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4 Advancing Toward Elimination
Pages 86-121

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From page 86...
... Also, as the risk of infection declines, more cases will be the result of reactivation of infection acquired many years earlier. Increasing efforts at prevention can accelerate the decline in the number of cases of tuberculosis, maintain momentum and interest in tuberculosis control programs, and act as preparation for a final push to elimination.
From page 87...
... · Programs of targeted tuberculin skin testing and treatment of latent infection be increased for high-incidence groups, such as HIV-infected individuals, undocumented immigrants, homeless individuals, and intravenous drug abusers, as determined by local epidemiological circumstances. BACKGROUND AND INTRODUCTION The recent success of tuberculosis control efforts indicates that, given adequate resources, the traditional control program that focuses on the treatment of active tuberculosis is once again functioning effectively and that a steady decline in cases should be expected.
From page 88...
... Finally, by challenging traditional concepts about contact investigations and expanding the definition of close contacts to include social contacts and others previously thought to be at lower risk of infection, many more recently infected individuals who are at an increased risk of developing tuberculosis will be identified. This chapter provides a brief background on the rationale for the treatment of latent infection and addresses these priority areas for the prevention of tuberculosis.
From page 89...
... In contrast, the use of isoniazid has never been challenged for individuals at high risk of tuberculosis, including recent tuberculin skin test converters, contacts of infectious patients, immigrants from countries with high rates of tuberculosis, and individuals with certain medical conditions, especially human immunodeficiency virus (HIV) infection.
From page 90...
... This means that either they must complete an approved course of tuberculosis treatment before entering the United States or that they must start therapy and have three consecutive negative sputum tests before coming to the United States. Individuals who do not complete therapy must have a relative arrange for treatment at the intended destination in the United States, with the concurrence of the local or state tuberculosis control program.
From page 91...
... There has been no evaluation of the rate of referral of immigration forms from ports without a quarantine officer, but it is believed that many of the forms are not collected and that when they are collected they are often held for long periods of time and sent to a port with a quarantine office in batches. When the immigration forms are collected and sent to health departments, the follow-up rate of screening of immigrants for tuberculosis can be quite high.
From page 92...
... Strategies to Ensure Case Identification and Treatment Completion A first step would be to expand the current screening of those applying to immigrate and the screening of refugees. Tuberculin skin testing for latent infection should be added to the current panel of tests used to screen for active tuberculosis (chest radiographs and sputum analysis)
From page 93...
... Individuals born in countries with the greatest burdens of tuberculosis account for 55 percent of the cases of tuberculosis among the foreign-born individuals each year. In particular, even though Mexico is estimated to have only a 17 percent prevalence of tuberculosis infection, Mexican-born individuals account for nearly one-quarter of the foreign-born individuals with tuberculosis each year and just under 10 percent of the total number of individuals with tuberculosis in the United States.
From page 94...
... At a minimum, the failure of an immigrant with a Class B tuberculosis designation to report to the health department for screening could be made grounds for deportation, as is already the case for immigrants with a Class A designation and a waiver to enter the United States. Issues and Concerns The committee carefully considered the issues surrounding tuberculin skin testing and treatment of latent infection for newly arrived immigrants.
From page 95...
... Because of the magnitude of the changes required by this recommendation, the committee suggests that this be implemented in a stepwise approach and that pilot programs be developed to evaluate strategies and assess their costs. The adoption of a mandatory tuberculin skin test screening program may trouble those concerned with the human rights of immigrants and refugees, foreign workers, and students.
From page 96...
... Certainly such organizations will have much to offer local tuberculosis control programs that may be called upon to provide treatment of newly arrived immigrants for latent infections. Nonpermanent Residents Screening of immigrants for latent tuberculosis infection and treatment (if necessary)
From page 97...
... Focusing on those who will be coming to the United States in the future will not address the problem of the estimated 7 million foreignborn individuals with tuberculosis infection already in the United States legally. For them, many of whom are already citizens and the vast proportion of whom may not know of their latent infections, and for all others not screened on entry, programs of culturally sensitive and linguistically appropriate aggressive outreach will be necessary.
From page 99...
... ADVANCING TOWARD ELIMINATION 99 the Eighth Amendment's prohibition against cruel and unusual punishment since it would expose prisoners to a preventable threat to their health (Lareau v. Manson, 651 F
From page 100...
... Additionally, there were the clinical risks associated with isoniazid therapy. "Since the risk of developing tuberculosis is low among immunocompetent young adults, the risk of coercive treatment of latent infection appears to outweigh the benefit." lust 3 years later, a successor New York state prison system health director adopted a policy of compulsory treatment for latent tuberculosis infection.
From page 101...
