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Trends in Tuberculosis — United States, 2013

March 25, 2014 Comments off

Trends in Tuberculosis — United States, 2013
Source: Morbidity and Mortality Weekly Report (PDF)

In 2013, a total of 9,588 new tuberculosis (TB) cases were reported in the United States, with an incidence rate of 3.0 cases per 100,000 population, a decrease of 4.2% from 2012 (1). This report summarizes provisional TB surveillance data reported to CDC in 2013. Although case counts and incidence rates continue to decline, certain populations are disproportionately affected. The TB incidence rate among foreign-born persons in 2013 was approximately 13 times greater than the incidence rate among U.S.-born persons, and the proportion of TB cases occurring in foreign-born persons continues to increase, reaching 64.6% in 2013. Racial/ethnic disparities in TB incidence persist, with TB rates among non-Hispanic Asians almost 26 times greater than among non-Hispanic whites. Four states (California, Texas, New York, and Florida), home to approximately one third of the U.S. population, accounted for approximately half the TB cases reported in 2013. The proportion of TB cases occurring in these four states increased from 49.9% in 2012 to 51.3% in 2013. Continued progress toward TB elimination in the United States will require focused TB control efforts among populations and in geographic areas with disproportionate burdens of TB.

See also: Implementation of New TB Screening Requirements for U.S.-Bound Immigrants and Refugees — 2007–2014

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CRS — The President’s Emergency Plan for AIDS Relief (PEPFAR), U.S. Global HIV/AIDS, Tuberculosis, and Malaria Programs: A Description of Permanent and Expiring Authorities

October 1, 2013 Comments off

The President’s Emergency Plan for AIDS Relief (PEPFAR), U.S. Global HIV/AIDS, Tuberculosis, and Malaria Programs: A Description of Permanent and Expiring Authorities (PDF)
Source: Congressional Research Service (via Federation of American Scientists)

Fighting HIV/AIDS, tuberculosis (TB), and malaria globally is a priority for Congress. The 108th and 110th Congresses enacted two pieces of legislation that have shaped U.S. responses to these diseases: P.L. 108-25, the United States Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act of 2003 (Leadership Act), and P.L. 110-293, the Tom Lantos and Henry J. Hyde United States Global Leadership Against HIV/AIDS, Tuberculosis, and Malaria Reauthorization Act of 2008 (Lantos-Hyde Act). The Leadership Act authorized $15 billion to be spent from FY2004 through FY2008 on fighting HIV/AIDS, TB, and malaria. The Lantos-Hyde Act amended the Leadership Act to authorize $48 billion for fighting the three diseases from FY2009 through FY2013.

The Leadership Act (and the legislation that it amends) is the primary vehicle through which U.S. global assistance for fighting these diseases is authorized. The Lantos-Hyde Act mostly amends the Leadership Act, though it amends some other acts, such as the Foreign Assistance Act of 1961, and includes some stand-alone authorities. The Leadership Act and the Lantos-Hyde Act (primarily through amendments to the Leadership Act) created frameworks for how the funds should be spent, established program goals and targets, and established coordinating offices for managing government-wide responses.

The Leadership Act required the President to establish the Coordinator of the United States Government Activities to Combat HIV/AIDS Globally (known as the Global AIDS Coordinator) at the Department of State. Congress appropriates the bulk of global HIV/AIDS funds to the Office of the Global AIDS Coordinator, which leads the President’s Emergency Plan for AIDS Relief (PEPFAR). The Global AIDS Coordinator distributes the majority of these funds to U.S. federal agencies and departments and multilateral groups like the Global Fund to Fight AIDS, Tuberculosis and Malaria. The Lantos-Hyde Act amended the Leadership Act to establish the Coordinator of the United States Government Activities to Combat Malaria Globally (known as the Malaria Coordinator) at the U.S. Agency for International Development (USAID) to oversee implementation of related efforts by USAID and the Centers for Disease Control and Prevention. Some authorities within these Acts are enduring, such as those that created the Global AIDS and Malaria Coordinator positions (Leadership Act, as amended) and permitted U.S. participation in advance market commitments for vaccine development (Lantos-Hyde Act). Other authorities, however, are set to expire, such as language authorizing funding for global HIV/AIDS, TB, and malaria programs.

