Prevention and Control of Tuberculosis in Migrant Farm Workers
Recommendations of the Advisory Council for the Elimination of
Tuberculosis *
Summary
Farm workers are approximately six times more likely to
develop tuberculosis (TB) than the general population of employed
adults. These recommendations are presented to assist health-care
providers serving migrant and seasonal farm workers. The following
services, listed by priority, that should be available for migrant
and seasonal farm workers and their family members are: a)
detection and diagnosis of those with current symptoms of active
TB; b) appropriate treatment and monitoring for those who have
current disease; c) contact investigation and appropriate
preventive therapy for those exposed to infectious persons; d)
screening and appropriate preventive therapy for asymptomatically
infected workers who may be immunosuppressed, such as those with
human immunodeficiency virus (HIV) infection; e) screening and
appropriate preventive therapy for children of migrant and seasonal
farm workers; and f) widespread tuberculin test screening for
workers and families with preventive therapy prescribed, as
appropriate. Health-care providers should immediately perform
appropriate diagnostic studies for persons with a productive,
prolonged cough, or other symptoms suggestive of tuberculosis.
Health departments should be immediately notified when TB is
suspected or diagnosed to enable examination of contacts and
initiation of other health department diagnostic, preventive, or
patient management services.
Workers and family members with uncomplicated pulmonary TB
should be treated with a regimen that includes isoniazid, rifampin,
pyrazinamide, and ethambutol (or streptomycin). Drug-resistant TB
is an important consideration since it requires altered treatment
regimes and because higher rates of resistance have been found in
ethnic and social groups comprising much of the migrant farm
worker-force. Patients should be monitored carefully for
compliance, treatment response, and toxicity. Ideally, patients
should be placed on directly observed therapy given by a
well-trained, outreach worker from the same cultural/language
background as the patients.
INTRODUCTION
The Department of Health and Human Services (DHHS) Advisory
Council for the Elimination of Tuberculosis (ACET) has published a
plan for the elimination of tuberculosis (TB) from the United
States by the Year 2010 (1). The plan gives top priority to
implementation of strategies to prevent TB in identifiable
high-incidence population groups, including migrant and seasonal
farm workers. In this document, a "migrant farm worker" is
defined as a laborer whose principal employment is in agriculture
on a seasonal basis and who establishes for the purposes of such
employment a temporary abode. The term "seasonal farm worker"
means a person whose principal employment is in agriculture on a
seasonal basis, but who does not move from area to area for work.
These recommendations are intended for health-care providers
serving migrant and seasonal farm workers -- providers who can
contribute to the elimination of TB in this population through
improved screening, prevention, and control activities. The
recommendations are also directed to health departments because of
their important role in assisting migrant health-care providers in
the prevention and control of TB among migrant and seasonal farm
workers. Finally, these recommendations are directed to public
policy and decision makers because many health departments and
migrant health-care providers do not now have the resources and
staff to fully implement these recommendations.
MIGRANT FARM WORKERS AND MIGRANT PATTERNS
Information provided by the Office of Migrant Health, DHHS,
indicates that there are an estimated 4.2 million migrant and
seasonal farm workers in the United States. Approximately 500,000
(12%) are served by federally supported migrant health centers (2).
Compared with the general population, these workers often have
numerous and complex health problems (e.g., TB, parasitic diseases,
other communicable diseases, diabetes, hypertension, high-risk
pregnancy, and neonatal problems), and they often live in
substandard housing and in very crowded conditions. Continuity of
medical care is difficult for migrant farm workers because they
move often. Migrant and seasonal farm workers and their families
often face linguistic, cultural, financial, immigration,
educational, and other barriers that also make it difficult for
them to obtain needed health-care services.
These barriers must be addressed by migrant health and public
health officials when designing and carrying out strategies for
implementing the recommendations in this report.
Migrant farm workers in the United States traditionally follow
one of three geographic migratory streams (travel patterns: East
Coast, Midwest, and West Coast). The race, ethnicity, and cultural
background of migrant farm workers vary somewhat from stream to
stream. Living and working conditions, as well as access to
transportation, also vary. These differing characteristics may
affect access to health-care and the formulation of strategies for
TB prevention and control. In all three streams, families often
migrate together to maximize family income. Some settle in a town
to pursue better educational or work opportunities, but often
remain tied to local agricultural activities.
