Progressing Toward Tuberculosis Elimination in
Low-Incidence Areas of the United States
Recommendations of the Advisory Council for the Elimination of Tuberculosis
Please note:
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text of this report has been corrected and does not correspond to the
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Prepared by
John A. Jereb, M.D.
Division of Tuberculosis Elimination
National Center for HIV, STD, and TB Prevention
The material in this report was prepared by the National Center for HIV, STD,
and TB Prevention, Harold W. Jaffe, M.D., Acting Director; Kenneth G. Castro,
M.D., Director, Division of Tuberculosis Elimination.
Summary
In 2000, 22 states had tuberculosis (TB) incidence rates less than or equal to the Advisory Council for the Elimination of
Tuberculosis (ACET) year-2000 interim objective of 3.5 cases/100,000 population, which is defined as low incidence. These states reported
1,949 TB cases, 11.9% of the national total of 16,377 cases in 2000. Health departments in low-incidence states, and in
low-incidence regions within states with higher rates, need distinctive strategies, based on their specific epidemiologic characteristics, for
maintaining skills and resources for finding increasingly rare TB cases, containing outbreaks, and ending transmission. Capacity for all the
essential components of a TB prevention and control program must be retained at local, state, and national levels; failure to do so increases
the risk of a new TB resurgence. In low-incidence areas, especially important are an adequate public health infrastructure and
creative integration of resources, some of which until now have not played a role in TB control. Operational research is needed for
determining the most efficient control measures. Eventually, with continued success in eliminating TB, low incidence will be attainable in all
states, and the nation will profit from the lessons learned in the current low-incidence states.
Introduction
Following a period of resurgence of tuberculosis (TB) that began in the mid-1980s and peaked in 1992, the United
States reestablished control over the disease. Before that epidemic, the public health infrastructure* and resources for TB control
had declined below the level needed to respond to an emergent threat
(1). Once the epidemic and its causes were
recognized, infrastructure and resources were restored in the early 1990s by a large infusion of resources at local, state, and national
levels (2). From 1992 through 2000, the incidence of TB decreased by 45%, reflecting the impact of renewed capability
to implement the essential elements of TB control. In 2000, the eighth consecutive year of decline, the TB incidence rate was
5.8 cases/100,000 population, the lowest ever recorded in this country.
The success in reversing the recent epidemic has refocused attention on eliminating TB in the United States. In 1999,
the Advisory Council for Elimination of Tuberculosis (ACET) called for a renewed commitment to its strategic plan
(3), which was published originally in 1989
(4). In 2000, the Institute of Medicine (IOM), in an independent review
(5), proposed a comprehensive action plan for TB elimination in the United States.
The recent epidemiologic trend noted above indicates that TB control is now entering a new phase in the United States,
a transition from low incidence to
elimination.† For example, in 2000, 22 (44%) states reported incidence rates
<3.5/100,000, which was the year-2000 interim objective set by ACET in the 1989 strategic plan
(4). These states are regarded as areas with
a low TB incidence rate, on target in the drive toward elimination. Furthermore, the fraction of U.S. counties reporting no
TB cases has increased steadily during the past several decades. In 2000, 1,606 (51%) counties reported no cases. Yet 712 (44%)
of these counties had reported one or more cases in the preceding 5 years, which underscores another public health challenge
in these settings, i.e., how to maintain sufficient resources to stay prepared for sporadic cases when TB becomes rare. Even
after elimination is achieved, a plan will be required for finding and treating sporadic cases, investigating transmission to
contacts, and preventing TB in those who are infected.
Distinctive challenges to TB control have arisen in regions where cases occur infrequently. Among documented obstacles is
the diversion of public health resources to other purposes, which predicts a "cycle of
neglect"(5,6). Tuberculosis outbreaks
have occurred in such areas and have produced severe and long-term effects (see Outbreaks). Low-incidence states or
local jurisdictions with minimal TB control programs sometimes are unprepared to detect and contain these outbreaks.
Likewise, shifting migration patterns are rapidly altering the TB epidemiology in communities and states that previously had not
had large immigrant populations who are at risk for TB (Box 1). In this scenario, existing TB control programs that are
equipped only for infrequent cases are confronted with an abrupt increase of cases and unfamiliar cultural issues. In addition, because
of the rarity of TB, some health-care providers in these settings lack either proficiency in TB diagnosis or familiarity with
the latest treatment guidelines.
During the era of resurgent TB, national attention and resources had to be focused on bringing the disease under control
in areas with the highest incidence rates, but states and communities in which TB incidence remained low did not receive
such large increases in resources. Further, few of the recommendations developed during the past decade to guide the national
effort to control TB have addressed the perspective of low-incidence settings.
ACET believes that continued progress toward TB elimination requires a strategy for TB control in low-incidence
settings. Although the 22 states that have achieved low-incidence status need a strategy now, all areas eventually will enter a phase of
low incidence if their programs have continued success. This ACET statement examines the challenges to TB control in
current low-incidence areas and offers recommendations for meeting those challenges. The purpose of this statement is to
inform federal, state, and local public health officials, health-policy makers, and the general health-care community about the
unique challenges of TB control and about the roles each can play to ensure progress toward elimination in those areas where
the disease is becoming increasingly uncommon. In these places, where TB has become a "rare" disease, the opportunity exists
to take decisive steps to eliminate it and to make pioneering contributions to TB elimination nationwide by inventing and
testing novel strategies.
Tuberculosis Profiles of Low-Incidence States
Epidemiologic Profiles
Strategies for state and local TB control must take their direction from detailed epidemiologic analysis. The results are
distinct for each of the low-incidence states. Although the low-incidence states all had an incidence rate of
<3.5 cases per 100,000 population in 2000, they reported a wide range in numbers of cases, from 4 (Vermont and Wyoming) to 383
(Pennsylvania), because their denominator populations vary widely. For making general comparisons with the rest of the United States, in
this report the 22 low-incidence states are grouped into two categories by the numbers of TB cases reported in 2000: low
caseload (<50 cases) and intermediate caseload (>50 cases) (Table 1). Expenditures for some routine TB-control items or activities,
such as chest radiographs, medicines, and outreach services, are based on per-case costs and are therefore dependent on caseloads.
In 2000, the 22 low-incidence states, encompassing 27.2% of the U.S. population, reported 1,949 TB cases, 11.9% of
the national total of 16,377 cases. The 13 low-incidence states with low caseloads reported from 4 to 49 cases each and a total
of 304 cases. The nine low-incidence states with intermediate caseloads reported from 77 to 383 cases each and a total of
1,645 cases.
