Notice of Funding Opportunity (NOFO)

CDC-RFA-PS22-2207: Strengthening Civil Surgeons’ Capacity to Improve LTBI Surveillance and Outcomes Among Status Adjusters

The Centers for Disease Control and Prevention (CDC) announced a Notice of Funding Opportunity (NOFO) on March 18, 2022, under a two-year cooperative agreement to support the creation of pilot projects to prevent TB disease among status adjusters examined by civil surgeons. The goals are to establish surveillance and improve linkage to care and treatment of latent tuberculosis infection (LTBI) for status adjusters.

Status adjusters are non-U.S.–born persons living legally in the United States on temporary visas who apply for permanent residency. As part of the process, applicants must have a medical examination that includes screening for TB with an interferon gamma release assay (IGRA) blood test and, if the IGRA is positive, a chest radiograph. Civil surgeons are physicians designated by the U.S. Citizenship and Immigration Services (USCIS) to provide medical examinations for status adjusters, including IGRA testing. Civil surgeons are required to report positive IGRA results of status adjusters to their local health departments (Tuberculosis Technical Instructions for Civil Surgeons | CDC).

This funding opportunity will help move the U.S. toward the goal of TB elimination (<1 TB case per million population) by focusing prevention efforts on non-U.S.–born persons, who account for about 70% of TB cases in the United States. It also aims to promote sustained collaboration between local health departments and civil surgeons.

Important Information

How to Apply

To apply for this funding opportunity, you must submit your application on www.grants.govexternal icon.

Application Deadline

The application deadline is May 18, 2022

Frequently Asked Questions

The NOFO announcement says that “recipients may not use funds for clinical care expect as allowable by law.” Are you able to clarify what CDC means by clinical care?

The intent of this NOFO is to improve surveillance of LTBI among status adjusters and implement education, training, and communication interventions to link status adjusters to TB preventive treatment. Funds shall not be used to provide direct clinical care to patients. Examples of clinical care include but are not limited to performing physical examinations, ordering or performing diagnostic tests or procedures, writing medical orders or prescriptions, and providing or administering medications.

Can funds be used to purchase food for patient incentives or for learning activities scheduled with partners?

Costs associated with food or meals are allowable when consistent with applicable federal regulations and HHS policies. See https://www.hhs.gov/grants/contracts/contract-policies-regulations/spending-on-food/index.htmlexternal icon. In addition, costs must be clearly stated in the budget narrative and be consistent with organization approved policies. Recipients must make a determination of reasonableness and organization approved policies must meet the requirements of 45 CFR Part 75.432.

What would be considered equipment?

CDC defines equipment as tangible non- expendable personal property (including exempt property) charged directly to an award having a useful life of more than one year AND an acquisition cost of $5,000 or more per unit. Any such proposed spending must be clearly identified in the budget. For additional information, please see the equipment section in the Budget Preparation Guidelines: https://www.cdc.gov/grants/documents/Budget-Preparation-Guidance.pdf pdf icon[PDF – 416KB].

Is the award $600,000 per year for a total of two years?

No. Each award is an estimated $600,000 total, which the recipient will be awarded up front and can spend over a two-year budget period. There will not be a continuation application or a continuation award for the second year.

Does the budget include indirect costs?

Budgets can include direct costs. Please see the CDC Budget Preparation Guidelines: https://www.cdc.gov/grants/documents/Budget-Preparation-Guidance.pdf

Can the funding be used to support cost of LTBI medications?

No. Funds cannot be used to cover the cost of LTBI medications but can be used to cover interventions around treatment.

How many awards will CDC make?

Currently, CDC is estimating three awards.

Can an applicant receive multiple awards?

Most often, only one award is issued to an entity, unless the NOFO specifies otherwise.

Can current CDC field assignees already embedded in a state/local program conduct some of this work if their host program/site is awarded under this NOFO? Would this be frowned upon or considered “overlap”?

This would likely be considered overlap, since the CDC field assignee is being paid by direct assistance on a different award. The issue at hand is that a CDC field assignee wouldn’t be able to provide in-kind efforts on this award without exceeding their percentage of effort.

When does the funding period start/end for this award?

The estimated award date is sometime during the middle to end of September 2022. Once awarded, the period of performance is two years long, with an estimated end date during the middle to end of September 2024.

Is there a form or specific format for the “Report on Programmatic, Budgetary, and Commitment Overlap” on page 24 under duplication of efforts?

No. There is not a specific form or format.

If a recipient receives referrals from other civil surgeons who do not qualify as “high-volume”, is it allowable to include this data for the project in addition to the data from confirmed “high-volume” civil surgeon partners?

This is a topic that CDC staff can talk through with awarded recipients, once project implementation is underway. Including such data is not required and will not have an impact on how applications are ranked/scored by the objective review panel.

Must applicants be a civil surgeon, or can applicants partner with a civil surgeon?

Only government entities or their bona fide agents are eligible to apply for and receive an award under this NOFO. Civil surgeons are not eligible to apply directly for the award. The expectation is that the government entity will partner with civil surgeons.

Can applicants submit multiple, separate applications to work with civil surgeons in different jurisdictions?