... Given the long-term strategy of tuberculosis elimination, the relative safety of carefully monitored treatment of latent infection, the risks to prisoners both HIV-infected prisoner and other prisoners of exposure to tuberculosis in overcrowded settings, and policy initiatives that extend the treatment of tuberculosis infection to nonincarcerated populations, the committee concludes that a program of mandatory prophylactic treatment in prisons will serve the interests of both inmate populations and the public health more broadly. EXPANDING CONTACT INVESTIGATIONS AND IMPROVING OUTBREAK MANAGEMENT CDC estimates that an average investigation of each case of tuberculosis in the United States results in the identification of approximately nine close contacts.
From page 102...
... As all cases of tuberculosis began by contact with an individual with tuberculosis, use of a strategy of the early identification and evaluation of contacts and completion of treatment for latent tuberculosis infection would clearly move the country toward tuberculosis elimination. Unfortunately, even in a country as rich with resources as the United States, contact investigations are often less than successful.
From page 103...
... In this situation, contact tracing may then lead to expanded outbreak investigation activities. The problems associated with contact investigations that must be addressed to achieve improvements in the effectiveness of these investigations are grouped into eight specific areas, which are identified and described in the following sections.
From page 104...
... Jurisdictions vary in the person assigned to carry out field investigation tasks. Some require assessment by a nurse, whereas others allow outreach staff to administer skin tests and collect sputum specimens from symptomatic patients.
From page 105...
... . Public health officials face many challenges in contact investigations that require massive screenings.
From page 106...
... In addition, pressure exerted by various organizations or groups to protect their members through case isolation or universal testing may be exerted. Skin testing problems because of false-positive results due to Mycobacterium bovis BCG continue to pose obstacles to the contact investigation process.
From page 107...
... Assuming a 90 percent efficacy of therapy among those who complete treatment, 582 cases of tuberculosis would be prevented if 44 percent of these people completed therapy, while 1,190 cases would be prevented if 90 percent of them completed therapy. Public Health Resources Jurisdictions with a high or medium prevalence of tuberculosis would likely find it most efficient to place the responsibility for contact investigations within their health departments.
From page 108...
... as a routine adjunct to outbreak investigations · Inclusion and discussion of contact information and follow-up during routine case conferences Use of expanded contact investigation teams and models when needed (Kellogg et al., 1987) · Availability of rapid smear tests for diagnosis to avoid the unnecessary expense and anxiety related to initiating unwarranted contact investigations · Connections to and ongoing communication with all reporting sites to encourage reporting of cases and suspected cases in a timely fashion · Connections to and ongoing communication with community-based organizations, neighborhood health centers, and other medical care providers to ensure that high-risk populations have access to appropriate and adequate contact care and federal)
From page 109...
... and the importance of the patient beginning and completing treatment for latent tuberculosis infection. Health departments should also be tracking contacts seen in the private sector for completion of treatment status and should provide assistance as needed, including directly observed therapy for treatment of latent infection.
From page 110...
... and the higher than expected proportion of cases in which transmission occurred from smear-negative individuals, as discussed in Chapter 2. As a result, various tuberculosis control programs use different methods for different aspects of contact investigations.
From page 111...
... This group has developed a list of international referrals to be used to monitor contacts who leave the state or country. Lack of Knowledge About Need for and Importance of Contact Investigations Contact investigation education has three components: provider education (including public health)
From page 112...
... Cultural beliefs that cause fear of stigmatization because of tuberculosis, tuberculosis and HIV coinfection, or other factors may also interfere with the contact investigation process. Patients may be reluctant to divulge contact information if they are worried about the perceptions of others.
From page 113...
... To overcome all of these obstacles, providers need skills in patient assessment, interviewing, counseling, communication, skin testing, and reading and evaluation. Models exist for some of these areas, such as training courses in contact investigation and interviewing skills offered through CDC-funded Model Tuberculosis Centers.
From page 114...
... For example, in a tuberculosis outbreak in a hospital nursery (Nivin et al., 1998) contact investigation difficulties included the fact that inadequate data on tuberculin skin testing of hospital employees were available and many records could not be located at all.
From page 115...
... The role of DNA fingerprinting in contact investigations needs to be further defined. Three recent reports suggest the importance of molecular epidemiology in understanding the application of the current contact investigation framework.
From page 116...
... If research demonstrates that new frameworks for contact investigations such as social networking or location-based screening are effective, health department staff and other providers will require training in their applicability and use. Education on tuberculosis and contact tracing strategies will need to be adapted to the characteristics of distinct population groups.
From page 117...
... Conclusion If tuberculosis elimination efforts are to be successful, prevention activities must be targeted to the groups at highest risk for progression from tuberculosis infection to disease. Contacts of patients with infectious cases of tuberculosis are such a high-risk group, and the tracing of contacts should be priorities for tuberculosis control programs.
From page 118...
... 1998. Outbreak of tuberculosis associated with a floating card game in the rural south: Lessons for tuberculosis contact investigations.
From page 119...
... 1996. Contact investigation of a neighborhood bar patron.
From page 120...
... 1996. Interpreting contact investigation results: The effect of BCG vaccination.
From page 121...
... 1996. Tuberculosis control through contact investigation.


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