The relative incidence-rate trends, 1993 through 2000, were estimated by aggregating the states into the two
low-incidence categories described above and comparing them with the remainder of the United States. The aggregated incidence
rate declined most quickly for higher-incidence states, at an average of 7.4% annually, and more slowly in the two groups of
low-incidence states, at an average of 5.8% annually in the intermediate-caseload states and at an average of 4.6% annually in
the low-caseload states. Within each category, the trends varied by state, and the TB incidence rate fluctuated considerably in
states with the lowest counts.
A descriptive comparison of TB cases among the two groups of low-incidence states and the remainder of the United States
can supplement the basic incidence data (Table 2). For example, TB patients in both groups of low-incidence states were
more often >65 years of age and more likely to be non-Hispanic white. The low-caseload, low-incidence states had the
highest percentage of American Indian/Alaska Native patients. The intermediate-caseload states had the lowest percentage of
cases among foreign-born persons. A smaller percentage of patients in the low-caseload states were incarcerated at the time
of diagnosis.
Reported results of human immunodeficiency virus (HIV) testing for TB patients provide a minimum estimate of the
degree of overlap between TB and HIV infection and of the implementation of HIV counseling and testing, which is
recommended for all TB patients. The fraction of TB patients aged 25 to 44 years (i.e., the age group accounting for the majority of
acquired immunodeficiency syndrome [AIDS] cases) with HIV coinfection was lowest in the low-caseload states, at 9.9%.
However, these states had a higher frequency of "test refusal" and "test not offered," which occurred in 24.2% of cases in the 25- to
44-year age group, possibly indicating difficulties in implementing HIV counseling and testing. Examples of such difficulties
are insufficient HIV awareness among health-care providers and patients or a need for increased HIV counseling and
testing services readily available to those patients who receive TB care outside of health departments.
Outbreaks
In recent years, several TB outbreaks have been reported from low-incidence states. Outbreaks pose immediate threats to
the health of communities, and in the long term, they expand the reservoir of latent TB infection. To control TB outbreaks,
health
departments must redirect resources that are already scarce, especially when TB programs are operating at full capacity.
The results of the following investigations in four areas with low TB incidence illustrate various outbreak situations and the
impact that each has caused:
Maine
During 1989-1992, a total of 21 cases in a small Maine community and its local shipyard were traced back to a source case
of pulmonary TB that was diagnosed after an 8-month delay
(7). During the entire previous decade, this community
had documented fewer than 10 cases. The contagious source-patient infected nearly 700 local residents and coworkers.
However, fewer than 350 of the infected contacts completed treatment for latent TB infection. Prompt discovery and management of
the index case could have limited transmission, and the number of secondary cases could have been reduced if more contacts
had received complete courses of treatment for latent TB infection.
North Dakota
During 1998, in a contact investigation of a 9-year-old child with cavitary pulmonary TB, approximately 50 children in
a small North Dakota town were found to be infected
(8). The first clue to discovering the source case was the diagnosis
of extrapulmonary TB in the child's adult guardian. In the previous 6 years, only one TB case in a patient <15 years had
been reported from all of North Dakota. The child had immigrated to North Dakota from the Republic of the Marshall Islands
in 1996, and although latent TB infection was detected then, it was not treated.
Indiana
From 1996 to 1998, a town in Indiana experienced a fivefold increase in TB cases
(9). DNA fingerprinting (by restriction fragment length polymorphism analysis) and a novel social-networking approach for investigating the outbreak linked
together 23 outbreak-related cases. The connection between the cases probably would not have been discovered by routine
interviews because the patients knew each other only through drug use and other illicit activities, and transmission probably
was occurring during secretive gatherings outside their homes. At least 15 of the cases might have been prevented by
comprehensive contact investigations followed by complete treatment of the infected contacts.
Kansas
From 1994 to 2000, epidemiology plus DNA fingerprinting linked 18 TB cases in Wichita, Kansas
(10). The common social thread connecting the patients was occupation as dancers in adult-entertainment clubs (i.e., "exotic dancers") or
association with exotic dancers. No single site for TB transmission was found, but
illicit-drug--using activities and incarceration
were possible risk factors. Of the 344 contacts who could be reached during the investigations, 302 were evaluated at least in
part for TB, and of these, 76 (25%) had latent TB infection. These were in addition to the 18 patients who had active TB.
Social barriers related to drug use and incarceration interfered with the contact investigations and probably contributed to the
long duration of the outbreak. Only three fourths of contacts who should have been treated actually started therapy, and the rate
of completing therapy was only 11%.
These four outbreaks were not isolated incidents, and similar TB outbreaks continue to occur throughout the United
States, some in low-incidence states (11). Such outbreaks highlight the need for maintaining response capacity
--- public
health infrastructure for TB control and resources to take action --- in all regions. Unanticipated TB cases can arrive with
newcomers to a region, or cases can arise sporadically from latent TB infection even in a population that has a low incidence rate.
The outbreaks described here also point to the problems of delayed case detection, incomplete contact tracing and treatment,
and the need for innovative methods for discovering and containing outbreaks early and for finding and treating latent
TB infection in at-risk persons before cases develop.
Program Profiles§
Each low-incidence state has a designated TB control officer, or a program manager who has most of the duties and
authority of a control officer. Each low-incidence state TB program has a medical consultant either on staff in the health department
or under contract. Sixteen state programs employ at least one TB nurse consultant with responsibilities for case management
and program oversight; in three of these programs the nurse consultant serves as the TB controller. The median number of
full-time personnel who are employed categorically in the state health department for TB control work is three workers per state
(range: 1--9). In each low-incidence state, the state program personnel work with both private providers and local public
health practitioners in the management of some or all cases.
In 15 of the 22 low-incidence states, a state advisory council for the elimination of TB provides guidance and advocacy for
the programs. Affiliates of the American Lung Association (ALA) are located in 18 of the states, and in 10 of these, the
ALA affiliate works directly with the state or local health departments in supporting TB control.
The administrative structure for TB control varies among low-incidence states. In some, the authority for TB control is
vested entirely in localities (e.g., counties or townships), and the TB program in the state health department serves a supportive
role. This structure is characteristic of intermediate-caseload states. Maintaining local TB expertise in this framework is
challenging because the health departments in some localities report and manage fewer than one case per year. Therefore, the state
TB program must be vigilant for lapses in program activities and for undetected problems, such as protracted TB outbreaks.
In other states, authority is shared between the localities and the state health department. In these states, the localities
are combined into several regions, which enables the state to assign regional TB consultants for efficient oversight and
assistance. This structure has intrinsic advantages for providing education updates to local personnel and thereby maintaining
expertise. In one state, Maine, all responsibility is vested in the state program because the localities do not have health departments,
and officials from the state health department work directly with health-care providers for planning case management.