This report explains which authorities within the Leadership and Lantos-Hyde Acts are set to expire and which are permanent. Table A-1 in the Appendix A offers a side-by-side comparison of the Leadership Act in its original form and the Lantos-Hyde Act, which amends the Leadership Act and other legislation. A third column explains which sections are set to expire and summarizes language in S. 1545 and H.R. 3177 that amend the Leadership Act, as amended. The Leadership Act, as amended and Lantos-Hyde Act include comprehensive reporting requirements. Table A-2 in the Appendix A lists the reporting requirements and describes the extent to which the Administration has complied with the requirements.

Rather than revisit some of the contentious issues that dominated debate when crafting the Lantos-Hyde Act, House and Senate Members introduced legislation (H.R. 3177 and S. 1545) that is narrowly aimed at key priorities: enhancing oversight of U.S. global HIV/AIDS, TB, and malaria programs; authorizing appropriations for the Global Fund through FY2018; and allocating a portion of HIV/AIDS funds for orphans and vulnerable children (OVC) and for HIV/AIDS treatment and care. Table B-1 in Appendix B summarizes key amendments in the bills, entitled the PEPFAR Stewardship and Oversight Act.

CRS — U.S. Global Health Assistance: Background and Issues for the 113th Congress

July 5, 2013 Comments off

U.S. Global Health Assistance: Background and Issues for the 113th Congress (PDF)
Source: Congressional Research Service (via U.S. Department of State Foreign Press Center)

Congressional support for global health programs has been increasing, particularly during the George W. Bush Administration. Combined global health funding from State-Foreign Operations, Labor-HHS and Defense appropriations rose from $1.7 billion in FY2001 to $8.9 billion in FY2012. The FY2013 Consolidated Appropriations Ac t (P.L. 113-6) includes approximately $8.4 billion for global health programs funded through State-Foreign Operations appropriations, up from $8.2 billion in FY2012. (FY2013 funding levels will likely change, however, due to sequestration.) These funds support global health programs implemented and managed by the U.S. Agency for International Development (USA ID), State Department and the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund)—a multilateral organization aimed at fighting HIV/AIDS, TB, and malaria worldwide. The act does not specify how much should be spent on global health programs through other appropriations.

Concern about infectious diseases, especially HIV/AIDS, has driven much of the budgetary increases. Excluding funding for the Global Fund, roughly 34% of the FY2001 U.S. global health budget was aimed at programs that address HIV/ AIDS. By 2012, about 57% of U.S. global health spending was aimed at fighting HIV/AIDS worldwide, and the FY2014 budget request calls for nearly 54% of global health spending to be aimed at the disease.

In the 112 th Congress, concerns about the strength of the U.S. economy and federal spending precipitated discussions about the role and effica cy of U.S. foreign aid, including global health programs. Critics began to push for U.S. global health programs to demonstrate impact and improve cost-efficiency. At the same time, supporters underscored the advances U.S. global health programs had made, the millions of lives saved in part with U.S. resources, and the promise of innovative health solutions. It is likely that this debate will continue in the 113 th Congress. Other issues the 113 th Congress may face include

  • deliberating funding levels for U.S. global health programs;
  • examining U.S. leadership of U.S. global health programs;
  • maintaining global HIV/AIDS commitments;
  • deliberating the reauthorization of the President’s Emergency Plan for AIDS Relief (PEPFAR) in FY2013; and
  • determining the appropriate mix of multilateral and bilateral spending for global HIV/AIDS, TB, and malaria programs.

