CDC's Response to Ending Neglect

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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.

The Plan

GOAL I: Maintain control of TB

Maintain the decline in TB incidence through timely diagnosis of active TB disease, appropriate treatment and management of persons with active disease, investigation and appropriate evaluation and treatment of contacts of infectious cases, and prevention of transmission through infection control.

Tuberculosis control efforts have two priorities: 1) to detect persons with active TB and treat them with effective anti-TB drugs, and 2) to identify contacts of infectious TB cases and evaluate and treat them as needed.

Effective treatment cures patients of TB disease and stops the transmission of infection to others. Being treated for active TB involves taking multiple anti-TB drugs daily or several times a week for at least 6 months. Anti-TB drugs must be prescribed properly and taken for the full treatment period. Otherwise, the disease may not be cured and could recur. Also, the TB organisms could become resistant to standard anti-TB drugs. To maintain control of TB and prevent drug-resistant disease, TB must be accurately diagnosed, an effective treatment regimen must be prescribed, and patients must take all of their medicine. The best way to ensure that patients adhere to anti-TB drug regimens is to provide a patient-centered approach that uses DOT, meaning that a provider watches the patient take the medication.

Contact investigation and follow-up are important for detecting cases of active TB and identifying persons who have latent TB infection and are at high risk for developing TB disease. The identification of every infectious or suspected case of TB should prompt an epidemiologic investigation to locate others who have potentially been exposed and are therefore at risk of infection. To maintain control of TB, contacts of potentially infectious TB cases must be evaluated and, if found to be infected, treated appropriately.

Objective I-A
Maintain and enhance local, state, and national public health surveillance for TB.

State and local health departments are legally responsible for protecting the public health.⁴⁸ In the setting of active TB, this responsibility includes 1) ensuring that each patient with active TB completes appropriate treatment, 2) ensuring that a contact investigation is conducted to identify other persons with potentially infectious TB, 3) arranging for the evaluation and treatment of persons with active TB or latent TB infection, and 4) conducting epidemiologic investigations in response to potential outbreaks and implementing control and prevention measures.

The foundation for these activities is public health surveillance (the ongoing, systematic collection, analysis, interpretation, and dissemination of health data). TB surveillance is critical for ensuring complete case finding, appropriate linkages to diagnostic and treatment services and contact investigations, and reliable information systems for monitoring TB trends and evaluating control programs. All states require designated health care professionals to report TB cases (and usually suspect TB cases) to local or state health departments.⁴⁸ All state health departments maintain TB surveillance systems. The extent of local surveillance activities depends on state statutes and the delegation of authority by state health departments. States and localities provide information on the numbers and characteristics of TB cases to the national surveillance system at CDC. The national system plays a critical role in monitoring national TB trends and guiding the planning and evaluation of national TB control efforts.

Ensuring that the surveillance system captures all persons with TB requires active case finding (also called active surveillance). Active case finding is a particularly important activity when the number of cases is decreasing and disease elimination is the goal. Active case finding can be supplemented by screening of high-risk populations.

Activities

1. Assist state and local health departments in periodic evaluations of TB surveillance systems.
2. Maintain support for the national TB surveillance system.
3. Conduct comprehensive and standardized evaluations of surveillance activities in all 50 states, the District of Columbia, and U.S. territories to help in the development and implementation of strategies to improve and enhance surveillance, especially active surveillance.

Objective I-B
Support the infrastructure needed for laboratory-based identification and treatment of TB.

TB control efforts depend on well-functioning mycobacteriology laboratories that can 1) detect, isolate, and identify TB organisms, 2) determine the organisms' susceptibility to anti-TB drugs, and 3) communicate promptly with clinicians so that diagnoses can be confirmed and treatment started. Both the laboratory and the clinician should have confidence in a laboratory's results. Accordingly, laboratories must institute efficient procedures, refer specimens to referral laboratories when necessary, and be adequately staffed to provide results in a rapid and efficient manner. All mycobacteriology laboratories must participate in recognized proficiency testing programs and establish levels of service that reflect the demonstrated quality of performance.

