CDC's Response to Ending Neglect

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The Plan

GOAL II: Accelerate the decline

Advance toward TB elimination through targeted testing and treatment of persons with latent TB infection, appropriate regionalization of TB control activities, rapid recognition of TB transmission using DNA fingerprinting methods, and rapid outbreak response.

Unprecedented low rates of TB disease and the focal distribution of pockets of lingering infection provide a historic opportunity to accelerate the decline in TB incidence and push toward TB elimination. TB programs can prevent new cases by 1) reducing the reservoir of persons with latent TB infection who will progress to active disease, 2) rapidly containing the transmission of TB disease and infection, 3) adding regionalized TB control activities to ensure the availability of infrastructure and expertise wherever TB cases occur, 4) characterizing circulating TB strains using DNA fingerprinting methods to rapidly recognize and interrupt continued TB transmission, and 5) quickly identifying, investigating, and responding to outbreaks of TB to interrupt transmission and prevent disease.

Objective II-A
Increase the capacity of TB control programs to implement targeted testing and treatment programs for high-risk persons with latent TB infection.

Targeted tuberculin skin testing for latent TB infection is a strategic component of TB control. Targeted testing identifies persons at high risk for developing TB who would benefit from treatment. Persons at increased risk for developing TB include those with recently acquired TB infection and those with clinical conditions that are associated with an increased risk for progression from latent infection to active disease. Targeted testing should be conducted only among groups at high risk and should be discouraged in those at low risk. Infected persons who are considered to be at high risk for developing active TB should be offered treatment for latent infection regardless of age.

In CDC's 1989 A Strategic Plan for the Elimination of Tuberculosis in the United States,¹ public health agencies were assigned responsibility for detecting and treating latent TB infection in high-risk groups. At that time, the administration of skin tests, interpretation of test results, and intensive follow-up required to ensure adherence with treatment were believed to be beyond the scope of private health care providers. By the mid-1990s, however, most routine TB testing was being done outside the public health system and the participation of other providers was recognized as essential to community efforts to prevent TB in high-risk groups. In recommendations published in 1995, health departments were charged with helping providers develop, implement, and evaluate locally appropriate TB screening programs.⁵⁸

The key roles for TB control programs in these efforts are to identify candidates for targeted testing and treatment (i.e., persons who, because of epidemiologic characteristics, are at high risk for having latent TB infection or developing TB disease if infected), ensure that TB patients have access to appropriate TB services, ensure that patients are evaluated and placed on treatment for latent TB infection as appropriate, and ensure that patients complete their treatment.

