⒈ Bruce Livesay Case Study

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Bruce Livesay Case Study

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Time-framed genotyping surveys and good fieldwork can unravel uncertainties in the epidemiology of TB in problematic populations at high risk , Genotyping surveys and epidemiologic investigations also can be used as a program monitoring tool to determine the adequacy of contact investigations 29,,, and evaluate the success of control measures designed to interrupt transmission of M. Programs that use genotyping for surveillance of all of the jurisdiction's M. Information from both sources is needed for optimum interpretation of the complex epidemiologic patterns of TB in the United States 84, Four fundamental strategies are used to achieve this goal Box 4 17 , , as follows:.

During the TB resurgence, the documented spread of TB, including multidrug-resistant TB, in health-care institutions and in the community ,, stimulated interest in the potential use of BCG to protect HCWs and others from exposure to M. Deficiencies in TB Control. Because TB control is a complex undertaking that involves multiple participants and processes, mistakes often occur, with adverse consequences. Common errors include 1 delays among persons with active TB obtaining health care; 2 delayed detection and diagnosis of active TB; 3 failed or delayed reporting of TB; 4 failure to complete an effective course of treatment for TB; 5 missed opportunities to prevent TB among children; and 6 deficiencies in conducting contact investigations and in recognizing and responding to outbreaks.

Homeless patients with TB symptoms often delay seeking care or experience delays in gaining access to care , and fear of immigration authorities has been associated with patient delay among foreign-born persons Patients who speak languages other than English or who are aged years are more likely than others to delay seeking care Cultural factors that might affect health-seeking behavior by foreign-born persons include misinterpretation or minimization of symptoms, self-care by using over-the-counter or folk medicines, and the social stigma associated with TB In certain societies, women with TB are less likely to take advantage of health-care services, perhaps because of stigma associated with the diagnosis, including a lower likelihood of marriage , Even in areas with open access to public health clinical services, persons at risk for TB might not seek evaluation and treatment because they are not aware that these resources are available for persons with limited financial means , Delayed detection of a case of TB and resulting delays in initiation of treatment can occur if the clinician does not suspect the diagnosis.

A survey conducted in NYC in found that the median delay within the health-care system defined as the time from first contact to initiation of treatment for active TB was 15 days range: days Asians and homeless persons were more likely to encounter delays in receiving a diagnosis than non-Asians and persons with stable housing. Persons without cough who had AFB smear-negative TB or who did not have a chest radiograph at their initial visit also experienced delays.

Regardless of the reason, the consequences of delays in diagnosis and initiation of effective therapy can be serious. In Maine, a shipyard worker aged 32 years who was a TB contact and who was untreated despite having symptoms of active TB, repeated medical visits, and a chest radiograph consistent with active TB did not receive a diagnosis of TB until 8 months after he became ill , and 21 additional cases of TB occurred among his contacts. Of 9, persons who were investigated as contacts, 7. Other instances of delayed or missed diagnoses of TB have been reported that have resulted in extended periods of infectiousness and deaths 22,24, These problems reflect the increasing difficulty in maintaining clinical expertise in the recognition of TB in the face of declining disease incidence Recognition of TB among patients with AFB-negative sputum smear results is a challenge for practitioners and has been associated with delays in reporting and treatment 22,, Failure to promptly report a new TB case delays public health responses e.

Although TB cases in the United States rarely remain unreported, timeliness of reporting varies median: days Failure to receive and complete a standard course of treatment for TB has adverse consequences, including treatment failure, relapse, increased TB transmission, and the emergence of drug-resistant TB At least two reasons exist for failure to complete standard treatment. Patients frequently fail to adhere to the lengthy course of treatment Poor adherence to treatment regimens might result from difficulties with access to the health-care system, cultural factors, homelessness, substance abuse, lack of social support, rapid clearing of symptoms, or forgetfulness 18, Also, as TB has become less common, clinicians might fail to use current treatment regimens These adverse outcomes are preventable by case-management strategies provided by TB-control programs, including use of DOT 13,, The absence of TB infection and disease among children is a key indicator of a community's success in interrupting the transmission of TB The TB resurgence included a reversal of the long-term decline in the incidence of TB among children, which indicated a failure of the public health system to prevent disease transmission Factors that contributed to transmission to children included delayed reporting, delayed initiation of contact investigations, and poor management of adult source-cases.

Deficiencies in contact investigations and failure to recognize and respond to TB outbreaks are among the most important challenges to optimal control of TB in the United States. These topics are discussed in detail in this statement along with the other essential components of TB control. Importance of TB Training and Education. The TB resurgence led ACET to call for a renewed focus on training and education as an integral part of strategies for TB control, prevention, and elimination 1. Factors indicating a need for this focus include the following:. Education of patients by clinicians, TB program staff, and trusted community members promotes acceptance and adherence to authoritative advice about controlling and preventing TB.