Unique Challenges to Good Tuberculosis Control in Low-Incidence States
The decrease in TB incidence to historic low levels creates challenges for public health officials who are working to
sustain programs and systems, especially when low incidence fails to indicate the full efforts required for comprehensive TB
control (Box 2). Responding to low case burdens by prematurely scaling down TB programs will re-create the conditions that
make another epidemic TB resurgence likely
(5). Ongoing investments are needed to retain personnel who have expertise
in programmatic methods of prevention and control. Although TB control programs in all states share these challenges,
especially that of sustainability, challenges in particular are amplified by circumstances in low-incidence states.
Loss of Expertise
When TB was more common, primary health-care providers diagnosed and treated it routinely. Now, because of decreasing
TB case rates, fewer primary health-care providers or even specialists have diagnosed or treated TB
(11,12). The current cadre of medical consultants familiar with treating persons with complex and drug-resistant TB will be retiring soon, and there are
no systematic plans to replace them. In addition, the complexities of treating HIV-infected patients with TB require
oversight from providers trained in both TB and HIV.
Scarcity of Special Facilities for Prolonged Health Care
A few TB patients require prolonged, low-intensity inpatient care or long-term involuntary detention
(13,14). When TB sanitoria were closed, affordable inpatient bed spaces for these patients were lost
(15). The expense of a long-term stay in a general hospital for just one patient who does not have third-party funds
(16) can exceed the entire annual budget of a
low-incidence state TB program. Long-term--care facilities generally do not have the experience and engineering features
required for TB infection control. Security arrangements for involuntary detention are expensive and sometimes difficult to
arrange, and incarceration solves little and raises concerns about human rights
(14,17). Although large TB programs have
developed flexible systems for providing long-term care to
special-needs patients (17), smaller programs encounter such patients
only occasionally and cannot afford comprehensive systems.
Laboratory Costs and Decreased Proficiency
The existence of a state TB laboratory ensures the availability of prompt, flexible, and reliable laboratory services that
are essential to TB surveillance and case management. However, justifying a TB laboratory is challenging when fewer
specimens are submitted for testing. Additionally, proficiency in laboratory skills (e.g., smears, culture, and species identification) is at
risk of declining because of fewer specimens being submitted for evaluation and fewer positive culture results
requiring mycobacterial identification and susceptibility testing
(5, 18). Maintaining a laboratory equipped for a safe
working environment is an expensive obligation that remains unchanged even if specimen quantities are decreasing.
Travel in Rural Areas
Some low-caseload, low-incidence states, particularly those of the Great Plains and the Rocky Mountains, require
creative solutions for overcoming the long distances that separate health-care providers from their patients and interfere
with comprehensive directly observed therapy. Although it is
essential that state TB control personnel in these states visit
local jurisdictions to furnish critical on-site technical
assistance, the time and expense of travel might stretch the program
resources beyond current capacity.
Loss of Funds and Personnel Dedicated to Tuberculosis Control
Because they need to reduce costs, some public health administrators might combine specific communicable
disease programs --- TB, HIV, vaccine-preventable diseases, and sexually transmitted diseases
--- at the state level, recognizing that
these diseases share some general characteristics. However, the state programs necessary for controlling each of these
communicable diseases are fundamentally different, with important variations in the underlying epidemiology and interventions for
the diseases. Combining these programs may inadvertently decrease the resources and expertise for TB control. In one state
where these programs have been combined, funds and personnel have been diverted away from TB control to other programs
(19). If programs are to be integrated at the state level, core capacity for TB control must be maintained; this includes the ability
to shift resources in response to increased needs. In contrast to the situation at the state level, cross-training of personnel at
the local level is necessary for providing sufficient public health services to communities served by small health departments.
Recommendations for Tuberculosis Programs in Low-Incidence Areas
ACET makes the following recommendations for sustainable TB control programs and strategies in low-incidence states
or regions. Although these recommendations are applicable to any state, they are designed specifically to address the
special challenges encountered by programs in low-incidence
areas. Therefore, ACET stresses innovation for meeting these
challenges, with the understanding that the best solutions will be unique to each state and locality. As observed by the IOM
Committee on the Elimination of Tuberculosis, the implementation of some recommendations will not be feasible without
additional resources (5).
Work Creatively To Ensure the Essential Components of Tuberculosis Control
CDC has recommended six essential components for TB prevention and control
(20). Sufficient capability in each
component is necessary for progress toward TB elimination.
Every state health department needs the basic framework for a TB
control program that includes all six components, and a designated program director. Following are suggestions for
low-incidence states that can help them meet the challenges of implementing all components of a TB control program. These suggestions
are made with an understanding that
higher-incidence programs will later be addressing the same challenges.
Planning and Developing Policy
The foundation of a state TB control program is its legal mandate to carry out necessary specific activities (e.g.,
surveillance, treatment, investigations, isolation of contagious patients). However, some states have outdated legal codes for
communicable diseases, which can hamper the program
(21). In low-incidence states, where the health department might not have
personnel with the expertise to draft the elements required in updated legislation, updated legislation from neighboring states can serve
as templates, and local chapters of ALA can provide technical assistance and legal advocacy.
A state TB control policy manual should be drafted in consultation with an advisory council of TB experts and should
be updated at least every 2 years. Although programs in low-incidence states can assist each other by sharing manuals for use
as templates, each program can anticipate a need for state-specific policies and procedures because of differences in
epidemiology, state administrative structure, and resources. Policies in the manual should cover the following topics: administration of
the program; training; reporting practices and surveillance; program evaluation; laboratory testing for mycobacteria; case
finding, holding, and management; treatment of persons with TB disease and latent TB infection; contact investigations;
targeted testing for latent TB infection; and standard responses to foreseeable adverse situations (e.g.,
uncooperative patients, outbreaks, and
multidrug-resistant TB).
Each state should also have a TB elimination plan designed for local circumstances. In low-incidence states, the plan
should emphasize the more challenging elements: maintaining a state TB program with sufficient resources to address the
essential components, finding and containing outbreaks in regions lacking personnel with TB expertise, and responding to an influx
of persons with increased TB risk, such as immigrants from high-prevalence countries. The elimination plan should
include strategies for addressing specific epidemiologic features of TB in the state, including the needs of specific groups at risk for
TB. For example, in some western states, where one third or more of the TB patients are American Indian, TB control
services require an approach adapted to cultural and
jurisdictional distinctions, ideally, one that has been developed in collaboration
with tribal health authorities (11) (Box 3).
