CDC's Response to Ending Neglect
GOAL I: Maintain control of TB
Maintain the decline in TB incidence through timely diagnosis of
active TB disease, appropriate treatment and management of persons
with active disease, investigation and appropriate evaluation and
treatment of contacts of infectious cases, and prevention of transmission
through infection control.
Tuberculosis control efforts have two priorities: 1) to detect
persons with active TB and treat them with effective anti-TB drugs,
and 2) to identify contacts of infectious TB cases and evaluate
and treat them as needed.
Effective treatment cures patients of TB disease and stops the
transmission of infection to others. Being treated for active TB
involves taking multiple anti-TB drugs daily or several times a
week for at least 6 months. Anti-TB drugs must be prescribed properly
and taken for the full treatment period. Otherwise, the disease
may not be cured and could recur. Also, the TB organisms could become
resistant to standard anti-TB drugs. To maintain control of TB and
prevent drug-resistant disease, TB must be accurately diagnosed,
an effective treatment regimen must be prescribed, and patients
must take all of their medicine. The best way to ensure that patients
adhere to anti-TB drug regimens is to provide a patient-centered
approach that uses DOT, meaning that a provider watches the patient
take the medication.
Contact investigation and follow-up are important for detecting
cases of active TB and identifying persons who have latent TB infection
and are at high risk for developing TB disease. The identification
of every infectious or suspected case of TB should prompt an epidemiologic
investigation to locate others who have potentially been exposed
and are therefore at risk of infection. To maintain control of TB,
contacts of potentially infectious TB cases must be evaluated and,
if found to be infected, treated appropriately.
Maintain and enhance local, state, and national public health surveillance
State and local health departments are legally responsible for protecting
the public health.48 In the setting of active TB, this
responsibility includes 1) ensuring that each patient with active
TB completes appropriate treatment, 2) ensuring that a contact investigation
is conducted to identify other persons with potentially infectious
TB, 3) arranging for the evaluation and treatment of persons with
active TB or latent TB infection, and 4) conducting epidemiologic
investigations in response to potential outbreaks and implementing
control and prevention measures.
The foundation for these activities is public health surveillance
(the ongoing, systematic collection, analysis, interpretation, and
dissemination of health data). TB surveillance is critical for ensuring
complete case finding, appropriate linkages to diagnostic and treatment
services and contact investigations, and reliable information systems
for monitoring TB trends and evaluating control programs. All states
require designated health care professionals to report TB cases
(and usually suspect TB cases) to local or state health departments.48
All state health departments maintain TB surveillance systems. The
extent of local surveillance activities depends on state statutes
and the delegation of authority by state health departments. States
and localities provide information on the numbers and characteristics
of TB cases to the national surveillance system at CDC. The national
system plays a critical role in monitoring national TB trends and
guiding the planning and evaluation of national TB control efforts.
Ensuring that the surveillance system captures all persons with
TB requires active case finding (also called active surveillance).
Active case finding is a particularly important activity when the
number of cases is decreasing and disease elimination is the goal.
Active case finding can be supplemented by screening of high-risk
- Assist state and local health departments in periodic evaluations
of TB surveillance systems.
- Maintain support for the national TB surveillance system.
- Conduct comprehensive and standardized evaluations of surveillance
activities in all 50 states, the District of Columbia, and U.S.
territories to help in the development and implementation of strategies
to improve and enhance surveillance, especially active surveillance.
Support the infrastructure needed for laboratory-based identification
and treatment of TB.
