DTBE Strategic Plan 2022-2026

Vision:

Elimination of tuberculosis in the United States (defined as <1 case/million persons annually)

Mission:

The mission of the Division of Tuberculosis Elimination (DTBE) is to promote health and quality of life by preventing, controlling, and eventually eliminating tuberculosis in the United States.

Strategic Framework, Core Values, Guiding Principles:

Strategic Framework: DTBE’s strategic plan is aligned with the National Center for HIV, Viral Hepatitis, STD and TB Prevention (NCHHSTP) Strategic Plan 2022–2026. The NCHHSTP goals are to reduce incidence of infection, reduce morbidity and mortality, reduce disparities, and promote health equity. DTBE’s goal is to reduce TB morbidity in the United States with a particular focus on reducing disparities in TB morbidity among disproportionately affected groups, including non–U.S.-born persons, racial and ethnic minority groups and persons in congregate settings (e.g., homeless shelters, correctional facilities). DTBE’s strategies, while similar to those laid out in the Center’s plan, focus on efforts unique to TB control and are aimed at eliminating TB. The six specific strategies that provide the framework for DTBE’s strategic plan are derived from the U.S. government’s response to the Institute of Medicine Report, Ending Neglect: The Elimination of Tuberculosis in the United States (2000), which were reaffirmed in A Call for Action on the Tuberculosis Elimination Plan published by STOP TB USA in 2010.

Core Values: DTBE embraces the core values enumerated in NCHHSTP’s strategic plan. The core values that guide how we think and work together, how we serve our communities, how we make decisions, and how we determine our priorities include the following:

• Excellence: Achieve the highest standard of performance in public health science, program, and policy
• Equity: Enhance research, policy, and program efforts to advance health equity
• Diversity and Inclusion: Recruit and maintain a highly trained, inclusive, and professional workforce that reflects the communities we serve
• Integrity: Be honest, accurate, and consistent
• Transparency: Ensure staff, partners, and the public timely access to accurate and complete information

Guiding Principles: NCHHSTP and DTBE prioritize the use of high-impact interventions, programs, and policies that are cost-effective and scalable, cross-sector collaboration that amplifies reach and engages communities across overlapping populations, and equity principles in the design, implementation, and evaluation of research, data analysis, surveillance, and intervention strategies. These principles will ensure the greatest impact on the three goals:

1. Reducing incidence of infections
2. Lowering morbidity and mortality
3. Reducing health disparities and promoting health equity

DTBE will implement programs, policies, and research that:

1. Are most cost-effective in reducing overall TB incidence, morbidity, mortality, and related health disparities;
2. Can be feasibly implemented at full scale with currently available resources (programs and policies should be practical to implement at the scale needed to meet the need in populations at risk for TB);
3. Will have the greatest impact on reducing TB incidence, morbidity, mortality, and disparities and promoting health equity when implemented; and
4. Include populations that are disproportionately affected to reduce disparities by ensuring that those with the highest rates of morbidity or who are most underserved are effectively reached.

Challenges and Opportunities

Challenges: As U.S. TB cases continue to decrease, the perception of TB as a public health risk diminishes as well. As a result, TB can seem to be of lower priority to the general public, clinicians, and many policymakers. Competition for public funds puts resources for TB control and research at risk. The greatest challenges include the following.

• Fewer patients with TB limits routine training opportunities in TB clinical, laboratory, research, and program efforts leading to loss of expertise and experience in TB. This loss of TB expertise and experience has resulted in decreased capacity to appropriately diagnose, treat, manage, and prevent TB.
• Persons at high risk for TB may receive care from private health care providers and community health centers that do not have a great deal of experience with TB. These health care settings may be an entry point for health care for many individuals at high risk for TB. Health care providers can play a critical role in TB elimination by routinely testing populations at high risk for tuberculosis, but may not consider TB testing a priority.
• TB drugs face the same problems that threaten the supply of antibiotics in general. As demand decreases and drug patents expire, manufacturers may weigh the balance of refurbishing facilities and procuring active ingredients against the profitability of the product. Research and development of new TB antibiotics has not kept pace with those of other types of medicine. Therefore, periodic shortages and supply interruptions of critical TB medications have occurred in the United States over the past ten years, resulting in interruptions in patient treatment, delays in treatment initiation, and potential increased community exposure to TB.
• While numbers of TB cases decline, outbreaks are increasingly concentrated among people who are medically underserved, including persons born outside the United States, racial and ethnic minority groups, and people experiencing homelessness, incarceration, and substance/alcohol use. Also, TB is associated with other acute and chronic health conditions, including inadequately controlled diabetes and HIV infection. The complexities of these social determinants and comorbidities affect the resources required for successful prevention and control efforts.
• Although the United States has not experienced the high percentages of drug-resistant TB cases reported globally, the threat of drug-resistant TB, including acquired resistance as a result of delayed diagnosis and inappropriate antibiotic treatment, continues to affect prevention and control efforts.