Finding and Managing Suspected and Confirmed Tuberculosis Cases
A state TB program, through its consultants, can provide the medical expertise that might be lacking in private and
public health-care facilities in low-incidence states. However, this can only be done when suspected cases are found and a referral
is made to the state public health department. General awareness of TB as a potential cause of cough-illness is difficult to
sustain
if the disease occurs rarely. Delayed case detection at the local level is a potential factor contributing to TB transmission
(see Outbreaks). In addressing this difficult challenge, the state program should maintain a listing of local persons
knowledgeable about TB in its policy manual. The list should not be regarded as static but should be updated annually because of
provider turnover.
Training should be targeted to expand the diagnostic knowledge of primary care providers, and it should be focused on
the localities with gaps in expertise. Many state health departments offer conferences and outreach initiatives to inform
local health-care providers about public health issues, and the TB program can take advantage of these events for delivering
and updating messages in the context of continuing
education.
Tuberculosis case managers face particular challenges when patients are under the care of private medical providers who
are unfamiliar with the potential contributions and the overall role of the health department. If private providers are
informed about the TB program through state-sponsored outreach and training programs, they will have a better understanding of
the current practices and the services offered by the health department even before they encounter suspected cases. One option
is to engage private providers in a case management team (Box 3). A management team allows the TB program to monitor
the progress of the patient, train the provider, and promote the services of the program by building rapport between public
and private sectors. Private providers who otherwise would reject directly observed therapy for their patients might reconsider
this option after learning about the services offered by the health department.
Prevention: Finding and Managing Latent Tuberculosis Infection
Tuberculosis controllers in low-incidence states have encountered crucial challenges in the transition from managing cases
to preventing cases. Expertise for contact investigations is lacking in some local areas, which contributes to incomplete
contact tracing and treatment and, eventually, to the occurrence of TB outbreaks
(7,11). Tuberculin skin testing skills, even in
health departments, have been lost. Local health departments do not have the staff required for monitoring completion of
therapy. Private medical providers might be reluctant to treat latent TB infection because of uncertainty about the
recommendations and concerns about adverse effects of treatment. Finally, for targeted testing projects, the populations involved can be
widely dispersed, which makes the projects less feasible.
Experience in responding to TB outbreaks has shown that innovative methods for contact investigation can be designed to
fit unusual situations by forming partnerships, for example, among local communities, local health-care providers,
academic medical centers, local and state health departments, and national public health agencies
(9--11). Flexible methods and the creative use of nontraditional, supplemental resources are required to maintain response capability. Even before
outbreaks occur, policymakers must be made aware of gaps in the resources and infrastructure required for response capability.
Targeted-testing activities for finding latent TB infection can be inefficient and expensive if low-risk persons are
included because large numbers must be tested and treated to prevent each TB case. Therefore, TB programs in low-incidence
states should restrict targeted-testing activities to well-delineated projects (Box 4), ones that have potential for efficiency, and
ones that have feasible implementation and evaluation components. General factors that improve efficiency are access to the
target population, a high prevalence rate of latent TB infection, a high risk of progression to disease in infected persons, and
methods to ensure completion of therapy. Targeted-testing projects must be evaluated for their ability to meet objectives for
finding latent infection and ensuring that patients are completely treated. Projects that do not meet objectives should be revised,
or they should be discarded in favor of more promising projects. Projects that do meet objectives can be expanded or adapted
to other settings.
Providing Laboratory and Diagnostic Services
The vital functions provided by the state TB laboratory require substantial fixed investments in facilities, equipment,
and personnel. The costs of maintaining the laboratory do not decrease even when the TB burden becomes very low.
When proficiency is at stake, the TB laboratory should assess the possibility of certain tests and functions being carried out at
contract laboratories or interstate regional public health laboratory reference centers without degrading the quality of the
services. Regional centers have proved satisfactory for DNA fingerprinting of
Mycobacterium tuberculosis isolates, and some
state laboratories have arranged for susceptibility testing of isolates through contracts with out-of-state laboratories.
Rapid, reliable communication of laboratory results is a crucial requirement for relocating tests and functions to other
sources. Most low-incidence state TB programs have difficulty in assuring reporting from laboratories if private medical providers
and hospitals send specimens to local hospital laboratories or to out-of-state contract laboratories for testing. This situation
is similar in the remainder of the country. It puts the TB program at a disadvantage because these laboratories might fail to
report
critical results promptly to the health department. They also might discard
M. tuberculosis isolates before subsequent
testing, such as DNA fingerprinting, can be done. Some states have found solutions to this difficulty that might provide models
for other low-incidence areas. In Minnesota, a public health regulation now requires that specimens for TB testing be split,
with half of each specimen sent to the state TB laboratory. A different approach is taken in Wisconsin, where the director of
the state TB laboratory leads a consortium of directors of TB laboratories located at hospitals throughout the state. This
innovative system allows the state program to promote quality assurance and good public health practice through a collaborative effort.
Collecting and Analyzing Data
Data collection is the starting point for both planning a strategy and evaluating a current program. In low-caseload,
low-incidence states data collection is often hindered by the scarcity of public health personnel at the local level and the
challenges of training these personnel in the methods of systematic and accurate data collection. State TB programs can ease the burden
at the local level by limiting requirements for data collection to the minimum needed for assessing epidemiology and
program activities. At the state office, the TB program needs an epidemiologist to participate in the analysis and interpretation of
results submitted by the localities. Because most TB programs in low-incidence states do not have epidemiologists assigned
full-time, the health department should provide part-time support from within the health department or through a contract.
This epidemiologic review could also be addressed through interstate regionalization; this option should be studied for its
potential to increase capacity.
For low-caseload, low-incidence states, the annual case incidence is generally such that single-digit changes represent
large relative shifts; therefore, analyses of yearly trends are inconclusive. The averaged changes over longer periods (e.g., 5-year
spans) might be more informative, but these results are less useful for immediate assessments of active problems. Under
these circumstances, epidemiologic and programmatic insight can be derived from an ongoing systematic review of anomalous
or special cases. Examples include investigations of TB cases with the following features: patients <15 years old; drug-resistant
M. tuberculosis isolates; extensive or advanced TB disease, which is suggestive of delays in diagnosis; or deaths before
patients complete treatment. Sentinel criteria such as these can prompt case reviews as part of program management.
Providing Consultation, Training, and Education
Education and training about TB are essential for sustainable control programs. Training should be directed not only to
health-care providers but also to decision makers, especially those who influence health-education curricula, and to the public.
All these groups should be kept aware of TB, the goal of elimination, and the means to achieve the goal.
