 

\6 Transmission of MDR-TB has occurred in settings ranging from
hospitals to correctional facilities, with active TB diagnosed for
patients, prisoners, and health care workers.  In November 1993, we
reported that the failure of a VA medical center to consistently
isolate TB patients, poor enforcement of isolation requirements, and
inadequate isolation rooms contributed to an outbreak of MDR-TB at
New Jersey's East Orange Medical Center between 1990 and 1992.  VA
Health Care:  Tuberculosis Controls Receiving Greater Emphasis at VA
Medical Centers (GAO/HRD-94-5, Nov.  9, 1993). 

\7 Barry R.  Bloom, and Christopher J.L.  Murray, "Tuberculosis: 
Commentary on a Reemergent Killer," Science, Vol.  257 (1992), p. 
1063. 


      SECOND PRIORITY:  TB
      PREVENTION
---------------------------------------------------------- Letter :2.2

Timely and successful treatment of contagious TB patients is critical
to decreasing TB transmission and containing the spread of TB. 
Identifying those with latent TB infection and giving them preventive
therapy when indicated is also very important.\8 Contact screening is
one method used to identify infected persons.  In this type of
screening, TB "contacts"--individuals who have been exposed to
persons known to have active, contagious TB--are approached and
encouraged to have a skin test to determine whether they have been
infected.  TB control programs can also use screening techniques to
identify infected persons among high-risk populations. 

Once identified, infected persons may be given preventive therapy,\9

generally 6 to 12 months of daily treatment with INH.  Patients who
take the medication for the required period are unlikely to later
develop active TB that could be spread to others.  The cost of
treating a person who is infected but without disease is estimated to
be significantly lower than the cost of treating a person with
contagious disease.  For example, a recent CDC study estimated that
costs associated with preventive therapy totaled about $150 per
person, while costs associated with outpatient treatment for
drug-susceptible cases equaled about $2,000 per person.\10 Another
1993 study of the economic impact of TB in New York City concluded
that $179 million was spent for TB-related hospitalizations in 1990
and noted that hospitalizations associated with TB/HIV coinfection
are 50 percent longer than those associated with TB alone.  The study
also concluded that inpatient TB care could have severe economic
consequences for New York City.\11


--------------------
\8 A positive reaction to a tuberculin skin test is the standard
method used to identify infected persons.  In some cases this test is
inadequate and a chest X ray is used. 

\9 CDC criteria for preventive treatment relate to the age of the
patient, the size of the skin reaction, and the presence of risk
factors such as HIV infection, recent contact with an infected
person, medically underserved or low-income status, or intravenous
drug use. 

\10 "Estimate of Identifiable Direct Costs of Tuberculosis in the
United States in 1991," prepared for the Centers for Disease Control
and Prevention by Battelle Medical Technology Assessment and Policy
Research Center (Washington, D.C.:  1993), p.  v. 

\11 Peter Arno and others, "The Economic Impact of Tuberculosis in
Hospitals in New York City:  A Preliminary Analysis," The Journal of
Law, Medicine and Ethics, Vol.  21 (1993), p.  321. 


      OTHER TB CONTROL PROGRAM
      OBJECTIVES
---------------------------------------------------------- Letter :2.3

Other TB control objectives include monitoring and evaluating the
progress made toward eliminating TB.  These activities include
ensuring that health care providers report cases of TB to local or
state health departments and that TB patients receive appropriate
treatment.  In addition, TB programs should maintain surveillance
data on the occurrence and distribution of TB cases and evaluate the
outcomes of treatment and prevention activities, such as monitoring
the number of TB patients who have completed treatment. 


      CDC PROVIDES LEADERSHIP AND
      ASSISTANCE TO LOCAL PUBLIC
      HEALTH EFFORTS
---------------------------------------------------------- Letter :2.4

At the federal level, CDC is charged with protecting the public
health of the nation by leading and directing the prevention and
control of diseases and preventable conditions.  State and local
public health agencies are primarily responsible, however, for
developing and delivering TB control and prevention services.  In
most cases, state and local laws and regulations specify a range of
TB control activities and legal procedures that can be used to
prevent TB transmission. 

One of CDC's primary methods of assisting state and local TB control
programs is a cooperative agreement program that provides federal
funds to state and local TB control programs.  These agreements
require substantial cooperation between CDC and state and local
governments, and they are intended to accomplish shared TB prevention
and control objectives.  The funds can only be used for specified
activities including (1) hiring staff to provide directly observed
therapy, (2) collecting data on TB incidence, and (3) purchasing some
equipment and supplies.  These funds cannot be used to (1) supplant
state or local funds, (2) provide inpatient care, (3) construct or
renovate facilities, or (4) purchase medications except on an
exception basis. 

CDC cooperative agreements allow CDC public health advisers (PHA) to
be assigned to areas with high TB incidence or unique and complicated
problems such as MDR-TB.\12 These PHAs provide health departments
with expertise in program operations and epidemiologic skills.  As of
November 1994, 48 PHAs and four medical officers were assigned to
state and local programs. 

CDC has also participated in developing a national plan for
eliminating TB.  In 1989, this effort resulted in a report titled, A
Strategic Plan for the Elimination of Tuberculosis in the United
States.  The plan called for a decrease in the incidence of TB in the
United States to less than one case per million population and
outlined a three-step action plan to accomplish that objective by
2010.  The strategy was intended to stimulate positive and
constructive discussion and action by the public and within the
medical community.  CDC also coordinated a National Tuberculosis
Training Initiative to inform public health officials of the
strategic plan and improve the quality of care available from public
health agencies. 

Three years later, when CDC believed that the increase in MDR-TB
outbreaks and other changes in the incidence of TB were jeopardizing
the Strategic Plan goals, the agency developed a National Action Plan
to Combat Multidrug-Resistant Tuberculosis.\13

The plan relates MDR-TB to serious problems in the health care
infrastructure and outlines steps that should be taken at the
national level to meet the threat of TB. 

The implementation and success of these plans depend on the
cooperation and commitment of local and state public health agencies
as well as the effectiveness of CDC's leadership and technical
assistance.  Although the federal government can guide the
recommended steps, the decisions and actions required to improve
treatment and prevention activities are made by state and local
public health officials. 

CDC has also issued specific guidelines and recommendations to
improve local TB control efforts.  Most of these are issued jointly
with the American Thoracic Society or as statements from the Advisory
Council for Elimination of Tuberculosis.  Several of these focus on
TB services for high-risk groups, such as migrant farmworkers, the
homeless, and at-risk racial and ethnic minority populations.  Others
provide direction on preventing the transmission of TB in health-care
settings, with a special emphasis on HIV-related issues.  In
addition, CDC maintains a national data system that tracks the
incidence of TB over time and in specific geographic locations.  CDC
also responds to public health emergencies and provides technical
assistance to states and localities. 


--------------------
\12 PHAs are CDC staff involved in preventing and controlling many
public health problems, from the traditional areas of infectious
disease to refugee programs, environmental catastrophes, and chronic
disease programs.  These advisers typically have expertise in program
operations and epidemiological skills that these health departments
cannot provide. 

\13 The Strategic Plan for the Elimination of Tuberculosis in the
United States was developed with input from many experts from within
and outside the Department of Health and Human Services.  The
National Action Plan to Combat Multidrug Resistant Tuberculosis was
developed by a task force of representatives from many federal
agencies. 


   SCOPE AND METHODOLOGY
------------------------------------------------------------ Letter :3

To characterize the TB epidemic nationally and in five hard-hit
cities, we reviewed national and local TB epidemiologic data from
1980 to 1993, interviewed TB control officials, and visited TB
control programs in Los Angeles, Chicago, Newark, Atlanta, and El
Paso.\14 To assess these cities' ability to contain and reverse
rising TB rates, we identified pertinent TB control activities and
the impact of these activities using management reports and CDC data. 
Outcome measures included the number of patients completing TB
treatment and the number of contacts identified for individuals with
active TB.  We examined local and state fiscal year budgetary and
expenditure data to determine how funding levels were adjusted to
changes in TB rates.\15 In addition, we reviewed CDC data on federal
contributions to local and state budgets. 

To determine the budgetary implications for state, local, and federal
governments of a continuing TB problem, we estimated future TB
program expenditures if current TB case rates and costs continue to
grow at the same annual rate as they grew from 1988 to 1991. 

Our work was performed between June 1993 and January 1995 in
accordance with generally accepted government auditing standards. 


--------------------
\14 This nonrandom, judgmental sample of U.S.  cities was chosen
because it represents cities that (1) had high TB rates or large
numbers of TB cases compared to other U.S.  cities of their size and
(2) received CDC funds for TB control activities.  The cities also
represented diverse populations at high risk for TB infection and
diverse geographic areas. 

\15 Unless otherwise specified, Los Angeles County data have been
used to characterize population changes, TB incidence, and TB control
and prevention activities.  In the case of Atlanta, Fulton County,
Georgia, data have been used to characterize TB control and
prevention activities.  Budget data were used to characterize state
and local funding when expenditure data were unavailable. 


   RETURN OF TB ACROSS NATION AND
   IN LOCALITIES
------------------------------------------------------------ Letter :4

A steady three-decade decline in TB in the United States came to a
halt in the mid-1980s.  New TB cases rose by 20 percent between 1985
and 1992.  This trend resulted in over 51,000 more TB cases than
expected by CDC given earlier decreases.  From 1992 to 1993, the
incidence declined by 5 percent; however, it remains uncertain
whether this decline has resulted from improvements in TB control
activities or recent changes in TB reporting procedures and the AIDS
surveillance case definition. 

CDC attributes the recent increases in TB to several factors,
including outbreaks in institutional settings with inadequate
infection control measures, the increased risk of disease among
HIV-positive persons, and the introduction of additional TB infection
by those from countries with high TB rates.  It has been estimated
that the direct treatment costs associated with additional cases
since 1985 resulting from increased active transmission equal $340
million.\16

Each of the cities we visited had increases in TB cases between 1985
and 1992 (see table 1).  This increase ranged from 10 percent to 71
percent (see fig.  1).  All five locations have had TB case rates,
the number of TB cases per 100,000 persons, that are far higher than
the national average.  In 1992, TB case rates ranged from 18.6 in El
Paso to 78.2 cases per 100,000 persons in Atlanta (see fig.  2). 