The primary residence or homebase areas (e.g., California,
Texas, Puerto Rico, and Florida) for all three streams are
economically disadvantaged areas.
East Coast Migrant Stream
In the East Coast stream, most workers have their primary
homebase, or winter home, in southern Florida. The largest cultural
groups in this stream are Hispanic, primarily Mexican Americans and
Mexicans, Central American refugees, and Puerto Ricans; other
groups in this stream are American blacks, Haitians and Appalachian
whites.
Migrants in the East Coast stream most often reside in
ethnically homogeneous labor camps, characterized by family unit
housing or single-sex barracks. A primary contractor or crew leader
usually contracts directly with a grower to supply farm workers.
The crew leader also provides meals and transportation, the cost of
which is usually deducted from workers' pay. Farm workers, during
the harvest season, may change camps or move to a new location with
a crew or group. Thus, outreach is a very important factor in
delivering health care to this migrant population.
Midwest Migrant Stream
In the Midwest stream, most farm workers use south Texas as
their homebase and work winter crops there before moving up into
the midwestern states. South Texas is the largest migrant homebase
area in the nation. Migrant farm workers from there also may move
into the East and West Coast migrant streams. Mexican Americans
constitute the majority of migrant farm workers in this stream, but
recently the number of Southeast Asian migrant farm workers has
been increasing in this stream.
The basic Midwest migrant family unit travels "upstream"
from the homebase community in groups with children and other
relatives, sometimes also accompanied by friends, including single
males. The migrant groups generally travel in cars with the crew
leader or "truckero" transporting personal possessions in a truck
for the crew. The crew leader's truck also may be used to haul
produce during harvesting.
Migrants in southern Texas live as part of the community in
"colonias" or unincorporated areas. These areas are not required
to have water, sewage, or electric services, and some colonias have
none. Three to six families may live under one roof on a 20' by 40'
plot of land. Family members cross the border to visit or stay with
relatives in Mexico during the winter months. When not in the
homebase area, migrants in the Midwest stream live primarily in
labor camps.
West Coast Migrant Stream
Most migrant farm workers in the West Coast stream use
southern California as homebase. This stream runs north through
Idaho, Oregon, and Washington. The West Coast stream consists
mostly of Mexican Americans from the southwest, primarily
California and Texas. American blacks, non-Hispanic whites, and
increasing numbers of Southeast Asians and Central Americans
comprise a smaller percentage of the migrant farm workers in this
stream. Southeast Asians, however, quickly settle in the area,
leaving the migrant stream.
The primary migrant units in the West Coast Stream are
individual families. Some single males come from Mexico to work the
crops and then return home. Many of these workers own their own
cars and have more mobility and better access to medical care.
Generally, there are better housing conditions in the West Coast
stream than in the other streams. However, migrants are living
under bridges and along river banks in Southern California. As in
other migrant streams, these migrant families live in labor camps
when they leave their homebase.
TUBERCULOSIS IN MIGRANT FARM WORKERS
Although the magnitude of the problem of TB among migrant and
seasonal farm workers is not clearly established, a survey
conducted by CDC during the period 1985-1989 assessed the
occupational and residential characteristics of TB cases reported
in 29 states; overall farm workers accounted for more than 5% of
all employed cases. Based on data from that survey, the risk of TB
among farm workers was estimated to be six times greater than the
general population of employed adults (CDC, unpublished data).
The first population-based study of TB in a random sample of
migrant farm workers, conducted in 1988 in North Carolina,
indicated a prevalence of active TB in 0.47% of Hispanics and 3.5%
of American blacks (3).