Such education can influence patients' decision-making about whether to accept and complete treatment for LTBI Because cultural and health beliefs might act as barriers to effective control of TB 18,19 , an increasing need exists for education targeted at populations at high risk TB-control programs should enlist community-based organizations and other key informants to discover the health beliefs, norms, and values of communities at high risk in their jurisdictions , Professional associations and academic institutions including schools of medicine, public health, and nursing will be valuable partners in developing an understanding of the health perceptions of these populations.

Education materials should be developed with input from the target audience to ensure that they are culturally and linguistically appropriate , In , CDC funded a project to develop a Strategic Plan for Tuberculosis Training and Education the Strategic Plan that provided guidance to agencies and organizations in the United States that offer TB training and education for public- and private-sector providers.

The Strategic Plan specified critical areas requiring attention, including 1 the need for culturally competent programs and materials, 2 effective methods and technologies, 3 collaboration and cooperation among training and education partners outside TB-control programs, and 4 adequate funding for training and education efforts. Substantial progress has been made in developing and disseminating resources for TB training and education. The network is coordinated by CDC and includes educators in local, state, and territorial health agencies. Professional societies and specialty boards are means for reaching private medical providers.

Including TB as a subject in state medical society programs, hospital grand rounds, and medical specialty board examinations would be a valuable resource for providers serving populations at low risk. New linkages should be established to reach providers serving populations at high risk e. The diagnosis of TB, management of patients with the disease, and public health control services rely on accurate laboratory tests. Laboratory services are an essential component of effective TB control, providing key information to clinicians for patient care and public health agencies for control services.

Thus, effective TB control requires a network of public and private laboratories to optimize laboratory testing and the flow of information. Public health laboratorians, as a component of the public health sector with a mandate for TB control, should take a leadership role in developing laboratory networks and in facilitating communication among laboratorians, clinicians, and TB controllers. Public health laboratories should ensure that clinicians and public health agencies within their jurisdictions have ready access to reliable laboratory tests for diagnosis and treatment of TB Specific tasks to ensure the availability, accessibility, and quality of essential laboratory services are 1 assessment of the cost and availability of TB laboratory services and 2 development of strategic plans to implement and maintain a systems approach to TB testing In this process, public health laboratories should assess and monitor the competence of laboratories that perform any testing related to the diagnosis, management, and control of TB within their jurisdictions; develop guidelines for reporting and tracking of laboratory results; and educate laboratory staff members, health-care providers, and public health officials about available laboratory tests, new technologies, and indications for their use.

For example, public health laboratories should lead the discussion on the costs, logistics requirements e. The process of coordinating TB laboratory services is usually best organized at the state level , and the Association of Public Health Laboratories has compiled descriptions of successful organizational models for integrated laboratory services Because the majority of initial TB laboratory work related to diagnosis of TB is conducted in hospitals, clinics, and independent laboratories , clinicians and public health agencies are increasingly dependent on the laboratory sector for the confirmation of reported cases, and public health laboratories are similarly dependent for referral of specimens for confirmatory testing and archiving.

However, as a result of laboratory consolidation at the regional or national level , private laboratories are experiencing more difficulties in fulfilling this function. In certain instances, consolidation has resulted in poor communication among laboratory personnel, clinicians, and public health agencies , Problems also have been identified in specimen transport, test result reporting, and quality control ,, In response, certain states e. The clinical laboratory sector should accept the responsibilities that accompany its emergence as a provider of essential TB testing This statement provides recommendations to guide turnaround times for essential tests, reporting to clinicians and jurisdictional public health agencies, and referral of specimens to public health laboratories or their designees.

Six tests performed in clinical microbiologic laboratories are recommended for optimal TB control services Table 3. These laboratory tests should be available to every clinician involved in TB diagnosis and management and to jurisdictional public health agencies charged with TB control. In addition, other tests that are useful in the diagnosis and management of selected patients and for specific TB control activities include M. Access to these specialized tests should be provided as needed. For suspected cases of pulmonary TB, sputum smears for AFB provide a reliable indication of potential infectiousness; and for AFB smear-positive pulmonary cases, a nucleic acid amplification assay NAA provides rapid confirmation that the infecting mycobacteria are from the M.

These two tests, which should be available with rapid turnaround times from specimen collection, facilitate decisions about initiating treatment for TB or a non-TB pulmonary infection, and, if TB is diagnosed, for reporting the case and establishing priority to the contact investigation. Growth detection and identification of M. Cultures also remain the cornerstone for the diagnosis of TB in smear-negative pulmonary and extrapulmonary cases and, along with sputum smears for AFB, provide the basis for monitoring a patient's response to treatment, for release from isolation, and for diagnosing treatment failure and relapse 5.