Diagnostic Standards and Classification of Tuberculosis in Adults and Children In April 2000, CDC and the American Thoracic Society (ATS) published Diagnostic Standards and Classification of Tuberculosis in Adults and Children.49 These standards are designed to provide a framework for and an understanding of the diagnostic approaches to latent TB infection and disease and to present a classification scheme that facilitates patient management. A person classified as having "clinical active TB" (Class 3) must have clinical, bacteriologic, or radiographic evidence of current TB. The bacteriologic evidence is established by isolation of M. tuberculosis in a fully functioning mycobacteriology laboratory.

Activities

1. Sustain state and local health department laboratories, and upgrade them as necessary.
   • Continue to support state and local health departments' mycobacteriology laboratories through cooperative agreements.
   • Strengthen the ability to provide technical support to state and local mycobacteriology laboratories.
   • Ensure the availability of back-up services to state and local mycobacteriology laboratories as needed.
   • Support the development of effective quality assurance and training programs for all laboratories that process mycobacteria specimens.
2. Enhance laboratory capacity to support outbreak investigations.
   • Continue to support TB outbreak investigations through DNA fingerprinting and enhanced drug-susceptibility testing.
   • Develop strategies for transferring technologies for DNA fingerprinting to state and city health departments, as appropriate.
   • Support regional laboratories that provide DNA fingerprinting services to state and local TB control programs.
3. Evaluate and support new approaches to providing reliable and timely laboratory services for TB diagnosis.
   • Monitor laboratory practices and capabilities in state and territorial mycobacteriology laboratories to determine work volume and proficiency levels.
   • Conduct operational studies in order to develop models for referring specimens and cultures that ensure rapid test results for smears, culture identification, and drug susceptibility testing, as well as studies to explore the feasibility of alternate approaches to providing laboratory services for TB diagnosis at the local, state, and regional levels.
   • Establish mechanisms for the timely feedback of laboratory results to health departments and clinicians charged with the care of TB patients and suspected TB patients.
   • Ensure that CDC has appropriate laboratory staff for conducting operational research and national assessments of laboratory practices, provide laboratory training, and promote quality testing.

Objective I-C
Ensure that patient-centered case management and monitoring of treatment outcomes are the standard of care for all TB patients.

Promoting patient-centered case management involves assessing each TB patient's needs and identifying a treatment plan that ensures the completion of therapy. High rates of completion of TB treatment (exceeding 90%) are most likely when treatment incorporates DOT, with multiple enablers (something that helps the patient complete treatment, e.g., transportation vouchers), incentives (something that will motivate the patient to successfully carry out program goals, e.g., food coupons), and other treatment enhancers (e.g., alternative treatment delivery sites, strategies to overcome social and cultural barriers to completion of treatment, use of outreach workers).¹⁸ DOT has been shown to be more effective than self-administered therapy in several observational studies in the United States^18,50 and also to be a cost-effective and, in some cases potentially cost-saving, alternative to self-administered therapy.⁵¹

Activities

1. Ensure that all patients with active TB are tested for HIV infection and that all patients with TB disease and HIV infection are appropriately and adequately treated.
2. Promote the use of enhanced DOT, including incentives and enablers, to ensure the completion of treatment in persons with active TB.
   • Continue to support DOT, including the use of incentives and enablers, through CDC cooperative agreement grants.
   • Where possible, provide housing for homeless TB patients, e.g., through Housing Opportunity for Persons with AIDS programs (administered by HUD).
   • Support the infrastructure needed to provide well-trained outreach workers.
   • Encourage DOT in primary-care facilities, drug treatment centers, HIV/AIDS residential facilities, HIV clinics, migrant clinics, and shelters.
   • Provide ongoing technical assistance, both on-site and by telephone, to promote the expanded use of DOT by health departments and other providers in the field and in clinics and other sites.