Migrant farm workers also have high rates of asymptomatic TB
infection (positive skin tests). A 1987 study showed a skin-test
positivity rate of 29% among U.S.-born blacks and 55% among Haitian
migrant farm workers in the Delmarva Peninsula (4). Tuberculin
testing of migrant farm workers employed in Virginia's Eastern
Shore showed overall skin-test positivity rates of 39% and 48% in
1984 and 1985, respectively (5). In a separate study conducted in
1988, Hispanic migrant farm workers in North Carolina had a
tuberculin skin-test positivity rate of 31% (6). A 1988 study
demonstrated a 47% prevalence rate of TB infection among migrant
farm workers 15-34 years of age and a 68% prevalence rate among
those greater than 34 years of age (7). In the population-based
study (3), tuberculin positivity rates ranged from 33% (Hispanics)
to 62% (blacks) to 76% (Haitians). These high rates of asymptomatic
TB infection suggest that screening and prevention activities
should be directed to migrant farm workers.
INFECTION AND TRANSMISSION
The TB organism M. tuberculosis, also known as the tubercle
bacillus, is transmitted primarily through the air from persons
with TB of the lung who are coughing. Persons who share the same
air with an infectious person for long periods of time are at risk
of becoming infected. This includes persons living in the same
household with the infectious person and those who travel in the
same vehicle. Most persons who become infected usually develop a
positive TB skin test, but remain asymptomatic and are not
infectious. The lifetime risk of acquiring clinically active TB
disease is about 10%; it is greatest in the first 2 years after
infection, but disease can also occur many years later. Impairment
of the immune system, such as by HIV infection, increases the risk
of clinically active TB.
RECOMMENDATIONS
ACET developed these recommendations for the Public Health
Service, public health departments, and for health-care providers
serving migrant and seasonal farm workers.
Prevention and Control
The following prevention and control activities should be
undertaken for all migrant and seasonal farm workers and their
families.
The services of highest priority that should be available to all
workers and their families, are:
Detection and diagnosis of those persons with current
symptoms of
active TB.
Appropriate treatment for those persons with disease.
Contact investigation and appropriate preventive therapy for
those persons exposed to infectious (sputum positive) TB.
Screening and appropriate preventive therapy for workers who
may
be immunosuppressed, including those with HIV infection.
The second priority is screening and appropriate preventive
therapy for children of migrant and seasonal farm workers.
The third priority is widespread tuberculin skin-test screening
of workers and families, followed by appropriate preventive
therapy.
Providing the above services will require a commitment of
resources from the national, state, and local levels.
Diagnosis
Pulmonary TB should be suspected in persons with a productive,
prolonged cough ( greater than 2 weeks in duration). Other
common
symptoms of TB include fever, chills, night sweats, fatigue,
loss
of appetite, weight loss, and, occasionally, hemoptysis
(coughing
up blood).
Persons with suspected pulmonary TB should receive an immediate
evaluation that includes: a medical history and physical
examination, chest x-ray, Mantoux tuberculin test, at least
three
sputum specimens (collected on separate days) for acid fast
bacilli
(AFB) smear, culture and drug susceptibility testing, and
HIV-antibody counseling and testing.
If the clinician confirms or suspects TB as a result of this
examination, the local health department should be notified so
that
appropriate examination of contacts can be initiated. Migrant
health-care providers should seek, and health departments should
provide, no-cost TB medical consultation, medication and
laboratory
services for migrant farm workers.
Hospitalization and Isolation
Health departments should ensure that inpatient care (e.g.,
hospitalization) is available at no cost to migrant farm workers
or
family members. Persons hospitalized with infectious TB should
be
placed in AFB isolation until they become noninfectious (8).
Health department TB control staff should be consulted on issues
regarding hospitalization, housing, and return to work. The
restriction of normal activities and the duration of such
restrictions depends upon: the degree of infectiousness, the
response to treatment, the nature of activities, and the
likelihood
that others might be exposed. Some patients are never infectious
and have no need for restrictions. Care must be taken in housing
TB
patients to ensure that those who may be infectious do not
expose
uninfected farm workers or family members. Patients who feel
well
may be able to continue normal work activities, particularly in
an
open-air work setting where there is little risk of exposure for
new or highly susceptible contacts.