The use of liquid media systems, which can provide information in less time than solid media in certain cases, 7 days , should be available in all laboratories that perform culture for mycobacteria. Detailed descriptions of these recommended laboratory tests; recommendations for their correct use; and methods for collecting, handling, and transporting specimens have been published 3, This section delineates organizational and operational responsibilities of the public health sector that are essential to achieve the goals of TB control in the United States.

However, a central premise of this statement is that continuing progress toward elimination of TB in the United States will require the collaborative efforts of a broad range of persons, organizations, and institutions in addition to the public health sector, which has responsibility for the enterprise. For example, clinicians who provide primary health care and other specialized health services to patients at high risk for TB, academic medical centers that educate and train them, hospitals in which they practice, and professional organizations that serve their interests can all make meaningful contributions to improve the detection of TB cases, one of the most important obstacles to continuing progress Box 1.

Similarly, important roles exist for such entities as community-based organizations representing populations at risk for TB and the pharmaceutical industry, which takes academic advances and develops the tools for diagnosis, treatment, and prevention of TB. This section discusses the importance to the TB elimination effort of participants outside the public health sector and proposes specific roles and responsibilities that each could fulfill toward that goal. The sponsoring organizations intend for these proposals to serve as the basis for discussion and consensus building on the important roles and responsibilities of the nonpublic health sector in continuing progress toward the elimination of TB in the United States.

Public Health Sector. The infrastructure for TB control has been discussed extensively in recent years. An analysis of contributing factors to the rise in the number of TB cases during concluded that the resurgence never would have occurred had the public health infrastructure been left in place and supported appropriately The need to maintain the TB-control infrastructure has been expressed repeatedly 1 ,2,13,, Among these four components, structural capacity i.

The responsibility for TB control and prevention in the United States rests with the public health system through federal, state, county, and local public health agencies. Programs conducted by these agencies were critical to the progress that has been made in TB control, and the deterioration of those programs following the loss of categoric federal funding contributed to the resurgence of TB in the United States during 1 ,2,13, Since , as a result of increased funding for TB-control programs, national incidence of TB disease has declined. These funds have been used to rebuild public health--based TB-control systems, and the success achieved highlights the critical role of the public health system in TB control.

TB control in the United States has traditionally been conducted through categoric programs established to address the medical aspects of the disease and the specific interventions required for its successful prevention and management 17 , CDC's Division of TB Elimination, in partnership with other CDC entities that conduct TB-related work, provides guidance and oversight to state and local jurisdictions by conducting nationwide surveillance; developing national policies, priorities, and guidelines; and providing funding, direct assistance, education, and program evaluation.

To meet the priorities of basic TB control Box 4 , state and local public health agencies with responsibility for TB control should provide or ensure the provision of a core group of functions Box 5. Jurisdictional public health agencies should ensure that competent services providing these core elements function adequately within their jurisdictions and are available with minimal barriers to all residents. How the core components of TB control are organized differs among jurisdictions, depending on the local burden of disease, the overall approach to public health services within the jurisdiction, budgetary considerations, the availability of services within and outside the public health sector, and the relationships among potential participants.

Certain jurisdictions provide core program components themselves, whereas other jurisdictions contract with others to provide them. In the majority of cases, the organization includes a mix in which the public health agency provides certain services, contracts for others, and works collaboratively with partners and stakeholders to accomplish the remainder Sharing of direct services, including patient management, increases the importance of the public health sector, which retains responsibility for success of the process. This evolving role of the public health sector in TB control is consistent with the widely accepted concept of the three core functions of public health that IOM proposed in assessment, policy development, and assurance Health Insurance Portability and Accountability Act.

To implement these privacy protections, the U. Department of Health and Human Services has issued a ruling on how health-care providers may use and disclose personally identifiable health information about their patients; these regulations provide the first national standards for requirements regarding the privacy of health information HIPAA also recognizes the legitimate need for public health authorities and others responsible for ensuring the public's health and safety to have access to personal health information to conduct their missions and the importance of public health disease reporting by health-care providers.

HIPAA permits disclosure of personal health information to public health authorities legally authorized to collect and receive the information for specified public health purposes. Such information may be disclosed without written authorization from the patient. Disclosures required by state and local public health or other laws are also permitted. Thus, HIPAA should not be a barrier to the reporting of suspected and verified TB cases by health-care providers, including health-care institutions. Planning and policy development. The blueprint for TB control for a given area is a responsibility of the jurisdictional public health agency. Policies and plans should be based on a thorough understanding of local epidemiologic data and on the capabilities and capacities of clinical and support services for clients, the fiscal resources available for TB control, and ongoing indicators of program performance.

