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Federal Tuberculosis Task Force Plan in Response to the Institute of Medicine Report, Ending Neglect: The Elimination of Tuberculosis in the United States

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The documents listed below are historical, archived information. The information contained in these documents, while accurate at the time of release, may not be the most current available.

Strategies and Action Steps

Domestic Federal Actions in Response to the Institute of Medicine Report on TB:
Ending Neglect: The Elimination of Tuberculosis in the United States

A. Strategies for Maintaining Control of TB

Maintaining control is a necessary prerequisite to elimination of the disease and requires strengthening labor-intensive activities that make optimal use of available tools to help find and cure all persons with active TB.

IOM Recommendation 3.1: “To permanently interrupt the transmission of tuberculosis and prevent the emergence of multidrug-resistant tuberculosis...”

Strategies
Action Steps

1. Ensure available clinical and public health services to provide continuous quality care for TB patients.

Lead Agency: CDC

Collaborating Agencies: IHS, VA, DOJ, SAMHSA, HRSA, NTCA

Start Date: FY 2002

Completion Date: Ongoing

a) Ensure that patient-centered case management and monitoring of treatment outcomes are implemented universally and are the standard of care for all patients.

  • Lead: NCHHSTP
  • Collaborators: IHS, VHA, HAB, FBOP, SAMHSA, BPHC, NTCA
  • Start Date: prior to FY 2002
  • Completion Date: Ongoing

b) Ensure appropriate care for patients with MDR TB and monitor their response to treatment and treatment outcomes.

  • Lead: NCHHSTP
  • Collaborators: IHS, VHA, HAB, FBOP, BPHC, NTCA
  • Start Date: prior to FY 2002
  • Completion Date: Ongoing

c) Support the infrastructure needed for laboratory-based identification and treatment of TB and ensure the provision of quality and timely laboratory services with appropriate safety facilities.

  • Lead: NCHHSTP
  • Collaborators: PHPPO, BPHC, NTCA
  • Start Date: prior to FY 2002
  • Completion Date: Ongoing

2. Improve and optimize follow-up of immigrants and refugees arriving in the U.S. with suspected TB.

Lead Agency: CDC

Collaborating Agencies: DOJ, ORR, DOS, NTCA, DHS/BICE

Start Date: FY 2002

Completion Date: FY 2005

a) Implement electronic surveillance of TB notifications for immigrants and refugees arriving in the U. S. with suspected TB in order to effectively communicate data between local, state, and federal programs and ensure appropriate domestic follow-up, and quality and continuity of care.

  • Lead: NCID
  • Collaborators: NCHHSTP, CA, PRM, SITD, ORR, NTCA
  • Start Date: prior to FY 2002
  • Completion Date: FY 2005

    1. Build the software and infrastructure to electronically transmit the data to state health departments. Identify and enlist a representative group of 8 state health departments (State TB Control Programs and State Refugee Health Programs) and 2 metropolitan health departments, and pilot the system.
      • Lead: NCID, NCHHSTP, NTCA
      • Collaborator: None
      • Start Date: prior to FY 2002
      • Completion Date: Ongoing

    2. With input from U.S. TB controllers, establish national performance measures, objectives, and data collection to enable assessment and improvement of domestic follow-up.
      • Lead: NCID, NCHHSTP
      • Collaborator: NTCA
      • Start Date: prior to FY 2002
      • Completion Date: FY 2003

    3. Fully implement the electronic surveillance for TB notification to 50 state health departments and remaining metropolitan health departments.
      • Lead: NCID
      • Collaborators: NCHHSTP, CA, PRM, NTCA
      • Start Date: FY 2003
      • Completion Date: FY 2005

    4. Build the software to collect and consolidate data from the overseas examining physicians (i.e., panel physicians) at panel physicians' facilities or at the U.S. ports of entry. Establish the infrastructure to collect the data at a centralized Immigration and Naturalization Service (INS) collection point (e.g., Mesquite, Texas) or to interface with the existing data collection system with the Department of State. Once software is operational, data will be transmitted directly to CDC, Division of Global Migration and Quarantine (DGMQ), for dissemination to the receiving health departments.
      • Lead: NCID
      • Collaborators: NCHHSTP, SITD, CA, PRM, NTCA

    5. Identify and enroll a selected group of overseas examining physicians (panel physicians) to collect and transmit the medical data to DGMQ.
      • Lead: NCID
      • Collaborators: SITD, CA, PRM
      • Start Date: FY 2002
      • Completion Date: FY 2005

3. Improve and ensure the quality of tuberculosis examinations conducted by overseas panel physicians and domestic civil surgeons.

