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TB Notes 1, 2004

A Statewide Targeted Tuberculin Testing Program In Tennessee

Dr. Connie Haley, TB Controller for Tennessee, came to CDC in 2002 and gave a presentation to DTBE staff about Tennessee’s targeted tuberculin testing program among foreign-born persons. In the following article, she provides an update on the program.

While the tuberculosis (TB) case rates in Tennessee have steadily decreased over the last decade, there continues to be a significant disparity in the rate of TB in foreign-born (FB) residents compared to U.S.-born residents (31.4 per 100,000 and 4.7 per 100,000, respectively, in 2002). Since 1996, the proportion of TB cases in Tennessee occurring among foreign-born residents has increased from 7 percent to 18 percent.  During the same time period there has been a 42 percent annual increase in Hispanic persons receiving services at Tennessee’s local health departments. According to the 2000 Census, approximately 160,000 Tennessee residents were born outside of the United States, the majority in TB-endemic countries. In consideration of the growing foreign-born population residing in Tennessee, a statewide Targeted Tuberculin Testing and Treatment Initiative (TTI) was implemented to address the potential of TB transmission within this and other high-risk groups, whose health directly affects that of the entire population.

In 2001, the Tennessee State Legislature increased the TB Elimination Program budget by $5 million annually to provide foreign-born persons with tuberculin testing, clinical evaluation, and treatment for TB or latent TB infection (LTBI), and new public health staff were hired to provide these services. The funds also enabled clinic renovations, the purchase of new clinic and laboratory equipment, transportation of patients to clinics, translation and interpretation services, and expanded physician services.  Outreach was implemented in local communities to identify and establish a relationship with foreign-born populations that would benefit from TB services.  Two concurrent arms of the TTI were developed. The first arm involves ensuring that TB services are provided to foreign-born persons already coming to the local health departments for other services such as immunizations, prenatal care, STD/HIV treatment or primary care visits.  The second arm involves the provision of TB services at community sites where foreign-born persons can be accessed. Specific community sites where TTI services can be delivered include churches or other religious gatherings, factories, grocery stores, restaurants, community centers, and residential sites such as apartment complexes.  

A statewide needs assessment indicated that to effectively implement planned TTI services, the following barriers must be addressed: cultural and linguistic diversity, Title VI requirements,1 lack of education among foreign-born clients, fear of the government and the health department, misconceptions and stigma surrounding TB and LTBI, and competing priorities of work schedules or family care. In reviewing these issues, the TB Elimination Program recognized that a successful initiative must strive to improve the quality of services provided to the foreign-born in addition to increasing the number of individuals tested and treated for LTBI. All health department TB staff received extensive cultural and linguistic competency training, and trained interpreters and telephone interpretation services were hired to facilitate communication. Standardized procedures for performing tuberculin skin testing, evaluation, treatment and follow-up were developed. In addition, written guidelines have been developed and in-person training was provided to TB control staff statewide. To enhance access to TTI services, public health staff provide tuberculin testing, dispensation of TB or LTBI medications, and routine clinical and laboratory monitoring during treatment at local community sites as well as at local health departments. 

In order to overcome patient fear and misconception about both the health department and about TB, avoid the appearance of discrimination by "targeting" a specific population, and increase acceptance of TTI services, a new policy of performing individualized TB risk assessment and counseling prior to tuberculin testing was established. A Risk Assessment Tool (RAT) was developed to serve as a flow chart for assessing an individual’s risk for TB or LBTI and to determine the need for tuberculin testing. The tool also serves as a data collection instrument and as documentation of services provided. Specific information obtained using the tool includes demographic information and patient identifiers, risk factors for TB infection, medical conditions associated with progression to active TB once infected, HIV risk factors, TB symptoms, and history of previous tuberculin testing or LTBI treatment. To ensure effective and accurate education of all patients, as well as encourage disclosure of personal information, a standardized script has been developed for use with the tool. This script outlines specific teaching points regarding TB and LTBI diagnosis, evaluation, treatment, follow-up, and clinical outcomes. 

Persons whose individualized risk assessment detects evidence of active TB are referred immediately to a physician. Persons who are identified as high risk for TB or LTBI or who have a history suggestive of untreated LTBI are provided tuberculin skin testing. Persons with a positive tuberculin skin test (TST) are then referred to regional heath department TB clinics for evaluation by experienced TB providers and are placed on appropriate therapy as indicated. Persons with no risk factors, medical conditions, TB symptoms or history suggestive of TB or LTBI are counseled that they are low-risk for developing active TB disease. Tuberculin testing is strongly discouraged for all low-risk persons, and these persons are dismissed with a health department card stating that they have been evaluated and found to be free of infectious TB. The card also contains written instructions to return if their risk of TB or LTBI changes or if they develop symptoms of TB disease. 

