Protecting the United States from the Health Security Risk of Global Tuberculosis
Tuberculosis (TB), an airborne infectious disease caused by the bacterium Mycobacterium tuberculosis, is the number one infectious disease killer in the world and among the top 10 causes of death worldwide.2 Moreover, numbers of drug-resistant forms of TB, currently 5 percent of global TB cases, are rapidly rising, posing a health security threat to the United States and the world. Cases of multidrug-resistant TB (MDR-TB) and extensively drug-resistant TB (XDR-TB) are difficult and costly to treat, and are often fatal. Epidemics of MDR-TB and XDR-TB can originate within U.S. communities or spread from other countries. To be effective in protecting Americans from a costly and potentially deadly disease, the U.S. government must address TB and drug-resistant TB both domestically and globally.
TB, including drug-resistant TB, is a growing global problem and world leaders are beginning to grasp the magnitude of the health threat, but have not yet committed the political will and resources to adequately address it. According to the World Health Organization (WHO), there were 10.4 million new cases of TB and 1.8 million deaths worldwide in 2015. Globally, HIV is the leading illness or condition that triggers the progression from inactive (i.e., latent) to active TB disease. Approximately 10 percent of TB patients globally are also infected with HIV, although the percentage of TB/HIV coinfection is as high as 60–70 percent in parts of sub-Saharan Africa. Each year there are approximately 600,000 new cases of MDR-TB and XDR-TB.3 Globally, only 20 percent of patients with drug-resistant TB receive treatment, and only half of those are treated successfully,4 meaning that the vast majority of patients with drug-resistant TB are continuing to spread disease until they die. If this situation persists globally, it is only a matter of time before the rising number of drug-resistant TB cases threatens Americans. The United States is not insulated from the rest of the world, and cannot afford to be complacent until it is too late.
It is more cost-effective for the U.S. government to invest in preventing the development and spread of drug-resistant TB epidemics globally than to respond to an epidemic in the United States. While the number of TB cases in the United States is currently relatively low, these cases are costly financially and in terms of human suffering. Financial costs are often borne by the public health system, and an outbreak of MDR-TB or even a single case of XDR-TB can bankrupt the public health budget of a city or locality. There are about 10,000 cases of TB and roughly 100 cases of drug-resistant TB annually in the United States. Treatment of a typical patient in the United States with drug-sensitive TB costs about $18,000, an average case of MDR-TB costs $154,000, and an average case of XDR-TB costs $494,000.5 If there were an epidemic of drug-resistant TB, these costs could quickly add up. In the 1990s, a resurgence of TB linked to the rise of HIV/AIDS led to outbreaks of MDR-TB in New York City and other major cities. The extensive public health efforts required to control outbreaks in New York City alone cost at least $1 billion.6
It is in the national interest of the U.S. government to invest resources wisely to prevent, detect, and treat TB cases at home and abroad. Several factors are coalescing to make this a possible turning point in the fight against global TB. Recent scientific and technological advances have brought forth new drugs, diagnostics, and service delivery technologies for TB care. Increased U.S. programmatic investments and technical advice at this moment can have a great impact on the global TB epidemic by helping to deploy these new tools more quickly to affected populations. U.S. scientific ingenuity is leading the way in TB research and product development, and there are promising new drugs, diagnostic technologies, and vaccine candidates in the pipeline. Internationally, world leaders are recognizing the impact of TB on their populations. It is a particularly opportune time for the United States to capitalize on the forward momentum and advance U.S. leadership on global TB control by working together with donor and affected countries to coordinate and amplify the impact of TB investments.
