Download Definition Chal•lenge Noun • a call to take part in a contest or

Jenny Flood | 2014 National TB Conference | Atlanta, Georgia | June 11, 2014
The Challenge
TB Elimination in the United States
Jennifer Flood MD MPH
National TB Controllers Association
June 11,2014
Definition
Chal•lenge
Noun
• a call to take part in a contest or competition
Questions
•
•
•
•
Who is competing?
What are the stakes?
Are we ready? Do we have a winning strategy? National Tuberculosis Controllers Association
www.tbcontrollers.org
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Jenny Flood | 2014 National TB Conference | Atlanta, Georgia | June 11, 2014
Who is competing? Who has the competitive edge? Statistics: Team U.S.A. • Each hour at least 1 new person is diagnosed with TB in the US • Each day at least 1 child under 14 is diagnosed with TB and >2 Americans with TB die • Each year over 100,000 exposed to TB • Today >10 million Americans with TB infection, most untested and untreated
Poor outcomes among children with CNS TB
California, 1993‐2011 (n=92)
Poor outcome
60%
Moderate Disability
Good Outcome
40%
Normal
0
10
Severe Disability
Death
Mild Disability
20
30
40
50
60
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National Tuberculosis Controllers Association
www.tbcontrollers.org
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Jenny Flood | 2014 National TB Conference | Atlanta, Georgia | June 11, 2014
MDR TB: the price paid
• It cost the U.S. healthcare system $53 million for MDR/XDR‐TB treatment during 2005‐2007
• Public sector insurance covered 100% of XDR‐
TB costs and 80% of MDR‐TB costs.
Source: Marks et al, EID, 2014
Tuberculosis deaths
Death of
infected mother
and twins in
Nevada, 2013
Among the ~900 TB deaths that occur yearly in the U.S.
The stakes
• Young lives saved
• Life without disability from TB
• Money to spend on other important things
National Tuberculosis Controllers Association
www.tbcontrollers.org
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Jenny Flood | 2014 National TB Conference | Atlanta, Georgia | June 11, 2014
Is TB elimination feasible?
2004 Brewer To control and beyond: moving towards eliminating the global tuberculosis threat
“Effective global TB control will require strategies that go beyond relying on treatment of people with active disease.” To eliminate TB, we must address the burden of 2007 Cain Tuberculosis among foreign‐born LTBI...”
persons in the United States: achieving tuberculosis elimination 2008 Dye
Eliminating human tuberculosis in the twenty‐first century
“coupling of control methods is particularly effective because treatments for latent infection and active disease act in synergy” 2012 Dye Prospects for Tuberculosis Elimination TB Elimination can be achieved by combining effective treatment, preventing new infection, and neutralizing existing latent infection. Modeling TB trends in the US
• Increasing proportion of TB Infection that is treated (baseline=5%)
Hill et al 2012 Modeling TB Trends in the USA
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Are we ready? National Tuberculosis Controllers Association
www.tbcontrollers.org
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Jenny Flood | 2014 National TB Conference | Atlanta, Georgia | June 11, 2014
The equipment • TST • AFB smear
• Whole genome sequencing
• 3HP
Our water bottle has holes in it
• Drug supply is interrupted
• And expensive
• We need a reliable supply to run the race
The stadium
• Health departments are becoming depleted
• There is promise of reinforcements: community providers and insurance expansion
• Providers without TB experience may be less skilled in the game • The incentives are not visible
National Tuberculosis Controllers Association
www.tbcontrollers.org
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Jenny Flood | 2014 National TB Conference | Atlanta, Georgia | June 11, 2014
Coaching: are the messages clear?
• Who is at risk, who needs testing and treatment? • Are those at risk systematically accessed beyond contacts and B notification? • Where are the
instructions for for community providers ? The team Who is in the lead?
National Tuberculosis Controllers Association
www.tbcontrollers.org
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Jenny Flood | 2014 National TB Conference | Atlanta, Georgia | June 11, 2014
Score keeping
Do we know how many – are infected?
– accessing care?
– getting tested?
– completing treatment?
A winning strategy?
The Institute of Medicine Report, 2000
1. Maintain control 2. Accelerate decline by increasing efforts at targeted testing and treatment 3. Develop new tools
4. Increase involvement in global TB control
5. Mobilize and sustain public support for elimination and measure progress toward the goal
National Tuberculosis Controllers Association
www.tbcontrollers.org
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Jenny Flood | 2014 National TB Conference | Atlanta, Georgia | June 11, 2014
Success in Meeting IOM Goals
Institute of Medicine Goal
Success Maintain control of tuberculosis
Yes
Accelerate the rate of decline of tuberculosis cases and rates by increasing efforts at targeted testing and treatment of latent tuberculosis infection
NO
Develop new tools
Yes/No
Increase the involvement of the US in global TB control
Yes
Mobilize and sustain public support for elimination; measure progress toward the goal NO
Funding
• In 2002, an increase of 3.8 fold from $140 million to $528 million to accelerate case decline was recommended?