There is no limit to the number of applications one applicant can submit. However, CDC will only accept the latest application submitted by the deadline. There is also no limitation on the number of high-volume civil surgeon partners an applicant can include in one application. If an applicant proposes to work with multiple civil surgeons, each civil surgeon will need to be covered by a letter of support (either individually or a group letter of support).

Can applicants reach out to civil surgeons in their jurisdiction to find out the number of IGRA-positive status adjusters with LTBI they report to the health department monthly on average, so that applicants know whether they have a qualifying civil surgeon partner?

Yes. Health departments should already be receiving reports of IGRA-positive status adjusters with LTBI from civil surgeons, under the 2018 Tuberculosis Technical Instructions for Civil Surgeons (https://www.cdc.gov/immigrantrefugeehealth/civil-surgeons/tuberculosis.html). Applicants are encouraged to reach out to potential civil surgeon partners in their legal jurisdictions, as a letter of support from at least one high-volume civil surgeon is an application requirement.

This NOFO requires each civil surgeon to report at least 10 IGRA-positive LTBI cases, on average, to the health department per month for the year 2021 in order to be considered high-volume.

Do IGRA-positive LTBI cases only count toward this minimum if they start treatment for LTBI?

High-volume civil surgeons are those who reported/referred at least 10 IGRA-positive LTBI cases, on average, to the health department per month for the year 2021. Patient treatment information/status is not part of this definition. However, the goal of this pilot project is to use the funding to implement an intervention that would help increase LTBI treatment for status adjusters diagnosed with LTBI who are reported/referred to the health department.

If a jurisdiction does not meet the requirement of having at least 1 civil surgeon who reports at least 10 IGRA-positive LTBI cases, on average, to the health department per month for the year 2021, would an application that proposes working with a smaller-volume civil surgeon be considered non-responsive?

That is correct – the applicant would be considered ineligible. CDC set this minimum requirement in order to generate enough data to learn more about the status adjuster population in general, TB programs’ role in the Tuberculosis Technical Instructions for Civil Surgeons reporting/referral process, and how to improve the care cascade for status adjusters with LTBI.

Can an applicant work with multiple civil surgeon providers that are part of the same practice/medical group?

An applicant may propose to work with multiple high-volume civil surgeons, as long as each individual civil surgeon reported/referred at least 10 IGRA-positive LTBI cases, on average, to the health department per month for the year 2021 and has signed a letter of support. During phase II review, an applicant with multiple high-volume civil surgeon partners will be scored based on the civil surgeon partner that reports the most status adjuster IGRA-positive LTBI cases per month on average.

Does the civil surgeon partner need to be in the same county as the applying entity?

High-volume civil surgeon partners should be in the jurisdiction of the government entity that is applying for this NOFO and has the legal authority to collect public health data from civil surgeons.

Is the line level data for all individuals adjusting their status, or only those diagnosed with LTBI?

Submission of line level data is required only for status adjusters with an IGRA-positive LTBI diagnosis. Submission of aggregate data is required for all status adjusters examined by the high-volume civil surgeon partner(s) (see page 8 of the NOFO for details).

Are all TB Latent Infection Surveillance System (TBLISS) fields required to be collected or only a core set of data elements to create a care cascade?

The list of questions on the original TBLISS form has been reduced for this project by removing fields that are not applicable to status adjusters. For example, the Administration section now has only two questions (Date Reported and Local Case Number), and the Epidemiologic Investigation section has been removed entirely. We have also excluded Qs 12b (regarding US Reporting Area).

The original TBLISS form can be found under “Related Documents” on the CDC-RFA-PS22-2207 Grant Opportunity webpage.

Which parts of TBLISS form constitute the care cascade required elements?

The TBLISS form has fields for corresponding elements of the cascade, including eligibility, test and test results, chest X-ray results, date therapy started, date therapy stopped, and reason stopped (completed therapy). CDC will work with recipients to finalize elements of the cascade.

For submitting line-listed data to the REDCap database, will manual data entry be required or will upload of electronic files (e.g., .csv) be supported?

All line-listed data must be submitted through REDCap. However, users can either use the REDCap interface or upload an electronic (.csv) file. If an electronic file is used, it must match the REDCap template.

Is there a published report that includes the number of status adjusters seen by each civil surgeon nationwide?

CDC’s Division of Global Migration and Quarantine as well as US Citizenship and Immigration Services colleagues were consulted during the planning of this NOFO, and according to those conversations, such numbers do not appear to be available.

Is there a predefined gap analysis format that you want applicants/recipients to use?

There is no pre-defined format or template for the gap analysis. The gap analysis will help inform the intervention development. The gap analysis should also help recipients understand their population of interest, determine how to best to reach them, identify needs, gaps, and barriers, and determine available existing resources. Information gathering methods can vary from interviews or surveys to literature reviews (see page 9 of the NOFO). Because this is a cooperative agreement, the final plan for the gap analysis can be finalized with CDC after award.

Should the gap analysis and interventions be based on high-volume civil surgeons or on a broader population (e.g., county or state level)?

The population for the gap analysis will be based on the site-specific needs and resources. CDC and the site will work together to define the gap analysis once the award is set, and can be either physician/clinic-specific or at a larger county scale, as long as it provides information on the needs relative to LTBI among status adjusters and civil surgeons in the location of the site. The gap analysis should reflect local demographics and experiences.