RESPONDING TO A TUBERCULOSIS OUTBREAK IN THE FACE OF LIMITED RESOURCES

CUTS TO CDC FUNDING PLACES COMMUNITIES AT RISK

FEATURING: Debbie Swanson, Nursing and Nutrition Supervisor, Grand Forks Public Health Department, Grand Forks, North Dakota


TB ON THE RISE

Tuberculosis, or TB as it is commonly called, is a disease of the past...right?

Not necessarily. Antibiotics changed the treatment of the disease dramatically in the 1940s and the decades since, yet TB is still very much a public health concern in the United States, and is increasing in some populations.

The 50,000 residents of Grand Forks, North Dakota faced an outbreak of TB beginning in 2010 and continuing into 2014, resulting in 27 people infected. In the decade prior to 2010, the number of TB cases typically reported in the community ranges from zero - two per year. Because the rates of infection had been so low, routine testing and surveillance activities had been limited to high-risk settings, such as shelters and correctional facilities. Health care providers were unaccustomed to seeing TB in their practices, and skills such as contact investigation and familiarity with treatment protocols were limited to just a few staff members at the local health department.

Because of the eroded public health infrastructure, the TB outbreak took the community largely by surprise. The majority of Grand Forks’ cases occurred in the fall of 2012, and the local health department was faced with ramping up a robust response with limited resources and a federal budget for TB of a mere $6,000, which had already been exhausted for that year. The financial resources needed to deal with the large TB outbreak – estimated to be more than $2 million – were provided by local and state agencies that responded swiftly and collaboratively to protect the community. More than 1,800 people were screened for TB, and 60 people were placed on preventive therapy for latent TB infection. Numerous contacts were lost to follow up during the lengthy investigation period and remain untreated.

Complicating the situation was a nationwide shortage of both the materials for TB skin testing, and isoniazid, the most commonly used drug for treatment of TB. The North Dakota Department of Health filled the gap by reallocating TB medications and testing supplies from other communities and tapping into the state’s general fund to pay for housing, food, and incentives to make sure homeless families remained in isolation while infectious and took their medications, which were delivered daily by public health nurses. Treatment can last for up to one year, and the side effects from the medications often cause patients to stop taking them. Additionally, the population affected was also experiencing homelessness, poverty, alcohol or drug abuse, making treatment adherence a greater challenge.

TB Rate

ALL HANDS ON DECK

The Division of TB Elimination at Centers for Disease Control and Prevention (CDC) is responsible for allocating grants to state health departments, who in turn provide funding to local health departments based on the number of TB cases historically in the community. The Grand Forks Public Health Department has seen their federal funding for the TB program level funded for the past five years. “The local investment to keep TB in check just keeps increasing exponentially,” according to Debbie Swanson, a public health nursing supervisor.

CDC’S DIVISION OF TUBERCULOSIS ELIMINATION

CDC supports health departments in all 50 states, 10 big cities, Washington, D.C., Puerto Rico, the Virgin Islands, and other territories through cooperative agreements for TB control and laboratory support. Funding levels are set using a formula that considers case numbers, complexity, laboratory workload, and training needs. Five of these grantees also serve as regional training and technical assistance centers. Through these cooperative agreements, CDC protects Americans from tuberculosis (TB), including drug resistant TB. Federal funding for TB has fluctuated over the years and when adjusting for inflation has markedly eroded by 21 percent over the past decade.i

CDC’S DIVISION OF TUBERCULOSIS ELIMINATION

CDC supports health departments in all 50 states, 10 big cities, Washington, D.C., Puerto Rico, the Virgin Islands, and other territories through cooperative agreements for TB control and laboratory support. Funding levels are set using a formula that considers case numbers, complexity, laboratory workload, and training needs. Five of these grantees also serve as regional training and technical assistance centers. Through these cooperative agreements, CDC protects Americans from tuberculosis (TB), including drug resistant TB. Federal funding for TB has fluctuated over the years and when adjusting for inflation has markedly eroded by 21 percent over the past decade.i

Federal investments in provider training, surveillance programs, maintenance of drug and testing material supplies, and public health infrastructure build the capacity necessary to protect local communities from age old diseases such as TB and prevent the development of drug resistant strains. This investment is needed, even in states where TB case rates have historically been low.

Unfortunately, the erosion of funding for this federal program left the health department largely on their own in responding to the outbreak. CDC did dispatch an “epi-aid” team and provided public health technical assistance several times during the extended outbreak. However, no direct financial assistance was available from CDC to help sustain the intense efforts needed to manage such a large response in a small community. “It was ‘all hands on deck’ for a close to a year for the Grand Forks Public Health Department,” according to a public health nurse involved in the TB response.

RISKS REMAIN

While the crisis may be over for now, health department officials expect TB to make a comeback, and return in a more virulent, drug resistant form. The strain of TB in the outbreak is already resistant to one drug, and related cases have occurred in other communities in North Dakota. According to Debbie, “we are doing what we can to share our experiences with other public health officials and bring more knowledge of TB to the health care community, but it’s a challenge to keep up.”

The North Dakota Department of Health worries that TB will show up in western North Dakota, where congregate housing to support the booming oil industry is prevalent and workers are very mobile. The public health infrastructure in western North Dakota is not nearly as prepared to deal with a TB outbreak. Their resources are already stretched thin.


AUTHOR
American Public Health Association

SOURCES
i Department of Health and Human Services Fiscal Year 2015. Centers for Disease Control and Prevention. Justification of Estimates for Appropriation Committees (2014). Retrieved from http://www.cdc.gov/fmo/topic/Budget%20Information/appropriationsbudgetformpdf/FY2015CJCDCFINAL.pdf