Open collaboration is essential among public health officials and community stakeholders, experts in medical and nonmedical TB management, laboratory directors, and professional organizations, all of whom provide practical perspectives to the content of state and local TB-control policy. Policies and procedures should reflect national and local standards of care and should offer guidance in the management of TB disease and LTBI. A written TB control plan that is updated regularly should be distributed widely to all interested and involved parties. The plan should assign specific roles and responsibilities; define essential pathways of communication between providers, laboratories, and the public health system; and assign sufficient resources, both human and financial, to ensure its implementation, including a responsible case manager for each suspected and verified case of TB.

The plan should include the provision of expert consultation and oversight for TB-related matters to clinicians, institutions, and communities. It should provide special guidance to local laboratories that process TB-related samples, assist local authorities in conducting contact or outbreak investigations and DOT, and provide culturally appropriate information to the community. Systems to minimize or eliminate financial and cultural barriers to TB control should be integral to the plan, and persons with TB and persons at high risk with TB infection should receive culturally appropriate education about TB and clinical services, including treatment, with no consideration for their ability to pay. Finally, the plan should be consistent with current legal statutes related to TB control.

Relevant laws and regulations should be reviewed periodically and updated as necessary to ensure consistency with currently recommended clinical and public health practice e. Collection and analysis of epidemiologic and other data. The development of policies and plans for the control of TB within a jurisdiction requires a detailed understanding of the epidemiology of TB within the jurisdiction. Mandatory and timely case reporting from community sources e. To facilitate the reporting process and data analyses, jurisdictions should modify systems as necessary to accommodate local needs and evolving technologies.

State and local TB-control programs should have the capability to monitor trends in TB disease and LTBI in populations at high risk and to detect new patterns of disease and possible outbreaks. Populations at high risk should be identified and targeted for active surveillance and prevention, including targeted testing and treatment of LTBI 4. Timely and accurate reporting of suspected and confirmed TB cases is essential for public health planning and assessment at all levels.

Analyses of these data should be performed at least annually to determine morbidity, demographic characteristics, and trends so that opportunities for targeted screening for disease or infection can be identified. Regular reviews of clinical data e. Data should be collected and maintained in a secure, computerized data system that contains up-to-date clinical information on persons with suspected and confirmed cases and on other persons at high risk. Each case should be reviewed at least once monthly by the case manager and by field or outreach staff to identify problems that require attention.

The TB-case registry should ensure that laboratory data, including data on sputum culture conversion and drug susceptibility testing of clinical isolates, are promptly reported, if applicable, to the health-care provider so any needed modifications in management can be made. This requires a communications protocol for case managers, providers, and the public health and private laboratory systems that will transmit information in a timely fashion. Aggregate program data should be available to the health-care community and to community groups and organizations with specific interests in public health to support education and advocacy and to facilitate their collaboration in the planning process.

Clinical and diagnostic services for patients with TB and their contacts. TB-control programs should ensure that patients with suspected or confirmed TB have ready access to diagnostic and treatment services that meet national standards 3,5. These services are often provided by state- or city-supported TB specialty clinics and staffed by health department personnel or by contracted service providers; however, persons may seek medical care for TB infection or disease in the private medical sector. Regardless of where a person receives medical care, the primary responsibility for ensuring the quality and completeness of all TB-related services rests with the jurisdictional health agency, and health departments should develop and maintain close working relations with local laboratories, pharmacies, and health-care providers to ensure that standards of care, including those for reporting, are met.

Clinical services provided by the health department, contracted vendors, or private clinicians should be competent, accessible, and acceptable to members of the community served by the jurisdiction. Hours of clinic operation should be convenient, and waiting intervals between referral and appointments should be kept to a minimum. Persons with symptoms of TB should be accommodated immediately i. Staff, including providers, should reflect the cultural and ethnic composition of the community to the extent that this is possible, and competent clinical interpreter services should be available to those patients who do not speak English.

All clinical services, including diagnostic evaluation, medications, clinical monitoring, and transportation, should be available without consideration of the patient's ability to pay and without placing undue stress on the patient that might impair completion of treatment. Clinical facilities should provide diagnostic, monitoring, and screening tests, including radiology services.

Health-care providers, including nurses, clinicians, pharmacists, laboratory staff members, and public health officials, should be educated about the use and interpretation of diagnostic tests for TB infection and disease. Clinics and providers should monitor patients receiving TB medications at least monthly for drug toxicity and for treatment response, according to prevailing standards of care 5.

A case manager, usually a health department employee, should be assigned to each patient suspected or proven to have TB to ensure that adequate education is provided about TB and its management, standard therapy is administered continuously, and identified contacts are evaluated for infection and disease. A treatment plan for persons with TB should be developed immediately on report of the case. This plan should be reviewed periodically by the case manager and the treating clinician and modified as necessary as new data become available The treatment plan should include details about the medical regimen used, how and where treatment is to be administered, monitoring of adherence, drug toxicity, and clinical and bacteriologic responses.