Lead Agencies: CDC, DOJ

Collaborating Agencies: NTCA, DOS

Start Date: FY 2002

Completion Date: Ongoing

a) Develop and implement a standardized, fully operational quality assessment program to evaluate the performance and effectiveness of overseas TB screening by panel physicians for immigrants and refugees.

  • Lead: NCID
  • Collaborators: NCHHSTP, NTCA, CA

    1. Expand the overseas quality assessment program and focus initially on countries with high prevalence of tuberculosis and HIV and/or high volume of immigration to the U.S.
      • Lead: NCID
      • Collaborators: NCHHSTP, PHPPO, CA, PRM, NTCA
      • Start Date: FY 2002
      • Completion Date: FY 2003

    2. Reestablish overseas posts to have responsibility for overseeing and ensuring the quality assessment program in selected regions with high prevalence of tuberculosis, HIV, and/or heavy volume of immigration to the U.S.
      • Lead: NCID
      • Collaborators: CA, PRM, PHPPO
      • Start Date: FY 2002
      • Completion Date: FY 2003

    3. Maintain a successful global quality assessment program.
      • Lead: NCID
      • Collaborators: CA, PRM, NTCA
      • Start Date: FY 2004
      • Completion Date: Ongoing

b) Implement a domestic quality assessment program to evaluate the effectiveness of screening by domestic civil surgeons for TB disease and latent TB infection among foreign-born persons already residing in the U.S. (i.e., adjustment of status applicants). This quality assessment program will (1) review and revise existing INS regulations governing the civil surgeon program; (2) create new forms and revise existing ones; (3) implement protocols for tracking the status of civil surgeon designations; (4) implement a standard protocol for CDC and health departments to evaluate the performance of civil surgeons; (5) use tools and resources developed by CDC for quality improvement of TB control programs; and (6) ensure that civil surgeon examination procedures and findings are integrated into effective targeted testing and treatment programs at state and local levels.

  • Lead: AND, NCID
  • Collaborators: NCHHSTP, NTCA
  • Start Date: FY 2002
  • Completion Date: Ongoing

c) Develop reliable and systematic linkages between local health departments and civil surgeons to ensure referral and treatment of latent TB infection among persons adjusting status. The linkage will require implementation of local strategies to improve communications between civil surgeons and local health departments to streamline the referral process, assist patients in accessing local health departments (LHDs), and ensure adequate resources for the LHD's evaluation and treatment of adjustment of status applicants referred.

  • Lead: AND, NCID, NCHHSTP
  • Collaborator: NTCA
  • Start Date: FY 2003
  • Completion Date: Ongoing

4. Facilitate continuity of care for prisoners and INS detainees across correctional facilities and communities in the U.S. and Mexico and elsewhere.

Lead Agencies: DOJ, USMS, HRSA

Collaborating Agencies: CDC

Start Date: FY 2002

Completion Date: Ongoing

a) Resurvey state laws for provisions regarding case transfers across correctional facilities, release and quarantine of persons with TB, and TB-related screening.

  • Lead: NCHHSTP
  • Collaborator: CDC/OD (OGC)
  • Start Date: prior to FY 2002
  • Completion Date: FY 2002

b) Develop reporting and discharge planning infrastructure for newly diagnosed and prevalent cases and suspects.

  • Leads: FBOP, USMS, NCHHSTP, DIHS
  • Collaborator: None
  • Start Date: prior to FY 2002
  • Completion Date: Ongoing

c) Implement Health Resources and Services Administration/Division of Immigration Health Services (DIHS) program for continuity of care for persons detained by the INS and subsequently released or paroled in the U.S., in order to facilitate the continuity of care in the community and have TB completion of treatment monitored on a national level; share data with TB controllers and with tracking organizations such as Cure TB and TBNet.

  • Lead: DIHS
  • Collaborators: D&R, NTCA
  • Start Date: FY 2002
  • Completion Date: Ongoing

    1. Develop a model for the implementation and maintenance of a continuity of care program for released or paroled INS detainees and establish/strengthen partnerships between INS, DIHS, TB controllers in other countries, state and local health departments, and community TB service providers. The program should include a uniform method of data collection, including uniform tracking numbers and data elements across programs and services (e.g., DIHS, INS, state health departments, CDC, TBNet, Cure TB, etc.), and access to databases by TB providers and TB controllers across programs.
      • Lead: DIHS
      • Collaborators: D&R, NTCA
      • Start Date: FY 2002
      • Completion date: Ongoing

    2. Coordinate tracking of patients released from INS custody to link paroled aliens to services in the U.S., to link deported aliens to services in the country of origin, and to monitor inplementation of infectious disease guidelines.
      • Lead: DIHS
      • Collaborators: D&R, NTCA
      • Start Date: FY 2002
      • Completion date: Ongoing

5. Continue to ensure TB medications are available and at federal pricing via the Department of Veterans Affairs national contract.