Effectiveness of Enhanced DOT The Public Health Tuberculosis Guidelines Panel reviewed 27 studies in which treatment completion for TB was used as an outcome.18 The studies classified treatment strategies into four categories: enhanced DOT, DOT, modified DOT, and unsupervised therapy. Enhanced DOT was defined as a comprehensive, patient-centered strategy of fully supervised DOT with multiple incentives and enablers. DOT was defined as fully supervised DOT without incentives or enablers. Modified DOT included DOT for only part of the treatment period, and unsupervised therapy involved no DOT. The median treatment completion rate for enhanced DOT was 90%, compared to rates of 86%, 81%, and 61% for DOT, modified DOT, and unsupervised therapy, respectively.

3. Develop guidelines and standards for patient-centered case management in public health clinics, managed-care settings, and other private sector settings.
   • Compile and review published studies of patient-centered case management.
   • Review effective models of patient-centered case management in state and local TB programs.
   • Convene a national meeting of TB controllers, TB nurse consultants, and clinicians experienced in TB care to develop guidelines and standards for patient-centered case management.
   • Through ACET, issue guidelines and standards for patient-centered case management.
4. Develop the capacity of state and local TB control programs to conduct systematic and comprehensive reviews of the outcome of treating patients with active TB (i.e., "cohort reviews").
   • Provide ongoing technical assistance to promote the use of cohort reviews of patients with active TB disease to monitor treatment outcomes.
   • Develop guidelines, models, and training materials for developing programmatic capacity to conduct cohort reviews.
5. Develop case-management information systems to facilitate the appropriate management of patients and the evaluation of their treatment outcomes.
   • Define the elements needed for effective case management and evaluation of case-management systems.
   • Develop an information system that captures these elements and promotes the effective management of patients with active TB.
   • Provide financial and technical support to allow programs to establish and use case-management information systems.
6. Explore ways to increase third-party reimbursement for TB services.
   • Conduct a study to 1) identify funding sources for outpatient TB services in a sample of TB cases, 2) determine facilitating factors and barriers to third-party billing and reimbursement, and 3) determine the current programmatic and fiscal impact of reimbursement.
   • Using study results, develop recommendations for strategies to maximize and improve third-party reimbursement for TB control activities.

Objective I-D
Develop community partnerships, and strengthen community involvement in TB control.

Because each community has its own TB management needs, optimal TB prevention and control activities require a multifaceted, multidisciplinary approach. Collaborative efforts between TB prevention and control programs and community groups, health care providers, and other organizations serving TB patients can 1) educate the public about TB, 2) ensure that community leaders, health care providers, and policy makers are knowledgeable about TB, 3) identify persons with TB disease and ensure that they complete appropriate treatment, 4) identify contacts of persons with infectious TB disease and ensure that they are appropriately evaluated and treated, and 5) coordinate, and in some instances provide, screening and prevention services for persons at high risk for developing TB disease.

Public health activities that are culturally appropriate and have broad-based community support have been shown to have a substantial effect on the health status of high-risk communities. Too often, TB patients and high-risk persons are suspicious or simply unaware of TB prevention and control services that are available to them. To ensure the quality, effectiveness, and appropriateness of activities, TB prevention and control programs need help from local groups in high-prevalence communities. Partnerships with community-based organizations (CBOs) and with health care providers with established relationships in the community can help ensure that high-risk populations have access to TB prevention services and that the services reflect local needs.

