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