Treatment (Tables 1 and 2)
Migrant and seasonal farm workers and family members with
uncomplicated pulmonary TB can be treated with the following 6-
month regimen: isoniazid, rifampin, pyrazinamide, and ethambutol
(or streptomycin) given for 2 months (initial phase), followed
by
isoniazid and rifampin for 4 months (second phase). Ethambutol
(or
streptomycin) should be included in the initial regimen until
drug
susceptibility studies are available. Among migrant workers,
higher
rates of resistance to isoniazid and streptomycin are known to
occur. Drug resistance is also more common in patients with a
history of previous treatment and in contacts to drug-resistant
patients.
Medication does not have to be given on a daily basis throughout
the entire course of treatment. Several options exist for
administering directly observed therapy. Intermittent (e.g.,
twice
weekly) therapy may be administered during the second phase
after
daily therapy during the initial phase. For those for whom
prolonged supervision of daily therapy during the initial phase
is
impractical, a regimen of daily isoniazid, rifampin,
pyrazinamide,
and ethambutol (or streptomycin) for 2 weeks, followed by twice
weekly administration of the same drugs for 6 weeks, and
subsequently twice weekly isoniazid and rifampin for 16 weeks
has
been shown to be highly effective (9). Alternatively, three
times
weekly administration of isoniazid, rifampin, pyrazinamide, and
ethambutol (or streptomycin) for 6 months yields equivalent
results
(10). (When isoniazid, ethambutol, and pyrazinamide are
administered 2 or 3 times weekly instead of every day, the
dosage
must be increased; the rifampin dose is the same for daily or
intermittent therapy.)
In cases of smear and culture negative pulmonary TB, when drug
resistance is unlikely, reducing the 6-month regimen to 4 months is
acceptable. The same regimen should be used to treat
sputum-culture-negative, tuberculin-positive persons with
radiographic evidence of healed TB or silicosis.
All persons with confirmed or suspected TB should be offered HIV
testing and counseling. For HIV seropositive patients, treatment
should be continued for a minimum of 9 months and for at least 6
months beyond documented culture conversion as evidenced by
three
negative cultures.
Patients treated with rifampin who are on methadone should have
the methadone dosage increased to avoid withdrawal symptoms
resulting from the interaction between the two drugs (11).
The treatment regimen should be appropriately revised if
resistance to any of the drugs in the regimen is found.
Treatment of extrapulmonary TB and TB related to drug resistance
or HIV infection may be complicated. For this reason, a health
department or another qualified TB and infectious disease
medical
expert should be consulted.
Monitoring Response (Table 3)
Patients should be medically assessed at least twice monthly
for symptoms and by smear until they become asymptomatic and
smear
negative. Cultures should be obtained at least monthly until
negative. Frequent smears and cultures are the most reliable
means
for detecting treatment failure. Treatment failure is often due
to
patient noncompliance with therapy, but also may be due to an
ineffective regimen (e.g., when the organisms are resistant to
the
drugs).
Patients should demonstrate sputum conversion within 3 months.
Appropriate medical consultation should be sought for patients
whose sputum does not convert within this time. Such patients
must
be evaluated for noncompliance and drug-resistant organisms.
Toxicity monitoring must be individualized and based on the
drugs
used in a given regimen and patient factors related to toxicity
(e.g., age and alcohol use). Patients should be evaluated at
least
monthly during therapy and questioned about reactions to
determine
toxicity, even if no problems are apparent. Patients should be
specifically instructed to look for symptoms associated with the
most common reactions to the medications they are
receiving. If symptoms suggesting drug toxicity occur,
appropriate
laboratory testing and medical evaluation should be performed
immediately.
All patients receiving isoniazid, rifampin, and/or pyrazinamide
should be instructed to report immediately any symptoms
suggesting
hepatitis (loss of appetite, nausea, vomiting, jaundice,
malaise,
unexplained elevated temperature of greater than 3 days
duration,
or abdominal tenderness).
Peripheral neuropathy associated with isoniazid administration
is uncommon at doses of 5 mg/kg. Among persons with conditions
in
which neuropathy is common (diabetes, uremia, alcoholism,
malnutrition), pyridoxine (50 mg day) may be given with
isoniazid.
It is also advisable to give pyridoxine with isoniazid to
pregnant
women or persons who have a seizure disorder.