TB control efforts depend on well-functioning mycobacteriology laboratories
that can 1) detect, isolate, and identify TB organisms, 2) determine
the organisms' susceptibility to anti-TB drugs, and 3) communicate
promptly with clinicians so that diagnoses can be confirmed and
treatment started. Both the laboratory and the clinician should
have confidence in a laboratory's results. Accordingly, laboratories
must institute efficient procedures, refer specimens to referral
laboratories when necessary, and be adequately staffed to provide
results in a rapid and efficient manner. All mycobacteriology laboratories
must participate in recognized proficiency testing programs and
establish levels of service that reflect the demonstrated quality
Diagnostic Standards and Classification
of Tuberculosis in Adults and Children
In April 2000, CDC and the American Thoracic Society (ATS)
published Diagnostic Standards and Classification of Tuberculosis
in Adults and Children.49 These standards are
designed to provide a framework for and an understanding of
the diagnostic approaches to latent TB infection and disease
and to present a classification scheme that facilitates patient
management. A person classified as having "clinical active
TB" (Class 3) must have clinical, bacteriologic, or radiographic
evidence of current TB. The bacteriologic evidence is established
by isolation of M. tuberculosis in a fully functioning
- Sustain state and local health department laboratories, and
upgrade them as necessary.
- Continue to support state and local health departments'
mycobacteriology laboratories through cooperative agreements.
- Strengthen the ability to provide technical support to state
and local mycobacteriology laboratories.
- Ensure the availability of back-up services to state and
local mycobacteriology laboratories as needed.
- Support the development of effective quality assurance and
training programs for all laboratories that process mycobacteria
- Enhance laboratory capacity to support outbreak investigations.
- Continue to support TB outbreak investigations through DNA
fingerprinting and enhanced drug-susceptibility testing.
- Develop strategies for transferring technologies for DNA
fingerprinting to state and city health departments, as appropriate.
- Support regional laboratories that provide DNA fingerprinting
services to state and local TB control programs.
- Evaluate and support new approaches to providing reliable and
timely laboratory services for TB diagnosis.
- Monitor laboratory practices and capabilities in state and
territorial mycobacteriology laboratories to determine work
volume and proficiency levels.
- Conduct operational studies in order to develop models for
referring specimens and cultures that ensure rapid test results
for smears, culture identification, and drug susceptibility
testing, as well as studies to explore the feasibility of
alternate approaches to providing laboratory services for
TB diagnosis at the local, state, and regional levels.
- Establish mechanisms for the timely feedback of laboratory
results to health departments and clinicians charged with
the care of TB patients and suspected TB patients.
- Ensure that CDC has appropriate laboratory staff for conducting
operational research and national assessments of laboratory
practices, provide laboratory training, and promote quality
Ensure that patient-centered case management and monitoring of treatment
outcomes are the standard of care for all TB patients.
Promoting patient-centered case management involves assessing each
TB patient's needs and identifying a treatment plan that ensures
the completion of therapy. High rates of completion of TB treatment
(exceeding 90%) are most likely when treatment incorporates DOT,
with multiple enablers (something that helps the patient complete
treatment, e.g., transportation vouchers), incentives (something
that will motivate the patient to successfully carry out program
goals, e.g., food coupons), and other treatment enhancers (e.g.,
alternative treatment delivery sites, strategies to overcome social
and cultural barriers to completion of treatment, use of outreach
workers).18 DOT has been shown to be more effective than
self-administered therapy in several observational studies in the
United States18,50 and also to be a cost-effective and,
in some cases potentially cost-saving, alternative to self-administered
- Ensure that all patients with active TB are tested for HIV infection
and that all patients with TB disease and HIV infection are appropriately
and adequately treated.
- Promote the use of enhanced DOT, including incentives and enablers,
to ensure the completion of treatment in persons with active TB.
- Continue to support DOT, including the use of incentives
and enablers, through CDC cooperative agreement grants.
- Where possible, provide housing for homeless TB patients,
e.g., through Housing Opportunity for Persons with AIDS programs
(administered by HUD).
- Support the infrastructure needed to provide well-trained
- Encourage DOT in primary-care facilities, drug treatment
centers, HIV/AIDS residential facilities, HIV clinics, migrant
clinics, and shelters.