                          Table 1
          
          Number of Newly Reported Active TB Cases
          for Five Communities and the Nation From
                        1980 to 1992

Ye   Los Angeles  Chicag  Newa  Atlant   El Paso    United
ar        County       o    rk       a      City    States
--  ------------  ------  ----  ------  --------  --------
19         1,426     762   148     190        89    27,749
 80
19         1,824     922   135     234        73    27,373
 81
19         1,423   1,069   145     219        76    25,520
 82
19         1,423     871   159     191        66    23,846
 83
19         1,289     752   141     177        63    22,255
 84
19         1,512     724   108     212        81    22,201
 85
19         1,426     716   118     196        71    22,768
 86
19         1,498     649   124     210        39    22,517
 87
19         1,335     682   154     196        82    22,436
 88
19         1,817     684   208     259        85    23,495
 89
19         2,074     705   188     203       101    25,701
 90
19         2,241     751   196     301       136    26,283
 91
19         2,325     795   185     308       101    26,673
 92
----------------------------------------------------------
Source:  CDC and state and local TB control program data.  Los
Angeles County TB case totals include cases in Long Beach and
Pasadena per CDC definition. 

   Figure 1:  Percent Increase in
   New TB Cases, 1985-92

   (See figure in printed
   edition.)

Note:  Los Angeles County TB case totals include cases in Long Beach
and Pasadena per CDC definition. 

   Figure 2:  Case Rate
   Comparison, Nation and Five
   Communities From 1980 to 1993

   (See figure in printed
   edition.)

Note:  Atlanta 1993 data were unavailable. 


--------------------
\16 Bloom and Murray, p.  1061. 


      GROWTH IN TB CASES HIGHER
      AMONG VULNERABLE POPULATIONS
---------------------------------------------------------- Letter :4.1

Although TB can be found in every segment of society, the disease is
growing most rapidly among the nation's more vulnerable
populations--the poor, the HIV positive, those living in substandard
housing, injection drug users, inmates in correctional facilities,
and those lacking access to health care services. 

Racial and ethnic minorities are often overrepresented in these
vulnerable populations.  In the cities we visited, the racial and
ethnic minority groups reflected this growth in TB.  For example, in
Atlanta, the number of cases among African Americans almost doubled
between 1980 and 1992, while the number of cases among whites
decreased by 26 percent.  In Los Angeles, the number of Hispanic
cases grew by 73 percent between 1985 and 1992, while the number of
cases among whites grew by 11 percent. 

Much of the recent increase in TB is among individuals with latent TB
infection who are more vulnerable to developing active TB due to HIV
infection.  For this reason, according to one TB expert, future
trends in new TB cases will be strongly linked to changes in HIV
incidence.  Because HIV and AIDS weaken the immune system,
HIV-infected persons are at a greatly increased risk of developing
active TB once infected.  CDC national data on the number of
individuals coinfected with HIV and TB in 1993, the first year this
information was collected, are still incomplete.  However, Los
Angeles reported that in 1992 about 12 percent of TB cases were among
HIV-infected persons.  The Fulton County, Georgia, TB program
reported that 40 percent of its TB cases are HIV positive. 


      SOCIAL FACTORS CONTRIBUTE TO
      TB SPREAD
---------------------------------------------------------- Letter :4.2

Other groups are at high risk of developing TB because of factors
that relate to poor health status or living conditions.  For example,
individuals who abuse substances such as alcohol and drugs often have
health problems or unstable living conditions that may place them at
higher risk of developing active TB if infected.  CDC estimates from
1993, the first year TB data on patient characteristics were
available, showed that substance abuse was a factor in almost 14
percent of TB cases.\17 Chicago health officials reported that
substance abuse has been historically associated with at least 10
percent, if not more, of the city's TB cases. 

TB is also a problem among the homeless and those who spend time in
correctional facilities.  For example, Los Angeles health officials
estimate that about 12 percent of their 1992 TB cases occurred among
homeless persons.  CDC survey data indicate that TB incidence among
inmates is at least three times higher than that among the general
adult population. 


--------------------
\17 CDC data are based on 17 reporting areas with data on patient
characteristics for at least 75 percent of its cases.  Substance
abuse includes injection and noninjection drug use and excessive
alcohol use. 


      HIGH TB RATES IN OTHER
      COUNTRIES CONTRIBUTE TO U.S. 
      TB PROBLEM
---------------------------------------------------------- Letter :4.3

Another group at risk for TB are foreign-born individuals who come
from countries where TB is more prevalent than it is in the United
States.  According to CDC data, these individuals accounted for 27
percent of all new U.S.  TB cases in 1992, and legal immigrants
accounted for 60 percent of the rise in TB cases from 1986 through
1992.  The states with the highest increases in new TB cases were New
York, California, Florida, Texas, and New Jersey.  These states were
also listed as the intended residence of 70 percent of the legal
immigrants entering the United States in 1992.  Three of the cities
we visited are located in these states, and in one of these cities,
Los Angeles, foreign-born individuals currently comprise about 66
percent of new TB cases. 


      GENERAL POPULATION MAY ALSO
      BE AT RISK
---------------------------------------------------------- Letter :4.4

Although TB is growing most rapidly among the nation's more
vulnerable populations, it could spread to the general population. 
For example, federal health officials recently reported that the
rates of TB infection among airline crew members who had flown for 3
months with a flight attendant with undiagnosed active TB was 16
times higher than the rate of infection among a similar group who had
not flown with that flight attendant.\18 In the cities we visited,
the potential spread of TB was evident.  For example, students tested
in one Chicago high school revealed an infection rate of
approximately 30 percent among those tested after a fellow student
was diagnosed with contagious TB.  A similar situation developed in a
suburban county outside Los Angeles, where eight students contracted
dangerous MDR-TB from one other student.  (See app.  I for a more
detailed description of how cities' TB activities are addressing TB
demographics and vulnerable populations.)


--------------------
\18 Cynthia Driver and others, "Transmission of Mycobacterium
Tuberculosis Associated With Air Travel," Journal of the American
Medical Association, Vol.  272, No.  13 (1994), pp.  1031-1035. 


   LOCAL PROGRAMS STRUGGLE TO
   CONTROL SPREAD OF ACTIVE TB
------------------------------------------------------------ Letter :5

None of the TB control programs in the cities we visited can ensure
that all of their TB patients complete appropriate treatment.  The
programs also have problems finding and screening all persons who
have been in contact with TB patients, although some of these
unscreened persons are likely to develop TB in the future, continuing
the cycle of disease.  As a result, residents of the cities we
visited continue to be at risk for TB infection.  In some cases, this
infection can be drug resistant and therefore more costly and
difficult to treat.  Recent federal monies support directly observed
therapy, outreach workers, and incentives to encourage patients to
comply with their treatment regimens. 


      LOCAL TREATMENT COMPLETION
      RATES FALL BELOW CDC'S GOAL
---------------------------------------------------------- Letter :5.1

Although CDC gives treatment completion its highest priority, U.S. 
TB control programs have difficulty ensuring that their patients
complete treatment.  According to CDC data, approximately one-fourth
of the TB patients in treatment in the United States between 1986 and
1992 did not finish their medication in recommended time frames.  TB
control officials in each of the cities agreed that successful
treatment completion is crucial to containing TB and that they have
given their highest priority to finding and treating active cases. 
However, in 1992, only one of the five cities, El Paso, met CDC's
objective of a 90-percent completion rate.\19 Treatment completion
rates in the remaining four cities ranged from 58 percent in Chicago
to 81 percent in Los Angeles (see fig.  3). 

   Figure 3:  Index of Treatment
   Completion During 1992

   (See figure in printed
   edition.)

Note:  CDC's provisional national average represents completion rates
from 75 reporting areas. 

Some TB control officials in the cities we visited attributed low
completion rates to patient characteristics as well as
resource-related problems.  For many patients, a variety of health
and socioeconomic problems, such as low income, homelessness, poor
access to health care, language barriers, and substance abuse, may
limit their ability to adhere to a structured treatment plan. 
Newark, for example, attributed its low completion rates to the
difficulties of providing treatment to persons with these problems. 
A Chicago TB official cited problems locating and treating some
patients, such as substance abusers, who purposely evade TB control
efforts out of fear of contact with local authorities.  Officials
also cited staffing problems as another factor contributing to low
completion rates. 


--------------------
\19 This 90-percent goal is included as a national objective in CDC's
guidance to localities for applying for cooperative agreement grants. 


      TREATMENT FAILURE EXPOSES
      PUBLIC TO MORE SERIOUS
      DISEASE AND INFECTION
---------------------------------------------------------- Letter :5.2

When TB control programs cannot ensure that patients complete
appropriate treatment, the risk of MDR-TB is high.  This condition
can be hard to control, and it is more dangerous than
drug-susceptible TB.  For example, drugs used to treat MDR-TB may be
more likely to lead to serious toxic effects.  MDR-TB also generally
requires long periods of hospitalization and more extensive
laboratory monitoring.  When treatment with antibiotics is
ineffective, surgery to remove infected lung tissue may be needed. 
According to CDC data, the proportion of cases tested that indicated
resistance to INH and RIF in Newark, Los Angeles, and Chicago in the
first quarter of 1992 were 9.5, 3.3, and 1.6 percent, respectively. 
The Fulton County, Georgia, Health Department estimated that 2 to 3
percent of its cases are resistant to INH and RIF.  According to one
El Paso health official, in 1993 approximately 4 percent of El Paso's
cases were resistant to one or more drugs. 

Newark health officials reported that MDR-TB is likely to increase
due to their city's historically low treatment completion rates.  An
El Paso health official told us that, although El Paso's percentage
of TB cases with MDR-TB is similar to that of the rest of Texas, the
potential for an MDR-TB outbreak exists due to El Paso's proximity to
the Mexican border city of Juarez.  In November 1993, 44 percent of
the TB cases seen in the Juntos clinics in Juarez were resistant to
one or more drugs, and three-fourths of the resistant cases were
MDR-TB.\20


--------------------
\20 However, the possibility of an MDR-TB outbreak may be mitigated
by new funding for the Juntos project, a special TB control project
allowing TB officials in El Paso to work with TB control officials in
Juarez on issues that affect TB control practices in both cities. 
(See app.  II for more details.)


      DIRECTLY OBSERVED THERAPY
      AND INCENTIVES ARE USED TO
      IMPROVE TREATMENT COMPLETION
      RATES
---------------------------------------------------------- Letter :5.3

TB control programs have used recent increases in their cooperative
agreement funds to hire more staff to locate patients and provide
them with their daily TB medications.  As a result, cities we visited
have been able to place more patients on directly observed therapy. 
For example, since this increase in federal assistance, Chicago's
Department of Health has raised the percentage of patients on
directly observed therapy at its clinics from approximately 19
percent to approximately 70 percent.  Similarly, El Paso has used
federal funds to hire outreach workers to provide directly observed
therapy to inmates of a local correctional facility. 

