Tuberculosis prevention and control activities in the United States: an overview of the organization of tuberculosis services

After a 20% increase in tuberculosis (TB) cases between 1986 and 1992, TB c ases in the United States have declined from 1993 through 1997, an average of 5 to 7 per cent per year. In this paper, we review trends and the curren t epidemiology of TB in the US, present a brief history of TB control effor ts in the country, and present the key strategies for TB control in the US. We describe the current organizational structure of TB services in the US, the role of the private sector in TB control, and how TB control is funded . Finally we discuss the mechanisms by which TB policy is developed. The US model represents a categorical disease program that combines a centr alized role of the national government in development of policy, funding, a nd in the maintenance of national surveillance, and a decentralized role of state and local jurisdictions, which adapt and implement national guidelin es and which are responsible for day-to-day program activities. Given the r elative success of this combined approach, other countries facing the chall enge of maintaining an effective TB control program in the face of increase d decentralization of health services may find this description useful.