Trends in Tuberculosis — United States, 2012

March 22, 2013 Comments off

Trends in Tuberculosis — United States, 2012

Source: Morbidity and Mortality Weekly Report (CDC)

In 2012, a total of 9,951 new tuberculosis (TB) cases were reported in the United States, an incidence of 3.2 cases per 100,000 population. This represents a decrease of 6.1% from the incidence reported in 2011 and is the 20th consecutive year of declining rates. Of the 3,143 counties in the United States, 1,388 (44.2%) did not report a new TB case during 2010–2012. This report summarizes provisional TB surveillance data reported to CDC’s National Tuberculosis Surveillance System in 2012. The TB rate in foreign-born persons in the United States was 11.5 times as high as in U.S.-born persons. In comparison with non-Hispanic whites, TB rates among non-Hispanic Asians, Hispanics, and non-Hispanic blacks were 25.0, 6.6, and 7.3 times as high, respectively. Although the number of cases dropped below 10,000 for the first time since standardized national reporting of TB began in 1953, a number of challenges remain that slow progress toward the goal of TB elimination in the United States. Initiatives to increase TB awareness and testing and treatment of latent infection and disease will be critical to TB elimination efforts, especially among foreign-born populations, racial/ethnic minorities, and other groups that are disproportionately affected.

CRS — U.S. Response to the Global Threat of Malaria: Basic Facts

June 19, 2012 Comments off

U.S. Response to the Global Threat of Malaria: Basic Facts (PDF)
Source: Congressional Research Service (via Federation of American Scientists)

In 2010, malaria infected an estimated 216 million people and killed 655,000 people, most of whom were children under the age of five in sub-Saharan Africa. Despite the current burden of disease, malaria is preventable and treatable. Congress has increasingly recognized malaria as an important foreign policy issue, and the United States has become a major player in the global response to the disease. In its second session, the 112 th Congress will likely debate the appropriate funding levels and optimum strategy for addressing the continued challenge of global malaria.

Congress has enacted several key pieces of legislation related to global malaria control. These include the Assistance for International Malaria Control Act of 2000 (P.L. 106-570); the U.S. Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act of 2003 (P.L. 108-25); and the Tom Lantos and Henry J. Hyde United States Global Leadership Against HIV/AIDS, Tuberculosis, and Malaria Reauthorization Act of 2008 (P.L. 110-293). These acts have authorized funds to be used in the fight against malaria and have shaped the ways in which U.S. malaria programs are coordinated and managed, including through the creation of the U.S. Global Malaria Coordinator at the United States Agency for International Development (USAID).

In 2005, in response to growing international calls for global malaria control and to the success of the President’s Emergency Plan for AIDS Relief (PEPFAR), President George W. Bush launched the President’s Malaria Initiative (PMI), which aims to halve the burden of malaria morbidity and mortality in 70% of at-risk populations in sub-Saharan Africa by 2014. PMI brought significant new attention and funding to U.S. malaria programs and made the United States one of the largest donors for malaria efforts. While U.S. funding for global malaria programs has increased each fiscal year since FY2004, support for malaria interventions increased most precipitously beginning in FY2007 as PMI has expanded into new countries. President Obama has continued to support PMI through the Global Health Initiative (GHI).

There is evidence that the growing international response to malaria has had some success in controlling the epidemic. Since 2000, global malaria incidence has decreased by 17% and malaria mortality by 26%. Since 2000, 43 countries have reported a reduction in reported malaria cases of more than 50%, including eight African countries that have experienced 50% reduction in either confirmed malaria cases or malaria admissions and deaths. The decreases in each of these African countries are associated with intense malaria control activities. Despite these successes, several key issues pose challenges to an effective scale-up of the response to malaria.

First, increasing reports of drug-resistant malaria in Southeast Asia and insecticide-resistant mosquitoes, largely in Africa, threaten the success of malaria control programs. Second, weak health systems, including shortages in health care personnel and inadequate supply chain networks, have limited the delivery of essential commodities for malaria control. There is also debate within the global health community over whether malaria efforts should increasingly target areas where malaria elimination is possible or whether efforts should remain concentrated on malaria control. This report outlines basic facts related to global malaria, including characteristics of the epidemic and U.S. legislation, programs, funding, and partnerships related to the global response to malaria. The report will be updated as events warrant.