Hyperuricemia may occur in patients receiving pyrazinamide, but
acute gout is uncommon.
The interaction of isoniazid and phenytoin increases the serum
concentration of both drugs. When these drugs are given
concomitantly, the serum level of phenytoin should be monitored.
Rifampin may accelerate clearance of drugs metabolized by the
liver. These include methadone, coumadin derivatives,
glucocorticoids, estrogens, oral hypoglycemic agents, digitalis,
anticonvulsants, ketoconazole, and cyclosporin. By accelerating
estrogen metabolism, rifampin may interfere with the
effectiveness
of oral contraceptives.
Outreach workers responsible for directly observed therapy
should be trained to identify symptoms related to reactions and
toxicity. They should also be trained to obtain sputum
specimens.
Monitoring Compliance
Treatment must be continuous to be effective. Identify
noncompliance early, before drug resistance, treatment failure,
or
relapse occurs, or before the patient is lost to follow-up.
A number of techniques have been developed to assist in
identifying the noncompliant patient. The majority of
noncompliant
patients is determined by their failure to return for follow-up
clinic visits. Thus, having an accurate appointment and
delinquent
referral system is paramount. An effective communication system
is
also needed to assure that the discovery of missed appointments
immediately comes to the attention of the responsible public
health
officials. Monthly pill counts are also helpful in early
identification of noncompliance.
The best way to ensure compliance is to place patients on
directly observed therapy given by a well-trained outreach
worker
from the same cultural/language background as the patient
population. Health departments should provide staff for this
purpose. As an alternative, a concerned and interested person
may
be identified to directly observe the patient's therapy (e.g.,
family member).
Incentives and enablers should be considered to encourage
patient compliance. These might include such items as food or
food
vouchers and transportation vouchers or tokens.
Long-term institutionalization is sometimes necessary for the
management of seriously uncooperative patients. If, despite the
best efforts of migrant health-care and health department staff,
an
infectious patient refuses treatment, temporary involuntary
isolation may be mecessary in accordance with state and local
public health laws and regulations. This option should be used
only
in rare instances and only after due process.
Contact Investigation
Contact investigation should begin as soon as a migrant or
seasonal farm worker or family member is suspected to have
infectious TB. The health department assumes this
responsibility.
The investigation normally involves a visit to the patient's
work
and housing site to observe transmission possibilities, identify
contacts, and to note factors that might affect compliance with
treatment or preventive therapy.
The investigation should begin with close contacts who are most
likely to be infected, usually the persons living with and
sharing
the same air space as the patient. Close contacts include family
members of workers traveling and working alone, if they have
lived
in the household during the preceding year. (The health
department
can make arrangements to ensure that out-of-area family members
and
other remote contacts receive appropriate examinations.)
High priority should be given to rapid examination of close
contacts who are children. Newly infected children can develop
life
threatening meningitis within weeks of infection unless
preventive
therapy is administered.
Contacts should be interviewed for symptoms and given a
tuberculin skin-test using the Mantoux technique. Those with
symptoms of respiratory disease or skin-test reactions of
greater
than or equal to 5mm should be given chest radiograph
examinations.
All contacts with reactions of greater than or equal to 5mm
should
be considered for preventive therapy. Close contacts of highly
infectious persons, especially young children, should be
considered
for preventive therapy even if the initial tuberculin test after
exposure is negative. The preventive therapy can be halted if
contact with the infectious person(s) is discontinued and a
repeat
tuberculin test, 3 months after exposure, remains negative.
Screening
Screening should be carried out by migrant health-care providers
in cooperation with employers and local health departments. In
the
absence of definitive data, screening of migrant farm workers
should be considered annually.
Emphasis should be placed on screening and preventive therapy
conducted in the homebase sites. However, since access to health
care is sometimes better in non-homebase areas, TB screening and
preventive therapy programs should be encouraged wherever
resources
and access to migrant farm workers permit. This is particularly
important for "settled out" workers who choose not to return to
homebase areas.
The Mantoux tuberculin skin test should be used to identify
persons who have been infected with M. tuberculosis. Multiple
puncture tests should not be used. Migrant and seasonal farm
workers, as well as members of their families, should be
considered
tuberculin positive according to the following criteria.