Yet the Trump administration’s budget proposal for Fiscal Year (FY) 2018 includes cuts to all the agencies and programs that are involved in addressing TB domestically and globally, including the U.S. Centers for Disease Control and Prevention (CDC), the U.S. Agency for International Development (USAID), the President’s Emergency Plan for AIDS Relief (PEPFAR), and the National Institutes of Health (NIH).7 The administration’s budget reduces the USAID bilateral TB program by 26 percent, the PEPFAR program by 18 percent, and the U.S. contribution to the multilateral Global Fund for AIDS, TB, and Malaria by 17 percent. It also cuts CDC’s domestic TB division by 8 percent and CDC’s global health funding by 20 percent. CDC does not receive direct funds for global TB and it leverages PEPFAR and other global health funding for its global TB activities. It is critical for Congress to work on a bipartisan basis with the administration on a negotiated FY 2018 budget and a forward-looking strategy that aligns with the health security challenges of TB.
To make the most of the newly available medical countermeasures, innovative scientific thinking, and burgeoning international political will, the time is ripe for a heightened U.S. focus on the global TB epidemic. We call for the U.S. government to invest strategically in domestic and global TB programs and research and development (R&D) that will contribute to ending the TB epidemic. In the short-term, there are existing and newly emerging treatments and diagnostics that can be deployed effectively to reduce the impact of TB in the United States and globally. Innovations in service delivery can enhance treatment outcomes and prevent the development and spread of MDR-TB and XDR-TB. Immediate and ongoing investments in R&D are also needed to stimulate new treatments, diagnostics, and ultimately a vaccine to end the global TB epidemic.
We recommend that the U.S. government take the following priority actions:
- Expand screening and treatment of inactive (or latent) TB in high-risk individuals in the United States, to reduce the pool of Americans who may develop TB or drug-resistant TB in the future
- Accelerate TB control in 10–15 countries of strategic importance to the United States by deploying increased resources and technical assistance, and rigorously monitoring the impact of interventions over a determined time period. Country selection should be based on criteria such as: high level of TB, TB/HIV, and MDR-TB burden, greatest sources of TB cases to the United States, demonstrated engagement on TB by political leadership, and demonstrated ability to partner with donors in implementing health programs. Based on demonstrated success, the U.S. government should then invest even more resources and expand this program into a presidential-level priority initiative similar to PEPFAR.
- Stimulate greater domestic investments for TB control in middle-income countries by engaging with national governments and by working with the World Bank and regional banks on additional financing mechanisms
- Support research and product development for the prevention, detection, and treatment of TB and drug-resistant TB
To support these actions, Congress should, through the budget and appropriations process, fulfill the U.S. commitment to the Global Fund, and increase funding, or at a minimum maintain level funding, in domestic, global, and R&D funding. In particular, we support the call for $450 million in FY 2018 for bilateral global TB control activities.
 Audrey Jackson is a senior fellow with the CSIS Global Health Policy Center in Washington, DC.
 World Health Organization (WHO), Global Tuberculosis Report 2016 (Geneva: WHO, 2016), http://apps.who.int/iris/bitstream/10665/250441/1/9789241565394-eng.pdf?ua=1.
 Ibid. MDR-TB is defined as TB that is resistant to rifampicin and isoniazid, the two most common TB drugs. XDR-TB is defined as TB that is resistant to all or nearly all first-line and second-line TB drugs. The figure of 600,000 also includes cases that are only resistant to rifampicin but must be treated with the same drugs as MDR-TB.
 WHO, Global Tuberculosis Report 2016.
 Centers for Disease Control and Prevention, “Take on Tuberculosis Infographic,” November 2016, https://www.cdc.gov/tb/publications/infographic/pdf/take-on-tuberculosis-infographic.pdf.
 T.R. Frieden, P.I. Fujiwara, R.M. Washko, and M. Hamburg, “Tuberculosis in New York City—turning the tide,” New England Journal of Medicine 333 (1995): 229–33.
 Office of Management and Budget, “Budget of the U.S. government: A new foundation for American Greatness, Fiscal Year 2018,” https://www.whitehouse.gov/sites/whitehouse.gov/files/omb/budget/fy2018/budget.pdf.