Social and behavioral factors that might interfere with successful completion of treatment also should be addressed. Patient-specific strategies for promoting adherence to treatment should take into account each patient's clinical and social circumstances and needs 5. Such strategies might include the provision of incentives or enablers e. Whether the patient's care is managed by a public health clinic or in the private sector, the initial strategy used should emphasize direct observation of medication ingestion by an HCW. Patient input into this process e. Expert medical consultation in TB should be available to the health-care community, especially for patients who have drug-resistant disease or medical diagnoses that might affect the course or the outcome of treatment.

Consultants may be employees of the health department or clinicians with expertise who are under contract with the health department. Inpatient care should be available to all persons with suspected or proven TB, regardless of the person's ability to pay. Hospitalized patients with suspected proven TB should have access to expert medical and nursing care, essential diagnostic services, medications, and clinical monitoring to ensure that diagnostic and treatment standards are met. Inpatient facilities that manage persons who are at risk for TB should have infection-control policies and procedures in place to minimize the risk for nosocomial spread of infection.

Facilities should report persons with suspected or confirmed TB to the health department and arrange for discharge planning as required by statute. Public health agencies should have legal authority and adequate facilities to ensure that patients with infectious TB are isolated from the community until they are no longer infectious. This authority should include the ability to enforce legal confinement of patients who are unwilling or unable to adhere to medical advice , This authority also should apply to nonadherent patients who no longer are infectious but who are at risk for becoming infectious again or becoming drug resistant. TB-control programs should serve as sources of information and expert consultation to the health-care community regarding airborne infection and appropriate infection-control practice.

A TB program's presence raises overall provider awareness of TB and facilitates timely diagnosis, reporting, and treatment. Collaboration with local health-care facilities to design and assist in periodic staff education and screening is often a health department function. Expertise in airborne infections by TB-control personnel may be shared with biologic terrorism programs to assist in the design and implementation of local protocols. Contact investigation, including education and evaluation of contacts of persons with infectious TB, is a key component of the public health mandate for TB control.

Often the primary responsibility of the case manager, contact investigation should proceed as quickly and as thoroughly as indicated by the characteristics of the specific case and by those of the exposed contact e. This statement includes recommendations on organizing and conducting contact investigations. TB-control programs that are prepared to implement enhanced TB-control strategies should initiate or facilitate implementation by other medical providers of programs for targeted testing and treatment of persons with LTBI on the basis of local epidemiologic data that identify populations at high risk.

Liaison with communities at high risk is critical to the success of TB control in any jurisdiction. TB-control programs should develop strong lines of communication with local community groups and organizations and their health-care providers to understand local priorities and beliefs about TB. Trusted community members can facilitate the design and implementation of strategies to improve TB diagnosis and prevention. Community-based clinical services that use local providers who are educated in TB treatment and prevention and who have a connection with the TB-control program can improve community acceptance of prevention and treatment of TB Training and education. TB-control programs should provide education and training in the clinical and public health aspects of TB to all program staff.

Staff members should receive appropriate education at regular intervals on the basis of their particular responsibilities in the program and should demonstrate proficiency in those areas when tested. Public health TB programs also should educate health-care providers both public and private , community members, public health officials, and policy makers on the basis of local epidemiology and needs. To ensure the availability of a competent workforce for TB that understands and meets the needs of its community, state TB programs should use resources from CDC-funded national TB centers, NIH-supported TB curriculum centers, NTCA, and other national and local agencies to create and implement education activities in coordination with schools of medicine, nursing, pharmacy, dentistry, and public health; community-based organizations and their constituents; local health-care providers; and health-care institutions Information management.

Information-management systems are key factors in medical safety and quality improvement , and should be prioritized by all TB-control programs. Information technology can improve care of patients with TB through standardized collection of data; tracking of test results and details of treatment, including administration of DOT; and prediction of interactions among medications. Information technology can also facilitate analysis and rapid distribution of epidemiologic data and the management of individualized treatment plans 5 and support ongoing program performance analyses.

Barriers to successful implementation of information technology include costs and resistance to change. Monitoring and evaluation. The systematic monitoring and analysis of program activities is a critical factor in enhancing program performance. Evaluation techniques provide TB programs with an evidence-based approach to assess and improve their TB-control strategies by understanding what causes good or bad program performance. Evaluation can also be used for program advocacy, assessing staffing needs, training and capacity building, directing limited resources to the most productive activities, accounting for available resources, generating additional resources, and recognizing achievement Each public health agency should develop its own priorities for program evaluation on the basis of the nature and dimensions of the TB problem in its jurisdiction and the way that services are organized.

