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TB Notes 1, 2001

Highlights From State And Local Programs

Recommendations on TB Screening of Students in Minnesota

In Minnesota, tuberculin skin testing of elementary and secondary school students was practiced widely until the 1970s, when such screening was discontinued as the prevalence of latent TB infection (LTBI) among students fell below 1% (or to 0% in many schools). While the incidence of TB in many areas of the United States has declined steadily since 1993, the number of cases of TB disease reported in Minnesota has increased markedly in recent years. In 2000, 178 new cases of TB disease were reported statewide, which is the second largest number of cases reported annually since 1980, following the 201 cases reported in 1999. Most notably, a large and increasing percentage of TB cases in Minnesota occur among persons born outside the United States, growing from 50% in 1995 to 82% in 2000. The changing epidemiology of TB in Minnesota reflects trends in the state's population demographics. The number of refugees and immigrants arriving from regions where TB is endemic (e.g., sub-Saharan Africa, Southeast Asia, Latin America, Eastern Europe) has greatly increased.

Recommendations of the Minnesota Department of Health (MDH)

Owing to the increasing incidence and changing epidemiology of TB in Minnesota, the Minnesota Department of Health (MDH) TB Prevention and Control Program has recently received questions from parents, school nurses, teachers, and others inquiring whether TB screening of students is indicated. In response to these concerns, in 2000 MDH convened a multidisciplinary workgroup to discuss the issue. The workgroup consists of school nurses; public health professionals; and clinicians from public TB clinics, private health care facilities, and Student Health Services at postsecondary schools. The purpose of the workgroup was to discuss whether the school setting may be an appropriate means to access high-risk populations for whom targeted TB screening is indicated and, if so, how such screening should be implemented. In collaboration with the workgroup, MDH developed the following guidelines regarding TB screening of students in Minnesota:

Elementary/secondary schools:

Universal TB screening (i.e., Mantoux tuberculin skin testing) of all students in school settings is not recommended. This is consistent with national guidelines.

Decisions to conduct screening should be based on an assessment of trends in the local epidemiology of TB and pertinent population demographics (e.g., immigration trends) in the community. The local public health department, in consultation with MDH, should assess the community's incidence and prevalence of TB, identify high-risk groups based on local epidemiology and demographics, and ascertain sites that are convenient for accessing group(s) to whom screening should be targeted (e.g., school, work site, or homeless shelter). On an annual basis, MDH will provide local health agencies with an individualized summary of local epidemiologic TB data to assist in this assessment.

Population-based screening for TB in community settings (including schools), when indicated, is primarily the responsibility of local public health departments. When the school setting is determined to be a convenient site at which to access a high-risk group, the local public health department should work with school nursing staff and school administrators to coordinate any school-based TB screening program. However, local public health agencies should be responsible for overseeing the screening program, ensuring linkages with essential clinical services and financial resources, and ensuring initiation and completion of therapy for LTBI, as indicated.

Decisions regarding implementation of a school-based TB screening program should be made jointly by local public health professionals in collaboration with school nurses and school administrators. MDH is also available for consultation, as needed.

A decision to conduct TB screening is a decision to treat LTBI, if identified. Targeted screening of persons at high risk for LTBI or TB disease must be accompanied by a plan for providing necessary follow-up. This plan must include resources for providing a follow-up chest x-ray, medical evaluation, treatment for LTBI or TB disease, and clinical monitoring during such treatment, as indicated. A plan to address each of these criteria should be developed before screening is initiated.

Systematic program evaluation is an integral part of any TB screening program. Programmatic indicators that should be evaluated include the number of students with history of prior TB disease or LTBI, the number of tuberculin skin tests administered, the number of tests read and the result of each in millimeters of induration, and rates of initiation and completion of treatment for LTBI (including reasons for discontinuation for those who fail to complete therapy). These data should be reviewed periodically to determine the yield and effectiveness of the screening program. If a low prevalence of TB disease or LTBI or suboptimal rates of completion of therapy are identified, decisions to continue the screening program should be re-evaluated. MDH is available for consultation on implementing a program evaluation system and evaluating resulting data.

Postsecondary Schools:

While the feasibility of targeted TB screening in elementary or secondary schools may often be limited by lack of resources, appropriate infrastructure, or access to health care services for students identified with LTBI or TB disease, the workgroup identified postsecondary schools (i.e., colleges, universities, and vocational/technical schools) as settings in which such screening is indicated and practical. For example, most postsecondary students are 18 years of age or older. Data indicate that the prevalence of LTBI increases with age, and adults with pulmonary TB disease are more likely than young children to be infectious. Postsecondary school students often live in congregate settings that may facilitate transmission of TB. Also, postsecondary students typically have access to student health services, thereby enabling them to obtain medical evaluation and treatment, if indicated. Therefore, with support of the workgroup, MDH developed the following recommendation:

In postsecondary schools, targeted tuberculin skin testing is recommended for all international students originating from (and other students traveling to) countries where TB is endemic. In this context, "international students" are defined as students who travel to the United States for the purpose of studying at the given postsecondary institution. In addition, all students whose studies involve extensive international travel to areas where TB is endemic are also candidates for tuberculin skin testing prior to travel and 10-12 weeks following their return to the United States.