- Provide ongoing technical assistance, both on-site and by
telephone, to promote the expanded use of DOT by health departments
and other providers in the field and in clinics and other
Effectiveness of Enhanced DOT
The Public Health Tuberculosis Guidelines Panel reviewed
27 studies in which treatment completion for TB was used as
an outcome.18 The studies classified treatment
strategies into four categories: enhanced DOT, DOT, modified
DOT, and unsupervised therapy. Enhanced DOT was defined as
a comprehensive, patient-centered strategy of fully supervised
DOT with multiple incentives and enablers. DOT was defined
as fully supervised DOT without incentives or enablers. Modified
DOT included DOT for only part of the treatment period, and
unsupervised therapy involved no DOT. The median treatment
completion rate for enhanced DOT was 90%, compared to rates
of 86%, 81%, and 61% for DOT, modified DOT, and unsupervised
- Develop guidelines and standards for patient-centered case management
in public health clinics, managed-care settings, and other private
- Compile and review published studies of patient-centered
- Review effective models of patient-centered case management
in state and local TB programs.
- Convene a national meeting of TB controllers, TB nurse consultants,
and clinicians experienced in TB care to develop guidelines
and standards for patient-centered case management.
- Through ACET, issue guidelines and standards for patient-centered
- Develop the capacity of state and local TB control programs
to conduct systematic and comprehensive reviews of the outcome
of treating patients with active TB (i.e., "cohort reviews").
- Provide ongoing technical assistance to promote the use
of cohort reviews of patients with active TB disease to monitor
- Develop guidelines, models, and training materials for developing
programmatic capacity to conduct cohort reviews.
- Develop case-management information systems to facilitate the
appropriate management of patients and the evaluation of their
- Define the elements needed for effective case management
and evaluation of case-management systems.
- Develop an information system that captures these elements
and promotes the effective management of patients with active
- Provide financial and technical support to allow programs
to establish and use case-management information systems.
- Explore ways to increase third-party reimbursement for TB services.
- Conduct a study to 1) identify funding sources for outpatient
TB services in a sample of TB cases, 2) determine facilitating
factors and barriers to third-party billing and reimbursement,
and 3) determine the current programmatic and fiscal impact
- Using study results, develop recommendations for strategies
to maximize and improve third-party reimbursement for TB control
Develop community partnerships, and strengthen community involvement
in TB control.
Because each community has its own TB management needs, optimal
TB prevention and control activities require a multifaceted, multidisciplinary
approach. Collaborative efforts between TB prevention and control
programs and community groups, health care providers, and other
organizations serving TB patients can 1) educate the public about
TB, 2) ensure that community leaders, health care providers, and
policy makers are knowledgeable about TB, 3) identify persons with
TB disease and ensure that they complete appropriate treatment,
4) identify contacts of persons with infectious TB disease and ensure
that they are appropriately evaluated and treated, and 5) coordinate,
and in some instances provide, screening and prevention services
for persons at high risk for developing TB disease.
Public health activities that are culturally appropriate and have
broad-based community support have been shown to have a substantial
effect on the health status of high-risk communities. Too often,
TB patients and high-risk persons are suspicious or simply unaware
of TB prevention and control services that are available to them.
To ensure the quality, effectiveness, and appropriateness of activities,
TB prevention and control programs need help from local groups in
high-prevalence communities. Partnerships with community-based organizations
(CBOs) and with health care providers with established relationships
in the community can help ensure that high-risk populations have
access to TB prevention services and that the services reflect local
- Promote the development of partnerships between local TB control
programs and community-based health centers and organizations.
- Develop local epidemiologic profiles of TB disease and infection
to assist in the identification of high-risk groups and of
health care providers with whom partnerships should be established.
- Identify gaps in services to high-risk groups that can be
met by the development of partnerships.
- Emphasize partnership development in cooperative agreement
announcements, program reviews, and site visits.
- Assist in developing the capacity of state and local TB
prevention and control programs to evaluate community partnerships.
- Assist state and local health departments in increasing
the capacity of CBOs to deliver TB services.
- Ensure that local TB control programs develop working partnerships
with Ryan-White providers and other HIV-care providers.
