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U.S. Department of Health and Human Services


TB Challenge: Partnering to Eliminate TB
in African Americans

Lessons Learned in a Mid-Western African-American Community with Low TB Incidence and Program Resources

Dawn Tuckey, Program Consultant, DTBE/FSEB

From 2001 through 2004, a low-incidence state experienced an increase in the number of tuberculosis (TB) cases.  In March 2004, the state department of health invited staff of CDC, the Division of Tuberculosis Elimination, to assist the state and local health officials in an epidemiologic investigation to prevent further spread of M. tuberculosis.

As a result of the investigation, a total of 26 TB cases were determined to be outbreak related.  Only cases that had a matching genotype of M. tuberculosis or, when no isolate was available for genotyping, an epidemiologic link to a previously identified case were included as outbreak-related cases in the investigation. 

During 2004, the county reported a total of 22 confirmed cases of TB.  The case rate (6.5 per 100,000) was more than three times the TB rate of the entire state (2.1 per 100,000). Current data indicate that 1,090 contacts to outbreak-related cases were identified.  Of the 26 outbreak-related cases, 10 (40%) had delayed diagnosis. The median age was 27 years (range: 6 months   51 years), 25 (96%) were African American, and 15 (58%) were female.

CDC staff determined that several factors contributed to this outbreak.  One factor was nonadherence to latent TB infection (LTBI) treatment among the contacts. If four nonadherent contacts had completed the LTBI treatment regimen, their own disease plus 16 additional cases may have been prevented.  A second contributing factor was delayed diagnosis.  This was caused by health care providers, as well as the patient's own delay in accessing health care.  For example, health care providers in low-incidence areas may have a low index of suspicion for TB.  Patients, on the other hand, may delay seeking medical care or may not disclose TB exposure to health care providers. The delayed TB diagnosis in this outbreak emphasizes the importance of educating both health care providers and patients about TB. Thirdly, the need to expand contact investigations was a critical factor in this outbreak. 

Prior to CDC's involvement, the contact investigation had two limitations.  Even though 43% of the close contacts had a positive skin test result, the initial contact investigation was not expanded beyond close friends and family to include contacts at work and other social settings.  The second limitation was the lack of staff to manage the TB patients and contacts; this occurs many times in low-incidence areas where resources are limited.

Thus, the lessons learned from this outbreak are as follows: (1) ensure completion of testing and treatment of contacts, (2) treat persons with LTBI and TB disease using directly observed therapy to ensure adherence, and (3) provide TB education to health care providers and the community.

This investigation also illustrates what can happen in a low-incidence area with limited TB resources, which is not uncommon in the United States. Therefore, this outbreak provides lessons for TB control by emphasizing the continued threat of TB in the United States, the importance of successful execution of TB control measures, and the need for resources to achieve prompt public health responses.


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

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Communications, Education, and Behavioral Studies Branch
1600 Clifton Rd., NE - Mailstop E-10, Atlanta, GA 30333