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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
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:
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
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.
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
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.
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 www.state.nj.us/health/.
-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,
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