- Ensure that community-based health care providers are trained
in the diagnosis and treatment of TB disease and latent TB infection.
- Conduct formative research on culturally appropriate training
for community-based health care providers who serve diverse
- Develop training targeted to community-based health care
- Continue to support the National TB Model Centers' development
of culturally appropriate training materials.
- Support efforts by state and local TB control programs to
identify and provide training to community-based health care
providers, including CBOs.
- Support efforts by HIV/AIDS providers funded under the Ryan-White
Care Act Program and other HIV-care providers to ensure adequate
and appropriate treatment, including enhanced DOT, of HIV-coinfected
persons with TB disease or latent TB infection.
DOT Provider Network
In 1992, the New York State Department of Health created
a network of public and private community providers to deliver
DOT services to TB patients. The DOT Provider Network includes
CBOs, social service providers, and advocacy organizations
that were already serving high-risk, hard-to-reach persons.
This network has allowed New York to offer DOT both at fixed
treatment centers (e.g., chest clinics, drug treatment centers)
and, through outreach, at locations convenient to the persons
being served. Providers are reimbursed through Medicaid and
work closely with the local health department. More than 20
institutions representing at least 70 fixed treatment centers
have become part of the network and now provide outreach services.
More than 1,700 referrals to the network were reported by
the end of 1993. Efforts to maximize referrals and expand
the network are ongoing. New alliances between DOT providers
and CBOs can establish support systems for patients, promote
adherence to therapy, and address the health and social problems
that place clients at high risk for TB.
Improve the timely investigation and appropriate evaluation and
treatment of contacts with active TB disease and latent TB infection.
Contacts of persons with infectious TB are at high risk for infection
and disease. The risk to contacts is related to the infectiousness
of the source patient, the characteristics of the contact, and the
characteristics of the environment they share. Prompt identification
and evaluation of contacts of infectious cases are essential for
good TB control. This is especially true for vulnerable high-risk
populations. For example, HIV-infected contacts who are also infected
with M. tuberculosis can develop clinically active disease
very rapidly, as early as 20 days after infection.52
The priority, speed, and extent of a contact investigation should
reflect the likelihood of transmission (based on the characteristics
of the source patient, contact, and environment) and the possible
consequences of infection (especially for HIV-infected contacts
and young children).
- Develop guidelines and standards for contact investigations.
- Review guidelines and standards for contact investigations
developed by state and local TB control programs.
- Develop draft recommendations and guidelines for conducting
- Seek comments on the recommendations and guidelines from
state and local TB control officials, health departments,
ACET, the National Tuberculosis Controllers Association (NTCA),
and others as appropriate.
- Publish the recommendations/guidelines for contact investigations.
- Enhance the capacity of state and local TB control programs
to conduct contact investigations, and ensure that infected contacts
complete TB treatment.
- Provide funding for enhanced contact investigation and treatment
of infected contacts through CDC's cooperative agreement grants.
- Provide ongoing technical assistance to health departments,
both on-site and by telephone, to promote expanded contact
- Develop and support training for TB control program staff
to enhance their ability to interview and investigate contacts.
- Conduct behavioral research to investigate reasons for nonadherence
with curative treatment and treatment of latent TB infection;
develop interventions to increase adherence.
- Develop the capacity of TB controllers to use social network
analysis in contact investigations
- Develop the capacity of state and local TB control programs
to evaluate the outcomes of contact investigations and respond
appropriately to the results of the evaluations.
- Include guidance on evaluation of contact investigations
in newly developed recommendations/guidelines.
- Increase the capacity of state and local TB programs to
conduct process and outcome evaluations of contact investigations.
- Conduct research to identify appropriate measures of effectiveness
for contact investigations.
- Develop systems to provide the information needed to manage
contacts and evaluate contact investigations.
- Define the elements needed for effective management of contacts
and evaluation of contact investigations.
- Develop an information system that captures these elements
and promotes the effective management of contacts of persons
with infectious TB.