Outside the United States, many countries use Bacille
Calmette-Guerin (BCG) vaccination as part of their TB control
activities, especially for infants. The degree of sensitivity to
tuberculin that is acquired after BCG vaccination is highly
variable. No reliable method exists for distinguishing
tuberculin
reactions caused by previous BCG vaccination from those caused
by
natural mycobacterial infections. Positive tuberculin reactions
in
BCG-vaccinated persons from high prevalence areas usually
indicate
infection with M. tuberculosis. Such persons should be evaluated
for preventive therapy.
Persons who have tuberculous infection should receive a chest
radiograph. If the radiograph does not show TB, preventive therapy
should be considered. Persons with abnormal radiographs and/or
other symptoms suggesting TB should be referred for further
evaluation.
Preventive Therapy
The use of preventive therapy can substantially reduce the risk
of TB (by more than 90%) in infected persons who comply with
therapy (12). A minimum of 6 months of preventive therapy is
recommended. However, a 12-month course is recommended for
tuberculin-positive persons with HIV infection.
Whenever necessary, preventive therapy should be directly
observed and should be administered twice weekly to facilitate
the
supervision of treatment (INH 15mg/kg up to 900mg).
Before migrant farm workers and their family members are placed
on preventive therapy, ensure that they are likely to complete
at
least 6 months of the regimen. The rationale for this policy is
to
ensure that persons receive the benefits from 6 months of
preventive therapy and not just the early risk of toxicity.
Persons
with a positive tuberculin reaction who are not placed on
preventive therapy should be counseled about the meaning of the
skin-test reaction and instructed to seek medical attention if
they
develop symptoms suggesting TB.
The following list defines those migrant and seasonal farm
workers and their family members with positive tuberculin
reactions
(who have not been previously treated) who should be considered
candidates for preventive therapy regardless of age:
Persons with known or suspected HIV infection, including
injecting drug users.
Close contacts of infectious persons.
Recent tuberculin skin test converters (defined as a greater
than or equal to 10 mm increase for those less than 35 years
old;
or a greater than or equal to 15 mm increase for those
greater than
or equal to 35 years old).
Persons with medical conditions that increase the risk of TB
(e.g., diabetes, being 10% or more below ideal body weight,
or
prolonged adrenocorticosteroid therapy).
Persons with a positive tuberculin test should be considered for
preventive therapy even if they have no other medical risk
factor
when they are less than 35 years of age.
Before therapy is initiated, baseline liver function studies
should be done for all persons greater than or equal to 35 years
of
age.
Persons on preventive therapy should be monitored at least
monthly, by questioning, for: compliance with prescribed
regimen,
symptoms of neurotoxicity (such as paresthesia of hands or
feet),
and signs consistent with hepatotoxicity (e.g., loss of
appetite,
nausea, vomiting, persistent dark urine, jaundice, malaise, or
unexplained elevated temperature of greater than 3 days
duration,
or abdominal tenderness especially in the upper right quadrant).
Patients should be advised to report immediately to their
health-care provider if any of these signs or symptoms occur.
Pill counts should be done each month for all persons on
preventive
therapy.
Follow-Up
When a migrant farm worker is departing and requires treatment
for active TB, preventive treatment, or diagnostic services,
health
providers should contact their state health department TB
control
officers to apprise them of the need for follow-up and of the
next
possible destination of the farm worker.
Out-of-state communications regarding TB care should be routed
through state health departments to ensure that the information
is
transmitted appropriately and that necessary follow-up is
initiated. Often the health-care provider or health department
will
receive a TB laboratory report after the person departs for
another
area. The report should be immediately telephoned or
expeditiously
mailed to the health department or health-care provider in the
next
area.
Although sharing necessary information between health-care
providers and health departments is encouraged to protect the
health of the worker and the public, information should be
shared
only on a need-to-know basis. Measures must be taken to ensure
confidentiality.
Migrants who are placed on antituberculosis treatment or
preventive therapy should be given records they can take with
them
to indicate their current treatment and diagnostic status.