In general, the first priority for evaluation efforts should be to focus on those activities and outcomes that relate most directly to the key strategies of TB control: detecting patients with infectious TB and administering a complete course of treatment; finding contacts and other persons at high risk with LTBI and treating them; and interrupting transmission of M. Targets for program performance have been established by CDC to assist public health agencies in treating TB patients, protecting their contacts, and improving the quality of case reporting for national surveillance Table 4.

These national objectives for program performance provide a starting point for state and local TB-control programs to use for program evaluation, but each TB-control program should establish methods to evaluate its performance. TB case management has typically been evaluated by reviewing individual charts and case conferences. Cohort analyses should be a cornerstone of evaluation by all TB-control programs. A guide to cohort analysis and other evaluation tools has been published Other program areas that should be monitored through formal evaluation methods include timeliness and completeness of reporting of TB cases and suspected cases, frequency of use of a recommended treatment regimen for patients with TB and LTBI, and quality of the program's databases for surveillance and case management.

To respond to the need for improved and standardized program evaluation activities, CDC and six state TB-control programs have established an Evaluation Working Group whose goal is to improve the capacity of TB-control programs to routinely conduct self-evaluations and use the findings to improve and enhance their programs. The group is developing indicators for program performance and an inventory of evaluation tools, including data collection instruments, data analysis methods, and evaluation training materials.

During the next 2 years, a draft set of these materials will be tested in three TB-control programs for utility, feasibility, and accuracy. Ultimately, this package of evaluation materials and resources will be made available to all TB-control programs. No single model exists for staffing public health TB-control programs. Approaches to TB control should be flexible and adaptable to local needs and circumstances. Two components of the public health workforce, public health nurses and community outreach workers, merit specific attention. Public health nurses. Public health nurses are registered nurses with a Bachelor of Science degree who are employed or whose services are contracted for by health departments.

Certain states require certification for additional competencies before being hired as a public health nurse. Public health nurses traditionally have played a prominent role in TB control in the United States. Their training, including that in nonmedical aspects of disease, has provided nurses with the special skills needed to manage or coordinate the medical and the social-behavioral concerns associated with the prevention and treatment of TB Their training includes 1 designing contact and source-case investigations; 2 educating patients, contacts, and families; 3 identifying ineffective drug therapy regimens and drug toxicities; 4 recognizing patient behaviors that might lead to poor adherence; and 5 developing strategies to encourage completion of therapy.

As health departments adapt to changing health-care environments, the role of public health nurses working to control TB also is evolving to accommodate the varied mechanisms by which services are delivered. Standards of practice for TB nursing are being updated by the National Tuberculosis Nurse Consultant Coalition, a section of NTCA, to guide jurisdictions in creating and maintaining a specialized nursing resource for TB control and prevention.

Community outreach workers. Community outreach workers are staff members who provide services, such as DOT, to patients outside of the clinic. They may also be classified as disease investigation specialists or community health educators. Because TB has become concentrated in specific populations e. Often members of the communities they serve, outreach workers connect the health-care system with populations at high risk, ensuring that the principles and processes of TB control are communicated to and understood by those populations.

Outreach workers' functions include facilitating treatment for patients and contacts; providing DOT; educating patients, their families, workplace personnel, and communities; and participating in contact investigations. In each case, outreach workers form a bridge between patients and health-care providers to achieve common understandings and acceptance of plans for diagnoses and treatment. Clinicians with specialized expertise, including nurse-case managers, should supervise outreach workers. Clinicians in medical practice in the nonpublic health sector play a vital role in TB control throughout the United States. Hospital- or clinic-based medical practitioners, including those working in emergency departments EDs , are usually the first source of medical care for persons with TB ; they also may provide ongoing management for TB patients The role of medical practitioners in TB control will increase as TB morbidity in the United States decreases and jurisdictions reduce or even eliminate public health clinical services for TB.

Medical practitioners are often not sufficiently knowledgeable about TB , and clinicians in private practice frequently do not follow recommended guidelines and make errors in prescribing anti-TB therapy ,, The failure of public health and private practitioners to interact effectively is a weak link in global TB control Successful models exist for acknowledging and facilitating the work of private medical practitioners in the complex process of diagnosing and treating persons with TB. For example, for each reported TB case in New Mexico, a collaborative case-management strategy is used that includes treating clinicians and pharmacists from the private sector in addition to public health case managers Another model of effective private-public partnerships was employed in NYC during the TB resurgence, with health department case management and DOT for patients under private care As TB elimination efforts continue, the role of medical practitioners will further expand because they provide access to populations that have been targeted for testing and treatment of LTBI.

Greater participation by the nonpublic health sector in preventive intervention has been advocated 2,51 , and clinical standards have been published to guide medical practitioners in managing patients with TB disease and LTBI 8. Civil surgeons are licensed physicians who are certified by the U. In , approximately , foreign-born persons applied for permanent residency and were screened by civil surgeons, compared with , such persons in CDC has responsibility for providing guidance on screening and treatment but has no regulatory role in monitoring the quality or outcomes of these examinations.

