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A summary of recommendations by the Advisory Council for the Elimination of Tuberculosis (ACET) and the National Tuberculosis Controllers Association (NTCA), published by CDC. It updates ACET's 1995 recommendations and is meant as an introduction for new TB controllers, a standard for evaluating programs, and a way to explain to decision-makers why each component matters. Clinical details that change quickly are kept in online appendices.
Why an update
TB has fallen a long way in the United States: 84,304 cases in 1953 against 8,920 in 2019, and a rate down more than eighteenfold, from 52.6 to 2.7 per 100,000, while the population doubled. With global incidence about 130 per 100,000, the U.S. counts as a low-incidence country.
But the decline has been interrupted before. After a plateau in 1984–1988, cases rose 14% in 1989–1992, driven by HIV, TB among people born in high-prevalence countries, transmission in congregate settings — hospitals, prisons, drug treatment centers, shelters — and decades of funding cuts made on the belief that TB was beaten. New federal money and the 1995 components reversed that resurgence. Today's risk is the opposite: falling case numbers can mean falling visibility and resources, and new tools for diagnosis, treatment and surveillance demand new approaches. The Institute of Medicine's 2000 report Ending Neglect set six goals that still apply: maintain control, speed the decline, develop new tools, address global TB, sustain public health support, and track progress toward elimination.
Three priority strategies
- Find and treat everyone with active TB until they are no longer infectious and complete treatment.
- Find and screen contacts of TB patients — to learn whether they have TB disease or infection and, for young children and others at high risk, whether to give "window" preventive treatment while waiting for a skin or blood test to turn positive.
- Screen, test and treat other high-risk people for latent TB infection (LTBI) — essential for elimination, given new immunosuppressive drugs, immigration from TB-endemic areas, and clinicians who see TB less and recognize it less.
Though aimed at individuals, these strategies cut current and future transmission in the community.
The ten essential components
State, local and tribal health departments, through cooperative agreements with CDC, are responsible for carrying these out or making sure they happen:
| Component | What it involves |
|---|---|
| 1. An overall plan and policy | written policies and procedures, advice to clinics and providers, infection control, laws and regulations that support TB control, qualified staff, and funding |
| 2. Surveillance | timely, accurate reporting of suspected and confirmed cases; a report of a verified case (RVCT) to CDC for every case; drug-resistance testing of every initial isolate; active case-finding among providers, labs and pharmacies serving high-risk groups |
| 3. Data collection and analysis | a case registry, transfer of information between jurisdictions, confidentiality, and local, state and national statistics |
| 4. Program evaluation and research | cohort reviews, registry reviews, national indicators, quality improvement and outside evaluation |
| 5. Setting priorities | especially where resources cannot cover every activity |
| 6. Laboratory and radiology | access to recommended tests for TB disease, drug resistance and LTBI |
| 7. Contacts and others at high risk | identifying, managing and treating them to prevent disease |
| 8. Managing people with TB | case management and treatment for patients and those being evaluated |
| 9. Training and education | for program staff, other health departments, clinicians, patients and families, communities and the public |
| 10. Collaboration | with medical, community and academic partners, neighboring TB programs, and agencies such as corrections, social services and immigration |
Some of the details
Latent TB. People with LTBI have no symptoms and cannot spread TB, but can develop disease decades later, especially if their immunity weakens. An estimated 13 million people in the U.S. have LTBI, and about 80% of U.S. TB cases are thought to come from reactivated infection — so finding and treating it is a cornerstone of elimination. Test only people at real risk, and only if evaluation and treatment can follow and are likely to be completed; routine testing of low-risk groups wastes resources and yields false positives. Retest someone only when a new risk arises. Shorter rifamycin-based regimens are now favored, with better completion and fewer side effects.
Treatment and adherence. Directly observed therapy (DOT) — a health worker or other responsible person watches each dose swallowed — is the standard of care, in a clinic, at home, work or school, or by video when in-person DOT isn't possible. Adherence plans should fit each patient's life and beliefs, with incentives (a gift card after two weeks) and enablers (transit passes, help with rent). When all less restrictive measures fail, programs should be ready to use legal authority — health officer orders, court-ordered DOT or detention — for patients who are infectious or at risk of becoming so, with due process and their basic needs met.
Contact investigations start as soon as a case of infectious respiratory TB is reported, working outward in concentric circles from those at highest risk. Programs calculate the patient's infectious period and an 8- to 10-week window for retesting, and give window prophylaxis to children under 5 and immunocompromised contacts. Genotyping links cases in the same chain of transmission, reveals unsuspected links, and exposes laboratory cross-contamination — false-positive cultures that can lead to needless treatment. A recommended outbreak definition: two or more contacts with active TB, or two or more cases within a year found to be linked.
Moving toward elimination
As cases fall, programs should add strategies such as:
- making LTBI reportable, not only TB disease;
- offering DOT to selected people with LTBI;
- enlisting private practitioners, student health services, employers of people born abroad, hospitalists and other health department programs to broaden LTBI screening and record results the same way;
- analyzing case and infection data at least yearly to target testing and treatment;
- keeping the public and clinicians aware of TB and LTBI through news releases, case reports and presentations;
- keeping partners in other agencies engaged in joint initiatives.
Sources
Based on Advisory Council for the Elimination of Tuberculosis and National Tuberculosis Controllers Association, "Essential Components of a Public Health Tuberculosis Prevention, Control, and Elimination Program," MMWR Recommendations and Reports, volume 69, number RR-7, Centers for Disease Control and Prevention; a work of the United States government in the public domain. This page summarizes a long report; its sections on staffing, funding, laboratory services, case management teams, training, partnerships and research, and its boxes on legal authority, TB classifications and skin-test cutoffs, are in the original.
Licenza: CC0 1.0 (pubblico dominio) · Tratto da www.cdc.gov
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