CDC Logo Tuberculosis Information CD-ROM   Image of people
jump over main navigation bar to content area
TB Guidelines
Surveillance Reports
Slide Sets
TB-Related MMWRs and Reports
Education/Training Materials
Ordering Information


U.S. Department of Health and Human Services


TB Challenge: Partnering to Eliminate TB
in African Americans

Alabama's Three-Part Strategy to “Put TB on the Run” In the African-American Community

J. Scott Jones, Senior Public Health Advisor, State of Alabama, Department of Public Health

When the discussion of health disparities between African Americans and white persons in Alabama comes around to her end of the table, Nancy Keenon leans forward to emphasize her point.  “We have a plan, and that plan is working.” Keenon is the Director of Alabama's Division of Tuberculosis (TB) Control.  Her division has two primary responsibilities: tracking TB and treating it.

The control of TB, which was once the leading cause of death in the state of Alabama, is a core public health function.  A committed group of physicians, labora-torians, nurses, and field staff   (also known as disease intervention specialists [DIS]) have made the control of TB in Alabama a reality.  To illustrate her point, Keenon states that Alabama counted more than 2,600 persons with TB in 1951.  This number contrasts with the 211 cases of TB reported in 2004.  Keenon credits the work of those who provided leadership throughout the division over the years and the dedicated field staff.  However, she knows that the work isn't over yet.  “TB is retreating, but the battle is far from over,” she warns.

Although blacks make up about 25% of the total population in Alabama, nearly 53% of all reported TB cases between 1999 and 2003 were found in this population.  In 2003 alone, 78% of TB cases reported among children less than 15 years of age were in non-Hispanic blacks. The clearest measure of this disparity is the case rate for TB: the 5-year average for case rates among blacks is 12.7 per 100,000 population when compared to the 3.5 per 100,000 population among whites. Or, stated another way, for every 13 blacks in the state diagnosed with TB, there are fewer than 4 whites with the disease.

A review and analysis of TB morbidity conducted by Keenon and her staff has led to the development of a three-part plan at the state level to reduce the burden of TB in the African-American community.  The Division has discovered a common factor when investigating reports of active TB disease among African-American children.  This factor, “diagnostic delay,” has been observed in three separate areas across the state.  The

first part of the Division's strategy will be to expand training opportunities for health care providers serving this high-risk community.  Reducing diagnostic delays is critical to the interruption of transmission and the prevention of secondary cases (often found in young children).

In 2005, the Division will develop and test targeted provider training.  Beginning in 2006, the Division will conduct at least one targeted-provider training in each major metropolitan area of the state.  The three-part plan is listed below:

  1. Prompt diagnosis facilitates earlier initiation of treatment and contact investigations.  In the second part of this strategy, the Division's DIS will improve how they find, evaluate, and bring to treatment persons in the community who have been exposed to, and infected with, M. tuberculosis.  Contact investigation and treatment of latent infection (LTBI) can prevent secondary cases of TB disease. 

  2. Renewed commitment to the African-American community includes partnerships with the Alabama Minority Health Section and with others who have traditionally served this community.  These partner-ships are necessary to prepare the Division's field staff for the challenge of operating across cultural and economic barriers.  Enhanced training for cultural competency already has been initiated and will be required for all TB field staff upon hiring.  Existing TB staff will be required to attend this training as part of the state's annual training plan.

  3. The third part of the Division's strategy requires recognition of a disturbing fact: African Americans are disproportionately represented in the state's correctional or penal system.  The rate of incarceration among African Americans is greater than 2 to 1 when measured against all other groups in the system.  The Division currently assists in the evaluation and investigation of persons with active TB disease in the state's prison system, and has identified opportunities for treating LTBI and preventing cases of TB disease in homes and communities after an inmate's release. 

The Division’s DIS will visit each prison and review charts monthly after the completion of each case or contact investigation.  These monthly visits are currently expected of the DIS, as is the requirement that staff remain engaged with wardens to ensure inmates with latent infection complete therapy.

“Our goal is to gradually reduce the burden of disease over the next 5 years; we know this plan will work, and there may be ways to accelerate the decline.”  Keenon is not looking for a magic bullet; she knows that TB will be difficult to eliminate.  “It will require us to communicate the advantages of preventive therapy more clearly, and this will require more than words.” Keenon adds, “Once the community sees and believes in the actions of our staff, and once we have earned the trust of the community--then we will have TB on the run.”


Released October 2008
Centers for Disease Control and Prevention
National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention
Division of Tuberculosis Elimination -

Please send comments/suggestions/requests to:, or to
CDC/Division of Tuberculosis Elimination
Communications, Education, and Behavioral Studies Branch
1600 Clifton Rd., NE - Mailstop E-10, Atlanta, GA 30333