CDC also suggests that communities use grant funds to implement
innovative strategies, including "enablers and incentives," to
encourage patients to comply with their treatment regimens.  These
can include gifts, such as money, or assistance, such as tokens. 
Four of the five TB programs we visited were using federal and local
funds or funds provided by community organizations in this manner. 
Chicago; Fulton County, Georgia; Los Angeles; and Newark provided
patients with incentives such as bus tokens, food vouchers, dietary
supplements, or personal hygiene products to persuade patients to
appear regularly for treatment.  Chicago TB officials report that
cash incentives have been effective with their TB patients. 


   LOCAL PROGRAMS STRUGGLE TO
   PREVENT FUTURE TB CASES
------------------------------------------------------------ Letter :6

Prompt and effective treatment of contagious TB patients is critical
to containing TB.  For this reason, all of the TB control programs we
visited focus their efforts on treating active TB patients, leaving
fewer resources than needed for other TB prevention efforts. 
Although those who have been in close contact with contagious TB
patients have the highest risk of developing infection, TB control
programs frequently cannot identify these persons.  Efforts to screen
and preventively treat other high-risk individuals are also limited,
and almost 34 percent of those who begin preventive therapy--6 to 12
months of daily treatment with INH--do not complete their treatment. 
Consequently, TB infection continues and cases develop among some who
are infected. 


      CONTACT INVESTIGATION
      PROBLEMS HINDER DISEASE
      PREVENTION
---------------------------------------------------------- Letter :6.1

According to CDC, detecting infected persons is crucial to TB
elimination efforts.  However, national data for 1992 indicate that
program staff have trouble identifying people who have had recent
contact with active TB patients.  Ideally, all those who have had
close contact with an individual who has contagious TB should be
identified and screened for TB infection.  However, data indicate
that TB control staff could not identify any contacts for 36.2
percent of active U.S.  TB cases in 1992. 

TB control officials in all of the cities we visited agreed that
their highest prevention priority after treating TB patients is
identifying, examining, and treating contacts of active TB cases. 
Yet in Chicago the percentage of cases with no contacts identified in
1992 exceeded the national average (see fig.  4).  Although Los
Angeles did not have any data for 1992 or prior years, the percentage
of cases with no contacts identified exceeded 50 percent during the
first half of 1993.  A Los Angeles County TB control official
reported that public health nurses in the 40 county public health
centers providing TB prevention services are not dedicated solely to
TB prevention.  Nurses are often responsible for activities in
several different public health programs.  As a result, nurses have
limited time available for crucial TB control activities such as
patient follow-up and identifying and examining TB contacts. 

   Figure 4:  Percentage of TB
   Cases With No Contacts
   Identified During 1992

   (See figure in printed
   edition.)

Notes:  Los Angeles data not available.

National average based upon 84 reporting areas. 

When TB control programs did find contacts, the number of contacts
they found was often well below the national average.  For example,
in 1992 the national average was 9.8 contacts for each active TB
patient identified.  However, the number of contacts found in 1992 in
the cities we visited ranged from 3.9 contacts per case in Fulton
County, Georgia, to 6.1 contacts per case in Chicago (see fig.  5). 

   Figure 5:  Number of Contacts
   Identified per TB Case During
   1992

   (See figure in printed
   edition.)

Notes:  Data not available for the Los Angeles County Health
Department.

National average based upon 84 reporting areas. 


      LOCAL TB PROGRAMS' SCREENING
      EFFORTS ARE LIMITED
---------------------------------------------------------- Letter :6.2

CDC encourages state and local health departments to conduct TB
screening programs targeted at high-risk groups, such as the foreign
born, the HIV positive, and medically underserved or low-income
racial and ethnic minority populations.  However, health officials in
all of the cities we visited told us that they cannot screen as much
as they believe is necessary because treatment of active cases is a
higher priority. 

In all of the cities we visited, TB or local public health clinics
provided skin tests and subsequent preventive therapy to the general
public.  However, targeted programs to high-risk populations,
excluding contacts and those infected with HIV, were limited although
all of the communities had low-income, at-risk populations
concentrated in racial and ethnic minority communities.  For example,
in Atlanta, African Americans are over-represented among TB cases. 
While they constituted over 67 percent of Atlanta's population, in
1990 African Americans accounted for 89 percent of TB cases.\21 Yet
Fulton County, Georgia, did not have any systematic screening
programs targeted to this high-risk group. 

In Los Angeles County, foreign-born individuals accounted for 33
percent of the city's population and 62 percent of the TB cases in
1990.\22 However, one TB official estimated that screening as many as
150,000 legal immigrants a year, and providing preventive therapy to
the estimated 50 percent of these immigrants who might need it, would
overwhelm the county's health system.  Even a pilot TB screening
program working with adult "English as a Second Language" schools was
limited by the resources of Los Angeles County; therefore, screening
services are only provided on a limited basis.  Data suggest,
however, that individuals in these schools are at an exceptionally
high risk for TB disease, as indicated by a 61-percent rate of latent
TB infection and the identification of three cases of active TB
disease.  According to one Los Angeles TB official, the program can
only screen 2 to 3 percent of those who need it. 

Some cities tried to screen individuals in high-risk settings, such
as local jails, drug treatment centers, and homeless shelters. 
Although these efforts can often uncover relatively high rates of
infection, the difficulty of maintaining contact with screened
individuals can hamper effective screening and prevention efforts. 
For example, Fulton County, Georgia, TB staff reported that, in 1993,
Fulton County jail screened a total of 8,104 inmates.  Skin tests for
90 percent of those tested revealed that 13.5 percent had a positive
reaction.\23 According to a jail official, about 982 inmates were
placed on preventive treatment in 1993.  Data on the number that
completed preventive treatment were unavailable because the average
jail stay is about 2 weeks.  Although a Fulton County TB outreach
worker is assigned to the jail, the county's clinic has no mechanism
to ensure that inmates continue preventive treatment after their
release. 


--------------------
\21 Based upon 1990 census data. 

\22 Based upon 1990 census data. 

\23 Generally, skin tests should be evaluated within 3 days. 


      PREVENTIVE TREATMENT
      FAILURES EXPOSE PUBLIC TO
      CONTINUING RISK FOR TB
---------------------------------------------------------- Letter :6.3

Both nationally and in the cities we visited, preventive efforts
often fail because persons on preventive therapy do not complete it. 
National data indicate that in 1992 almost 34 percent of the 150,287
persons on preventive therapy did not complete their treatment.\24
Despite the priority given to identifying and treating persons who
have been in close contact with TB patients, 31 percent of the 24,429
infected contacts placed on preventive therapy did not complete their
treatment. 

The cities we visited also had this problem.  Two of the TB programs,
in Chicago and Los Angeles, reported that they cannot maintain data
on preventive therapy completion because they lack the resources
needed to monitor the number of persons they place on preventive
therapy.  In El Paso, Fulton County, and Newark, where data are
collected, the percentage of all persons who did not complete
preventive therapy ranged from about 36 percent in El Paso to 60
percent in Newark. 


--------------------
\24 CDC's total excludes those who were diagnosed with active TB
disease, died during the period, moved and transferred records, or
were discontinued by a physician due to an adverse reaction. 


   LOCAL FUNDING SHORTFALLS LEAD
   TO INCREASING DEPENDENCE ON
   FEDERAL RESOURCES
------------------------------------------------------------ Letter :7

TB programs have had difficulty fulfilling their TB control
responsibilities as state and local financial resources failed to
keep up with the need for TB services.  As a result, federal funding
has become an important factor in the ability of the local health
departments we visited to prevent and control TB. 


      FEDERAL GOVERNMENT PROVIDES
      ASSISTANCE TO STATE AND
      LOCAL PROGRAMS
---------------------------------------------------------- Letter :7.1

CDC provides federal TB control funds to state and local public
health departments through cooperative agreements.\25 Between fiscal
years 1982 and 1993, appropriations for CDC cooperative agreements
grew from $1 million to over $34 million.  This amount was augmented
in 1993 by an additional appropriation of $39 million in emergency
funds for six states and seven cities in which rising TB rates were
having a severe impact.  In fiscal year 1994, grant appropriations
more than tripled from original 1993 appropriations, reaching $111.5
million.\26

Recent CDC funding increases expanded surveillance, prevention, and
control activities, including the hiring of additional staff,
primarily outreach workers, the purchase of equipment to improve TB
case reporting, and upgrading state laboratories to improve the speed
and accuracy of TB diagnosis. 

Two of the cities we visited, Los Angeles and Chicago, receive
cooperative agreement funds directly.  The other three cities,
Newark, Atlanta, and El Paso, receive their funds through statewide
cooperative agreements.  In Atlanta, Chicago, and Los Angeles, CDC
staff have or are holding managerial positions in local TB control
programs.  All of the cities are located in states that have received
funds for laboratory upgrades.  In addition, El Paso receives CDC
support for binational TB control, and Newark receives support for
model TB programs. 

In all of the cities we visited, cooperative agreement funds have
been generally increasing while TB rates have risen.  Table 2 shows
the level of CDC funding received by these cities from 1983 to 1994. 
CDC has also provided technical assistance to three of the cities we
visited. 

In a discussion with CDC officials, they told us that it takes 2
years for funding increases to show results.  This is because of
government funding cycles as well as the long-term nature of TB
treatment. 



                          Table 2
          
          CDC Cooperative Agreement Awards to Five
               Communities From 1983 to 1993

          (In dollars not adjusted for inflation)

           Los                            Fulton
Ye     Angeles                           County,   El Paso
ar      County   Chicago  Newark\a       Georgia  County\b
--  ----------  --------  --------  ------------  --------
19     334,099   210,698    48,078       109,000         0
 83
19     399,523   235,563    54,824       134,098         0
 84
19     431,661   245,498    56,642       150,912         0
 85
19     426,591   228,599    58,391       115,700         0
 86
19     484,816   275,038    58,632       122,000         0
 87
19     556,393   307,146    61,038       126,000    20,819
 88
19     736,869   469,465    82,530       291,742    19,619
 89
19     819,504   572,199    69,942       260,000   189,056
 90
19     860,526   742,216    85,585       290,000   193,576
 91
19   1,937,031   848,704   182,093       385,462   188,587
 92
19   5,312,049  2,019,65   976,592       760,149   209,927
 93                    7
19   6,739,865  2,760,13  1,011,90     2,213,570   368,547
 94                    8         4
----------------------------------------------------------
\a In 1994, Newark also received $2,347,003 from CDC for its model TB
program. 