TB controllers in low-incidence states cite consultation, training, and education as both their most important functions
and their biggest challenges. Training and education in particular are crucial for maintaining provider competence in both
the public health and private medical care sectors. Providers in public health need training to stay current with new guidelines
for diagnosis and treatment and maintain mastery of program management. Providers in private practice and other settings
outside of health departments need training so they will "think TB" in the first place and become familiar with the advantages
of collaborating with the health department. Typically, these providers keep full schedules and are occupied with many
other health problems more prevalent than TB. Enticements, such as guest speakers, and incentives, such as continuing
education credits, can gain their interest and participation.
Perhaps the greatest difficulties that low-incidence states encounter in the area of training are in obtaining funds and time
to travel. When working with private medical providers in particular, the most effective means for building rapport is to
visit localities routinely and meet with providers. In states with small health departments, this rapport pays dividends for years,
and it can establish some providers as consultants who assist the TB program. State policymakers need to be informed about
the essential role of travel, especially in areas with minimal local expertise. If travel funds are restricted despite the need, the
TB program should combine tasks, including training, into occasional trips and should take advantage of the most effective
media for long-distance communications (Box 3).
Personnel in local health departments are likely to require cross training for their many tasks. The state TB program
should couple its training activities with those of other programs as often as possible to conserve resources. However, new workers
in the TB program should receive TB-specific training that prepares them for all aspects of program operations and
case management. All public health personnel who provide TB-related services require periodic refresher courses, regardless
of whether TB is their main responsibility.
Tuberculosis training is another activity that can be explored for interstate regionalization; this approach has already
been implemented in some areas (e.g., the course on TB diagnosis and treatment at the Denver National Jewish Center
for
Immunology and Respiratory Diseases). Regional TB controllers' meetings are another vehicle for training updates.
Drawbacks of the current regional approaches to training are that participants have to travel and that only providers who already have
a role in TB are likely to participate.
The three CDC-funded National Tuberculosis Model Centers, located in New Jersey, California, and New York,
consolidate treatment and training expertise and offer training curricula, course materials including videotapes, and technical
assistance. The training materials are offered at a nominal fee, and their consultation is provided at no cost. The range of their services
is listed on their Internet sites.
For programs in low-incidence states to achieve more rapid progress toward elimination, some resources for TB control
will have to be directed to TB prevention activities. The higher-priority prevention activities, specifically finding and
treating recently infected contacts of contagious TB patients, can turn into long-term, labor-intensive commitments, as shown by
the outbreaks described earlier. The intensity and duration of these outbreaks demonstrate the need for the availability of
public health personnel who are able to devote a substantial fraction of their time to TB control over a period of months to years.
Gaps in contact evaluation and treatment are a particular problem that can be overcome by a system of "case
management" adapted from the standard case-management plans designed for TB patients. Directly observed therapy for latent TB
infection can be undertaken where feasible, such as in places of employment, schools, and other institutional settings, especially if
the infected contacts have additional risk factors for active TB.
Undertaking prevention activities requires negotiation with policymakers and support from partners to anticipate the
eventual increases in the relative cost of prevention as TB becomes rarer (Box 4). An advantage of taking up the cause of prevention
is that it increases the visibility of the TB program and demonstrates a need for resources. Inversely, the long-term costs of
failing to raise prevention as a priority issue are not only a delay in reaching elimination but a further decrease in resources as
active cases become rarer.
Implement a Tuberculosis Elimination Plan
An elimination plan is the conceptual basis for all TB program activities because it lays out the short- and long-term tasks,
and it provides a common language for communicating with strategic partners. Low-incidence states, in particular, need
to consider how an elimination plan can attract the attention of the public and policymakers who might believe that TB is
no longer a public health threat. An effective area for emphasis is the disparity of TB incidence rates between social groups
with high and low economic status. This illustrates that TB is
not only an issue of public health but also one of social
justice.
An elimination plan should address, on an individual state level, the unique challenges to good tuberculosis control in
low-incidence states (see previous discussion) and should capture all of the recommendations listed in the section Work
Creatively to Ensure the Essential Components of Tuberculosis Control. The plan should integrate these elements into a strategy that
fits local and regional circumstances and should provide interim objectives for assessing implementation of the plan and
its effectiveness.
Make Progressing Toward Tuberculosis Elimination in Low-Incidence Areas
a National Priority
ACET recommends that the nation help low-incidence states to eliminate TB. Doing so now invests in the future of all
TB programs because those states not currently at the low-incidence level will be able to build on the experience of those that
are. The current low-incidence states have the opportunity to test novel strategies for partnerships, funding,
communications, education and training, and regionalization. An investment of national TB resources will benefit TB elimination in other
parts of the country.
Roles and Responsibilities
Local and state health departments have the most important role in contributing to the core components for TB control,
and most recommendations in this document are directed toward those agencies. The federal government plays a
central coordinating role in TB control, and many other agencies and associations can help, especially those working with groups
most at risk for TB. The specific contribution of these organizations in complementing state and local TB control efforts
are described below:
Federal Government
The U.S. national TB program consists of CDC's Division of Tuberculosis Elimination (DTBE), in the National Center
for HIV, STD, and TB Prevention, in collaboration with the Division of AIDS, STD, and TB Laboratory Research and
the Division of Global Migration and Quarantine, in the National Center for Infectious Diseases, and with the Division
of Laboratory Systems, in the Public Health Practice Program Office
(22). The national TB program is responsible for
assessing TB-control capacity throughout the United States and documenting gaps in this capacity. This program also should
sponsor regional agreements among states to share resources when such agreements will enhance services and reserve capacity
without weakening the TB control capacity of individual states.
ACET recommends that the national TB program at CDC maintain a national pool of expertise in research,
program management, laboratory proficiency, outbreak response, epidemiology, and diagnosis and treatment of TB, especially for
drug-resistant disease. CDC also should provide consultative, educational, and financial support for state and
regional mycobacteriology laboratories. This might include periodic on-site assessment and consultation as well as assistance in
obtaining necessary testing services not available within a given state.
The national TB program should sponsor operational research to discover and test more effective methods for addressing
the unique challenges of TB prevention and control in low-incidence states. CDC should also provide technical assistance for
TB surveillance and program evaluation in low-incidence states. This assistance should include consultation on the
epidemiologic profile used to develop each state's elimination plan. Consistent with these efforts, CDC should provide easy-to-use
computer programs for case reporting, morbidity analysis, case and contact management, and related follow-up.