Activities

1. Promote the development of partnerships between local TB control programs and community-based health centers and organizations.
   • Develop local epidemiologic profiles of TB disease and infection to assist in the identification of high-risk groups and of health care providers with whom partnerships should be established.
   • Identify gaps in services to high-risk groups that can be met by the development of partnerships.
   • Emphasize partnership development in cooperative agreement announcements, program reviews, and site visits.
   • Assist in developing the capacity of state and local TB prevention and control programs to evaluate community partnerships.
   • Assist state and local health departments in increasing the capacity of CBOs to deliver TB services.
   • Ensure that local TB control programs develop working partnerships with Ryan-White providers and other HIV-care providers.
2. Ensure that community-based health care providers are trained in the diagnosis and treatment of TB disease and latent TB infection.
   • Conduct formative research on culturally appropriate training for community-based health care providers who serve diverse populations.
   • Develop training targeted to community-based health care providers.
   • Continue to support the National TB Model Centers' development of culturally appropriate training materials.
   • Support efforts by state and local TB control programs to identify and provide training to community-based health care providers, including CBOs.
   • Support efforts by HIV/AIDS providers funded under the Ryan-White Care Act Program and other HIV-care providers to ensure adequate and appropriate treatment, including enhanced DOT, of HIV-coinfected persons with TB disease or latent TB infection.

Objective I-E
Improve the timely investigation and appropriate evaluation and treatment of contacts with active TB disease and latent TB infection.

Contacts of persons with infectious TB are at high risk for infection and disease. The risk to contacts is related to the infectiousness of the source patient, the characteristics of the contact, and the characteristics of the environment they share. Prompt identification and evaluation of contacts of infectious cases are essential for good TB control. This is especially true for vulnerable high-risk populations. For example, HIV-infected contacts who are also infected with M. tuberculosis can develop clinically active disease very rapidly, as early as 20 days after infection.⁵² The priority, speed, and extent of a contact investigation should reflect the likelihood of transmission (based on the characteristics of the source patient, contact, and environment) and the possible consequences of infection (especially for HIV-infected contacts and young children).

Activities

1. Develop guidelines and standards for contact investigations.
   • Review guidelines and standards for contact investigations developed by state and local TB control programs.
   • Develop draft recommendations and guidelines for conducting contact investigations.
   • Seek comments on the recommendations and guidelines from state and local TB control officials, health departments, ACET, the National Tuberculosis Controllers Association (NTCA), and others as appropriate.
   • Publish the recommendations/guidelines for contact investigations.
2. Enhance the capacity of state and local TB control programs to conduct contact investigations, and ensure that infected contacts complete TB treatment.
   • Provide funding for enhanced contact investigation and treatment of infected contacts through CDC's cooperative agreement grants.
   • Provide ongoing technical assistance to health departments, both on-site and by telephone, to promote expanded contact investigations.
   • Develop and support training for TB control program staff to enhance their ability to interview and investigate contacts.
   • Conduct behavioral research to investigate reasons for nonadherence with curative treatment and treatment of latent TB infection; develop interventions to increase adherence.
   • Develop the capacity of TB controllers to use social network analysis in contact investigations
3. Develop the capacity of state and local TB control programs to evaluate the outcomes of contact investigations and respond appropriately to the results of the evaluations.
   • Include guidance on evaluation of contact investigations in newly developed recommendations/guidelines.
   • Increase the capacity of state and local TB programs to conduct process and outcome evaluations of contact investigations.
   • Conduct research to identify appropriate measures of effectiveness for contact investigations.
4. Develop systems to provide the information needed to manage contacts and evaluate contact investigations.
   • Define the elements needed for effective management of contacts and evaluation of contact investigations.
   • Develop an information system that captures these elements and promotes the effective management of contacts of persons with infectious TB.
   • Provide financial and technical support to programs to establish and use contact-management information systems.

Objective I-F
Ensure appropriate care for patients with MDR TB, and monitor their response to treatment and their treatment outcomes.