Opportunities: The decline of TB incidence could be accelerated by prioritizing TB control efforts to address disparities in TB morbidity among people in the United States who are most at increased risk for TB disease and reactivation of latent TB. To this end, DTBE will support 1) robust TB programs to ensure persons with TB complete treatment; 2) rapid molecular testing for identification of cases of drug-resistant TB; 3) genotyping to rapidly identify outbreaks; 4) prevention efforts through expanded latent tuberculosis infection (LTBI) testing (using interferon-gamma release assays) and treatment (with new shorter course regimens); and 5) the latest in clinical, programmatic and epidemiologic research. To maximize outreach, activities will focus on the following populations:

• Non–U.S.-born persons: 71.5% of TB patients in 2020;

• • Mexico, Philippines, India, Vietnam, and China are the leading countries of origin among non–U.S.-born persons diagnosed with TB in the United States.
  • Among non–U.S.-born persons diagnosed with TB, 48.7% have lived in the United States for ≥ 10 years.
• Racial/ethnic minority groups: 89% of overall TB patients; 71.8% of cases among U.S.-born persons; case rates 7–32 times higher than White persons;
• Persons living with HIV: ~4.8% of TB patients;
• Persons with diabetes: ~22.5% of TB patients;
• Persons experiencing homelessness: ~4.3% of TB patients;
• Persons who are incarcerated: ~2.6% of TB patients;
• Persons who use drugs or alcohol: ~1–9% of TB patients

Goal:

Reduce TB morbidity in the United States with a particular focus on reducing disparities in TB morbidity among disproportionately affected groups, including non–U.S.-born persons, U.S.-born racial and ethnic minority groups, and persons experiencing homelessness or incarceration.

Strategies:

1. Maintain control of TB: Maintain the decline in TB incidence through timely diagnosis of TB disease, appropriate treatment and management of persons with TB disease (both drug-susceptible and drug-resistant), investigation and appropriate evaluation and treatment of contacts of people with infectious TB disease, and prevention of further transmission through infection control.
2. Accelerate the decline: Advance toward TB elimination through appropriate regionalization of TB control activities, rapid recognition of TB transmission using genotyping methods, rapid outbreak response and targeted testing and treatment of persons with latent TB infection by engaging communities that experience high burden of TB disease and expanding partnerships with health care agencies, clinicians, and community organizations.
3. Develop new tools: Develop and assess new tools for the diagnosis, treatment, and prevention of TB.
4. Contribute to international TB control as a global leader in research and program efforts: Disseminate advances made in domestic TB control (e.g., programmatic/laboratory improvements, applied laboratory research, TB Trials Consortium research, TB Epidemiologic Studies Consortium research) with CDC’s Division of Global HIV and Tuberculosis (DGHT) and other partners; collaborate with CDC’s Division of Global Migration and Quarantine (DGMQ), the division responsible for reducing the risk of disease importation through medical screening guidelines for all physicians performing the mandatory overseas and U.S. based examinations of refugees and immigrants; reductions in global TB are critical to the goal of U.S. TB elimination as 71.5% of U.S. TB cases in 2020 occurred in non-U.S.-born persons.
5. Mobilize and sustain support: Mobilize and sustain support for TB elimination by engaging and communicating with policy and opinion leaders, health care providers, affected communities, TB survivors, and the public.
6. Track progress: Monitor progress toward the goal of TB elimination, and regularly report on progress to all partners, policymakers, and priority populations.

Activities:

Specifically, to fulfill our mission and implement our strategies for TB Elimination, DTBE carries out the following:

1. Conducts routine surveillance (including drug susceptibility), outbreak and molecular cluster detection and investigation, and specialized periodic surveys

   Supports DTBE strategies: I, II, VI

   Examples: National Tuberculosis Surveillance System (NTSS), National Tuberculosis Molecular Surveillance Center (NTMSC), TB Genotyping Information Management System (TB GIMS), Tuberculosis Latent Infection Surveillance System (TBLISS), Aggregate Reports on Program Evaluation (ARPE), Large Outbreaks of Tuberculosis in the United States (LOTUS) Surveillance