CDC should collaborate on low-incidence initiatives with other member agencies of the Federal Tuberculosis Task
Force.¶ The federal agencies whose missions include ensuring health care services for groups at risk for TB
--- medically underserved
persons, foreign-born persons, American Indians and Alaska Natives, migrant workers, persons in long-term care facilities, inmates
of correctional facilities, substance users, and homeless persons --- must integrate TB prevention activities into their
general performance standards, working with their constituency organizations. Agencies that influence education for
health professionals should ensure that TB remains in the curriculum, especially for future health-care providers who will serve
in rural areas or work with at-risk groups. Agencies that shape public health research policy should promote or support studies
to determine optimal TB control methods for low-incidence areas. Agencies that support basic research should promote
studies for new methods ofTB diagnosis, treatment, and prevention, including a safe, effective
vaccine (23).
Nongovernmental Organizations
The National Tuberculosis Controllers Association (NTCA), an organization of all state TB control officers and
other interested persons, supports several key functions: conducting surveillance to detect sentinel trends in programmatic
issues, acting as a conduit for bringing the concerns of its individual members to national attention, and providing a forum
for solving problems and sharing the results of novel strategies in low-incidence areas. As the unified advocacy organization for
TB controllers, NTCA seeks to maintain sufficient programs and systems in all health jurisdictions and can play a central role
in promoting the TB programs of low-incidence states.
The American Lung Association, the American Thoracic Society (ATS), the Infectious Diseases Society of America,
the American Academy of Pediatrics, and the National Coalition for the Elimination of Tuberculosis should
specifically incorporate the perspective of low-incidence states when making new recommendations. Tuberculosis controllers in
low-incidence states should be consulted when these organizations promote activities with partners and coalitions.
For many years, ATS has advanced TB control in the United States through its sponsorship of national guidelines for
diagnosis and treatment, its engagement in national planning activities, and its conferences, which provide a forum for
communication among TB researchers and pulmonary medicine specialists. More recently, the Infectious Diseases Society of America also
has cosponsored the development and dissemination of these national guidelines and, along with the American Academy
of Pediatrics, has engaged increasingly in related health-professional activities. Continued participation of these organizations
in TB-related work helps foster advancement in technical competence nationally.
Because family practitioners and general internists provide primary health care to patients in rural areas, the
American Academy of Family Physicians and the American College of Physicians-American Society of Internal Medicine can
be especially influential in low-incidence states. Other specialty professional organizations, such as the American College of
Chest Physicians, have members who are knowledgeable about the diagnosis and treatment of TB. All organizations of
health-care
professionals can reinforce TB awareness by including it on the agenda for specialty training and certification and
in conferences for continuing medical education.
Research Agenda for Tuberculosis Low-Incidence Areas
Several potential strategies for TB control in low-incidence states need to be evaluated. Research in these states should
focus primarily on evaluating promising strategies, which requires methodical consideration of each one.
Test the Feasibility of Regionalization
Regionalization of TB control within state boundaries is already a programmatic feature in some states.
Interstate regionalization among low-incidence states should be studied by creating consortiums focusing on operational research.
An interstate consortium could explore, for example, the value of sharing a TB epidemiologist and a nurse consultant
among several low-incidence states.
Study Population-Based DNA Fingerprinting
DNA fingerprinting should be done on all isolates of
M. tuberculosis from several low-incidence states, and the results
should be analyzed for their usefulness in revealing unsuspected transmission patterns. The public health value of discovering
these transmission patterns should be determined.
Evaluate New Modes of Training
Distance-based learning and self-teaching for TB control are attractive for their affordable convenience, but their impact
on programmatic effectiveness remains to be evaluated fully. New modes of training should be compared with traditional
face-to-face classroom methods to evaluate their relative effect on improving TB-control knowledge and program impact. This area
of research should draw on current efforts to implement and evaluate approaches to distance learning and "virtual classrooms."
Establish Pilot Model Tuberculosis Elimination Programs
The optimal size, structure, and strategy for a TB program under specific epidemiologic and administrative circumstances in
a low-incidence state are unknown. Several pilot model programs should be established in low-incidence states, with
an integrated evaluation component testing the contributions of various factors in the programs. These model programs
also should serve as centers of excellence by providing consultation and education to health departments in other states.
Compare Innovative Case Management Systems
Some health departments have explored novel systems for TB case management (Box 3). These methods should be
compared for their effectiveness and benefits, with the goal of making the best methods available to other TB control programs
facing similar challenges.
Evaluate Prevention Strategies
The cost and the effectiveness of contact investigations, the obstacles to successful outcomes in these investigations, and
the utility of the "concentric circles" model, described previously
(24), should be determined for low-incidence states.
Specific strategies for contact investigations should be described, tested, and compared for their merits.
Targeted testing for latent TB infection has an uncertain role in TB control, especially in low-caseload, low-incidence
states. Persons at risk for TB might be few in number and difficult to reach through conventional health-care systems, which
would result in low yields and treatment completion rates. Novel strategies for overcoming these challenges should be proposed
and tested for their effectiveness in finding and completely treating infected persons.
The benefits and expense of surveillance for latent TB infection have not been determined. A pilot surveillance system, or
a state system already in existence, should be evaluated for its potential to aid in case prevention and to guide the strategies of
the TB control program.
Conclusion
The United States needs a coordinated commitment to eliminating TB in low-incidence areas as a prelude to eliminating it
in the entire nation. Critical to this effort is an understanding that low-incidence areas will require distinctive strategies. On
the pathway to TB elimination, all states eventually must confront a dwindling yet lingering TB problem by maintaining
TB-control programs and linking systems that can assume some of the functions of TB-control programs. Failure to meet
the challenges raises the spectre of a new TB resurgence. The keys to addressing the challenges will lie in maintaining a
general public health infrastructure, planning creatively, and integrating and using resources that until now have not played a role
in TB control.
Acknowledgments
Reports in the text boxes were prepared by Gary Simpson, M.D., Ph.D., New Mexico Department of Health;
N. Alexander Bowler, M.P.H., Wyoming Department of Health; Wendy Mills, M.P.H., Minnesota Department of Health; and Kathleen
F. Gensheimer, M.D., Maine Department of Health. ACET also gratefully acknowledges the tuberculosis surveillance
statistics and analysis provided by Marisa Moore and Robert Pratt, Division of Tuberculosis Elimination, National Center for
HIV, STD, and TB Prevention.
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* Public health infrastructure is the "underlying foundation that supports the planning, delivery, and evaluation of public health activities and practices. Its
three basic components are workforce capacity and competency, information and data systems, and organizational capacity." (Source: CDC. Public health's
infrastructure: a status report. Atlanta: CDC, 2001).
† Elimination was defined by ACET in 1989 as a TB incidence rate <1 case per year per million population.
§ The Division of Tuberculosis Elimination, CDC, keeps records about state TB programs as part of the federal TB cooperative agreement funding process.