Because of their access to foreign-born persons at high risk, civil surgeons are a critical component of TB control. Although civil surgeons receive immigration-focused training, little information is available on the knowledge, attitudes, and practices of civil surgeons. A recent survey indicated that among physicians serving as civil surgeons in California, Massachusetts, and New York, the majority were graduates of U. As a result of these findings, efforts are under way to develop guidance documents and training materials for physicians who screen immigrants for TB infection and disease. Community health centers typically provide primary health-care services to populations that encounter barriers to receiving those services at other sites in the health-care system, such as low-income working persons and their families, immigrants and refugees, uninsured persons, homeless persons, the frail elderly, and poor women and children.

Patients at high risk for TB often receive primary and emergency health care in community health centers For example, community health centers in certain inner-city areas might serve primarily a clientele of homeless persons, whereas centers in neighborhoods in which certain racial and ethnic populations are concentrated might become predominant health-care providers for immigrants and refugees. Newly arriving refugee families are frequently directed to community health centers to receive federally supported health-screening services, which might include targeted testing and treatment for LTBI. Persons with symptoms of TB might go first for evaluation and care to a community health center.

For these reasons, community health centers are a critical part of efforts to control and prevent TB. Hospitals provide multiple services that are instrumental to the diagnosis, treatment, and control of TB. Hospitals with active outpatient and EDs often serve as sites of acute and primary medical care for homeless persons, inner-city residents, immigrants and refugees, and other persons at high risk for TB.

Also, hospital staff members often provide medical consultation services for the diagnosis and management of TB by public health and community clinicians. Laboratory services provided by hospitals for community-based medical care providers might include key diagnostic tests for TB. TB cases often are detected during hospitalization at acute-care hospitals , Hospital-based health professionals evaluate patients for TB, establish the diagnosis, and initiate treatment regimens and reporting of cases to public health departments. Instances of delayed recognition, diagnosis, and treatment for TB among hospitalized patients subsequently found to have TB have been reported 24, , indicating a need for more effective training and education of hospital medical staff members.

Venues such as staff conferences and medical grand rounds, conducted regularly by hospitals, can be sources of training and education on clinical, laboratory, and public health concerns that arise during evaluation and initial medical management of hospitalized patients with TB. Hospitals should protect their patients, staff, and visitors from exposure to M. The importance of effective TB infection control was emphasized during the TB resurgence in the United States, when hospitals were identified as sites of transmission of multidrug-resistant TB Implementation of effective infection-control guidelines has been effective in reducing transmission of TB in hospitals 56,, Academic institutions including schools of medicine, public health, and nursing have an opportunity to contribute to TB control in the United States and worldwide.

Students from diverse disciplines, including the clinical and laboratory sciences, nursing, epidemiology, and health services should be introduced to applicable concepts of public health in general and, because TB is a major cause of preventable illness and death in developing countries 44 , to TB in particular. Federal funding for programs e. Researchers at academic institutions are critical to efforts to improve the prevention, management, and control of TB because of their efforts to develop new tools, including new diagnostic tests, new drugs, better means of identifying and treating LTBI, and basic research to create a vaccine for TB ,, As with hospitals, academic institutions can provide benefits to other participants in TB control.

Conferences, grand rounds, and other presentations are a source of continuing education for private medical practitioners and other community-based HCWs. As well-trained specialists, researchers at academic institutions can provide clinical, radiographic, and epidemiologic consultation to medical practitioners and public health agencies. A majority of academic institutions manage university-based hospitals, which often serve populations at high risk. University hospitals can become models for TB risk assessment of patients, inpatient care, and infection-control practice, and they can serve as tertiary care sites for an entire community or region. Partnerships between academic institutions and public health agencies are mutually beneficial In certain cases, health departments and public health TB clinics are staffed or managed by faculty physicians from academic institutions.

This partnership facilitates use of these clinics for graduate medical training for physicians in subspecialty areas e. Because they are involved with medical practice, research, education, advocacy, and public health, medical professional organizations are critical partners in TB control efforts. Greater participation of the nonpublic health medical sector is needed to maintain clinical expertise in the diagnosis and management of TB in an era of declining incidence.

Organizations whose memberships include primary care medical practitioners can make significant contributions to the control, prevention, and elimination of TB by including TB in their training and education agendas. With a membership of approximately 14, health professionals, including clinicians trained in pulmonary diseases, ATS conducts research, education, patient care, and advocacy to prevent respiratory diseases worldwide. IDSA promotes and recognizes excellence in patient care, education, research, public health, and the prevention of infectious diseases.