The resurgence of TB in the United States that started in 1985 exposed an insidious problem for TB control: the rise in MDR TB (M. tuberculosis strains resistant to at least the two first-line TB drugs, isoniazid and rifampin). From 1982 through 1986, only 0.5% of new TB cases were resistant to both isoniazid and rifampin.⁵³ By 1991, however, 3% were resistant to both drugs, and 14% were resistant to at least one.⁵⁴ Against this background of increasing numbers of TB cases and increasing drug resistance, a dangerous new phenomenon appeared: outbreaks of MDR TB in institutional settings. From 1990 through 1992, CDC investigated outbreaks in eight hospitals and one correctional system and identified almost 300 cases of MDR TB. Death rates were shockingly high - 43% to 100%. Although most cases occurred in HIV-infected patients, several health care workers and prison guards were also stricken.

The flare-up of cases and outbreaks of MDR TB reflected serious underlying problems in the U.S. health care infrastructure. Increasing proportions of TB cases were occurring in persons who were homeless; were born in other countries; or had substance abuse, mental health, or other problems, such as HIV infection, that made adherence with treatment difficult. At the same time that the number and complexity of TB cases were increasing, financial constraints were resulting in cutbacks in TB control programs. As a result, health departments lacked the resources needed to manage difficult-to-treat patients and control outbreaks.

Reversing the increase in TB and MDR TB required vigorous TB control measures and a significant hike in public spending.^{14, 19, 55} With the drop in TB cases, however, there has also come a decline in TB treatment expertise, especially MDR TB, which requires complicated drug regimens and meticulous patient monitoring. Because the cost of treating MDR TB is so high, many programs are unable to provide optimal treatment for affected patients. Without renewed funding and support, MDR TB outbreaks may once again spread unchecked and exact their heavy price.

National Action Plan to Combat Multidrug-Resistant Tuberculosis In response to the emergence of MDR TB, a federal Task Force was convened in 1991 to develop a national plan to combat the problem. The resulting National Action Plan to Combat Multidrug-Resistant Tuberculosis5 identified the problems to be addressed, outlined objectives for addressing each problem, and listed the implementation steps needed to attain each objective. The main objectives were to 1) determine the magnitude and nature of the MDR TB problem, 2) improve the rapidity, sensitivity, and reliability of diagnostic methods, 3) manage MDR TB patients and prevent patients with drug-susceptible TB from developing drug-resistant disease, 4) identify persons infected with or at risk of developing MDR TB and prevent them from developing clinically active TB, 5) minimize the risk of transmission to patients, workers, and others in institutional settings, 6) control outbreaks, 7) increase TB programs' effectiveness in managing patients and preventing MDR TB, 8) enhance training, education, and information dissemination, and 9) conduct research on more effective tools with which to combat MDR TB.

Activities

1. Enhance the capacity of laboratories to rapidly diagnose MDR TB.
   • Monitor laboratory practices and capabilities in all mycobacteriology laboratories.
   • Provide funding through cooperative agreements for the upgrading of state and local mycobacteriology laboratories as appropriate.
   • Continue support of state and regional laboratories that can rapidly identify and determine drug susceptibilities of M. tuberculosis isolates.
2. Develop networks of providers with expertise in the management of patients with MDR TB to facilitate the referral of patients and the initiation of appropriate therapy.

   • Identify providers and centers with expertise in the management of patients with MDR TB.

   • Work with selected health departments, acute-care institutions, medical schools, and public and private providers to establish regional centers of excellence for treating difficult-to-manage MDR TB cases.
3. Develop information systems for use in managing and monitoring the treatment outcomes of patients with MDR TB.
   • Define the elements needed for the effective management of persons with MDR TB.
   • Develop an information system that captures these elements and promotes the effective management of persons with MDR TB.
   • Provide financial and technical support to programs for establishing and using MDR TB patient-management information systems.

Objective I-G
Ensure that health care facilities maintain infection-control precautions.

TB control programs are sources of information and consultation to the medical community on infection-control practices that should be maintained to prevent TB transmission. During interactions with the medical community, TB control programs should emphasize the need to maintain a high level of suspicion for TB in evaluating patients who have TB symptoms and the importance of early diagnosis, appropriate isolation, and prompt initiation of treatment.