\b According to an El Paso public health official, $134,000 of the
$189,056 awarded to the city in 1990 was used to support TB
binational control activities in Juarez.  In subsequent years,
approximately $90,000 of the funds awarded to El Paso was used for
these activities. 


--------------------
\25 Nine cities receive these funds directly from CDC.  Other cities
receive them through their state governments. 

\26 A portion of CDC's $25.5 million TB/HIV appropriation has also
been used by CDC to supplement cooperative agreement monies. 


      STATE AND LOCAL FUNDING HAS
      NOT KEPT PACE WITH THE NEED
      FOR TB SERVICES
---------------------------------------------------------- Letter :7.2

While TB rates were rising in these cities, state and local resources
targeted to TB control activities did not keep pace with the need for
treatment and preventive services.  Our analysis of the five cities'
total TB expenditures\27

determined that, for four of the TB programs, state and local funding
in constant dollars remained fairly even or declined during periods
when case rates were increasing (see fig.  6).  A similar pattern
exists for dollars expended or budgeted per case (see fig.  7).  For
example, while case rates increased in Newark between 1986 and 1990,
total nonfederal funding in constant dollars decreased by more than
47 percent--from $199,100 to $103,800.  In the fifth city, Los
Angeles, state and local funding generally increased until 1992, but
not at the same pace as the increase in TB case rates.\28

   Figure 6:  Source of TB Control
   Funds by Location

   (See figure in printed
   edition.)

Notes:  CDC funds are based on CDC data and include current awards
plus past unobligated funds.  State funds are based on budget data
for Los Angeles County and El Paso and on expenditure data for Newark
and Fulton County.  For Chicago, no state funds were received.  Local
funds are based on budget data for Chicago and El Paso, on
expenditure data for Fulton County, and on budget and expenditure
data for Los Angeles County.  For Newark, the state and CDC provides
almost 100 percent of TB funds.

All dollars adjusted for inflation to 1983 dollars and years
indicated are fiscal years. 

\a In 1989 and 1990, El Paso received some funding from CDC. 

   Figure 7:  Dollars Expended or
   Budgeted per Case by Location

   (See figure in printed
   edition.)

Notes:  CDC funds are based on CDC data and include current awards
plus past unobligated funds.  State funds are based on budget data
for Los Angeles County and El Paso and on expenditure data for Newark
and Fulton County.  For Chicago, no state funds were received.  Local
funds are based on budget data for Chicago and El Paso, on
expenditure data for Fulton County, and on budget and expenditure
data for Los Angeles County.  For Newark, the state and CDC provides
almost 100 percent of TB funds.

All dollars adjusted for inflation to 1983 dollars and years
indicated are fiscal years. 

While state and local resources were lagging behind rising case
rates, the TB programs in these cities relied on federal funding for
an increasing portion of their total TB budgets.  For example, in
Chicago local funds accounted for almost 83 percent of the TB budget
in 1988, and federal funds accounted for 17 percent.  By 1992, the
local portion had dropped to 61 percent, while the federal portion
had increased to 39 percent.  During this period, TB caseloads
increased by 17 percent.  TB officials in four of the cities we
visited believe that local and state governments will not be the
source of major increases in TB funding in these cities.  In the
fifth city, El Paso, officials believe that additional resources may
be available from the state but not from local government. 

Despite increases in federal funding, total funding per TB case in
constant dollars in these cities has generally declined, even when
the number of cases was rising.  For example, in Los Angeles funding
per case in constant dollars declined from $8,583 in 1988 to $4,915
in 1992.  During this period, the number of TB cases rose from 1,190
to 2,198, and federal funding increased from $556,393 to $1,937,031. 
In 1992, these expenditures per case in the cities we visited ranged
from $4,915 per case in Los Angeles to $1,432 per case in Chicago
(see fig.  8). 

   Figure 8:  Dollars Expended or
   Budgeted per TB Case, 1992

   (See figure in printed
   edition.)

Notes:  CDC funds are based on CDC data and include current awards
plus past unobligated funds.  State funds are based on budget data
for Los Angeles County and El Paso and on expenditure data for Newark
and Fulton County.  For Chicago, no state funds were received.  Local
funds are based on budget data for Chicago and El Paso, on
expenditure data for Fulton County, and on budget and expenditure
data for Los Angeles County.  For Newark, the state and CDC provides
almost 100 percent of TB funds.

All dollars for fiscal year 1992 are adjusted to 1983 dollars. 


--------------------
\27 TB budget data are presented in constant 1983 dollars.  In cases
where expenditure data were unavailable, budget data were used. 
Years indicated are fiscal years.  Years included correspond to years
for which data are available at each location. 

\28 Los Angeles data are only available for 1988 to 1992. 


   WEAKNESSES IN PUBLIC HEALTH
   INFRASTRUCTURE HAMPER TB
   CONTROL EFFORTS
------------------------------------------------------------ Letter :8

TB officials in four of the cities we visited reported that staffing
shortages caused by hiring freezes, attrition, competing priorities,
and resource limitations have affected their ability to supply TB
services.  For example, TB control officials in Chicago indicated
that staffing limitations have hindered their ability to follow up on
patients and ensure that they complete their treatment.  TB control
officials in Los Angeles reported that competing duties have limited
the availability of staff to perform TB control and prevention
services.  In addition, some programs have had difficulties
attracting physicians and staff with the necessary skills to manage
TB programs. 

TB control officials and program reviews also cited several problems
with equipment and facilities.  For example, Fulton County, Georgia,
TB officials indicated that until recently, the county TB clinic used
a World War II era X ray machine.  In the El Paso TB clinic and one
of Chicago's TB clinics, patients of the HIV/AIDS clinic and the TB
clinic share the same waiting room.  Officials in Los Angeles,
Chicago, and Fulton County also indicated that inadequate records and
information technology limit their ability to monitor TB patients in
their cities.  (See app.  II for a discussion of how infrastructure
problems hinder TB control efforts in the cities we visited). 


   TB COSTS COULD GROW
   SIGNIFICANTLY GIVEN CURRENT
   TRENDS
------------------------------------------------------------ Letter :9

The cost of TB will continue to grow if current epidemiologic trends
and TB control practices continue.  In 1991, total expenditures for
TB prevention, including both inpatient and outpatient TB treatment
amounted to over $700 million, according to CDC estimates.  If
medical costs and TB case rates continue to follow recent trends, we
expect that total expenditures (in 1991 dollars) will exceed $1
billion in 1995.  By 1999, the resources required for the treatment
of TB could range from $1.2 to $1.5 billion-- close to double what
they were in 1991.\29 \30

Approximately two-thirds of these costs result from inpatient
hospitalization expenditures.  We estimate that these expenditures
(measured in 1991 constant dollars) could increase by 126 percent
between 1991 and 1999 to equal $983 million if current trends
continue.\31 Survey data indicate that more than 55 percent of these
costs may be borne by the federal government under the Medicaid and
Medicare programs.  These data also indicate that the Medicaid
program currently bears the largest burden of these costs.  (See app. 
IV.)

The remaining one-third of costs result largely from outpatient TB
expenditures for services such as those provided by local TB control
programs.  These are generally borne by state and local governments. 
We estimate that national outpatient expenditures (measured in 1991
dollars) could grow 101 percent between 1991 and 1999.  In some of
the nation's hard-hit cities, these expenditures may grow even
faster. 

The size of costs for controlling TB, and related expenditures, will
depend on the effectiveness of TB control programs.  For instance,
effective identification and treatment of infected persons could
prevent many TB cases, while improvements in active TB treatment
completion could decrease hospitalization costs.  These improvements
would also decrease the risk of rising MDR-TB cases and their
significantly higher costs. 


--------------------
\29 We used the CDC estimates of costs in 1991 as the basis of our
cost projections.  Our analysis assumes that caseloads will grow at
the same annual rate as active reported cases from 1988 to 1991, an
average of 5.5 percent.  In this analysis, costs for inpatient care
grow at the 1980 to 1991 average annual rate of growth for total
hospital costs, after controlling for inflation.  We assume that
costs per case for outpatient care will grow at the average rate of
growth for the medical care consumer price index from 1980 to 1991
after adjusting for inflation.  We assume that the CDC budget will
grow at the same rate as outpatient costs per case.  Expenditures are
stated in 1991 dollars unless otherwise noted. 

\30 Because TB caseloads grew less rapidly in 1992 and declined in
1993, we also prepared our projections using the average annual rate
of caseload growth from 1988 to 1993.  The average rate of growth
fell from an average of 5.5 percent per year to 2.5 percent. 
Projected spending fell from $1.5 billion to $1.2 billion in 1999
under these assumptions.  Because of the rapid rise in the cost of
treating an individual case, TB spending would rise under our
assumptions even if the number of new cases were constant.  Our
estimates show that TB expenditures would rise to $990 million if the
number of new TB cases were constant at 1991 levels. 

\31 Even if the number of new TB cases is constant at 1991 levels,
inpatient expenditures would grow by 47 percent to $640 million as
the cost of treating a case rises. 


   CDC HAS STARTED TO IMPROVE
   OVERSIGHT OF TB CONTROL
   ACTIVITIES
----------------------------------------------------------- Letter :10

CDC has begun initiatives intended to improve federal oversight of TB
control activities as well as local management of TB control.  For
example, the agency began to improve national surveillance of TB
cases when, in January 1993, it distributed a new, more detailed case
reporting form to public health departments.  As a result, CDC has
begun to capture national data on drug susceptibility, HIV status,
and directly observed therapy use.  CDC also implemented a
computerized surveillance system to facilitate data entry and
transfer from state and local health departments to CDC. 

A second information system, the Tuberculosis Information Management
System (TIMS) is designed to serve the information needs of TB
clinics and state and local health departments as well as CDC. 
According to CDC, TIMS will help TB control programs manage
individual patients, contacts, and persons receiving preventive
therapy.  It will also help state and local managers evaluate their
progress toward meeting TB elimination objectives and identify
obstacles to meeting these objectives. 

CDC has also stressed the importance of program improvement.  In an
October 1993 memo to state and large city TB control officials, the
Director of CDC's Division of Tuberculosis Elimination noted that
almost no improvement has occurred in program performance in the last
3 years.  The memo also encouraged these officials to identify
significant changes or deficiencies in their areas so that program
changes could be made to correct these problems.  A year later, a
second memo from the Director re-emphasized the importance of program
objectives and informed TB field staff that the Director intended to
recommend that future TB cooperative agreement funding decisions be
influenced by applicants' progress in managing their programs and
meeting the TB control objectives specified in their funding
applications. 