See also: U.S. Response to the Global Threat of Tuberculosis: Basic Facts (PDF)
See also: U.S. Response to the Global Threat of HIV/AIDS: Basic Facts (PDF)

Trends in Tuberculosis — United States, 2011

March 25, 2012 Comments off

Trends in Tuberculosis — United States, 2011
Source: Morbidity and Mortality Weekly Report (CDC)

In 2011, a total of 10,521 new tuberculosis (TB) cases were reported in the United States, an incidence of 3.4 cases per 100,000 population, which is 6.4% lower than the rate in 2010. This is the lowest rate recorded since national reporting began in 1953 (1). The percentage decline is greater than the average 3.8% decline per year observed from 2000 to 2008 but not as large as the record decline of 11.4% from 2008 to 2009 (2). This report summarizes 2011 TB surveillance data reported to CDC’s National Tuberculosis Surveillance System. Although TB cases and rates decreased among foreign-born and U.S.-born persons, foreign-born persons and racial/ethnic minorities continue to be affected disproportionately. The rate of incident TB cases (representing new infection and reactivation of latent infection) among foreign-born persons in the United States was 12 times greater than among U.S.-born persons. For the first time since the current reporting system began in 1993, non-Hispanic Asians surpassed persons of Hispanic ethnicity as the largest racial/ethnic group among TB patients in 2011. Compared with non-Hispanic whites, the TB rate among non-Hispanic Asians was 25 times greater, and rates among non-Hispanic blacks and Hispanics were eight and seven times greater, respectively. Among U.S.-born racial and ethnic groups, the greatest racial disparity in TB rates occurred among non-Hispanic blacks, whose rate was six times the rate for non-Hispanic whites. The need for continued awareness and surveillance of TB persists despite the continued decline in U.S. TB cases and rates. Initiatives to improve awareness, testing, and treatment of latent infection and TB disease in minorities and foreign-born populations might facilitate progress toward the elimination of TB in the United States.

Projected effects of tobacco smoking on worldwide tuberculosis control: mathematical modelling analysis

October 5, 2011 Comments off

Projected effects of tobacco smoking on worldwide tuberculosis control: mathematical modelling analysis
Source: British Medical Journal

Tobacco smoking could substantially increase tuberculosis cases and deaths worldwide in coming years, undermining progress towards tuberculosis mortality targets. Aggressive tobacco control could avert millions of deaths from tuberculosis.

See: Smoking Could Lead to 40 Million Excess Tuberculosis Deaths by 2050 (Science Daily)

CRS — The Global Challenge of HIV/AIDS, Tuberculosis, and Malaria

May 24, 2011 Comments off

The Global Challenge of HIV/AIDS, Tuberculosis, and Malaria (PDF)
Source: Congressional Research Service (via Federation of American Scientists)

The spread of human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS), tuberculosis (TB), and malaria across the world poses a major global health challenge. The international community has progressively recognized the humanitarian impact of these diseases, along with the threat they represent to economic development and international security. The United States has historically been a leader in the fight against HIV/AIDS, TB, and malaria; it is currently the largest single donor for global HIV/AIDS and has been central to the global response to TB and malaria. The 112th Congress will likely consider HIV/AIDS, TB, and malaria programs during debate on and review of U.S.-supported global programs, U.S. foreign assistance spending levels, and foreign relations authorization bills.

Over the last decade, Congress has demonstrated bipartisan support for addressing HIV/AIDS, TB, and malaria worldwide, authorizing more than $37 billion for U.S. global efforts to combat the diseases from FY2001 through FY2010. During this time, Congress supported initiatives proposed by President George W. Bush, including the President’s Emergency Plan for AIDS Relief (PEPFAR) and the President’s Malaria Initiative (PMI), both of which have demonstrated robust U.S. engagement in global health. Through the Global Health Initiative (GHI), President Barack Obama has led efforts to coordinate U.S. global HIV/AIDS, TB, and malaria programs and create an efficient, long-term, and sustainable approach to combating these diseases.