2. Provides funding and embedded staff to state and local TB programs to support case finding and reporting, completion of treatment, contact investigation, and targeted testing and treatment of latent TB infection

   Supports DTBE strategies: I, II, VI

   Examples: Tuberculosis Elimination and Laboratory Cooperative Agreement, DTBE public health advisors and medical officers assigned to state and local TB programs, special initiatives to address latent TB infection testing and treatment in populations at increased risk of TB

3. Supports expert medical care through funding expert medical consultation

   Supports DTBE strategies: I, II

   Examples: TB Centers of Excellence (COEs)

4. Guides preparedness and provides programmatic consultation, technical assistance, and outbreak response assistance to state and local health departments

   Supports DTBE strategies: I, II

   Examples: DTBE Outbreak Response Plan, Outbreak Evaluation Unit, DTBE medical officers, TB Epi-Aids and onsite and remote technical assistance from DTBE epidemiologists, program consultants, and other subject matter experts

5. Conducts program evaluation to improve programs

   Supports DTBE strategy: VI

   Examples: National TB Indicators Project (NTIP), program evaluation component of Tuberculosis Elimination and Laboratory Cooperative Agreement, Tuberculosis Program Evaluation Network (TB-PEN)

6. Provides laboratory diagnostic services; builds and maintains laboratory capacity

   Supports DTBE strategies: I, II, III

   Examples: National TB Reference Laboratory, laboratory capacity building through Tuberculosis Elimination and Laboratory Cooperative Agreement, Cooperative Agreement support to Association of Public Health Laboratories, National TB Laboratory Center of Excellence, National TB Molecular Surveillance Center, Molecular Detection of Drug Resistance Service

7. Conducts critical, programmatically relevant behavioral, epidemiological, clinical, laboratory, and operational research to develop and evaluate new tools and interventions for diagnosis, treatment, prevention, and control of TB (to help programs work more effectively and more efficiently)

   Supports DTBE strategy: III

   Examples: Tuberculosis Trials Consortium (TBTC), Tuberculosis Epidemiologic Studies Consortium (TBESC), whole genome sequencing for outbreak detection, improving molecular detection of drug resistance and better understanding of TB immunology

8. Provides data management; statistical, economic, and epidemiologic modeling; and information technology support

   Supports DTBE strategies: I, II, III, IV, VI

   Examples: Data management and statistical support for NTSS, NTMSC, TBTC, TBESC, economic and epidemiologic modeling activities, including those through NCHHSTP Epidemiologic and Economic Modeling cooperative agreement (NEEMA)

9. Supports intramural infrastructure (salaries, travel, equipment, and supplies) required for maintaining subject matter experts in TB

   Supports DTBE strategies: I, II, III, VI

   Examples: DTBE program consultants and other public health advisors, medical officers, epidemiologists, scientists, statisticians, laboratorians, administrative staff, and infrastructure needed to support their work

10. Obtains external expert consultation and advice to ensure that research and program activities are responsive to emergent public health concerns

    Supports DTBE strategies: I, II, V, VI

    Examples: Advisory Council for the Elimination of TB (ACET), Office of Infectious Diseases Board of Scientific Counselors, ad-hoc consultations

11. Develops and evaluates evidence-based training and educational materials, policies, and guidelines to ensure competency in TB diagnosis, treatment, laboratory capacity, surveillance and reporting, and programmatic prevention and control

    Supports DTBE strategies: I, II, III, IV, V, VI

    Examples: TB Core Curriculum, TB Self-Study Modules, TB Program Managers’ Course, TB Laboratory Course, National Tuberculosis Surveillance System training, TB Genotyping Information Management System training, TB Diagnosis and Treatment Guidelines, and TB Centers of Excellence for Training, Education, and Medical Consultation

12. Develops education, risk, and media communications (web- and print-based) to aid in preparedness and public awareness of TB prevention and control issues

    Supports DTBE strategies: I, II, III, V

    Examples: Online TB Fact Sheets, DTBE internet and intranet sites, media releases and responses, talking points, social media, Think. Test. Treat TB Campaign

13. Cultivates relevant external partnerships, as well as collaborates within CDC and across other federal agencies

    Supports DTBE strategies: I, II, III, IV, V

    Examples: National TB Controllers Association, Stop TB USA, TB Elimination Alliance, American Thoracic Society, Infectious Diseases Society of America, American Academy of Pediatrics, the Association of Public Health Laboratories, National Institutes of Health, Department of Homeland Security

Overarching Tactics:

Sustain commitment

• Build and maintain partnerships, including with other disease programs and providers