The data about programs are not standardized but are presented here for a general description.
¶ Health Resources and Services Administration; U.S. Department of Justice, Federal Bureau of Prisons; Indian Health Service; Food and Drug Administration;
National Institutes of Health; U.S. Department of Labor, Occupational Safety & Health Administration; U.S. Department of Justice, Immigration
and Naturalization Service; Department of Veterans' Affairs; Centers for Medicare & Medicaid Services (Formerly HCFA); Substance Abuse & Mental Health
Services Administration; U.S. Department of Housing and Urban Development; U.S. Agency for International Development
BOX 1. Minnesota: Impact of changing immigration patterns
The annual TB incidence rate for Minnesota
consistently has been less than the national average. The rate was
less than 3.5 cases per 100,000 population from 1993
through 1998, which would have put Minnesota in the
low-incidence category. However, the case count began
increasing in 1994 at an average of 9% per year, and by 1999 the
incidence rate had increased to 4.2/100,000.
The most remarkable feature of the recent upsurge in
Minnesota is the large and growing fraction of cases among
foreign-born persons. From 1995 to 1999, cases occurring
in persons born outside the United States increased from
50% to 78% of the total cases, and in 2000 these cases
accounted for 82%. Although the number of cases reported for
U.S.-born persons decreased by 42% from 1995 to 1999,
the number reported for foreign-born persons doubled in
this same period.
These epidemiologic trends are connected to changes
in immigration patterns. For the federal fiscal year 2000,
the U.S. Congress established a ceiling of 85,000 new
refugees to be admitted to the United States, which includes
17,000 persons from Africa. This is more than twice the number
of African refugees admitted annually since 1995.
Approximately 3.5% of refugees admitted to the United States
initially arrive in Minnesota. During 1995--1999,
Minnesota was the initial destination for 11,955 refugees. More
than 3,900 of these arrived in 1999, which was more than
double the 1998 arrivals. In 1999, 75% of the primary
refugees coming to Minnesota were from sub-Saharan Africa, in
contrast to earlier in the decade, when most refugees were
from Southeast Asia. Most of the recent African refugees are
coming from Somalia, and they are being followed by other
Somalis who initially arrived elsewhere in the United
States. Approximately 40,000 Somali persons now reside in
Minnesota, making up the largest Somali population
anywhere outside Somalia.
Foreign-born TB patients in Minnesota during 1995--1999 originated from 52 countries. Of 156 foreign-born
patients in 1999, 52% originated from sub-Saharan Africa. The
number of Somalian TB patients increased from 2 (4%) of
53 foreign-born patients in 1993 to 56 (36%) of 156 in
1999. Demographic trends indicate that the Somalian
population in Minnesota will grow in upcoming years, and further
increases in TB are anticipated.
Providing services to foreign-born TB patients
presents substantial challenges. Some patients have complicating
factors such as drug-resistant or extrapulmonary disease.
Many patients face economic hardships and cultural or
linguistic barriers that interfere with obtaining medical care,
adhering to prescribed therapy, and participating in contact
investigations. The state TB control program is meeting these
challenges by building culturally specific outreach
capacity consisting of providers for directly observed therapy,
language interpreters, incentives, enablers, translated
educational materials, and convenient referral mechanisms.
Tuberculosis control in Minnesota involves the
collaboration of private health-care providers, the state health
department, and a decentralized system of more than 80
local public health agencies that provide direct services such
as contact investigations. Local resources and expertise
vary widely, and culturally sensitive health-care services are
not readily accessible in rural areas. The state TB control
program works directly with local public health agencies
and also provides clinical consultation for hospitals, clinics,
long-term care facilities, and correctional facilities statewide.
The consultation, coordination and surveillance
services offered by the Minnesota TB control program are critical
to maintaining adequate capacity statewide. This program
is seeking additional resources for expanding prevention
activities, particularly culturally specific targeted testing
for latent TB infection among foreign-born persons.
BOX 2. Wyoming: Case counts tell less than half the story
In Wyoming, a state with a very low TB incidence,
the health department reported four cases (0.8 per
100,000 population) for 2000. However, that very low case
count does not reflect the substantial amount of work
required to keep caseloads at this level. There were 231 contacts
for these cases, including 171 contacts of a patient with
contagious pulmonary TB at the state penitentiary. In
addition to the four counted cases, the Wyoming
program managed three cases in persons who moved to
Wyoming from Massachusetts, Texas, and California after the
cases had been counted by those states. (According to
national surveillance definitions, these cases are counted by the
reporting states, not by the program receiving the
patients.) One of these cases posed difficult and expensive
management problems, and the three cases together led to
more than 60 additional contacts being evaluated in Wyoming.
Two additional patients with clinically suspected TB
required public health investigations before the TB
diagnosis was excluded. Additional contacts were evaluated
for the suspected cases. The experience in this
low-incidence state illustrates that case counts alone should not be
the basis for projecting resource needs for a TB program.
BOX 3. New Mexico: Partnerships for tuberculosis
case management
With its annual incidence rate of 2.5/100,000,
New Mexico became a low-incidence state in 2000. New
Mexico shares some of the features of other western
low-incidence states: low caseloads (46) were reported in 2000, 27%
of cases were in American Indians, and vast rural
distances are an obstacle to case management. Other similarities
are local health departments with disparate resources and
a small state TB control program. Many American
Indian TB patients receive their health care through the
U.S. Indian Health Service or tribally managed health-care
systems, which further complicates surveillance and case
management because of conflicts of jurisdiction.
In 1994, the state program began a collaborative
case management strategy, which has been successful in
facilitating communication among participants. For each
new TB case, the state medical director for infectious
diseases convenes a management team consisting of the state
TB nurse consultant, the state TB case manager, the
treating physician, the pharmacist as needed, and a local
public health nurse. If the Indian Health Service or a tribal
health agency is providing care for the patient,
representatives from these agencies are included. The team is
convened by a telephone conference. Real-time computer video
links also are being established for more areas. Laboratory
results and radiographs can be shared by the computer
link, which is able to protect patient confidentiality. After
planning initial case management, the team reconvenes
routinely until the case is closed.
This system has been effective, and all participants
endorse it. The rate for completion of therapy within 1
year for 1998, the latest year with data finalized, was
96.5% (1998 national average 79.1%; national objective
90%). The New Mexico strategy not only builds strong
liaisons among the participants but is a forum for educating
and training health-care providers who do not routinely
participate in TB care. The drawbacks have been the
substantial time commitment required to convene the
case management teams and the expense of
telecommunications, an expense which is offset by reduced travel costs.