- Provide financial and technical support to programs to establish
and use contact-management information systems.
Ensure appropriate care for patients with MDR TB, and monitor their
response to treatment and their treatment outcomes.
The resurgence of TB in the United States that started in 1985 exposed
an insidious problem for TB control: the rise in MDR TB (M. tuberculosis
strains resistant to at least the two first-line TB drugs, isoniazid
and rifampin). From 1982 through 1986, only 0.5% of new TB cases
were resistant to both isoniazid and rifampin.53 By 1991,
however, 3% were resistant to both drugs, and 14% were resistant
to at least one.54 Against this background of increasing
numbers of TB cases and increasing drug resistance, a dangerous
new phenomenon appeared: outbreaks of MDR TB in institutional settings.
From 1990 through 1992, CDC investigated outbreaks in eight hospitals
and one correctional system and identified almost 300 cases of MDR
TB. Death rates were shockingly high - 43% to 100%. Although most
cases occurred in HIV-infected patients, several health care workers
and prison guards were also stricken.
The flare-up of cases and outbreaks of MDR TB reflected serious
underlying problems in the U.S. health care infrastructure. Increasing
proportions of TB cases were occurring in persons who were homeless;
were born in other countries; or had substance abuse, mental health,
or other problems, such as HIV infection, that made adherence with
treatment difficult. At the same time that the number and complexity
of TB cases were increasing, financial constraints were resulting
in cutbacks in TB control programs. As a result, health departments
lacked the resources needed to manage difficult-to-treat patients
and control outbreaks.
Reversing the increase in TB and MDR TB required vigorous TB control
measures and a significant hike in public spending.14, 19,
55 With the drop in TB cases, however, there has also come
a decline in TB treatment expertise, especially MDR TB, which requires
complicated drug regimens and meticulous patient monitoring. Because
the cost of treating MDR TB is so high, many programs are unable
to provide optimal treatment for affected patients. Without renewed
funding and support, MDR TB outbreaks may once again spread unchecked
and exact their heavy price.
National Action Plan to Combat Multidrug-Resistant
In response to the emergence of MDR TB, a federal Task Force
was convened in 1991 to develop a national plan to combat
the problem. The resulting National Action Plan to Combat
Multidrug-Resistant Tuberculosis5 identified
the problems to be addressed, outlined objectives for addressing
each problem, and listed the implementation steps needed to
attain each objective. The main objectives were to 1) determine
the magnitude and nature of the MDR TB problem, 2) improve
the rapidity, sensitivity, and reliability of diagnostic methods,
3) manage MDR TB patients and prevent patients with drug-susceptible
TB from developing drug-resistant disease, 4) identify persons
infected with or at risk of developing MDR TB and prevent
them from developing clinically active TB, 5) minimize the
risk of transmission to patients, workers, and others in institutional
settings, 6) control outbreaks, 7) increase TB programs' effectiveness
in managing patients and preventing MDR TB, 8) enhance training,
education, and information dissemination, and 9) conduct research
on more effective tools with which to combat MDR TB.
- Enhance the capacity of laboratories to rapidly diagnose MDR
- Monitor laboratory practices and capabilities in all mycobacteriology
- Provide funding through cooperative agreements for the upgrading
of state and local mycobacteriology laboratories as appropriate.
- Continue support of state and regional laboratories that
can rapidly identify and determine drug susceptibilities of
M. tuberculosis isolates.
networks of providers with expertise in the management of patients
TB to facilitate the referral of patients and the initiation of
- Develop information systems for use in managing and monitoring
the treatment outcomes of patients with MDR TB.
- Define the elements needed for the effective management
of persons with MDR TB.
- Develop an information system that captures these elements
and promotes the effective management of persons with MDR
- Provide financial and technical support to programs for
establishing and using MDR TB patient-management information
Ensure that health care facilities maintain infection-control precautions.