Make the argument: Publish additional studies on cost effectiveness, costs of treatment, and return on investments

• Continue to support the Program Evaluation and Health Economics Team within DTBE’s Data Management, Statistics, and Evaluation Branch (DMSEB)
• Continue to share stories of persons affected by TB
• Monitor cooperative agreement and contract activities on health economics and cost effectiveness
• Publish clinical practice guidelines based on innovative TB research findings

Maintain basic TB control functions

• Support case finding and treatment by epidemiologic and demographic characteristics of TB patients reported by jurisdictions (funding formula)
• Support jurisdictions in contact investigation practices and implementation of recommendations (Molecular Epidemiology and Outbreak Investigations Team [MEOIT])
• Engage state authorities in situations where state or local TB programs are incapable of implementing practices to halt transmission (MEOIT, Field Operations Teams)

Expand effective latent TB infection testing and treatment strategies

• Increase outreach to communities and healthcare providers, such as through Federally Qualified Health Centers (FQHCs).
• Develop messaging and other communication strategies for improving treatment initiation (and completion) for those infected who are at highest risk of progressing to TB disease
• Support major initiative for expanded targeted latent TB infection testing and treatment with the following components:

• • Expand use of surveillance system for latent TB infection (e.g., TB Latent Infection Surveillance System)
  • Promote testing to priority populations in primary care settings and congregate settings
  • End low yield testing of persons at low risk of TB
  • Scale up use of interferon-gamma release assays, especially for non–U.S.-born persons
  • Scale up use of short-course latent TB infection treatment (e.g., 12-dose treatment for latent TB infection)
  • Develop outreach and communication tools to engage affected communities and their medical providers (e.g., Think. Test. Treat TB campaign)
• Conduct research on optimal implementation strategies for latent TB testing and treatment expansion (e.g., TBESC III) and LTBI treatment regimen shortening (TBTC)

Maintain or increase focus on prevention of TB disease in the United States for non-U.S.-born persons

• Take advantage of new diagnostics (e.g., interferon-gamma release assay) and treatment/drug regimens
• Consider expanding TB Technical Instructions for overseas TB screening for immigration to include additional visa categories (e.g., students, temporary workers)
• Assess TB and latent TB infection testing and treatment patterns for non-U.S.-born persons who are applying for naturalization of citizenship by working with U.S. civil surgeons

Maximize impact of limited resources

• Promote and harness scientific and technological advancement
• Share federal policies and programs that could augment TB programs’ efforts; for example, some programs already use 340B program for discounted drug purchases, some use Medicaid Section 1115 waivers, some have adopted TB Medicaid Option, and others are making advances under the Affordable Care Act

Goals for Health Equity in Tuberculosis Prevention and Control

The Centers for Disease Control and Prevention has launched an agency-wide strategy to integrate health equity into all agency public health work with the goal of reducing health disparities. In an effort to incorporate this strategy, DTBE developed three goals that focus on populations who experience health disparities related to TB disease. The overall goal is to reduce TB incidence in these populations by approximately 20% between 2019 and 2025.

• Goal 1: Decrease the TB incidence rate among non-U.S.–born Asian persons from 26.2 per 100,000 (2019) to 20.8 per 100,000 by December 31, 2025. This goal will reduce health inequities by bringing the incidence rate among non-U.S.–born Asian Americans closer to the TB rate for U.S.-born Asian populations (1.5 per 100,000 in 2019).
• Goal 2: Decrease the TB incidence rate among non-U.S.–born Hispanic/Latino persons from 10.2 per 100,000 (2019) to 8.2 per 100,000 by December 31, 2025. This goal will reduce health inequities by bringing the incidence rate among non-U.S.–born Hispanic and Latino persons closer to the TB rate for U.S.-born Hispanic/Latinos populations (1.5 per 100,000 in 2019).
• Goal 3: Decrease the TB incidence rate among U.S.-born non-Hispanic Black or African American persons from 2.6 per 100,000 (2019) to 2.0 per 100,000 by December 31, 2025. This goal will reduce health inequities by bringing the incidence rate among U.S.-born non-Hispanic Black or African American persons closer to the TB rate for U.S.-born white persons (0.4 per 100,000 in 2019).

Achieving these goals will reduce health inequities overall and bring the U.S. TB rate closer to the goal of TB elimination in the United States (<1 case per million annually). In 2020, a 20% decline in TB incidence was achieved for non-U.S.-born Hispanic/Latino persons and non-Hispanic Black or African American persons; however, the magnitude of health disparities remains similar relative to non-Hispanic White persons.