Despite progress in fighting HIV/AIDS, TB, and malaria, these diseases remain leading global causes of morbidity and mortality. Many health experts urge Congress to bolster U.S. leadership against these diseases and increase funding for such programs. In contrast, some Members of Congress have proposed cuts to these programs as part of deficit reduction efforts. This report reviews the U.S. response to HIV/AIDS, TB, and malaria and discusses several issues Congress may consider as it debates spending levels and priority areas for related programs.

Fraud and Abuse of Global Fund Investments at Risk without Greater Transparency

May 23, 2011 Comments off

Fraud and Abuse of Global Fund Investments at Risk without Greater Transparency (PDF)
Source: U.S. Senate Committee on Foreign Affairs (GOP)

DEAR COLLEAGUES: Through the President’s Emergency Plan for AIDS Relief (PEPFAR), the United States is providing both bilat- eral and multilateral assistance to disadvantaged populations to prevent and treat people with HIV/AIDS, tuberculosis and malaria. As of December 2010, U.S. investment in these programs totaled more than $32 billion. The U.S. provides its multilateral assistance through the Global Fund to Fight AIDS, Tuberculosis and Malaria, an independent entity which receives contributions from both countries and private organizations and provides medication and health services through nearly 600 grants in more than 140 countries. Although the Global Fund has demonstrated significant accomplish- ments and successes in saving lives through its antiretroviral drug programs and its prevention work, it has recently come under fire for mismanagement of grants in several countries. Following the release of several critical reports, some donors to the Fund have suspended their contributions until all mismanagement practices and abuses of funds can be rectified.

Many of the new Members of the Senate who have no direct experience with PEPFAR and the Global Fund have asked Com- mittee staff for a brief primer on these programs in anticipation of having to make funding decisions relative to the these global initiatives. I requested Senior Professional Staff Members Shellie Bressler and Lori Rowley to produce this primer. Their report examines the history and operation of PEPFAR and the Global Fund, the problems and initial improvements made to it, and the most recent challenges it faces. It also provides a series of recommenda- tions for implementation by both the U.S. Government and the Global Fund for strengthening existing systems for the distribution of supplies, medication and services in order to prevent further mismanagement and to ensure that the maximum number of peo- ple may benefit from the health prevention and treatment efforts of the Global Fund.

These tough recommendations run the gamut from withholding U.S. funds to the United Nations Development Fund (whose Development Program is a large recipient of Global Fund grants) until the organization’s internal procedures allow for greater access to their internal audit and investigation documents, to a recommendation for the development of an additional layer of protec- tion and an early warning system in those nations where insta- bility and/or government corruption are a concern.

I hope you find this report useful and that we may work together to reduce fraud, improve transparency and ensure maximum value for the U.S. investment in these global health programs.

Sincerely, RICHARD G. LUGAR, Ranking Member.

Active Tuberculosis among Homeless Persons, Toronto, Ontario, Canada, 1998–2007

March 25, 2011 Comments off

Active Tuberculosis among Homeless Persons, Toronto, Ontario, Canada, 1998–2007 (PDF)
Source: Emerging Infectious Diseases

While tuberculosis (TB) in Canadian cities is increasingly affecting foreign-born persons, homeless persons remain at high risk. To assess trends in TB, we studied all homeless persons in Toronto who had a diagnosis of active TB during 1998–2007. We compared Canada-born and foreign-born homeless persons and assessed changes over time. We identified 91 homeless persons with active TB; they typically had highly contagious, advanced disease, and 19% died within 12 months of diagnosis. The proportion of homeless persons who were foreign-born increased from 24% in 1998–2002 to 39% in 2003–2007. Among foreign-born homeless persons with TB, 56% of infections were caused by strains not known to circulate among homeless persons in Toronto. Only 2% of infections were resistant to first-line TB medications. The rise in foreign-born homeless persons with TB strains likely acquired overseas suggests that the risk for drug-resistant strains entering the homeless shelter system may be escalating.