TB control programs are sources of information and consultation
to the medical community on infection-control practices that should
be maintained to prevent TB transmission. During interactions with
the medical community, TB control programs should emphasize the
need to maintain a high level of suspicion for TB in evaluating
patients who have TB symptoms and the importance of early diagnosis,
appropriate isolation, and prompt initiation of treatment.
- Update and disseminate guidelines for the prevention of TB transmission
in health care facilities, including outpatient settings.
- Promote the development of partnerships between local TB control
programs and congregate living settings (e.g., prisons, jails,
homeless shelters) to ensure appropriate infection control and
prevent the transmission of TB.
- Develop local epidemiologic profiles of TB disease, including
DNA fingerprinting results, to help in the identification
of groups with ongoing TB transmission.
- Identify the congregate living settings and health care
providers of these high-risk groups with whom partnerships
should be established.
- Identify gaps in services to high-risk groups that would
best be met by developing partnerships to ensure infection
control and prevent TB transmission in congregate living settings.
- Emphasize partnership development in cooperative agreement
announcements, program reviews, and site visits.
- Provide assistance in developing programmatic capacity to
evaluate community partnerships.
Develop improved engineering and personal protective techniques
to prevent TB transmission.
CDC's 1994 TB infection control guidelines presented recommendations
for TB control based on a risk assessment process that classified
healthcare facilities according to various categories of TB risk.56
A corresponding series of controls, which included administrative,
environmental, and personal protective control measures, was presented.
The second level of this hierarchy is the use of environmental controls
to prevent the spread and reduce the concentration of infectious
droplet nuclei. These environmental controls include: 1) controlling
the source by use of local exhaust ventilation, 2) controlling the
airflow to prevent contamination of air in areas adjacent to the
source, 3) diluting and removing contaminated air by use of general
ventilation, and 4) cleaning the air by use of air filtration alone
or together with ultraviolet germicidal irradiation (UVGI). The
first two levels of the hierarchy (administrative and environmental
controls) minimize the number of areas where exposure to infectious
TB may occur. They also reduce, but do not eliminate, the risk in
the few areas where exposure can still occur (e.g., airborne infection
isolation rooms; treatment rooms in which cough-inducing or aerosol-generating
procedures are performed; autopsy rooms; etc.). Because persons
entering these areas may be exposed to M. tuberculosis, the
third level of this hierarchy of controls is the use of personal
respiratory protective equipment in situations that pose a relatively
high risk for exposure.
The foundation for these activities is derived from basic research,
and information gained will be used to aid in the selection of effective
engineering controls and respirators.
- Improve engineering control measures for TB.
- Encourage and support research into development of improved
engineering techniques for preventing transmission of M.
tuberculosis in high risk environments.
- Utilize computational fluid dynamics (CFD) to assess the
efficacy of environmental controls supplemental to room ventilation.
- Utilize CFD to evaluate the ability of various ventilation
configurations/designs to prevent the migration of TB from
one room to another.
- Access adequacy of personal protective equipment.
- Determine if the current user-seal checks as described by
the manufacturers of N95 filtering facepiece respirators actually
help to ensure an adequate fit.
- Develop a no fit-test, high-protection factor respirator
- Conduct a workplace study of how well N95 filtering facepiece
respirators perform in actual health-care settings, including
determining penetration and service time restraints.
- Conduct surveillance of how respirators are used for protection
against TB in health-care settings (types, duration of use,
types and frequency of fit-tests used, and other critical
- Conduct testing of newly certified N95 respirators to determine
how well each certified respirator performs, enabling health
care workers to make informed and proper respirator selection.
Improve TB control in foreign-born populations entering or residing
in the United States.