   CONCLUSIONS
----------------------------------------------------------- Letter :11

In five of the nation's hardest hit cities, TB control programs have
had difficulty in responding to the resurgence of tuberculosis.  In
many instances, these programs could not ensure that TB patients
would complete the recommended full course of treatment.  Such
failures increase the risk of TB infection as well as TB cases. 
Screening and prevention efforts were also hindered by the need to
focus TB control efforts on identifying and treating active TB
patients. 

The response of local and state governments to the TB problem in
these cities has been limited.  State and local contributions have
fluctuated, declined, or grown slowly in constant dollars; and local
TB officials do not expect increased assistance from these sources. 
As a result, local TB officials are wary of MDR-TB outbreaks in their
cities and uncertain that local resources will be adequate to combat
such emergencies. 

Recent increases in CDC cooperative agreements account for most of
the growth in TB funding.  Federal funding for TB control began to
rise dramatically in 1993, with appropriations more than tripling
between 1993 and 1994.  These increases are helping to improve the
number of patients who complete their full course of treatment by
expanding the use of directly observed therapy.  They are also
helping to improve case reporting, laboratory capability, and the
speed and accuracy of TB diagnosis.  In addition, CDC has implemented
two new information systems that will provide better information on
the spread of TB and help programs better manage TB patients,
contacts, and individuals receiving preventive therapy. 

Will 1993's decline in TB cases continue?  It is clear from our work
that the problem of tuberculosis is severe in certain communities. 
Recent funding increases and CDC's attempts to better monitor TB
activities are promising and may improve TB control.  We encourage
CDC in these efforts.  Through vigilant monitoring, CDC will be
better positioned to provide prompt and effective assistance to
hard-hit cities such as those we visited. 


   AGENCY AND OTHER COMMENTS
----------------------------------------------------------- Letter :12

HHS and TB control officials in Atlanta, Chicago, El Paso, Los
Angeles, and the state of New Jersey reviewed a draft of this and
agreed it is an accurate presentation of TB control efforts.  We
incorporated their technical comments as well as those from four
experts in TB control as appropriate. 


--------------------------------------------------------- Letter :12.1

As agreed with your office, unless you publicly announce its contents
earlier, we plan no further distribution of this report until 30 days
after its issue date.  At that time, we will send copies to others on
request.  If you have any questions about this report, please call me
at (202) 512-7119.  Other major contributors are listed in appendix
V. 

Sincerely yours,

Mark V.  Nadel
Associate Director
National and Public Health Issues


DEMOGRAPHIC AND HEALTH FACTORS
INCREASE TB RATES AND CHALLENGE TB
SERVICE DELIVERY
=========================================================== Appendix I

Treating persons with tuberculosis is often complicated by conditions
such as poverty, AIDS, and substance abuse.  Consequently, TB control
programs have the difficult task of developing and implementing
programs that take into account the social and economic conditions
that coincide with the TB epidemic in their locations. 


   TB GROWS AMONG THE POOR AND
   MINORITY POPULATIONS
--------------------------------------------------------- Appendix I:1

Tuberculosis is an increasing public health problem among America's
racial and ethnic minorities.  In all the cities we visited, TB cases
have been rising rapidly among these populations, who are also more
likely to be poor and experience barriers to obtaining health care
services. 

This growth was most evident among African Americans in Los Angeles,
Newark, and Atlanta and among Hispanics in El Paso.  The growth in TB
cases among African Americans in Los Angeles, Newark, and Atlanta was
more than twice the national growth rate.  Table I.1 shows the growth
of TB cases by race and ethnicity. 



                         Table I.1
          
            Percentage Growth Rates in Reported
           Tuberculosis Cases, United States and
                 Five Communities, 1985-92

Race/                  Los                              El
ethnic  United     Angeles  Chicag          Atlant    Paso
ity     States      County       o  Newark       a    City
------  ------  ----------  ------  ------  ------  ------
Africa      27          76      20      59      59       0
 n
 Ameri
 can
Hispan      75          73      33     113       0      37
 ic
Asian       46          41       6     300       0       0
----------------------------------------------------------
The number of cases is also concentrated among racial and ethnic
minorities in all of these cities.  In 1992, almost 80 percent of
Chicago's TB cases were among either Hispanic or African American
people.  In Los Angeles, about 70 percent of the TB cases were among
either Hispanic or Asian people.  TB cases in El Paso and Newark have
been concentrated in a single racial or ethnic minority group for
several years.  In 1992, 80 percent of Newark's cases were among
African Americans and 91 percent of El Paso's cases were among
Hispanics.  Table I.2 shows the 1992 racial and ethnic distribution
of TB in these communities. 


      CDC URGES RESPONSIVENESS TO
      COMMUNITY NEEDS
------------------------------------------------------- Appendix I:1.1

CDC urges cities with cases concentrated in specific geographic
locations or socioeconomic groups to develop services that are
responsive to community needs.  For example, CDC suggests that
screening and prevention programs be specifically adjusted to such
communities' needs.  It also urges communities to use outreach
workers with appropriate cultural and linguistic skills to locate
patients, perform directly observed therapy, locate and examine
contacts, and educate patients on the importance of treatment
adherence. 


         CASE EXAMPLE:  ATLANTA
         STRUGGLES TO PROVIDE
         SERVICES TO HIGH RISK
         RESIDENTS
----------------------------------------------------- Appendix I:1.1.1

In Atlanta, the TB case rates have exceeded the national average for
over two decades.  Atlanta led the nation's cities with a population
over 250,000 in the number of TB cases in 1992.  Its case rate was
78.2 per 100,000 population.  TB infection continues to be endemic,
particularly among African Americans, who comprised 74 percent of the
cases in 1980 and 87 percent of the cases in 1992.  This group also
accounted for 84 percent of those living below the poverty level in
1979 and 87 percent in 1989. 

This situation has significantly burdened the Fulton County, Georgia,
Health Department which provides public health services to most of
the city of Atlanta.  Among the TB cases seen at the county's single
outpatient TB clinic (about 92 percent of the cases in the county),
approximately 40 percent of the people are HIV-positive and at least
10 percent are homeless. 

According to the TB control officials that we interviewed, systematic
screening and preventive therapy for Atlanta's large at-risk
population is beyond the means of the Fulton County Public Health
Department.  Like most TB control programs, this program must focus
their limited screening and prevention activities on identifying
contacts of new cases.  In addition, the program uses both skin tests
and X rays to evaluate all HIV-positive individuals identified at
Atlanta's largest HIV testing site.  With their remaining resources,
they provide walk-in screening at neighborhood clinics and technical
assistance to other groups such as Fulton County jail staff who
screen inmates.  They also provide testing materials to a group that
screens homeless people. 

Although TB control officials believe that they are making headway in
Atlanta, they are concerned about their inability to mount an
organized prevention program to diminish the large number of
TB-infected individuals. 



                         Table I.2
          
              Percentage of Tuberculosis Cases
             Occurring Among Ethnic and Racial
             Minorities, United States and Five
                     Communities, 1992

Race/                  Los                              El
ethnic  United     Angeles  Chicag          Atlant    Paso
ity     States      County       o  Newark       a    City
------  ------  ----------  ------  ------  ------  ------
Africa      36          17      61      79      87       0
 n
 Ameri
 can
Hispan      20          45      16       9      .3      91
 ic
Asian       14          26       9       2       1       0
----------------------------------------------------------

         CASE EXAMPLE: 
         SOCIOECONOMIC CONDITIONS
         EXACERBATE NEWARK'S TB
         CASE RATE
----------------------------------------------------- Appendix I:1.1.2

In Newark, poverty and high numbers of injection drug users, AIDS
patients, and homeless people contribute to high TB case rates. 
Moreover, TB control officials believe that the city's poor treatment
completion rates are related to the socioeconomic and behavioral
problems seen among Newark's TB patients, many of whom are high risk
and poor minority individuals.  Between 1988 to 1991, close to half
of TB patients did not complete their treatment within desired time
frames.  Although 1992 saw some improvement when this figure declined
to 27.6 percent, TB officials and physicians remain wary.  According
to one official, it is still difficult to detain or commit those who
refuse therapy. 

Low treatment completion rates also add to Newark's multiple
drug-resistant (MDR) TB rates, according to officials.  During the
first quarter of 1991, 13.2 percent of the TB cases tested for MDR in
Newark were resistant to isoniazid and rifampin.  Tests performed
during this same period in 1992 indicated that 9.5 percent of the
cases tested were similarly resistant.  According to an official, who
believes that a large enough MDR outbreak could 'wipe out' the TB
clinic's resources, "MDR-TB will remain a problem until all patients
receive [directly observed therapy]."

TB control officials are also concerned about the spread of MDR-TB to
New Jersey from New York City, where MDR-TB rates are even higher. 
Because of this, the state supplied Newark almost $700,000 in
additional funding for drugs and outreach workers in 1991.  Since
then, Newark's treatment completion rate has improved, but it is
still well below CDC's goal of 90 percent. 


   TB ESTIMATES AMONG THE HOMELESS
   FAR EXCEED THE NATIONAL AVERAGE
--------------------------------------------------------- Appendix I:2

Since the turn of the century, TB has been recognized as a public
health problem among the homeless.  Today, the high incidence of TB
among the homeless can be attributed to medical and socioeconomic
factors such as poor nutrition, alcoholism and overcrowding in poorly
ventilated shelters.  For many homeless persons, substance abuse and
HIV infection increase the risk of developing active TB.  Treating
infected homeless individuals is particularly important since they
are commonly not discovered until they arrive in hospitals with
advanced TB disease that already they may already have spread to
others. 

Although national data are not available, screening activities at
selected shelters and clinics have identified active TB symptoms
among 1.6 to 6.8 percent of the persons tested.  In addition to high
disease rates, screening activities have also found that between 18
and 51 percent of those tested were infected with TB.  These high
levels of infection suggest that, without intervention, cases of
tuberculosis will continue to develop. 

The spread of tuberculosis among the homeless was a problem in all of
the cities we visited.  In Los Angeles, about 12 percent of the TB
patients treated were homeless in 1992.  Similarly, Fulton County,
Georgia, TB officials estimate that about 10 percent of their TB
cases occur among the homeless.  Chicago TB officials estimate that
the homeless comprise about 5 percent of their TB cases. 

CDC has indicated that TB treatment is likely to be more successful
if homeless patients have a reliable source of food and shelter.  CDC
also notes that, when appropriate shelter is unavailable,
hospitalization in an acute care facility may be needed.  In
addition, CDC encourages the screening of homeless people when it is
likely that they will cooperate with screening efforts and complete
preventive therapy if needed. 