Activities

1. Develop and enhance the capacity of state and local TB control programs to implement effective targeted testing and treatment programs for latent TB infection.
   • Promote the development of partnerships with CBOs that provide health care services and other health promotion activities for high-risk groups.
   • Provide funding to ensure collaboration between TB control programs and CBOs.
   • Conduct research to identify effective strategies and interventions that increase the proportion of persons with latent TB infection who initiate and complete treatment.
   • Develop systems to evaluate targeted testing programs for high-risk persons and to ensure that the programs are effective in preventing the development of TB.
2. Enhance the capacity of local TB control programs to identify appropriate populations for targeted testing.
   • Provide training in epidemiologic methods and data analysis to increase the ability of TB program staff to analyze local surveillance data.
   • Identify additional sources of data (e.g., immigration patterns, HIV-seroprevalence studies) for use in making decisions about appropriate populations for targeted testing.
   • Provide ongoing technical assistance to TB control programs to help in the identification of appropriate high-risk groups for targeted testing.
   • Promote the development of partnerships with CBOs that might have access to persons at high risk and that might be appropriate sites for targeted testing programs.
3. Ensure that all patients with HIV infection are evaluated for latent TB infection and are appropriately treated.
   • Ensure that TB program staff are aware of the epidemiology of HIV infection, the prevalence of TB/HIV coinfection, and the prevalence of HIV infection in persons with active TB in their communities.
   • Promote the development of partnerships with CBOs that might have access to persons with HIV infection and that might be appropriate sites for targeted testing programs.
   • Provide funding to ensure collaboration between health departments and HIV providers to establish targeted testing programs.
   • Work with national organizations and other federal agencies to ensure that the practice of testing for and adequately treating latent TB infection is the standard of care for persons with HIV infection.
   • Develop systems to evaluate targeted testing programs for persons with HIV infection and to ensure that the programs are effective in preventing the development of TB in persons with HIV infection.
4. Promote the development of partnerships between TB control programs and correctional facilities to ensure that inmates are appropriately screened for latent TB infection and TB disease.
   • Ensure that TB control programs establish contacts in the correctional system and promote the development of partnerships with correctional facilities to establish effective targeted testing programs and to follow inmates released before the completion of treatment.
   • Provide funding to ensure collaboration between health departments and correctional health care providers for establishment of targeted testing programs.
   • Work with national organizations and other federal agencies to ensure that testing for and adequately treating latent TB infection are components of correctional health care.
   • Develop systems to evaluate targeted testing programs for persons incarcerated in correctional facilities and to ensure the effectiveness of the programs in preventing the development of TB in inmates.
5. Develop and implement information management systems to provide the data needed to evaluate targeted testing programs.
   • Define the elements needed for effective management of persons with latent TB infection.
   • Develop an information system that captures the elements of targeted testing and promotes the effective management of persons with latent infection.
   • Provide financial and technical support to programs to establish and use patient information management systems for targeted testing programs.
   • Establish criteria for the effectiveness of targeted testing programs, and base future funding on those criteria.

Objective II-B
Promote the appropriate regionalization of TB control activities in high, intermediate, and low TB-incidence areas of the United States.

As the incidence of TB declines, economies of scale dictate that the geographic focus for TB control activities should be expanded. Ideally, patients should not have to travel to regional centers for treatment of their disease; however, regionalization of resources for case management, contact investigation, and outbreak investigations should be evaluated.

Activities

1. Implement the recommendations of ACET on control of TB in low-incidence areas.
2. Implement geographically defined operations research to assess the role of regional approaches in high, intermediate, and low TB-incidence areas.
   • Work with programs in low-incidence areas to develop operational research studies and protocols.
   • Implement these protocols in high-, intermediate-, and low-incidence areas.
   • Publish the results of the studies, and base the development or continued support of appropriate interventions on the results.
3. Convene a national meeting to disseminate the results of the operational research studies and to develop recommendations for the regionalization of TB control activities.

Objective II-C
Characterize circulating M. tuberculosis strains using DNA fingerprinting methods.

Characterization of M. tuberculosis with DNA fingerprinting is a powerful tool for 1) confirming TB cases linked by traditional epidemiologic methods, 2) identifying clusters of patients infected with genetically related or identical strains of M. tuberculosis and determining common sources of infections, 3) guiding contact investigations and the appropriate use of preventive therapy, and 4) identifying laboratory cross-contamination as the cause of misdiagnosis. When used to track the transmission of a specific strain, DNA fingerprinting can help assess the effectiveness of TB control programs a particularly useful methodology for areas with low TB incidence as the United States approaches TB elimination.

Activities

1. Use DNA fingerprinting to strengthen TB control efforts.
   • Create Regional Centers of DNA Fingerprinting Excellence that can provide DNA fingerprinting for all new isolates of M. tuberculosis.
   • Establish a DNA Fingerprinting Training Program to build laboratory, epidemiologic, and analytic capacity to assess and promote fingerprinting standards and practices, including newer DNA fingerprinting approaches.
   • Establish a National DNA Fingerprinting Registry and Surveillance System to facilitate the identification of TB outbreaks that cross state lines.
   • Develop local capacity in the use of DNA fingerprinting to identify laboratory misdiagnoses of TB and thereby reduce the number of persons who are inappropriately treated for TB.