Lead Agency: CDC

Collaborating Agency: FDA,
HRSA

Start Date: FY 2002

Completion Date: Ongoing

a) Facilitate State TB program utilization of the existing Department of Veterans Affairs contract for federal pricing of TB medications.

  • Lead: NCHHSTP
  • Collaborators: CDER, BPHC, HAB
  • Start Date: FY 2002
  • Completion Date: Ongoing

 

 

6. Develop improved engineering techniques to prevent TB transmission.

Lead Agencies: CDC, NIH

Collaborating Agency: OSHA

Start Date: FY 2006

Completion Date: FY 2006

a) Encourage and support research to develop improved engineering techniques for preventing transmission of M. tuberculosis in high-risk environments.

  • Lead: NIOSH, NIAID
  • Collaborator: OSHA
  • Start Date: FY 2002
  • Completion Date: FY 2006

b) Use computational fluid dynamics to assess the efficacy of engineering controls supplemental to room ventilation.

  • Lead: NIOSH
  • Collaborator: None
  • Start Date: FY 2002
  • Completion Date: FY 2004

c) Use computational fluid dynamics to evaluate the ability of various ventilation configurations/designs to prevent the migration of TB microbes from one room to another.

d) Assess adequacy of personal protective equipment: (i) determine if the current user-seal checks as described by the manufacturers of N95 filtering facepiece respirators actually help to ensure an adequate fit; (ii) develop a no fit-test high-protection factor respirator performance test; (iii) conduct workplace study of how well N95 filtering facepiece respirators perform in actual health-care settings, including determining penetration and service time restraints; (iv) conduct surveillance of how respirators are used for protection against TB in health- care settings (types, duration of use, types and frequency of fit-tests used, etc.); and (v) conduct testing of newly certified N95 respirators to determine how well each certified respirator performs, enabling health care workers to make an informed and proper respirator selection.

  • Lead: NIOSH
  • Collaborator: None
  • Start Date: FY 2002
  • Completion Date: FY 2003 (i, iii, iv) FY2004 (ii, v)

IOM Recommendation 3.2: “To ensure the most efficient application of existing resources...”

Strategies
Action Steps

1. Evaluate existing policies and referral systems for TB patients who may move within and between localities, states, and/or countries.

Lead Agency: CDC

Collaborating Agency: NTCA

Start Date: FY 2002

Completion Date: FY 2003

a) Conduct a systematic review of existing policies and referral systems for TB patients who may move within and between localities, states, and/or countries.

  • Lead: NCHHSTP
  • Collaborator: NTCA
  • Start Date: FY 2002
  • Completion Date: FY 2002

b) Conduct a study of the outcomes of moved TB patients to determine if there are any adverse implications for continuity of care and treatment.

  • Lead: NCHHSTP
  • Collaborators: NCID, NTCA
  • Start Date: FY 2002
  • Completion Date: FY 2002

c) Convene a meeting of state and local TB controllers, or their designees, to develop a comprehensive process for referral of TB patients who move within and between localities, states, and/or countries.

  • Lead: NCHHSTP
  • Collaborators: NCID, NTCA
  • Start Date: prior to FY 2002
  • Completion Date: FY 2003

d) Determine the need to revise the Report of a Verified Case of Tuberculosis (RVCT) to expand data on patients who move.

  • Lead: NCHHSTP
  • Collaborators: NCID, NTCA
  • Start Date: FY 2002
  • Completion Date: FY 2004

2. Develop tools for improving the quality of public health TB control programs and related evaluation.

Lead Agency: CDC

Collaborating Agencies: NTCA, VA

Start Date: FY 2002

Completion Date: Ongoing

a) Establish an evaluation section in the Division of Tuberculosis Elimination (DTBE) to develop tools for evaluating and improving the quality of TB control programs.

  • Lead: NCHHSTP
  • Collaborators: VHA, PHPPO
  • Start Date: FY 2003
  • Completion Date: Ongoing

b) Periodically review for accuracy the nation's TB surveillance (case reporting) system, case management and contact data collection systems, and related protocols and guidelines; update as appropriate.

  • Lead: NCHHSTP
  • Collaborators: PHPPO, NTCA
  • Start Date: FY 2002
  • Completion Date: Ongoing

c) Develop training for program evaluation and conduct training on-site at state and local TB control programs, regional meetings, and national meetings involving TB control program staff.