During the first year of the initiative (March 2002 to February 2003), over 40,000 persons received education and individualized risk assessment for TB and LTBI.   Almost 23,000 of the individuals screened and educated were identified as having increased risk for TB infection and subsequently received tuberculin skin testing.  Of note, five cases of active TB disease were detected as a direct result of targeted testing activities. LTBI was diagnosed in 15 percent of all high-risk persons tested, and in 36 percent of foreign-born persons tested. In contrast, only 1 percent of low-risk individuals were found to have a positive TST, and many of these could represent false-positive results due to environmental mycobacteria. These data indicate that tuberculin testing programs targeting high-risk populations enable early detection of active TB cases and identification of persons with LTBI who would benefit from treatment. Persons born in TB-endemic areas appear to have the highest rate of TB infection and are thus an appropriate priority group for tuberculin testing and treatment of LTBI. Furthermore, our findings indicate that tuberculin testing of low-risk persons has low yield and thus is not an effective use of limited public health resources. 

Several significant challenges have been encountered during the early phases of this program. While a large number of high-risk persons were identified and provided services, over 17,000 low-risk persons were also provided TB or LTBI screening and education and over 10,000 of these were given tuberculin skin tests. Public health workers were initially resistant to the idea of refusing to provide requested services such as skin tests, even to persons with no apparent risk for LTBI or TB. However, the extremely low rate of tuberculin positivity among low-risk persons has slowly convinced our staff that limiting testing of low-risk persons is unlikely to result in a missed opportunity to detect or prevent active TB. Another barrier to reducing skin testing of low-risk persons is the existence of various licensure rules and broad administrative policies that require tuberculin testing regardless of TB or LTBI risk. For example, TSTs have routinely been required for school teachers, bus drivers, day care workers, foster care parents and children, and volunteers who provide nonmedical personal services for the elderly, among others. In addition, some large employers have required skin testing for employment. Even though the targeted tuberculin testing and treatment guidelines published by CDC in 2000 recommend that routine testing for administrative purposes be discontinued,2 current regulations are difficult to change. To date we have had to address this problem one group at a time. In 2002, we implemented a joint policy with the Department of Education to discontinue required skin testing of teachers and bus drivers, and in 2003 we implemented similar policies at the Department of Human Services and the Tennessee Commission on Aging and Disability.

Another unanticipated challenge we have encountered has been defining the concepts of high- vs. low-risk and determining who should have a tuberculin skin test. Frequently, health department personnel who provide tuberculin testing are not designated TB staff but rather work in other programs such as WIC, immunization or primary care. We have recently determined that some staff do not understand what factors determine whether a person has increased risk of LTBI or TB disease and symptoms that are more likely attributable to causes other than pulmonary TB may be overreported (i.e., chronic cough of COPD or acute symptoms of upper respiratory infections).  In addition, risk factors such as “travel to high-TB risk areas,” “children exposed to adults in high-risk categories,” “patients receiving immunosuppressive therapy,” and “residents and employees of high-risk congregate settings” are hard to define for persons who infrequently perform TTI services.  We are currently revising our state guidelines and providing more specific written protocols to enable all public health personnel to better identify persons who would benefit from TB testing and treatment versus those who should be counseled and dismissed.  In addition, we hope that statewide retraining and a highly coordinated “train-the-trainer” approach will help us overcome these problems to provide more effective TTI services to the appropriate populations statewide.

A final limitation to implementing a statewide targeted tuberculin testing and treatment program is certainly the high cost and large number of staff required to deliver the needed services. However, by reallocating the cost and staff time that are currently expended providing TST and other preventive services to low-risk persons, perhaps local TB control programs can accomplish targeted testing of a specific high-risk group.  Given the great success of our TTI during the initial year, we are optimistic that this statewide initiative will reduce the incidence of active TB among Tennessee residents, particularly the foreign-born. Implementation of this program is thus a big step toward our goal of TB elimination in Tennessee.

—Reported by Connie Haley, MD, MPH
TB Control Officer, and
Katie Garman, MPH, CHES, Epidemiologist
Tennessee Department of Health


1. Title VI of the 1964 Civil Rights Act (42 U.S.C. 2000d-1) states that "No person in the United States shall, on the ground of race, color, or national origin, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity receiving Federal financial assistance." Title VI bars intentional discrimination as well as disparate impact discrimination (i.e., a neutral policy or practice that has a disparate impact on protected groups).

2. CDC. Targeted tuberculin testing and treatment of latent tuberculosis infection. MMWR 2000;49(No. RR-6):1-51.


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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