Several states are grappling with how to handle current public health threats around the re-emergence of measles just as they also continue efforts to end the ongoing tuberculosis (TB) epidemic.
Both threats came up during discussions at the March 14 hearing, entitled the “Review of the Ebola outbreak in the Democratic Republic of the Congo (DRC) and Other Emerging Health Threats,” held by members of the U.S. Senate Appropriations Subcommittee on Labor, Health and Human Services, Education, and Related Agencies.
U.S. Sen. Dick Durbin (D-IL), for instance, said he was surprised to learn this week that the No. 1 cause of death in Alaska right now is TB. In fact, the death rate from TB in Alaska, he said, is three times that of the national average.
“So it is a battle that isn’t easily won,” Sen. Durbin said. “And internationally, the argument can be made that we’re not even getting close to winning” against TB.
He asked witnesses why the United States has failed to make an impact on tuberculosis.
“That’s a good question,” responded Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases (NIAID) at the National Institutes of Health (NIH).
“The numbers are stunning,” Dr. Fauci said. “When you tell people that, they don’t believe it. Tuberculosis is the leading cause of infectious disease deaths in the world. It’s the leading cause of death among HIV-infected individuals. One-third of the world’s entire population — between 20 percent and 30 percent — is infected with latent tuberculosis. There are 10 million new cases each year and 1.8 million deaths per year.
“So your question is obvious: ‘What the heck is going on? Why in 2019 do we still have that?’ And it’s a complicated issue,” Fauci said.
First of all, he explained, TB hasn’t been addressed as a global problem with the 21st century technology of drug development and vaccine development as it had been previously. He noted that TB became a treatable disease in developed countries with such developments.
But then drug-resistant TB came on the scene, followed by an almost 40-year gap in which not one new class of TB drugs was developed, Fauci said. Only recently, within the last few years, have “a couple of new drugs” emerged to successfully fight TB, he added.
The other issue, according to Fauci, is that TB is one of the diseases considered to be “the disease of the poor people of the world” and countries that lack access to healthcare are where TB has been “ravishing people.”
On the upside, however, Fauci said there’s been a “major global surge” during the last year and a half in trying to get “enthusiastic about tuberculosis” that started with a ministerial meeting he attended in Moscow in November 2017 and then with last year’s United Nations Special Session on Tuberculosis.
And “very soon, within the next few days,” Fauci said that the Lancet Commission on Global Surgery is slated to release information “looking at everything we have to do” around tackling TB, he said.
The TB problem is “neglected,” Fauci said.
U.S. Sen. Roy Blunt (R-MO), chairman of the subcommittee, broached the measles topic during the hearing when he posed questions about the Strategic National Stockpile (SNS).
The U.S. Centers for Disease Control and Prevention (CDC) earlier this week reported that since Jan. 1 roughly 230 cases of measles have re-emerged in the United States. The highly contagious respiratory disease was eradicated in 2000 in the United States, but it has remained endemic in several countries around the world — the cause for the current outbreaks in 12 states, the CDC says.
During 2018, a total of 372 total cases of measles was reported in the United States, according to the CDC, which designated that amount as the second-highest yearly total in more than 20 years.
Currently, the nation’s stockpile is largely maintained by the Office of the Assistant Secretary for Preparedness and Response (ASPR) at the U.S. Department of Health and Human Services (HHS). Sen. Blunt asked Dr. Robert Kadlec, who heads the ASPR, about any new concerns he has regarding how to manage both the measles outbreak in the United States and the Ebola outbreak in West Africa, as well as what resources Kadlec thought were needed to manage them.
“One of the issues here is prioritizing what the threats are and what we need in the stockpile,” Kadlec testified on Thursday.
Historically, the U.S. Department of Homeland Security has made the threat determinations, based on intelligence, for what has been needed in the SNS. “Much of that has been derived from terrorism,” said Kadlec. “I think the critical consideration today is how do you take real-world events and current intelligence to modify the approach?”
There is a limited supply in the SNS of the Ebola vaccine “that we’re prepared to mobilize to support the efforts of USAID and CDC in West Africa,” Kadlec said, “so we have to make critical decisions about replenishment of what that supply looks like and further production.”
“Subject to the measles issue,” he said, “which is one that maybe doesn’t touch on the SNS because we don’t have a measles vaccine for that, but a lot of the networks and capabilities have been worked on together with CDC and ASPR in terms of preparedness at the state and local levels [and] have been very significantly beneficial for the response to measles.”
Kadlec said ASPR now is focused on a strategic plan for how to improve being nimble in responding to a new outbreak and how the office might better work with NIH, CDC and the U.S. Department of Defense “to mobilize what might be a nascent capability, vaccine or diagnostic and quickly run it through the paces to deploy it in real time.”
Regarding resources, Kadlec said, “we have a significant shortfall that we anticipate in 2020 and in 2021 with the stockpile” regarding replenishment of vaccines and other products. He estimated the shortfall to be roughly $900 million in 2020 and about $800 million in 2021.
There’s another issue complicating the measles situation, testified Dr. Robert Redfield, the CDC’s director.
“I think the current vaccine hesitancy we have in our country is something that we need to plan to continue to try and address,” said Redfield. “The reason we’ve already had seven measles outbreaks this year and 17 last year in this country is all driven by vaccine hesitancy.”
Redfield said that vaccination is America’s most powerful tool to prevent disease. “It is going to be one of our most powerful tools in our stockpile to confront threats and so bringing the American public to a point of being more aggressive in accepting vaccines for themselves, their families, their schools, their churches, their workplaces” is vitally important, he added.
And although the flu vaccine, for example, won’t prevent a person from getting the flu, Redfield said, “it has a strong predictive value to protect you from death.” He noted that 80,000 Americans died in 2018 due to the flu.
“Continuing to get the American public affirmative towards the importance of [vaccines] is going to be critical because when a pandemic comes, the countermeasure is most likely going to be a vaccine,” he said.