  • Lead: NCHHSTP
  • Collaborator: NTCA
  • Start Date: FY 2002
  • Completion Date: FY 2003

d) Provide resources through the federal Cooperative Agreements to state and local TB control programs so that evaluation of TB program activities can be implemented. Incorporate results of evaluation in decisions regarding the allocation of federal funds.

  • Lead: NCHHSTP
  • Collaborators: NTCA, NCID
  • Start Date: FY 2002
  • Completion Date: Ongoing

e) Evaluate the effectiveness of screening for TB and latent TB infection in foreign-born persons in the United States.

  • Lead: NCHHSTP
  • Collaborators: NCID, NTCA
  • Start Date: FY 2002
  • Completion Date: Ongoing

3. Develop short- and long-term plans for integrated information systems that are cross-jurisdictional and facilitate surveillance, case management, and program evaluation.

Lead Agency: CDC

Collaborating Agencies: VA, HRSA, IHS, NTCA

Start Date: FY 2002

Completion Date: Ongoing

a) Survey state and local TB control programs to determine current status of their information systems, which programs are currently using TIMS for case management and program evaluation, other systems being used by programs for case management and program evaluation, programs' data needs for case management and program evaluation, and what data items are currently being collected.

  • Lead: NCHHSTP
  • Collaborator: NTCA
  • Start Date: FY 2002
  • Completion Date: FY 2002

b) Develop an integrated information system that is both strong enough and flexible enough to facilitate surveillance, case management, and program evaluation and accommodate the needs of the various TB control programs. This system should have the capacity to expand as needed and be flexible enough for programs to customize the system to meet their needs.

  • Lead: NCHHSTP
  • Collaborators: BPHC, HAB, VHA, IHS, NTCA
  • Start Date: FY 2002
  • Completion Date: FY 2004

c) Assist state and local TB control programs to implement the new information system.

  • Lead: NCHHSTP
  • Collaborator: NTCA
  • Start Date: FY 2004
  • Completion Date: FY 2006

d) Annually evaluate Veterans Health Administration TB-related activities and policies; revise as appropriate.

  • Lead: VHA
  • Collaborator: None
  • Start Date: FY 2002
  • Completion Date: Ongoing

IOM Recommendation 3.4: “To maintain quality in TB care and control services in an era of increased use of managed care systems and privatization of services...”

Strategies
Action Steps

1. Encourage states to adopt the Medicaid eligibility option for coverage of individuals infected with TB as described in section 1902(z) of the Social Security Act.

Lead Agencies: CMS, CDC

Collaborating Agency: NTCA

Start Date: FY 2002

Completion Date: FY 2003

a) Encourage states to adopt the TB option described in 1902(z) of the State Medicaid Manual at the National Eligibility Training Conference held in Atlanta (November 6-8, 2001) and the 2003 National TB Controllers Workshop in Washington, DC (June 10-11, 2003).

  • Leads: CMS, NCHHSTP
  • Collaborator: None
  • Start Date: FY 2002
  • Completion Date: FY 2003

 

 

2. Evaluate funding sources (including public and private third-party payers) and explore ways to increase third-party reimbursement for TB services.

Lead Agency: CDC

Collaborating Agency: NTCA

Start Date: FY 2002

Completion Date: FY 2004

a) Identify funding sources for outpatient TB services in a sample of TB cases.

  • Lead: NCHHSTP
  • Collaborator: NTCA
  • Start Date: FY 2002
  • Completion Date: FY 2003

b) Determine facilitating factors and barriers to third-party billing and reimbursement.

  • Lead: NCHHSTP
  • Collaborator: NTCA
  • Start Date: FY 2002
  • Completion Date: FY 2003

c) Determine the current programmatic and fiscal impact of reimbursement.

  • Lead: NCHHSTP
  • Collaborator: NTCA
  • Start Date: FY 2002
  • Completion Date: FY 2003

d) Using study results, develop recommendations for strategies to maximize and improve third-party reimbursement for TB control activities.

  • Lead: NCHHSTP
  • Collaborator: NTCA
  • Start Date: FY 2003
  • Completion Date: FY 2004

3. For TB care in the private sector, including managed care organizations (MCOs), evaluate the capacity of public health programs to monitor care.

