Fewer Than One Case per Million: CDC's Plan to Eliminate Tuberculosis in the United States

The goal CDC's Division of Tuberculosis Elimination (DTBE) works toward has a precise definition: fewer than one TB case per million people a year in the United States. Its approach has two halves — find and treat active TB disease, and test for and treat latent TB infection before it progresses to disease.

The hard part is not only the bacterium. As U.S. cases fall, TB looks like less of a risk to the public, to clinicians and to policymakers, and in the competition for public money its funding for control and research is put at risk.

Who gets TB now

Cases are increasingly concentrated among people who are medically underserved.

Three equity goals, for 2025

CDC's agency-wide health equity strategy led the division to three goals, together aiming to cut incidence in these groups by about 20% between 2019 and 2025:

There was progress: in 2020, incidence fell 20% among non-U.S.-born Hispanic/Latino people and non-Hispanic Black or African American people. But the size of the disparities relative to non-Hispanic White people stayed about the same.

Six strategies

The framework comes from the U.S. government's response to the Institute of Medicine report Ending Neglect: The Elimination of Tuberculosis in the United States (2000), reaffirmed in STOP TB USA's A Call for Action on the Tuberculosis Elimination Plan (2010).

1. Maintain control — timely diagnosis, proper treatment of drug-susceptible and drug-resistant disease, and evaluation and treatment of contacts.
2. Accelerate the decline — genotyping to spot transmission, rapid outbreak response, and targeted testing and treatment of latent infection in high-burden communities.
3. Develop new tools for diagnosis, treatment and prevention.
4. Contribute to global TB control, working with CDC's global HIV and TB division and the division that sets medical screening for immigrants and refugees — because reducing TB worldwide is critical when 71.5% of U.S. cases are in people born abroad.
5. Mobilize and sustain support among policymakers, providers, affected communities, TB survivors and the public.
6. Track progress and report it.

In practice that means national surveillance, funding and embedded staff for state and local TB programs, the National TB Reference Laboratory, research through the TB Trials Consortium and the TB Epidemiologic Studies Consortium, expert consultation through the TB Centers of Excellence, and the Think. Test. Treat TB campaign.

What stands in the way

• Lost expertise. With fewer patients, there are fewer chances to train clinicians, laboratorians, researchers and program staff, and the capacity to diagnose, treat and prevent TB has declined.
• The wrong front door. People at high risk often get care from private providers and community health centers with little TB experience, who may not make TB testing a priority.
• Fragile drug supplies. TB drugs share the antibiotic market's problems: falling demand and expiring patents leave manufacturers weighing whether production is worth it, and new TB antibiotics have lagged other medicines. Shortages and supply interruptions have occurred over the past ten years, interrupting and delaying treatment.
• Complex patients. Homelessness, incarceration, substance use, poorly controlled diabetes and HIV all raise the resources needed.
• Drug resistance. The U.S. has not seen the high shares of drug-resistant TB reported globally, but resistance acquired through delayed diagnosis or inappropriate treatment remains a threat.

Where the next gains are

The division plans to back rapid molecular testing for drug resistance, genotyping to find outbreaks fast, and wider latent TB testing with interferon-gamma release assays and treatment with shorter regimens — such as the 12-dose course. Among its tactics: reach at-risk people through Federally Qualified Health Centers, end low-yield testing of people at low risk, consider extending overseas TB screening for immigration to more visa categories (students, temporary workers), and share financing routes some programs already use — 340B drug discounts, Medicaid Section 1115 waivers, the TB Medicaid Option and the Affordable Care Act.

The 2030 yardsticks

Program targets were set by projecting, from 2015–2023 data, what the top 20% of U.S. TB programs are expected to achieve in 2030 (programs with fewer than 150 cases in 2021–2023 were left out). A selection:

Sources

Based on "Tuberculosis Elimination Priorities," Division of Tuberculosis Elimination, National Center for HIV, Viral Hepatitis, STD, and Tuberculosis Prevention, Centers for Disease Control and Prevention; a work of the United States government in the public domain.