Activities

1. Update and disseminate guidelines for the prevention of TB transmission in health care facilities, including outpatient settings.
2. Promote the development of partnerships between local TB control programs and congregate living settings (e.g., prisons, jails, homeless shelters) to ensure appropriate infection control and prevent the transmission of TB.
   • Develop local epidemiologic profiles of TB disease, including DNA fingerprinting results, to help in the identification of groups with ongoing TB transmission.
   • Identify the congregate living settings and health care providers of these high-risk groups with whom partnerships should be established.
   • Identify gaps in services to high-risk groups that would best be met by developing partnerships to ensure infection control and prevent TB transmission in congregate living settings.
   • Emphasize partnership development in cooperative agreement announcements, program reviews, and site visits.
   • Provide assistance in developing programmatic capacity to evaluate community partnerships.

Objective 1-H
Develop improved engineering and personal protective techniques to prevent TB transmission.

CDC's 1994 TB infection control guidelines presented recommendations for TB control based on a risk assessment process that classified healthcare facilities according to various categories of TB risk.⁵⁶ A corresponding series of controls, which included administrative, environmental, and personal protective control measures, was presented. The second level of this hierarchy is the use of environmental controls to prevent the spread and reduce the concentration of infectious droplet nuclei. These environmental controls include: 1) controlling the source by use of local exhaust ventilation, 2) controlling the airflow to prevent contamination of air in areas adjacent to the source, 3) diluting and removing contaminated air by use of general ventilation, and 4) cleaning the air by use of air filtration alone or together with ultraviolet germicidal irradiation (UVGI). The first two levels of the hierarchy (administrative and environmental controls) minimize the number of areas where exposure to infectious TB may occur. They also reduce, but do not eliminate, the risk in the few areas where exposure can still occur (e.g., airborne infection isolation rooms; treatment rooms in which cough-inducing or aerosol-generating procedures are performed; autopsy rooms; etc.). Because persons entering these areas may be exposed to M. tuberculosis, the third level of this hierarchy of controls is the use of personal respiratory protective equipment in situations that pose a relatively high risk for exposure.

The foundation for these activities is derived from basic research, and information gained will be used to aid in the selection of effective engineering controls and respirators.

Activities

1. Improve engineering control measures for TB.
   • Encourage and support research into development of improved engineering techniques for preventing transmission of M. tuberculosis in high risk environments.
   • Utilize computational fluid dynamics (CFD) to assess the efficacy of environmental controls supplemental to room ventilation.
   • Utilize CFD to evaluate the ability of various ventilation configurations/designs to prevent the migration of TB from one room to another.
2. Access adequacy of personal protective equipment.
   • Determine if the current user-seal checks as described by the manufacturers of N95 filtering facepiece respirators actually help to ensure an adequate fit.
   • Develop a no fit-test, high-protection factor respirator performance test.
   • Conduct a workplace study of how well N95 filtering facepiece respirators perform in actual health-care settings, including determining penetration and service time restraints.
   • 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, and other critical elements).
   • Conduct testing of newly certified N95 respirators to determine how well each certified respirator performs, enabling health care workers to make informed and proper respirator selection.

Objective I-I
Improve TB control in foreign-born populations entering or residing in the United States.

In 2001, the TB case rate among foreign-born persons was 26.6 per 100,000 population, a rate which is almost 9 times higher than the rate of 3.1 per 100,000 observed among the U.S.-born population (see graph).⁷

