Summary. All new TB cases and suspected cases should be reported promptly to the health department by the clinician. Early reporting is essential for the prompt evaluation of persons who have been in contact with the TB patient (contacts). Contact investigations are done by the health department and should start with the close contacts who are most likely to be infected, as well as young children and HIV-infected persons. In addition to case finding, surveillance, and patient care, the health department is responsible for overall planning and policy for TB control efforts within its jurisdiction. This planning includes reviewing appropriate laws and regulations to support TB control activities, building networks and coalitions with community-based organizations, providing expert consultation to local institutions and practitioners, developing an overall TB control strategy, and ensuring adequate staffing and funding in order to carry out TB control objectives. In addition, voluntary organizations such as the American Lung Association and the American Thoracic Society can play a key role in mobilizing community resources for TB control.
The first priority of state and local health department TB programs is identifying and treating all persons who have TB disease. This means finding cases of TB and ensuring that patients complete appropriate therapy.
The second priority is finding and evaluating persons who have been in contact with TB patients to determine whether they have TB infection or disease, and treating them appropriately.
Screening high-risk groups for TB infection to identify candidates for preventive therapy is also an important function of state and local health departments (as well as hospitals, drug treatment facilities, nursing homes, correctional facilities, and other facilities caring for persons at high risk for TB). Such screening programs should always be targeted at specific groups known to be at high risk for TB (see Groups That Should Be Screened).
TB reporting is required by law in every state. All new TB cases and suspected cases should be reported promptly to the health department by the clinician. Cases may also be reported by infection control nurses or by pharmacies when TB drugs are dispensed. In addition, all positive TB smears and cultures should be reported promptly by laboratories.
Early reporting is important for the control of TB, and it gives clinicians access to the resources of the health department for assistance in case management and contact investigation. State and local health departments have different procedures for reporting TB and other infectious diseases. Health care providers should become familiar with the system used in their area.
All drug susceptibility results should be forwarded to the health department. These results are important for the evaluation and treatment of infected contacts. In addition, health departments use this information to determine drug resistance rates in their area.
Although TB care and treatment are often provided by other medical care providers, the health department has the ultimate responsibility for ensuring that TB patients do not transmit infection to others.
Health departments must ensure that medical services are available, accessible, and acceptable for TB patients, suspects, contacts, and others at high risk, without regard to the patient's ability to pay for such services.
As noted earlier, most health departments have public health nurses or community outreach workers who can work with patients and clinicians to help the patients adhere to and complete treatment. Often, health departments can assign a worker with the same cultural and linguistic background as the patient to assist in designing and implementing a treatment plan.
Prompt and thorough contact investigation is essential for the control of TB. Contact investigations should start with the persons who are most likely to be infected--those who most frequently come in contact with the person who has infectious TB. These close contacts are usually family members or other persons who live in the same household. Close contacts may also include friends, coworkers, or persons in a carpool with the patient. Close contacts constitute the inner circle of the TB contact investigation and should receive priority for examination.
High priority should be given to examining contacts who are children or who are HIV infected. Newly infected children are at high risk for miliary TB and possibly meningitis, which can develop within weeks unless the child is given preventive therapy. In HIV-infected persons, TB infection may progress rapidly to TB disease; in some instances, the interval between exposure and the development of disease has been as short as 20 days. Therefore, contacts who are children or who are HIV infected should be given preventive therapy regardless of skin test results.
Contacts should be given a Mantoux tuberculin skin test (5 TU). Contacts with a positive skin test result (5 mm or greater) or signs or symptoms of TB disease should be evaluated carefully to rule out disease before isoniazid preventive therapy is prescribed.
If the skin testing of close contacts reveals that the rate of positive skin test results (the infection level) in this group exceeds that expected for the general population, the investigation should proceed to the next circle of contacts--those who come in contact with the patient, but less frequently than the close contacts. This may include frequent household visitors, close relatives, and friends. The investigation should stop when the rate of skin test positivity in the tested group is no higher than that expected for the general population in the community.
In general, contacts who may pose a greater risk to others (e.g., teachers, hospital nursery workers, other health care workers) or who are at greater risk themselves (e.g., HIV-infected persons) should be tested even though they may not necessarily be close contacts.
TB control programs should periodically review applicable local laws, regulations, and policies that aim to protect the public from TB to ensure that they are consistent with currently recommended medical and public health practices.
TB control programs should form networks and coalitions with community-based organizations that work in communities with a high prevalence of TB to ensure that community leaders, clinicians, and policy makers are knowledgeable about TB; to educate the public about TB; and in some instances, to help provide screening and prevention services.
TB control programs should guide and oversee the TB control efforts of local institutions and practitioners (and local health departments where appropriate) to ensure that these efforts reflect the current standards of care and public health practice.
Health department staff or other experts may provide consultation in monitoring for adverse reactions and adherence to therapy, patient care, DOT, treatment of drug-resistant TB, laboratory methods, infection control practices, contact or outbreak investigations, and available resources.
TB control programs should develop an overall TB control strategy in collaboration with local clinicians, professional societies, and volunteer organizations. Ideally, the plan should be developed by the state or local TB advisory council, in conjunction with community TB coalition representatives.
TB control programs should seek out funding necessary for carrying out TB control activities, and they should educate policymakers about the local TB problem and local program priorities, needs, and objectives. Programs should have adequate and appropriate staff to meet their objectives.
Voluntary organizations, including the state and local affiliates of the American Lung Association and American Thoracic Society, are important components of community TB prevention and control efforts. Lung associations and thoracic societies have historically supported the need for adequate community resources. They and other community-based organizations have assisted in convening medical advisory groups, consulting on the development of state and local TB medical policies, convening local advisory councils for the elimination of TB, conducting TB training courses and providing training materials, and assessing the progress of community prevention and control efforts.