In 2001, the TB case rate among foreign-born persons was 26.6 per
100,000 population, a rate which is almost 9 times higher than the
rate of 3.1 per 100,000 observed among the U.S.-born population
Mexico, the Philippines, and Vietnam are the countries of origin
for nearly half of all foreign-born persons with TB in the United
States. Although screening with a chest radiograph, followed by
acid-fast bacilli (AFB) smears for persons with abnormal radiographs,
is required for the approximately 435,000 immigrants and refugees
prior to arrival in the United States annually, approximately 32
million foreign-born persons entering the United States each year
are not screened for TB (approximately 30.2 million persons with
a nonimmigrant visa status; 275,000 undocumented immigrants; and
50,000 - 1.5 million asylees). Furthermore, a number of recent studies
suggest that the screening, tracking, and notification system currently
in place for immigrants and refugees is not uniformly effective
in identifying persons with active TB or ensuring appropriate treatment
and follow-up in the United States. Since the immigration status
of foreign-born persons with TB at the time of entry to the United
States is not systematically collected, it is unclear how many foreign-born
persons with TB were missed at the time of mandatory immigrant and
refugee screening, were appropriately screened but developed TB
after entering the country, or were in a visa category for which
no screening was required. Information is urgently needed in order
to develop strategies to reduce the incidence of TB among the ever-increasing
pool of foreign-born persons entering and residing in the United
- Conduct studies of at-entry immigration characteristics of foreign-born
persons with TB, to include
- Prospectively collect information on immigration and refugee
status in the Report of Verified Case of Tuberculosis (RVCT)
form used for reporting individual case data to CDC via the
Tuberculosis Information Management System (TIMS), a surveillance
and case management software application used by TB control
- Conduct studies in various epidemiologic settings (border
states, Hawaii, port cities, and U.S. heartland areas with
large numbers of immigrants and refugees) in order to refine
current estimates of risk of TB among various groups of foreign-born
- Use 2000 census data to update TB case rates for foreign-born
persons overall and by country of origin.
- Increase information about foreign-born populations in the
United States by
- Conduct contact investigation studies involving foreign-born
- Modify program management reports to collect separate data
for foreign-born persons.
- Add immigration status to the RVCT.
- Build local capacity to collect and analyze data on foreign-born
persons with TB that can be used to develop local profiles.
- Improve state and local health department capacity to develop
epidemiologic profiles of their foreign-born TB patients.
- Conduct prospective studies of immigration profiles of foreign-born
persons with TB to assist in targeting newly arrived immigrants
for targeted testing and treatment of latent TB infection.
*Any reference to future development of the RVCT (such as adding
variables to it) is also part of CDC's transition plan to the TB
program area module in the new National Electronic Disease Surveillance
- Conduct operational research to develop better methods and procedures
for identifying and accessing high-risk border populations.
- Improve TB case tracking of TB patients who move across the
U.S.-Mexico border by adding a binational variable to the RVCT,
and by improving TB information exchange between the United States
- Improve the sensitivity and specificity of the overseas screening
- Conduct studies to evaluate the efficacy of overseas screening.
- Based on pilot study data, develop new algorithms (such
as conducting repeat testing in the United States, conducting
all screening in the United States, adding skin test requirements
for certain immigration categories, and adding culture to
- Minimize improper classification.
Minimize loss of information from panel physicians.
- Expand and enhance the existing quality assessment program
training for panel physicians who evaluate immigrant and refugee
applicants outside the United States.
- Update technical instructions and forms for panel physicians.
Improve health department notification about arrival of immigrants
with radiographic evidence of (noninfectious) TB (classification
"B1") by developing and implementing a system of electronic
Minimize delayed or omitted follow-up of class B1 immigrants
by conducting intervention studies to improve immigrants' understanding
of follow-up in the United States.
Improve ongoing assessment of immigrants with radiographic
evidence of TB (classes A/B1/B2) and refugees by adding an indicator
to program management reports.
Improve quality of civil surgeon screening for immigrants, refugees,
and asylees by
- Implement a system of overseas data capture and transmission
to the United States.
- Improve training of responsible Department of State staff.
- Evaluate all immigrant and refugee arrivals.
- Consolidate all arrival data at one site.
Improve communication with foreign-born TB patients to improve
their compliance with therapy and contact investigation by hiring
field staff conversant in major foreign-born community languages.