Mexico, the Philippines, and Vietnam are the countries of origin for nearly half of all foreign-born persons with TB in the United States. Although screening with a chest radiograph, followed by acid-fast bacilli (AFB) smears for persons with abnormal radiographs, is required for the approximately 435,000 immigrants and refugees prior to arrival in the United States annually, approximately 32 million foreign-born persons entering the United States each year are not screened for TB (approximately 30.2 million persons with a nonimmigrant visa status; 275,000 undocumented immigrants; and 50,000 - 1.5 million asylees). Furthermore, a number of recent studies suggest that the screening, tracking, and notification system currently in place for immigrants and refugees is not uniformly effective in identifying persons with active TB or ensuring appropriate treatment and follow-up in the United States. Since the immigration status of foreign-born persons with TB at the time of entry to the United States is not systematically collected, it is unclear how many foreign-born persons with TB were missed at the time of mandatory immigrant and refugee screening, were appropriately screened but developed TB after entering the country, or were in a visa category for which no screening was required. Information is urgently needed in order to develop strategies to reduce the incidence of TB among the ever-increasing pool of foreign-born persons entering and residing in the United States.

Activities

1. Conduct studies of at-entry immigration characteristics of foreign-born persons with TB, to include
   • Prospectively collect information on immigration and refugee status in the Report of Verified Case of Tuberculosis (RVCT) form used for reporting individual case data to CDC via the Tuberculosis Information Management System (TIMS), a surveillance and case management software application used by TB control programs.*
   • Conduct studies in various epidemiologic settings (border states, Hawaii, port cities, and U.S. heartland areas with large numbers of immigrants and refugees) in order to refine current estimates of risk of TB among various groups of foreign-born persons.
2. Use 2000 census data to update TB case rates for foreign-born persons overall and by country of origin.
3. Increase information about foreign-born populations in the United States by
   • Conduct contact investigation studies involving foreign-born persons.
   • Modify program management reports to collect separate data for foreign-born persons.
   • Add immigration status to the RVCT.
   • Build local capacity to collect and analyze data on foreign-born persons with TB that can be used to develop local profiles.
4. Improve state and local health department capacity to develop epidemiologic profiles of their foreign-born TB patients.
   • Conduct prospective studies of immigration profiles of foreign-born persons with TB to assist in targeting newly arrived immigrants for targeted testing and treatment of latent TB infection.

*Any reference to future development of the RVCT (such as adding variables to it) is also part of CDC's transition plan to the TB program area module in the new National Electronic Disease Surveillance System (NEDSS-TB).

5. Conduct operational research to develop better methods and procedures for identifying and accessing high-risk border populations.
6. Improve TB case tracking of TB patients who move across the U.S.-Mexico border by adding a binational variable to the RVCT, and by improving TB information exchange between the United States and Mexico.
7. Improve the sensitivity and specificity of the overseas screening algorithm:
   • Conduct studies to evaluate the efficacy of overseas screening.
   • Based on pilot study data, develop new algorithms (such as conducting repeat testing in the United States, conducting all screening in the United States, adding skin test requirements for certain immigration categories, and adding culture to the algorithm).
8. Minimize improper classification.
• Expand and enhance the existing quality assessment program training for panel physicians who evaluate immigrant and refugee applicants outside the United States.
• Update technical instructions and forms for panel physicians.
9. Minimize loss of information from panel physicians.
• Implement a system of overseas data capture and transmission to the United States.
• Improve training of responsible Department of State staff.
• Evaluate all immigrant and refugee arrivals.
• Consolidate all arrival data at one site.
10. Improve health department notification about arrival of immigrants with radiographic evidence of (noninfectious) TB (classification "B1") by developing and implementing a system of electronic TB notification.
11. Minimize delayed or omitted follow-up of class B1 immigrants by conducting intervention studies to improve immigrants' understanding of follow-up in the United States.
12. Improve ongoing assessment of immigrants with radiographic evidence of TB (classes A/B1/B2) and refugees by adding an indicator to program management reports.
13. Improve quality of civil surgeon screening for immigrants, refugees, and asylees by

• Revising technical instruction and medical forms for civil surgeons.

• Collaborating with the Immigration and Naturalization Service (INS) for civil surgeon training.