Screening programs targeted to high-risk postsecondary school students should also reflect the general MDH guidelines for TB screening of elementary and secondary school students (described above). For example, a targeted screening program should be accompanied by a plan for providing necessary medical evaluation, follow-up, and treatment for students identified with LTBI or TB disease. Postsecondary schools at which not all students have access to centralized health care services should consider and identify other means to ensure appropriate follow-up services prior to implementing a targeted TB screening program. Also, programmatic indicators should be routinely and systematically evaluated to assess the effectiveness of the screening program.

These recommendations regarding TB screening of elementary, secondary, and postsecondary school students are general public health guidelines focused on decisions about population-based screening in the school setting. They are not intended to be clinical guidelines for determining whether screening is indicated for a specific patient. As indicated by current national guidelines, clinicians should carefully assess each patient's individual risk factors for TB when making decisions about TB screening, evaluation, and treatment for a given patient.

Related Resources

With input from the workgroup, MDH developed several practical tools for use by school staff and public health professionals following the diagnosis of a case of infectious TB disease in the school setting. These tools include fact sheets, prototype letters addressed to parents and guardians of students at the school and those students for whom TB screening is recommended, and a letter to notify local clinics about a school-based contact investigation so providers can anticipate calls from parents. MDH recommendations regarding TB screening of students and related resources are available on the MDH TB Program's Web site.

-Submitted by Wendy Mills, MPH
Epidemiologist and Acting TB Supervisor
Minnesota Department of Health

Revised Strategic Plan for TB Elimination Released in New Jersey

The New Jersey Department of Health and Senior Services (NJDHSS) released its Revised Strategic Plan for the Elimination of Tuberculosis in New Jersey (2000) in conjunction with World TB Day. The plan was developed by the Tuberculosis Advisory Steering Committee of the New Jersey Thoracic Society at the request of the NJDHSS.

The original State TB Plan (1992) focused on four prevention and control strategies: surveillance, disease prevention, disease containment, and program assessment and evaluation. The revised plan updates these recommendations in light of the Institute of Medicine (IOM) report, Ending Neglect: The Elimination of Tuberculosis in the United States. In addition, the revised plan has been shaped by many of the joint statements of the American Thoracic Society (ATS) and CDC, the latest of which was Targeted Tuberculin Testing and Treatment of Latent Tuberculosis Infection. These and other applicable publications, as well as pertinent TB Web sites and links, are included in the "Pertinent References" section at the end of the plan.

The revised plan includes two new sections: "Funding" and "Training and Education." The committee felt that adequate funding, with the implementation of the plan, would contribute greatly to the achievement of the case-rate objective for TB that is included in Healthy New Jersey 2010, A Health Agenda for the First Decade of the New Millennium: Reduce the incidence of TB to 2.4 cases per 100,000 population. For reference purposes, the active TB case rate for 2000 was 6.7 cases per 100,000 population. The NJDHSS will continue its collaboration with the New Jersey Medical School National TB Center for training as well as for other TB strategies.

The Steering Committee is developing a work plan to prioritize activities and methods and recommend milestones and completion dates. Once received, NJDHSS staff will expand the work plan to include assigned staff and provide periodic status reports.

The revised plan can be found at the NJDHSS Web site at

-Submitted by Kenneth Shilkret
Sr. Public Health Advisor
TB Program Manager, NJDHSS

Minnesota State Health Department Holds TB Incentives Drive

The use of incentives can play an important part in helping TB patients adhere to the lengthy treatment regimen needed to cure their disease. Unfortunately, most public health departments are strapped for funds to purchase such "luxuries." Some of us know of TB program staff members who frequent garage sales and second-hand stores to purchase incentive items for their patients. As a special holiday project in December 2000, staff from the TB Prevention and Control Program at the Minnesota Department of Health (MDH) coordinated a drive to collect items to be used by local health departments statewide as incentives for their TB patients. We invited our coworkers in the Division of Infectious Disease Prevention and Control to join us in a "Holiday TB Incentives Drive." Signs advertising the project were posted around the building, and a box was placed in a central area in which our coworkers could deposit items. We encouraged donations of nonperishable food; toiletries; and new or gently used winter clothing, kitchen equipment, toys, and books.

We were overwhelmed by the generous response from our coworkers. During 1 month, nearly 600 items were donated. Two especially nice donations included over 100 new Boyd stuffed animals contributed through a charitable organization and 75 toothbrushes donated by a staff member's dental office. The Boyd toys and boxes of matching clothes for the animals arrived straight from the factory, so we held a lunchtime "tea party" at which epidemiologists, clerical staff, and nurses joined together to unpack boxes and dress teddy bears over cookies and milk! At the end of the month-long drive, TB Program staff sponsored a doughnut and coffee break for our coworkers at MDH to express our appreciation for their enthusiastic participation and generosity.

In Minnesota, local health departments in 87 counties perform direct TB services such as contact investigations and directly observed therapy. The MDH TB Program is distributing the donated incentive items to these local public health agencies' TB programs based on the local incidence of TB, the complexity of cases, and the local agencies' particular needs. Local TB staff members have appreciated this demonstration of support for their efforts, and patients have enjoyed the incentives. Additional benefits of this project have included strengthened relationships between MDH TB Program staff and our coworkers in other disease prevention and control programs and increased awareness among MDH staff about the activities and special needs of local TB programs. Owing to the success of this first Holiday TB Incentives Drive, we plan to continue the project in upcoming years and possibly to expand it into an ongoing effort throughout the year.

-Submitted by Deborah Sodt, RN, MPH
TB Nurse Consultant
Minnesota Department of Health


Released October 2008
Centers for Disease Control and Prevention
National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention
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