All of the cities we visited have provided some TB services to the
homeless.  For example, Fulton County, Georgia, has used state funds
to maintain 15 beds in the Walton House (a single-room occupancy home
for the homeless) for noncontagious homeless TB patients.  Similarly,
in Chicago, CDOH has contracted with an agency that has provided
health care to the city's homeless population for several years to
provide TB screening and preventive services.  In Newark, a Homeless
Health Care Program operated by the city's Community Health Division
supplies TB screening services. 


         CASE EXAMPLE:  LOS
         ANGELES MODEL PROGRAM
         SUGGESTS THAT HOMELESS
         CLIENTS RESPOND WELL TO
         TREATMENT INCENTIVES
----------------------------------------------------- Appendix I:2.0.1

Homeless patients often suffer from physical and mental illness,
addiction, and associated problems that place them at high risk of
developing TB and make successful treatment difficult.  Los Angeles
County currently provides TB services to homeless persons in Central
Los Angeles through a model program operating from the city's skid
row TB clinic.  As part of their clinic activities in this location,
TB control staff provide directly observed therapy and incentives,
such as housing and meal vouchers, to homeless patients to help them
comply with their TB treatment plans.  The housing voucher for a
single-room occupancy hotel in skid row is provided at a cost of $15
per day.  Up to three hot meals a day at a skid row cafeteria are
provided at a cost of $3 per meal.  The total cost per day is about
$24.  The overall cost of the county-funded program is $400,000. 

According to Los Angeles County, 95 percent of the 108 homeless
patients participating have either remained compliant with supervised
drug therapy or successfully completed their treatment.  The program
is considered successful by Los Angeles TB officials, considering the
difficulty in treating homeless TB patients.  According to one
official, more single-room occupancy hotels rooms are needed to
expand this program and meet the needs of homeless TB patients. 


         CASE EXAMPLE:  TRANSIENT
         BEHAVIOR FRUSTRATES
         CHICAGO'S EFFORTS TO
         SCREEN THE HOMELESS
----------------------------------------------------- Appendix I:2.0.2

In 1992, the Chicago Department of Health (CDOH) used CDC cooperative
agreement funds to implement a pilot screening and prevention program
at 12 homeless shelters that the department believed might be housing
some clients with active TB.  For several years, through a contract
with Chicago Health Outreach, Inc., clients have been tested for TB
within 2 weeks of arriving at 21 of Chicago's homeless shelters. 
Clients are also given information about the purpose of the tests and
the importance of follow-up and preventive therapy. 

Clients with positive skin tests are referred to one of the CDOH TB
clinics for further evaluation if they show evidence of active TB. 
TB-infected clients are also provided culturally sensitive HIV
pretest counseling and HIV antibody testing.  Often, a nurse
transports the client to the clinic for the evaluations. 

CDOH TB officials also conducted a one-day screening program aimed at
homeless shelter clients and staff in 1993.  Over 2,405 clients and
shelter staff were screened at 68 percent of Chicago area shelters. 
However, over half of those screened did not return to have their
tests read.  CDOH staff reported that one of the reasons for this
poor participation was the inherent transiency of the shelter
population. 


   SUBSTANCE ABUSERS AT HIGHER
   RISK OF TB INFECTION THAN
   OTHERS
--------------------------------------------------------- Appendix I:3

Substance abusers are also at high risk for tuberculosis infection
due to their poor and often crowded living conditions, high rate of
homelessness, and frequent use of drugs in crowded and poorly
ventilated areas.  Once infected, drug-dependent persons may also be
more likely to develop TB than those who are not drug dependent. 
This higher risk has been attributed to factors, such as HIV
infection, that are often prevalent in drug-dependent populations. 

Three of the cities we visited indicated that substance abuse was an
important factor in their TB caseload.  Chicago officials estimate
that almost 10 percent of their cases are among those with chronic
substance abuse problems.  Fulton County officials reported that
cocaine usage was a problem among many of their TB patients; and TB
officials in New Jersey included injecting drug use among the
societal problems contributing to high TB rates in Newark. 


         CASE EXAMPLE:  DESPITE
         FEDERAL REQUIREMENT, SOME
         TB-INFECTED SUBSTANCE
         ABUSERS IN LOS ANGELES
         ARE NOT RECEIVING
         PREVENTIVE THERAPY
----------------------------------------------------- Appendix I:3.0.1

In March 1993, the Secretary of the Department of Health and Human
Services required treatment centers receiving funding from the
substance abuse prevention and treatment block grant to refer their
clients to TB services.  However, this requirement appears to have
had limited impact in Los Angeles.  Most of those found to be
infected with TB are referred to the county health centers because
the drug treatment facilities do not have sufficient resources to
provide preventive therapy.  However, no mechanism exists to ensure
that these individuals follow up on their referral, and those who do
sometimes wait weeks for their appointments. 


   TB TREATMENT AND PREVENTION
   SERVICES NEEDED IN CORRECTIONAL
   FACILITIES
--------------------------------------------------------- Appendix I:4

TB remains a public health problem in correctional facilities, where
overcrowding and high levels of TB infection can increase the risk of
TB transmission.  According to one CDC survey, based on data
collected between 1984 and 1985, the incidence of TB in correctional
facilities was more than three times higher than it was among persons
between the ages of 15 and 64 living outside of correctional
facilities. 

Jail inmates, many of whom are high-risk minorities, HIV infected, or
substance abusers, are at extremely high risk for TB and can pose
difficulties for their communities.  For instance, according to the
public health commissioner of El Paso, Texas, El Paso could face a TB
epidemic or MDR-TB outbreak because of the high number of HIV
positive and MDR-TB-infected detainees who pass through the El Paso
immigration and naturalization facility. 

For these reasons, CDC urges public health departments to maintain
records on TB cases that have been identified in correctional
facilities in their area.  CDC also urges public health departments
to work with correctional staff to arrange continuing TB treatment
and preventive therapy for released inmates. 

All of the cities we visited have correctional facilities in their
areas.  In two of the cities, Los Angeles and Chicago, county jail
health service staff provide treatment services.  TB screening occurs
in jails in these communities; and the facilities in Los Angeles and
Chicago have been leaders in using X rays to quickly identify active
TB cases. 


         CASE EXAMPLE:  CHICAGO IS
         ADDRESSING PROBLEMS WITH
         COORDINATION THROUGH
         COOPERATIVE EFFORT
----------------------------------------------------- Appendix I:4.0.1

Between 1986 and 1991, TB screening activities at Cook County Jail
identified 96 inmates with active TB.  While in jail, these patients
received treatment from Cook County's Cermak Health Services, which
provides medical services at the jail.  Upon their release, inmates
were instructed to go to the nearest CDOH clinic for further
treatment.  In 1990, CDOH TB clinics questioned its patients about
confinement in the Cook County Jail.  Over 21 percent of the TB
patients questioned in 1990 indicated that they had at one time or
other been confined in Cook County Jail. 

Until recently, CDOH and Cermak Health Services faced difficulties
coordinating their activities.  In some instances, the jail released
inmates without notifying either Cermak Health Services or CDOH of
their action.  Without this notification, it was difficult for CDOH
to perform the follow-up needed to ensure that released inmates
received treatment.  In other instances, follow-up by CDOH was
difficult because inmates used pseudonyms or incorrect addresses. 
Cermak Health Services also reported difficulty referring released
inmates with TB infection to CDOH for preventive therapy. 

CDOH and the jail have recently improved the follow-up problem
through assignment of two outreach workers to the jail's health
services.  The outreach workers, supported through CDC cooperative
agreement funds, will trace and test contacts of the TB cases and
ensure follow-up treatment for inmates who are released from jail. 
In addition, follow-up of active TB cases has also improved with the
advent of the city's computerized TB network.  Now, upon an inmate's
release, Cermak notifies CDOH's TB office and other providers by
entering release data into the network.  Also, Cermak schedules an
appointment at one of the TB clinics for the released inmate and in
some cases provides a $10 incentive to the inmate upon arrival at the
clinic for treatment. 


   CASES OF TB AMONG FOREIGN-BORN
   REFLECT MAJOR GLOBAL PROBLEM
--------------------------------------------------------- Appendix I:5

The presence of a large foreign-born population in a community can
significantly influence TB incidence when many of these individuals
come from countries with high TB rates.  Foreign-born individuals can
arrive in the United States already infected with TB or with TB that
has been inadequately treated, in which case they are at risk of
developing drug-resistant disease.  For this and other reasons,
foreign-born individuals today account for more than one-fourth of
U.S.  TB cases.  Those with tuberculosis infection or clinical
disease who illegally enter the country pose another, even more
difficult problem.  No mechanism exists for screening these persons
for TB before they enter the United States, and they are likely to
avoid official public agencies once they are in the country because
of fear of deportation. 

High TB rates in other nations are particularly affecting TB control
activities in three of the cities we visited.  Although the number of
new TB cases in the foreign-born population decreased by 59 percent
from 1982 to 1990 in Chicago, this trend has reversed, and in 1992,
foreign-born cases comprised 16.4 percent of Chicago's cases.  Over
one-third of these persons were from Mexico, the Philippines, Poland,
India, Vietnam, and Korea--parts of the world where TB is endemic. 
All the cities we visited have foreign-born populations, but the high
rates of TB in other countries has affected El Paso and Los Angeles
most dramatically. 


         CASE EXAMPLE: 
         INTERNATIONAL COOPERATION
         MAY IMPROVE EL PASO'S TB
         PROBLEMS ON THE
         U.S.-MEXICO BORDER
----------------------------------------------------- Appendix I:5.0.1

El Paso is particularly vulnerable to TB infection through
unidentified contagious TB cases residing across the border. 
Seventy-five percent of El Paso's newly diagnosed patients identify
contacts in Juarez, and 80 percent of the pediatric cases diagnosed
in El Paso were linked to TB cases in Mexico.  Since 1985,
approximately 40 to 50 percent of El Paso's TB patients are
foreign-born, coming mainly from Mexico. 

According to the World Health Organization, TB rates in Mexico are
currently 110 per 100,000, compared with 10 per 100,000 in the United
States.  Studies of undocumented Mexican and Central American aliens
since 1974 produced similar numbers.  As noted in a document prepared
by the El Paso City-County Health District, this ratio suggested the
possibility of 635 individuals in Juarez with active TB. 