Minimize risk of treatment interruption due to INS custody,
deportation, or return to country of origin by
Revising technical instruction and medical forms
for civil surgeons.
Collaborating with the Immigration and Naturalization
Service (INS) for civil surgeon training.
Assigning responsibility for civil surgeon designation
to the public health arena (state health departments or CDC).
Improve tracking of foreign-born persons across jurisdictions
by electronic notification of immigrants with class A/B1/B2 status
to health departments.
Improve case surveillance along the Mexican border by
- Working with INS to establish policy to ensure that TB patients
in INS custody are managed appropriately and followed to cure.
- Conducting a cohort study to assess TB outcomes.
Ascertain risk of TB in foreign-born children and children of
foreign-born parents by
- Including TB in the CDC Division of Global Migration and Quarantine
Binational Infectious Disease Surveillance project.
- Establishing a binational TB case registry.
Conducting special epidemiologic/risk factor studies among
immigrant/refugee children and adoptees arriving in the
United States through collaborative epidemiologic research
Studying TB in foreign-born children and children of foreign-born
parents to determine why TB was not prevented.
Educate the public and train health care providers to maintain excellence
in TB services.
As stated in the IOM report, as TB becomes less common, there
will also be fewer individuals with the experience and the correct
knowledge to ensure that the right steps are taken and procedures
followed to control and eliminate this disease. The IOM report also
states, "The most direct solution for decreased experience
is increased training."
In an effort to identify and coordinate TB education and training
resources, in 1997 the CDC funded a project to develop a strategic
plan for TB training and education. To ensure a broad representation
of issues and sectors for inclusion in the strategic plan, six work
groups were established. These work groups gathered information
on specific topics and summarized their findings in position papers
that were presented at a 2-day summit held in October 1998, a meeting
that brought together experts to forecast TB training needs and
efforts for the next 5 years. The recommendations from the summit
were used to develop the Strategic Plan for Tuberculosis Training
and Education, which was designed to provide guidance to U.S.
agencies and organizations that conduct TB training and education
for public and private sector providers.
the result of recommendations highlighted in the Strategic
Plan for Tuberculosis Training and Education, DTBE established
the TB Education and Training Network (TB ETN)
for educators in state, big city, and territorial health departments.
The goals of the TB ETN are to
- Build, strengthen, and maintain collaboration among the
key agencies and organizations in TB education and training
- Provide a mechanism for the sharing of TB education and
training resources to avoid duplication of effort
- Develop, improve, and maintain access to TB training and
- Provide updated information about TB courses and training
- Assist representatives in building education and training
- The Strategic Plan for Tuberculosis Training and Education,
the blueprint that addresses the training and educational needs
for TB control, should be fully funded.
- Develop and fund programs for the education of health care providers
and TB patients.
Provide funding for projects that call for government, academic,
and nongovernmental agencies to work in collaboration with international
partners to develop training and educational materials.
- Further the development of culturally and linguistically appropriate
educational materials for persons with or at risk for TB.
- Continue the development of an academic detailing project
targeting high-risk providers and patients with latent TB infection.
- Develop partnerships with CBOs to ensure that TB control staff
are skilled in working with their communities.
- Continue to support an educators' network for developing and
disseminating educational materials, as well as enhancing the
skills of these TB educators.
- Collaborate with training partners, such as the NIH, to expand
TB education at the academic medical center level (i.e., medical,
nursing and allied health professions schools).
- Provide training and educational technical assistance for
the national TB programs in high-burden countries.
- Participate in international advisory groups, including
the Collaborative for Training and Education in Russia and
the Newly Independent States; the Training Task Force of the
Tuberculosis Coalition for Technical Assistance; the Stop
TB Partnership Advocacy and Communications Task Force; the
International Union Against TB and Lung Disease (IUATLD) TB
Education Work Group; and the Partners in Health Peru Project.
- Utilize the training and education expertise in the United
States to build capacity with global partners to systematically
identify and address training and education needs in TB control