Maine, with its TB incidence rate of 1.9/100,000 for
2000, has reported an average of 24 cases per year for the past
8 years, with large annual fluctuations (range: 13--35
cases) but no evident rate trends. In 2000, 33% of Maine's
TB patients were foreign born.
From January 1999 to July 2000, three
epidemiologically unrelated TB cases were found among employees of a
single food-processing plant in Maine. During contact
investigations for the first two patients, 295 workers were
evaluated; 66 (22%) were found to have latent TB infection.
However, only nine of the infected contacts were born in the
United States, suggesting that some of the infections discovered
in the contact investigations were acquired in the
contacts' countries of origin, before exposure occurred in the
food-processing plant. Worksite contacts were not sought for
the third patient because no transmission to household
contacts was found and the likelihood of worksite
transmission was very low.
In observance of the recommendations of the Institute
of Medicine report (5), in 2001, TB control personnel
from the Maine Bureau of Health selected the
food-processing plant as a feasible site for targeted testing and
supervised treatment for persons with latent TB infection. The
Bureau established a partnership with representatives from the
food processing plant's management, employees, the
American Lung Association of Maine, the Maine TB
Consultants Group, and local medical providers. Half or more of
the plant's 800 workers are foreign born, and 34 languages
are spoken as "first languages" by these workers. Employee
turnover is frequent, which means that TB-infected employees
need to be treated before they leave employment at the
plant, and also that the evaluation of new employees for latent
TB infection will have to be a continual process.
The anticipated yield from targeted testing is
approximately 60 cases of latent TB infection in the first year
and 30 per year in subsequent years. These yields were
projected from the experience with contact investigations in the
plant. If treatment completion rates with directly observed
therapy exceed 80%, approximately one TB case per year might
be prevented primarily through this project, although
additional secondary cases might be averted and resources saved
by avoiding contact investigations and controlling outbreaks.
Current funds and resources available to the TB
control program in Maine are adequate for only the
high-priority activities of case finding, case management, and contact
investigations; few resources are available for redirection
to the proposed targeted-testing project, which would
require an overall funds/resources increase of approximately
25% above the current level.
Exploring this proposed project in Maine has
already shown that the inclusion of community partners from
the start is a critical investment in meaningful planning.
Also, if low-incidence states are to implement the
TB-prevention recommendations of IOM (5), the efforts must be
backed by financial and political support. Finally, because of
the large investment required for targeted testing projects,
a health department needs to plan its strategy carefully
and integrate an evaluation component into projects so that
effectiveness is monitored after implementation.
Advisory Council for the Elimination of Tuberculosis
Membership List, May 2002
Chair: Charles M. Nolan, M.D., Director, Tuberculosis Control Program, Harbor View Medical Center,
Seattle, Washington.
Executive Secretary: Ronald O. Valdiserri, M.D., Deputy Director, National Center for HIV, STD, and TB
Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia.
Members: Stephanie B.C. Bailey, M.D., Metropolitan Nashville/Davidson County Health Department,
Nashville, Tennessee; David L. Cohn, M.D., Denver Public Health, Denver, Colorado; Wafaa M. El-Sadr, M.D., Harlem
Hospital Center, New York, New York; Vinnie Gee, Columbia University, Harlem Hospital Center, New York, New York; L.
Masae Kawamura, M.D., San Francisco Department of Public Health, San Francisco, California; Christina Larkin, M.P.A.,
Mayor's Office of Health Insurance Access, New York, New York; Michael S.A. Richardson, M.D., Pulmonary Critical
Care Associates, Washington, D.C.; Lawrence L. Sanders, Jr., M.D., Morehouse School of Medicine, Atlanta, Georgia; and
Charles Edward Wallace, Ph.D., Texas Department of Health, Austin, Texas.
Ex Officio Members: Amy S. Bloom, M.D., U.S. Agency for International Development, Washington, D.C.;
Theresa Bryant-Watkins, M.D., Health Resources and Services Administration, Bethesda, Maryland; Georgia S. Buggs,
M.P.H., Office of Minority Health, U.S. Public Health Service, Rockville, Maryland; James E .Cheek, M.D., Indian Health
Service, Albuquerque, New Mexico; Ann M. Ginsberg, M.D., Ph.D., National Institutes of Health, Bethesda, Maryland; Warren
W. Hewitt, Jr., Substance Abuse and Mental Health Services Administration, Rockville, Maryland; Maria C. Rios, M.D.,
HIV/AIDS Bureau, Rockville, Maryland; and Gary A. Roselle, M.D., Department of Veterans Affairs, Cincinnati, Ohio.
Liaison Representatives: American Lung Association, Fran Dumelle, M.S., Washington, D.C.; American Thoracic
Society, John B. Bass, Jr., M.D., Mobile, Alabama; Association for Professionals in Infection Control and Epidemiology, Rachel
L. Stricof, M.P.H., Albany, New York; Baltimore City Health Department, Ruth Vogel, Baltimore, Maryland; Cook
County Correctional Services, James McAuley, M.D., Chicago, Illinois; Division of Consolidated Laboratory Services, James
Pearson, M.D., Richmond, Virginia; Division of Immigration, Gene Migliaccio, M.D.; Washington, D.D.; Hospital
Infection Control Practices Advisory Committee, Alfred DeMaria, Jr., M.D., Jamaica Plain, Massachusetts; Infectious Disease
Society of America, Henry M. Blumberg, M.D., Atlanta, Georgia; National TB Controllers Association, Sue Etkind, M.S.,
Jamaica Plain, Massachusetts, Carol J. Pozsik, M.P.H., Columbia, South Carolina, and Lee B. Reichman, M.D., Newark, New
Jersey; Society for Healthcare Epidemiology of America, Michael L. Tapper, M.D., New York, New York; and International
Union Against Tuberculosis and Lung Diseases, Anne Fanning, M.D., Edmonton, Alberta, Canada.
Working Group on Low Incidence
Chair: Charles M. Nolan,
M.D., Seattle-King County Department of Health, Seattle, Washington
Members: Anne Fanning,
M.D., Walter C. Mackenzie Health Science Center, Edmonton, Alberta, Canada;
Kathleen F. Gensheimer, M.D., Maine Department of Human Services, Augusta, Maine; Warren W. Hewitt, Jr., M.S., Substance
Abuse and Mental Health Services Administration, Rockville, Maryland; Carol J.
Pozsik, M.P.H., South Carolina Department of Health and Environmental
Control,Columbia, South Carolina; Ruth Vogel, Baltimore City Health Department, Baltimore, Maryland; Charles Edward Wallace, Ph.D., Texas Department of
Health, Austin, Texas.
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