Drug-resistant TB is also a problem in Mexico, and, according to one
El Paso health official, it is "impossible to keep this problem on
one side of the border." A binational strategy has been developed
that may mitigate many of the difficulties faced by El Paso's TB
control program.  Known as the Juntos project, funded by CDC, and
coordinated by the Pan American Health Organization, this program is
intended to help El Paso and be a model for other United States
border towns and cities that must deal with the influx of TB cases
from Mexico.  The underlying premise of the project is that TB
eradication cannot succeed in the United States without effective
prevention and control efforts in high incidence area such as the
United States-Mexico border. 

Juntos program activities include case finding, screening, treatment,
case management, follow-up, and prevention education.  According to a
1993 program review of this binational project, much progress has
been made toward implementing a program for treating active TB
patients in the Ciudad Juarez health centers.  Moreover, this
binational effort has improved the access and continuity of care of
TB cases as those infected cross between the two nations. 
Recommendations for improvements include more complete daily
supervision of patients receiving directly observed therapy and
developing a TB case registry that includes the same data for TB
cases in both nations. 


         CASE EXAMPLE:  SHEER
         VOLUME OF FOREIGN-BORN
         OVERWHELMS LOS ANGELES'
         SYSTEM
----------------------------------------------------- Appendix I:5.0.2

In 1992, about 92,000 legal immigrants came into Los Angeles from
many countries.  Local doctors, designated by U.S.  embassies and
consulates, screen these persons for active TB with chest X rays
before they arrive in this country.  Skin tests are usually not
required, and TB infection without active disease is not grounds for
denying legal entrance into the United States.\32

Consequently, Los Angeles TB control officials do not know the extent
of TB infection among foreign-born individuals in Los Angeles. 
However, a Los Angeles TB control official estimated that about half
of the legal immigrants who enter Los Angeles County are infected
with TB. 

According to one TB control official, incidents of fake X rays and
poor-quality X rays, that are impossible to read, have occurred. 
Ideally, according to one TB control official, the Immigration and
Naturalization Service could assist the TB control program in its
efforts to identify individuals from countries with endemic TB.  He
added

     "Of course, if all legal immigrants were referred to the county
     for screening and preventive treatment, the system would
     collapse under the strain."

Expansion of TB screening at "English as a Second Language Schools"
in 1995 will help this problem, although it will only reach a
fraction of these students in Los Angeles. 


--------------------
\32 Skin tests, however, are required if the person in question is
under 15 years of age and ill or in close contact with a family
member with suspected tuberculosis. 


   HIV IS A MAJOR FACTOR IN RISING
   NUMBER OF TB CASES
--------------------------------------------------------- Appendix I:6

The rapid spread of HIV and AIDS during the 1980s is generally cited
as a major factor in the increase of TB in the United States. 
According to CDC, approximately 10 percent of the estimated 1 million
HIV-positive people in the United States are also infected with TB. 
While HIV does not seem to increase the risk of infection, it does
appear to accelerate the progression from infection to active
disease.  For this reason, the risk of coinfected people developing
TB is estimated at about 8 percent per year.  The risk among
HIV-negative persons is estimated at about 5 to 10 percent during
their lifetime. 

The association between TB and HIV creates several problems for local
health departments.  TB diagnosis is more difficult, and the longer
time frames needed to identify drug-resistant patients have
contributed to unusually high mortality rates among HIV- positive
patients in MDR-TB outbreaks in institutional settings.  CDC has
reported that nine MDR-TB outbreaks in hospitals and correctional
facilities have resulted in direct transmission of MDR-TB to other
patients and health care workers.  In eight of these outbreaks, 82 to
100 percent of the patients were HIV infected.  Mortality in these
eight outbreaks was extremely high, ranging from 72 percent to 93
percent, and the median interval until death was 4 weeks at six of
the locations. 

TB control officials we interviewed expressed concern about the
relationship between HIV and tuberculosis in their cities.  In Fulton
County, 40 percent of persons with TB are HIV positive, and officials
predict a continued increase in TB rates "given the hidden factor of
HIV." In Newark, TB officials believe that rates will continue to
climb due in part to the city's high prevalence of HIV.  Although
city statistics are unavailable, New Jersey officials suspect that
coinfection in Newark is at or above the estimated statewide rate of
12 to 15 percent.  Officials in El Paso were also concerned about the
growth of the HIV-TB coinfected population, with coinfection rates in
the county continuing to rise from less than 1 percent of total cases
in 1986 to almost 17 percent for the first 9 months of 1993. 
Although the 1992 estimated coinfection rate in Los Angeles was lower
at 12.4 percent, the city had 273 coinfected cases. 


         CASE EXAMPLE:  DESPITE
         HIV ACTIVITIES, LOS
         ANGELES REACHES ONLY A
         FRACTION OF ITS OVERALL
         HIV POPULATION
----------------------------------------------------- Appendix I:6.0.1

Los Angeles County's TB control program devotes staff to working with
HIV/AIDS service providers, jails, shelters, and hospices.  The
county TB control program employs two public health nurses fulltime
to work with HIV/AIDS service providers to offer appropriate TB
services for their patients.  These providers include the county's 16
HIV Early Intervention Clinics funded by federal Title I Ryan White
funds and AIDS shelters and hospices.  These two nurses also work
with the county's health centers to encourage testing for both HIV
and TB infection.  The Los Angeles County jail now has a skin testing
program for prisoners who are HIV positive.  However, problems have
included the release of prisoners before skin tests can be read and
the refusal of others to comply with preventive therapy.  For other
prisoners, skin tests are not done because most prisoners are not
around long enough to determine the results, let alone to
preventively treat them for TB infection for 6 months.  The TB
control office also works with 30 AIDS shelters and hospices to
ensure that these facilities screen for TB and that those with
infectious TB do not reside in these settings.  At these AIDS
shelters and hospices, those with nonactive TB are also monitored to
make sure that they stay on their medication to remain noninfectious. 

Beginning in June of 1992, the TB control office began to work with
HIV Early Intervention Clinics (funded with federal Ryan White
monies) to screen for TB.  However, even with this program, a TB
official noted that most individuals coming to these clinics are not
"early" in the progression of their disease and estimate that they
are only reaching a fraction of the HIV-positive population living in
Los Angeles County.  According to this official, another problem is
that despite CDC recommendations, private doctors at these early
intervention clinics will not begin these patients on preventive
therapy without a positive skin test reaction. 


INFRASTRUCTURE ISSUES AFFECT TB
CONTROL EFFORTS
========================================================== Appendix II

Effective TB control throughout the United States requires an
investment in human resources, facilities, and information systems. 
An adequate number of staff is critical for ensuring that programs
provide screening, prevention, and treatment services.  TB services
should be readily accessible and provided in facilities that minimize
the potential for transmitting the disease.  Lastly, information
systems are essential for monitoring and evaluating TB efforts. 

The five TB programs we visited faced problems maintaining an
infrastructure for effective TB control.  Infrastructure problems
ranged from inadequate staffing levels to outdated equipment.  We
observed many of these problems in our visits to TB clinics, and TB
control officials noted many of the same problems during our
interviews.  In addition, evaluations of the TB programs over the
years have also cited infrastructure problems.  Although TB programs
may have addressed some of these problems, we include them to
illustrate the difficulties TB control programs have had responding
to the rise in tuberculosis. 


   STAFF SHORTAGES HINDER
   PROGRAMS' ABILITY TO RESPOND TO
   RISING TB RATES
-------------------------------------------------------- Appendix II:1

Most of the communities reported that staffing shortages have
affected their ability to respond to the TB epidemic.  Factors
influencing staff shortages include hiring freezes and attrition.  In
addition, TB program officials reported that the traditionally low
salaries of public health departments have limited their ability to
hire staff.  Officials also cited difficulties recruiting staff with
necessary management skills.  Consequently, staff shortages, in part,
affected the TB programs' ability to coordinate with other TB
providers.  Lastly, competing public health priorities affected the
availability of staff to provide TB services. 


   HIRING FREEZES, ATTRITION, AND
   LOW SALARIES CONTRIBUTE TO
   STAFFING SHORTAGES
-------------------------------------------------------- Appendix II:2

Some of the communities we visited experienced hiring freezes, which
affected their TB programs.  For example, in April 1992, Los Angeles
County imposed a hiring freeze on all positions, including federally
funded ones.  As a result, the TB office was prevented from using
over $1 million in federal funds for hiring critical staff for the
health centers that provided TB services. 

In December 1992, the hiring ban was lifted but reinstated the
following April.  This time, federally funded positions were exempted
from the freeze; however, the TB program was still affected.  In
1993, a Blue Ribbon Panel convened by the director of the Los Angeles
County Department of Health Services concluded,

     "dealing with hiring freezes.  .  .has taken time and energy
     from important (TB) control work; contributed to the
     underutilization of federal funds; and (led to) diminished
     morale."

The panel noted that between April 1, 1992, and January 31, 1993,
$1,128,583 in federal tuberculosis funds were not spent; $673,027
were rolled forward and thus available in 1993-1994, still leaving an
estimated $455,556 unused.  According to CDC, in such cases, these
funds are not lost:  a grantee can request approval for using the
funds for TB-related activities.  If CDC receives no such request
from the grantee, it uses the funds to offset next year's award. 

Attrition is another staffing issue that may compromise the ability
of TB control programs to respond to the increased incidence of TB. 
For example, when we visited one Chicago TB clinic, only one doctor
was available to treat all TB patients because the second one had
resigned earlier that year and had not yet been replaced.  This
situation resulted in a heavy patient caseload, which placed demands
upon the staff and patients alike.  For example, on peak days, this
one physician often evaluated from 30 to 40 patients; nurses often
worked through their lunch hours to assist with patient care; and
patients may have waited several hours to see the physician. 

Lastly, TB control officials in Fulton County and Newark stated that
the low salaries in public health departments limit their ability to
hire qualified staff.  For example, Fulton County's TB director said
that the county and the state of Georgia have difficulty recruiting
public health professionals, specifically physicians, due to low
salaries. 


      TB PROGRAMS HAVE DIFFICULTY
      FINDING STAFF WITH PROGRAM
      MANAGEMENT EXPERIENCE
------------------------------------------------------ Appendix II:2.1

Some of the TB programs we visited also had difficulty attracting
staff with the skills necessary to manage TB control programs.  In
instances such as these, CDC assigns public health advisers (PHA),
CDC staff with expertise in program operations and epidemiological
skills, to health departments in need of such expertise.  Three of
the TB programs we visited currently have PHAs assigned.  In Chicago
and Los Angeles, PHAs hold senior managerial positions in the local
TB control programs and have held those positions for several years. 
For example, Chicago's TB director is a CDC employee who has managed
the Chicago Department of Health's (CDOH) TB program for more than 10
years.  In 1992, a PHA was assigned to Fulton County Health
Department.  Since she was appointed in November 1992, she has
supervised 14 outreach workers who identify contacts, make sure
patients keep their appointments, and provide directly observed
therapy to the same patients. 