Tuberculosis Outbreak Investigations in the United States, 2002–2008

March 25, 2011 Comments off

Tuberculosis Outbreak Investigations in the United States, 2002–2008 (PDF)
Source: Emerging Infectious Diseases

To understand circumstances of tuberculosis transmission that strain public health resources, we systematically reviewed Centers for Disease Control and Prevention (CDC) staff reports of US outbreaks in which CDC participated during 2002–2008 that involved >3 culture-confirmed tuberculosis cases linked by genotype and epidemiology. Twenty-seven outbreaks, representing 398 patients, were reviewed. Twenty-four of the 27 outbreaks involved primarily US-born patients; substance abuse was another predominant feature of outbreaks. Prolonged infectiousness because of provider- and patient-related factors was common. In 17 outbreaks, a drug house was a notable contributing factor. The most frequently documented intervention to control the outbreak was prioritizing contacts according to risk for infection and disease progression to ensure that the highest risk contacts were completely evaluated. US- born persons with reported substance abuse most strongly characterized the tuberculosis outbreaks in this review. Substance abuse remains one of the greatest challenges to controlling tuberculosis transmission in the United States.

Trends in Tuberculosis — United States, 2010

March 25, 2011 Comments off

Trends in Tuberculosis — United States, 2010
Source: Morbidity and Mortality Weekly Report (CDC)

In 2010, a total of 11,181 tuberculosis (TB) cases were reported in the United States, for a rate of 3.6 cases per 100,000 population, which was a decline of 3.9% from 2009 and the lowest rate recorded since national reporting began in 1953 (1). This report summarizes provisional 2010 data from the National TB Surveillance System and describes trends since 1993. Despite an average decline in TB rates of 3.8% per year during 2000–2008, a record decline of 11.4% in 2009 (2), and the 2010 decline of 3.9%, the national goal of TB elimination (defined as <0.1 case per 100,000 population) by 2010 was not met (3). Although TB cases and rates decreased among foreign-born and U.S.-born persons, foreign-born persons and racial/ethnic minorities were affected disproportionately by TB in the United States. In 2010, the TB rate among foreign-born persons in the United States was 11 times greater than among U.S.-born persons. TB rates among Hispanics, non-Hispanic blacks, and Asians were seven, eight, and 25 times greater, respectively, than among non-Hispanic whites. Among U.S.-born racial and ethnic groups, the greatest racial disparity in TB rates was for non-Hispanic blacks, whose rate was seven times greater than the rate for non-Hispanic whites. Progress toward TB elimination in the United States will require ongoing surveillance and improved TB control and prevention activities to address persistent disparities between U.S.-born and foreign-born persons and between whites and minorities.

Elephant-to-Human Transmission of Tuberculosis, 2009

March 22, 2011 Comments off

Elephant-to-Human Transmission of Tuberculosis, 2009 (PDF)
Source: Emerging Infectious Diseases

In 2009, the Tennessee Department of Health received reports of 5 tuberculin skin test (TST) conversions among employees of an elephant refuge and isolation of Mycobacterium tuberculosis from a resident elephant. To determine the extent of the outbreak and identify risk factors for TST conversion, we conducted a cohort study and onsite assessment. Risk for conversion was increased for elephant caregivers and administrative employees working in the barn housing the M. tuberculosis–infected elephant or in offices connected to the barn (risk ratio 20.3, 95% confidence interval 2.8–146.7). Indirect exposure to aerosolized M. tuberculosis and delayed or inadequate infection control practices likely contributed to transmission. The following factors are needed to reduce risk for M. tuberculosis transmission in the captive elephant industry: increased knowledge about M. tuberculosis infection in elephants, improved infection control practices, and specific occupational health programs.

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