2. Use DNA fingerprinting to increase the understanding of TB epidemiology and provide the scientific foundation for improved interventions to eliminate TB.
   • Study geographic and temporal variability in genotypes to better understand the natural history of M. tuberculosis strains currently in circulation in the United States (especially MDR strains, strains that cause relapses, and geographically widespread strains) and to evaluate the impact of interventions locally and regionally.

   • Identify and investigate unrecognized transmission of TB in groups at high risk (e.g., HIV-infected persons, residents of correctional and long-termcare facilities, migrant farm workers, homeless persons).

   • Identify and investigate unusual and difficult-to-recognize settings where TB transmission has occurred, especially in areas that have achieved low TB incidence.

   • Study the frequency of reinfection, relapse, and infections with multiple strains of M. tuberculosis.

   • Use DNA fingerprinting to monitor progress toward eliminating TB transmission.
3. Develop and evaluate new DNA fingerprinting tools.
   • Evaluate newly developed DNA fingerprinting technologies (e.g., spoligotyping, minisatellite-based typing systems, fluorescent amplified fragment-length polymorphism).
   • Develop novel strain typing and DNA fingerprinting approaches.
   • Develop and evaluate fingerprinting methods or strategies that can provide rapid strain typing for real-time application in TB control efforts.

Objective II-D
Develop national, state, and local capacity to respond to outbreaks of TB.

When TB is very common, clusters of cases caused by recent transmission blend into the generally high morbidity. However, when TB is less common, even small case clusters are very noticeable and are considered to be "outbreaks." In the United States, several interrelated factors are converging to make TB case clusters more prominent and troublesome. First, M. tuberculosis transmission is now uncommon, and most members of the population have not been infected. Therefore, a burst of transmission causes a disturbance that stands out from the low background level. At the same time, however, the low background level has led to reduced personnel resources and thus limited our capacity to find and cure TB and to investigate contacts. Many health care providers now lack familiarity with TB, have difficulty diagnosing it, and are unaware of current treatments. The combination of delayed case detection, enhanced opportunities for transmission to susceptible contacts, and reduced response capacity yields sporadic "TB outbreaks."

Each TB outbreak is a setback for TB elimination. As the incidence of TB declines, the identification of and response to outbreaks will become a more important component of TB control. Responding to these outbreaks will require careful planning, marshaling of resources, development and maintenance of expertise, and development and use of interventions to interrupt transmission and prevent TB disease.

Activities

1. Implement and evaluate CDC's outbreak response plan.
   • Conduct a pilot study on implementation of the outbreak response plan.
   • Evaluate the plan, and identify needed improvements.
   • Finalize the plan based on results of the evaluation.
   • Implement the plan.
   • Devise mechanisms for ongoing evaluations and revisions.
2. Provide guidelines, technical assistance, and templates to help state and local TB control programs develop and implement their own outbreak response plans.
3. Enhance the capacity of CDC and state and local TB control partners to respond rapidly to outbreaks, conduct appropriate investigations, and implement necessary programmatic activities to interrupt TB transmission.
   • Ensure that CDC maintains appropriate numbers of trained scientific staff to help states and localities investigate TB outbreaks.
   • Ensure that CDC maintains appropriate numbers of trained program staff both in the field and at headquarters to respond appropriately to TB outbreaks and to provide technical assistance as needed to state and local TB programs.
   • Through training and funding, develop the capacity of state and local TB programs to respond rapidly and appropriately to TB outbreaks.
4. Evaluate the cost and impact of outbreak investigations and subsequent programmatic interventions.
   • Define the data elements needed to evaluate the cost and impact of outbreak investigations and interventions.
   • Develop data management systems to capture these elements.
   • Conduct a comprehensive evaluation of outbreak responses by CDC, and help state and local programs develop evaluations of their responses to outbreaks.

Last Reviewed: 05/18/2008
Content Source: Division of Tuberculosis Elimination
National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention

 
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