Special
care should be taken to instruct such persons on how to take
their
medications and how and where to get additional medication and
medical care at the destination sites.
Different areas have different protocols for the treatment of
active TB and for the preventive treatment of infected persons.
However, once a patient starts treatment or a preventive
treatment
regimen, the same regimen should be continued in the migrant's
next
location (unless medically contraindicated).
Role of Public Health Departments
Health departments should ensure the provision of TB services
for migrant and seasonal farm workers regardless of ability to
pay.
These services should include diagnostic services,
antituberculosis
medication, laboratory services, contact follow-up and inpatient
and outpatient clinical services. Making medical care accessible
to
the migrant farm workers and their families often means
providing
services in migrant health-care centers or near the work site.
Health departments should make outreach services available for
directly observed therapy.
Health departments should ensure that expert TB medical
consultation is available to the clinicians and nurses providing
health-care services to migrant farm workers.
Health departments should teach migrant health personnel how to
perform and read intracutaneous Mantoux tuberculin tests. To aid
in
this training, CDC has made training materials available through
state health departments.
Whenever possible, physicians and nurses from the migrant health
centers should be invited to attend state and local health
department TB control staff training programs.
Role of the Public Health Service
The Public Health Service (PHS) should promote collaboration
between health departments and migrant health centers in the
homebase states and elsewhere to plan and carry out TB screening
and preventive therapy programs. The PHS should require
documentation of such collaboration as part of applications for
federally funded migrant health and TB grants and cooperative
agreements. In addition, as part of routine site visits, PHS
staff
should review related activities and make proposals for more
effective implementation of the recommendations in this
document.
The CDC and the Health Resources and Services Administration,
with the assistance of the Migrant Clinicians Network, should
jointly develop a prototype TB medical history card to be given
to
migrant workers. The card should indicate results of the
worker's
latest tuberculin test, history of preventive therapy, and
appropriate current and past treatment and diagnostic status.
This
card can serve as a supplement to, but cannot substitute for,
complete medical records
Full implementation will require the commitment of additional
resources at the national, state and local levels. Implementation
of these recommendations is an important step in the TB elimination
effort. Most importantly, implementation of these recommendations
will be of great benefit to individual migrant farm workers and
their families whose economic and social progress is being impeded
by the occurrence of TB.
For further information on TB diagnosis, treatment,
monitoring, and control the following references are recommended:
Treatment of Tuberculosis and Tuberculosis Infection in Adults
and Children, American Review of Respiratory Disease,
1986;134(2):355-63.
Diagnostic Standards and Classification of Tuberculosis 1990,
American Review of Respiratory Diseases, 1990;142(3):725-35.
Control of Tuberculosis in the United States, American Review of
Respiratory Diseases, 1992 (in press).
Core Curriculum on Tuberculosis, developed by the American
Thoracic Society and CDC and supported by a grant from the
Pittsfield AntiTuberculosis Association.
Improving Patient Compliance, CDC, revised February, 1990.
Reprints are available from either state or local health
departments or from American Lung Association offices.
References
CDC. A strategic plan for the elimination of tuberculosis in
the
United States. MMWR 1989;38(No.S-3):1-25.
Health Resources and Services Administration. An atlas of state
profiles which estimates number of migrant and seasonal farm
workers and members of their families. 1990:9-10,13.
Ciesielski SD, Seed JR, Esposito PH, Hunter N. The epidemiology
of TB among North Carolina migrant farm workers. JAMA
1991;265:1715-9.
Jacobson ML, Mercer MA, Miller LK, Simpson TW. Tuberculosis
risk
among migrant farm workers on the delmarva peninsula. Am J
Public
Health 1987;77:29-32.
CDC. Tuberculosis among migrant farm workers-Virginia. MMWR
1986;35:467-9.
Simmons JD, Hull P, Rogers E, Hart B. Tuberculosis control
migrant study of 1988. North Carolina Medical Journal
1989;50:309-10.
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The Advisory Council for the Elimination of Tuberculosis
recognizes that a variety of terms are used and preferred by
different groups to describe race and ethnicity. Racial and ethnic
terms used throughout this document reflect the way data are
collected and reported by official health agencies.
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