In recent years, IDSA has joined ATS in focusing education and advocacy activities on TB through its annual meetings, publications, and sponsorship of this series of statements. Other medical professional organizations also can support TB control efforts. Medical professional organizations can 1 provide TB education to their members through meetings, symposia, statements, and web sites; 2 serve as venues for better communication between the private medical and public health sectors; 3 promote the TB research agenda locally and nationally; and 4 advocate for resources for strong TB control globally and in the United States. Involvement of community groups in TB control has long been encouraged The critical importance of such involvement is underscored by the trend in the United States for TB to be limited to certain populations at high risk e.

Programs for education and targeted testing and treatment of LTBI should be organized for these populations. The public health sector frequently experiences difficulty in gaining access to persons in populations of high risk Such persons might be socially marginalized, as in the case of new refugees, or they might be suspicious of persons representing government agencies, as in the case of undocumented aliens. Furthermore, the target population's own view of its health-care priorities, often best articulated by community-based organizations that represent them, should be considered in the design of public health interventions Social, political, religious, and health-related organizations that have arisen from grassroots efforts to meet community needs often can facilitate access to public health programs Community-based organizations can be particularly effective in providing information and education on TB to their constituencies.

As part of the communities they serve, such organizations are often highly regarded in their communities, and their messages might be accepted more positively than those delivered by the jurisdictional health department. Correctional facilities are common sites of TB transmission and propagation , TB is believed to be the leading cause of death for prisoners worldwide Targeted testing for and treatment of LTBI in correctional facilities have been demonstrated to have a substantial public health impact Testing and treatment for LTBI is carried out more easily in prisons because the length of stay is generally sufficient to permit completion of a course of treatment.

Jails have proved convenient sites for targeted testing, but subsequent treatment of LTBI has proved challenging Innovative methods for assuring completion of treatment for LTBI in jail detainees have been proposed Because of their communal living arrangements, correctional facilities, like health-care facilities, have the responsibility to limit the transmission of TB within the institution and to protect their inhabitants and staff from exposure. This is a particular challenge in jails because of the short lengths of stay for the majority of detainees. Even in prison systems, abrupt and unexpected transfers of detainees among institutions might occur, with little consideration for health issues.

Prisons and jails frequently house HIV-infected persons in separate facilities to ensure adequate health care. However, recent publications describing outbreaks of TB in such settings have emphasized the hazard of this strategy 35 , Because of their essential role in developing new diagnostics, drugs, and vaccines, the pharmaceutical and biotechnology industries are partners in TB control. Although development of new tools for diagnosis, treatment, and prevention of TB has been deemed essential to the effort to combat the disease globally and to continue to make progress toward its elimination in the United States and other developed countries 1 ,2,45, , progress in these fields has been slow.

Slow progress in this field has been attributed to private industry's perception that such products are not needed in developed countries and do not offer profit opportunities in resource-poor countries , These organizations have provided venues to identify and address obstacles to developing new tools for TB among private industry, public and academic researchers, and philanthropic organizations. These organizations also receive support from the private sector. The pharmaceutical industry has also contributed to the global TB control effort by assisting in making drugs for TB, including second-line drugs for patients with multidrug-resistant TB, more affordable , Such actions can enable pharmaceutical companies to become leaders in efforts to improve TB control and prevention.

Case detection and case management include the range of activities that begin when a diagnosis of TB is first suspected and end with the completion of a course of treatment for the illness. TB case management describes the activities undertaken by the jurisdictional public health agency and its partners to ensure successful completion of TB treatment and cure of the patient. The rationale and methodology of TB case management have been described previously 5. Organizational aspects of case management from the viewpoint of the jurisdictional public health agency are also discussed in this statement.

Case detection includes the processes that lead to the presentation, evaluation, receipt of diagnosis, and reporting of persons with active TB. Case detection involves patients with active TB who seek medical care for symptoms associated with TB, their access to health care, their health-care providers, the consultants and clinical laboratories used by those health-care providers, and the responsible public health agency. Although steadily increasing treatment completion rates 14 indicate that progress has been made in the management of TB patients, TB case detection is still problematic. Delays in diagnosis and report of TB cases continue to be common. The majority of pulmonary TB cases continue to be diagnosed at an advanced stage.

Earlier diagnosis would result in less individual morbidity and death, greater success in treatment, less transmission to contacts, and fewer outbreaks of TB. The first step in improving TB case detection is to remove barriers in access to medical services that are often encountered by persons in high-risk categories. Such barriers might be patient-related, such as cultural stigmas associated with the diagnosis of TB, which might lead foreign-born persons to deny or hide symptoms , , or fear of being reported to immigration authorities if medical care is accessed Foreign-born persons, particularly recently arrived immigrants, refugees, and other persons of low SES might not have access to primary health services because they do not have health insurance or they are not familiar with the U.

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