Lead Agency: CDC

Collaborating Agency: NTCA

Start Date: FY 2002

Completion Date: Ongoing

a) Identify and/or develop recommendations to (1) improve collaboration between health departments and providers as recommended in CDC's Essential Components of a Model TB Program (this may include model MCO policies, TB Health Plan Employer Data and Information Set (HEDIS) indicators, and/or CDC public health performance standards) and (2) emphasize health departments' major responsibilities for monitoring and ensuring the quality of all TB-related activities in the community as part of their responsibility to protect the public health.

  • Lead: NCHHSTP
  • Collaborators: PHPPO, NTCA
  • Completion Date: FY 2002
  • Start Date: FY 2002

b) Establish and implement methodologies to review, evaluate, and improve ability of public health programs to monitor care, based on identified standards, indicators, and policies.

  • Lead: NCHHSTP
  • Collaborator: NTCA
  • Start Date: FY 2002
  • Completion Date: Ongoing

IOM Recommendation 3. 5: “To promote a well-trained medical (in a broad sense) workforce and educated public...” :

Strategies
Action Steps

1. Prioritize and implement a strategic plan for TB training/education designed to educate patients, workers, and providers, particularly of high-risk populations.

Lead Agency: CDC

Collaborating Agencies: IHS, VA, DOJ, SAMHSA, NIH, HRSA, FDA, NTCA, DOL

Start Date: FY 2002

Completion Date: FY 2005

a) Engage in a participatory review of the 1998 "Strategic Plan for Tuberculosis Training and Education" document; convene meeting of original workgroup members and additional key partners, including representatives from targeted stakeholder audiences; review progress; update plan; disseminate revised document; monitor and evaluate progress; reconvene partners on a yearly basis to review findings and adjust the plan, as appropriate.

  • Lead: NCHHSTP
  • Collaborators: PHPPO, NIOSH, NHLBI, NTCA , OSHA, VHA
  • Start Date: prior to FY 2002
  • Completion Date: Ongoing

b) After review/revision of the “Strategic Plan,” conduct needs assessment with appropriate stakeholder audiences to assess currently available tools and guidelines, utilization, and level of implementation. Based on information gathered, conduct a gap analysis to determine development needs for products and infrastructure. Use this information to supplement objectives/goals of “Strategic Plan for Training and Education.”

  • Lead: NCHHSTP
  • Collaborator: NTCA
  • Start Date: prior to FY 2002
  • Completion Date: Ongoing

c) Evaluate existing educational materials and communication products; evaluate usefulness of guidelines and recommendations for target audiences; plan for updates where necessary.

  • Leads: NCHHSTP, NIOSH
  • Collaborators: CDRH, NTCA, OSHA
  • Start Date: prior to FY 2002
  • Completion Date: Ongoing

d) Working in collaboration with patient and provider representatives (including potentially exposed workers), as well as technical and communication experts, develop patient and provider education materials that are culturally and linguistically appropriate for target audiences.

  • Leads: NCHHSTP, NIOSH
  • Collaborators: NTCA , OSHA
  • Start Date: prior to FY 2002
  • Completion Date: FY 2005

e) Identify culturally appropriate incentives and enablers to help ensure completion of therapy for infection and disease.

  • Lead: NCHHSTP
  • Collaborators: NTCA, OSHA
  • Start Date: prior to FY 2002
  • Completion Date: FY 2004

f) Enhance training and education of providers by (i) increasing cultural competency among health care workers; (ii) working with agency Offices of Minority Health in developing appropriate resources and interventions; (iii) training health care workers regarding contact investigations; and (iv) developing additional education/training materials addressing skills for persons conducting the contact investigation.

  • Leads: NCHHSTP, NIOSH, IHS, BPHC, DIHS, FBOP, OSHA
  • Collaborator: NTCA
  • Start Date: FY 2002
  • Completion Date: FY 2005

2. Sustain support of existing Model TB Centers and consider development and expansion of Model TB Centers in order to ensure better access to training and education resources regionally for both high- and low-incidence areas.

Lead Agency: CDC

Collaborating Agencies: NIH, NTCA

Start Date: FY 2002

Completion Date: Ongoing

a) Monitor progress of ongoing training and consultative activities by Model TB Centers.

  • Lead: NCHHSTP
  • Collaborators: NHLBI, NTCA
  • Start Date: prior to FY 2002
  • Completion Date: Ongoing

b) Convene Model TB Center representatives yearly to revise and update work plans.

  • Lead: NCHHSTP
  • Collaborators: NHLBI, NTCA
  • Start Date: prior to FY 2002
  • Completion Date: Ongoing

c) Announce availability of new resources for expansion of Model TB Centers.

  • Lead: NCHHSTP
  • Collaborators: NHLBI, NTCA
  • Start Date: 2003
  • Completion Date: Ongoing
 
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