• Assigning responsibility for civil surgeon designation to the public health arena (state health departments or CDC).
  
  
  
  

14. Improve communication with foreign-born TB patients to improve their compliance with therapy and contact investigation by hiring field staff conversant in major foreign-born community languages.
15. Minimize risk of treatment interruption due to INS custody, deportation, or return to country of origin by
• Working with INS to establish policy to ensure that TB patients in INS custody are managed appropriately and followed to cure.
• Conducting a cohort study to assess TB outcomes.
16. Improve tracking of foreign-born persons across jurisdictions by electronic notification of immigrants with class A/B1/B2 status to health departments.
17. Improve case surveillance along the Mexican border by
• Including TB in the CDC Division of Global Migration and Quarantine Binational Infectious Disease Surveillance project.
• Establishing a binational TB case registry.
18. Ascertain risk of TB in foreign-born children and children of foreign-born parents by

    • Conducting special epidemiologic/risk factor studies among immigrant/refugee children and adoptees arriving in the United States through collaborative epidemiologic research projects.

    • Studying TB in foreign-born children and children of foreign-born parents to determine why TB was not prevented.

Objective I-J
Educate the public and train health care providers to maintain excellence in TB services.

As stated in the IOM report, as TB becomes less common, there will also be fewer individuals with the experience and the correct knowledge to ensure that the right steps are taken and procedures followed to control and eliminate this disease. The IOM report also states, "The most direct solution for decreased experience is increased training."

In an effort to identify and coordinate TB education and training resources, in 1997 the CDC funded a project to develop a strategic plan for TB training and education. To ensure a broad representation of issues and sectors for inclusion in the strategic plan, six work groups were established. These work groups gathered information on specific topics and summarized their findings in position papers that were presented at a 2-day summit held in October 1998, a meeting that brought together experts to forecast TB training needs and efforts for the next 5 years. The recommendations from the summit were used to develop the Strategic Plan for Tuberculosis Training and Education, which was designed to provide guidance to U.S. agencies and organizations that conduct TB training and education for public and private sector providers.

As the result of recommendations highlighted in the Strategic Plan for Tuberculosis Training and Education, DTBE established the TB Education and Training Network (TB ETN) for educators in state, big city, and territorial health departments. The goals of the TB ETN are to Build, strengthen, and maintain collaboration among the key agencies and organizations in TB education and training Provide a mechanism for the sharing of TB education and training resources to avoid duplication of effort Develop, improve, and maintain access to TB training and education resources Provide updated information about TB courses and training initiatives Assist representatives in building education and training skills

Activities

1. The Strategic Plan for Tuberculosis Training and Education, the blueprint that addresses the training and educational needs for TB control, should be fully funded.
2. Develop and fund programs for the education of health care providers and TB patients.
• Further the development of culturally and linguistically appropriate educational materials for persons with or at risk for TB.
• Continue the development of an academic detailing project targeting high-risk providers and patients with latent TB infection.
• Develop partnerships with CBOs to ensure that TB control staff are skilled in working with their communities.
• Continue to support an educators' network for developing and disseminating educational materials, as well as enhancing the skills of these TB educators.
• Collaborate with training partners, such as the NIH, to expand TB education at the academic medical center level (i.e., medical, nursing and allied health professions schools).
3. Provide funding for projects that call for government, academic, and nongovernmental agencies to work in collaboration with international partners to develop training and educational materials.
   • Provide training and educational technical assistance for the national TB programs in high-burden countries.
   • Participate in international advisory groups, including the Collaborative for Training and Education in Russia and the Newly Independent States; the Training Task Force of the Tuberculosis Coalition for Technical Assistance; the Stop TB Partnership Advocacy and Communications Task Force; the International Union Against TB and Lung Disease (IUATLD) TB Education Work Group; and the Partners in Health Peru Project.
   • Utilize the training and education expertise in the United States to build capacity with global partners to systematically identify and address training and education needs in TB control efforts.