What happened? Olympic financial security
NBC secures Olympic Games through 2032 for $7.75 billion
What could this buy in TB dollars?
National Tuberculosis Controllers Association
www.tbcontrollers.org
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Jenny Flood | 2014 National TB Conference | Atlanta, Georgia | June 11, 2014
The fans
President’s Strategic Plan
• HIV strategic plan has presidential commitment
Why not TB ? Why are we so far from the finish line?
“The biggest gap is in the limited messaging about the failure of the national TB elimination plan. I am sure that few officials are aware that there is actually a national plan to eliminate TB in this country. In fact, the public thinks it has already happened. Even fewer know that the funding to implement the plan was never provided and we have had this obvious failure since elimination was targeted to occur in 2010”. Randall Reves, 2014
National Tuberculosis Controllers Association
www.tbcontrollers.org
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Jenny Flood | 2014 National TB Conference | Atlanta, Georgia | June 11, 2014
Wisdom from Dr. Ken Castro “Insanity is doing the same thing over and over again and expecting different results”. Albert Einstein
New Strategy? Change the game‐plan 1 Find and treat TB
2 Identify exposed 
3 Find, test, treat infected
1
National Tuberculosis Controllers Association
www.tbcontrollers.org
1
1
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Jenny Flood | 2014 National TB Conference | Atlanta, Georgia | June 11, 2014
The voices to be heard
These two TB survivors, Natalie Nelson Skipper and Jigna Rao deserve our most forceful commitment. For the many who encounter TB, we need to push hard to win.
Summary • This has been a very long competition
• Our opponent is well‐conditioned • Top strengths: air travel, drug resistance, invisibility, persistence, and worldwide presence • Our strategy rests largely on a drug supply now less reliable and affordable Our competitive edge
• Our equipment just became sharper: 12 dose therapy will get more through prevention • Transmission is at a nadir in the US
• Harness the expertise – harness it • Keep health depts strong (athletes) and build partnerships(teams) • We have a national strategy‐follow it
National Tuberculosis Controllers Association
www.tbcontrollers.org
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Jenny Flood | 2014 National TB Conference | Atlanta, Georgia | June 11, 2014
Getting to the finish line
• Make prevention a priority with a clear messages and measures • The highest level commitment‐ President’s endorsement – is needed
• Turn up the heat‐ play to win
TB Free: the challenge
Think into the future and compete to win!
Acknowledgements
APHL, ASTHO, ATS, CDC, CSTE, FIND, IDSA, IPPA, NTCA, PATH, RTMCCs, TB researchers, RESULTS, STOP TB USA, TAG, TB patients , NACCHO, WHO National Tuberculosis Controllers Association
www.tbcontrollers.org
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Jenny Flood | 2014 National TB Conference | Atlanta, Georgia | June 11, 2014
END Are we stumbling?
National Tuberculosis Controllers Association
www.tbcontrollers.org
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Jenny Flood | 2014 National TB Conference | Atlanta, Georgia | June 11, 2014
News from The Hill
Rising drug prices trigger civil war between healthcare lobbies By Ferdous Al‐Faruque The insurance industry is picking a fight with pharmaceutical companies over the rising cost of specialty drugs. Insurers say the high prices are raising healthcare costs for insurance companies and everyone else, threatening the sustainability of the U.S. healthcare system. Drug makers say the high prices are necessary to recoup research and development costs. They also say insurers should cover more of the cost of pharmaceuticals. National Tuberculosis Controllers Association
www.tbcontrollers.org
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Jenny Flood | 2014 National TB Conference | Atlanta, Georgia | June 11, 2014
Measurement
National Tuberculosis Controllers Association
www.tbcontrollers.org
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Jenny Flood | 2014 National TB Conference | Atlanta, Georgia | June 11, 2014
TB Free: Game On! Choosing wisely campaign
• Identifies practices that may not provide benefit and instead waste resources
• Is TB screening on the Top 5 lists of medical services that provide no overall benefit to patients in most situations? NO!
• TB treatment and prevention is wise!
National Tuberculosis Controllers Association
www.tbcontrollers.org
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