      STAFFING SHORTAGES AFFECT
      COORDINATION AMONG TB
      PROVIDERS
------------------------------------------------------ Appendix II:2.2

Staff shortages can also affect coordination among service providers. 
Treatment is provided in a variety of settings, such as hospitals,
correctional facilities, and clinics.  Several of the TB programs we
visited had difficulty coordinating TB services among the various
health care providers and settings in their communities. 

In Chicago, for example, the CDOH TB program is responsible for
protecting people from the effects of TB.  In 1992, 65 local
hospitals and private physicians diagnosed 88 percent of the city's
TB patients and treated about two-thirds.  Chicago area health
officials reported that some patients with TB may be lost in this
maze of health care providers and may not complete treatment within
recommended time frames.  Although CDOH maintains a citywide
surveillance network and central TB case registry, a CDOH official
reported that due to staff shortages and time constraints CDOH does
not always follow up to ensure that patients receive and complete
treatment.  This is one of the factors contributing to Chicago's
historically low treatment completion rates. 


      TB PROGRAMS OFTEN COMPETE
      WITH OTHER HEALTH PROGRAMS
      FOR STAFF
------------------------------------------------------ Appendix II:2.3

Competing health department priorities often affect the availability
of TB staff.  In both Chicago and Los Angeles, TB staff may also
provide other health services.  For example, in the 41 Los Angeles
County health clinics and subcenters, public health staff are
responsible for many different disease programs, including TB, and
staff are not dedicated to TB alone.  As cited in Los Angeles
County's cooperative agreement application,

     "although not intended .  .  .  this has resulted in a reduction
     in the extent and quality of tuberculosis program activities and
     .  .  .  in a stringency of TB expertise at the health center
     level."


   INADEQUATE FACILITIES AND
   EQUIPMENT HAMPER TB CONTROL
   EFFORTS
-------------------------------------------------------- Appendix II:3

Health care facilities where those with infectious disease are likely
to be seen must have adequate ventilation as well as appropriate
space and equipment to provide safe and effective TB care.  Several
of the TB control programs we visited could not ensure, however, that
their facilities were designed and maintained to minimize TB
transmission.  For example, in El Paso three program employees in the
past year who had had a negative TB skin test tested positive,
indicating recent TB infection.  These three test results indicate
that TB transmission may have occurred at work.  A recent
environmental assessment also produced 14 recommendations for
improvements in air quality control at the city's TB clinic.  A
program review of Los Angeles County's TB control program also cited
inadequate ventilation in some outpatient clinics. 

Ensuring a safe environment for TB treatment is particularly
important for patients with a weakened immune system.  In both the El
Paso TB clinic and one of Chicago's TB clinics, patients of the
HIV/AIDS and TB clinics share the same waiting room.  This situation
is of concern because HIV infection is the strongest risk factor for
progression from TB infection to active TB disease.  In some of these
cases, patients can die before TB treatment can begin. 

In addition to inadequate ventilation and isolation, some of the TB
clinics also lacked modern equipment.  Diagnostic X ray equipment is
critical in detecting cases of active TB and in following response to
treatment.  However, two of the communities we visited at one time
lacked adequate or modern X ray machines.  For example, until a few
years ago, Fulton County TB clinic's sole X ray machine was a World
War II-era machine.  The machine was so antiquated that younger
technicians did not know how to operate it.  An evaluation of the Los
Angeles County TB program cited nonfunctioning X ray machines at some
clinics and recommended that they be replaced. 

CDC requirements for a "model TB center" state that TB services
should be readily accessible to persons with TB.  In both Fulton
County and El Paso, only one health department clinic provided
treatment to patients with active TB.  Although Chicago has three
clinics for treating active cases, it may take a patient over 2 hours
to get to a clinic by public transportation. 


   TB SURVEILLANCE AND MONITORING
   ACTIVITIES MINIMIZED BY
   OUTDATED INFORMATION SYSTEMS
-------------------------------------------------------- Appendix II:4

An essential function of all TB control programs is the assessment,
surveillance, and monitoring of TB cases and contacts.  Effective
information systems are necessary for maintaining TB case registries,
generating program management data, and tracking TB cases and
contacts.  Several of the TB programs we visited did not have
efficient information systems.  For example, in El Paso, when we
requested information on patient demographics, staff had to sort
through the patient records and hand count and tally the information. 

The Fulton County TB program relies on a 1960s mainframe computer to
update patient information every 6 weeks.  A 1991 evaluation found
that the system does not allow the TB program to monitor delinquent
appointments or analyze TB trends.  Fulton County TB officials
referred us to the state of Georgia's TB control program for trend
data.  Similarly, a program review of Los Angeles County's TB program
reported that the program's mainframe system was inflexible, slow,
and expensive to alter and contained incomplete data.  The review
reported that as a result, Los Angeles County TB officials lack
important management data for evaluating and planning program
activities. 


METHODOLOGY USED TO ESTIMATE TB
EXPENDITURES THROUGH 1999
========================================================= Appendix III

One goal of this review was to estimate expenditures for TB treatment
for 1995 through 1999.  To accomplish this goal, we identified
baseline data for TB expenditures, simulated TB expenditure growth
under a variety of assumptions, and examined the sensitivity of our
results to the choice of assumptions.  Our simulations show that TB
spending could double from 1991 levels if current trends continue. 

We used CDC estimates of costs in 1991 as a baseline for treatment
expenditures.  In a report prepared for the CDC, Battelle Medical
Technology Assessment and Policy Research Center estimated the direct
costs of treating TB in 1991.\33 This report included the following
direct costs:  CDC surveillance and outbreak control; screening and
follow-up examinations; contact investigations; preventive treatment;
outpatient treatment for suspected cases, drug-susceptible cases,
multiple drug-resistant (MDR) cases and other drug-resistant cases;
and inpatient hospitalization treatment with related physician
services.  Indirect costs (such as productivity losses due to death
and disability) as well as research and capital expenditures were not
included.  Inpatient care accounted for much of the costs of TB
treatment and were estimated using a 16-state data set of all payers
and all discharges from short-stay hospitals for a principal
diagnosis of TB.  Battelle extrapolated these results to the total
U.S.  population. 

To project these costs into the future, we made the following
assumptions: 

Caseloads will grow at the same annual rate as active reported cases
from 1988 to 1991, an average annual rate of 5.5 percent.\34

Costs per case for outpatient and preventive services will rise at
the average rate of growth for the medical care Consumer Price Index
(CPI) from 1980 to 1991, less the average annual Consumer Price
Index-Urban (CPI-U) growth rate for the same period.  This
calculation gives the rate of medical cost growth above the general
inflation rate in the economy as a whole.  The medical CPI average
growth rate was 8.13 percent for 1980 to 1991, while the CPI-U grew
at an annual rate of 4.67 percent.  Our annual rate of medical cost
growth, above the general inflation rate, is 3.46 percent. 

Costs per case for inpatient care will grow at the 1980-91 average
annual rate of growth for total hospital costs, adjusted for
inflation.  That rate was 5 percent per year. 

The CDC budget for TB will grow at the same annual rate as the cost
per case for outpatient and preventive services. 

Federal, state, and local governments will continue to share the same
proportion of inpatient costs as the 1990 data used by CDC.\35

The results of our simulations are summarized in table I.1.  Under
these assumptions, total expenditures will grow from about $700
million in 1991 (the baseline estimate Battelle reported to CDC) to
over $1.5 billion by 1999 (in 1991 dollars)).  Inpatient expenditures
will account for most of the spending, totaling over $982 million in
1999. 



                        Table III.1
          
          Expenditure Projections for TB Treatment

               (In millions of 1991 dollars)

              1991    1995    1996    1997    1998    1999
----------  ------  ------  ------  ------  ------  ------
CDC TB        $6.3    $7.2    $7.5    $7.7    $8.0    $8.3
 budget
Prevention    78.4   111.3   121.4   132.5   144.7   157.9
Outpatient   182.1   258.4   282.0   307.8   335.9   366.7
 care
Inpatient    434.9   653.6   723.7   801.3   887.2   982.3
 care
Total       $701.7  $1,030  $1,134  $1,249  $1,375  $1,515
                        .5      .6      .4      .8      .2
----------------------------------------------------------
To test the sensitivity of our results and to account for a recent
decline in the number of active TB cases reported, we altered our
first assumption and allowed caseloads to grow at the same annual
rate as active reported cases from 1988 to 1993.  This allowed us to
incorporate two additional years of actual experience into our
forecast.  Based on this new assumption, the average annual caseload
growth rate declined from 5.5 to 2.5 percent, but projected 1999
expenditures only declined from $1.5 to $1.2 billion. 



(See figure in printed edition.)Appendix IV

--------------------
\33 "Estimate of Identifiable Direct Costs of Tuberculosis in the
United States in 1991," prepared for the Centers for Disease Control
and Prevention by Battelle Medical Technology Assessment and Policy
Research Center, (Washington, D.C.:  1993), p.  v. 

\34 Other growth rates in this analysis were computed for 1980 to
1991.  We excluded caseload growth rates for 1980 to 1987 because
cases were steady or declining.  Recent trends better reflect the
recent resurgence in TB growth and are, therefore, better indicators
of future growth.  Because we are interested in the consequences of
rising caseloads, we calculated the trend based on 1988-91 data. 

\35 Battelle, p.  C-8. 


COMMENTS FROM THE PUBLIC HEALTH
SERVICE
========================================================= Appendix III


GAO CONTACTS AND STAFF
ACKNOWLEDGMENTS
=========================================================== Appendix V

GAO CONTACTS

Rose Marie Martinez, Assistant Director, (202) 512-7103
Jennifer Weil Arns, Evaluator-in-Charge, (312) 220-7697
Nancy Donovan, Assignment Manager, (202) 512-7136

ACKNOWLEDGMENTS

In addition to those named above, the following individuals also made
important contributions to this report by managing the case studies
and data collection for the five locations we visited:  Debra Carr,
Madeline Chulumovich, Howard Cott, Cassandra Gudaitis, and Cynthia
Hooten.  Susan Lawes provided advice on data collection and analysis
and Patrick Redmon performed the TB cost estimates.  Catherine
Colwell referenced the report. 

