Comprehensive Tuberculosis Health Programme
Core Priority Framework
A comprehensive TB health programme must prioritize three sequential activities: (1) case detection and treatment of active TB disease, (2) contact investigation and management, and (3) targeted testing and treatment of latent TB infection (LTBI) in high-risk populations. 1
Essential Programme Components
1. Case Detection and Treatment (Highest Priority)
Active case finding is the foundation of TB control and must precede all other activities. 1
Ensure rapid diagnostic access: Jurisdictional public health agencies must provide clinicians with current, accurate, and timely diagnostic services including sputum smear microscopy, culture, and drug susceptibility testing 1
Target high-yield screening settings: Screen during contact investigations, outbreak investigations, immigrant/refugee evaluation (Class A/B1/B2 notification status), congregate settings, homeless shelters, and correctional facilities 1
Implement directly observed therapy (DOT): All TB treatment should use DOT to prevent drug resistance from non-compliance 2
Standard treatment regimens: Use isoniazid, rifampin, pyrazinamide, and ethambutol for 8 weeks, followed by isoniazid and rifampin for 16 weeks (6-month total) for drug-susceptible pulmonary TB 2
Evaluate screening effectiveness: Periodically assess all case detection activities to determine their usefulness based on local TB epidemiology 1
2. Contact Investigation Programme (Second Priority)
Contact investigations follow only case detection and treatment in priority and are critical for TB control. 1
Establish comprehensive protocols: Develop written procedures identifying persons responsible for each investigation step and processes to maximize efficiency within available resources 1
Prioritize high-risk contacts: Focus tuberculin skin testing first on contacts at highest risk for progression to active TB—those aged <5 years, HIV-infected persons, and those with other immunocompromising conditions 1
Implement DOT for LTBI in contacts: Consider directly observed preventive therapy for all contacts, with highest priority for high-risk contacts 1
HIV counseling and testing: Establish procedures for voluntary HIV testing of contacts based on local epidemiology of TB and HIV co-infection 1
Apply legal authority: Use existing communicable disease laws to compel examination of contacts who fail to comply with requirements 1
Develop outbreak response plans: Include indications for plan initiation, notification procedures, response team composition, staffing sources, contact follow-up plans, and criteria for requesting CDC assistance 1
3. Targeted Testing and Treatment of LTBI (Third Priority)
LTBI programmes should only be developed after the programme satisfies national objectives for management of active TB cases and contacts. 1
Identify and prioritize high-risk populations: Categorize populations into tiers based on expected impact and efficacy, with Tier 1 groups (HIV-infected persons, recent contacts, persons with fibrotic lesions on chest X-ray) receiving highest priority 1, 3
Treatment regimens for LTBI: Use 6-9 months of daily isoniazid (300 mg for adults, 10 mg/kg up to 300 mg for children), or 20-30 mg/kg twice weekly (not exceeding 900 mg) under direct observation when daily adherence cannot be assured 2
Maximize patient convenience: Employ staff from targeted populations, provide medical translation, ensure cultural sensitivity, offer flexible clinic hours, provide outreach services for transport, and use incentives and enablers—all services free of cost 1
Shorter regimens for special settings: In correctional facilities, use 4 months of rifampin as an alternative to improve completion rates 1
Infection Control in High-Risk Settings
Healthcare Facilities and Congregate Settings
All healthcare institutions and high-risk sites must implement TB infection control programmes using a hierarchy of administrative controls, engineering controls, and respiratory protection. 1
Administrative controls are paramount: Early recognition and prompt isolation of persons with suspected TB is the most important component of airborne infection control 1
Train frontline staff: Employees with first patient contact must be trained to detect infectious TB by routinely asking about M. tuberculosis exposure, previous TB infection/disease, current symptoms, and medical conditions increasing TB risk 1
Healthcare worker screening: Test all HCWs for M. tuberculosis infection at employment, with subsequent testing frequency based on institutional risk assessment 1
Use appropriate TST cutoffs: For HCWs without other risk factors, use 15 mm induration (not 10 mm) to define positive baseline testing at employment; an increase of ≥10 mm on subsequent testing indicates conversion unless the worker is a TB contact, HIV-infected, or immunocompromised (then ≥5 mm is positive) 1
Correctional facility requirements: Implement risk assessment, staff training, LTBI screening and treatment, isolation of infectious inmates, treatment and discharge planning, and contact investigation 1
Education and Community Engagement
Provider Education
Health departments, academic institutions, and medical professional organizations must provide continuing TB education to clinicians, focused on those serving high-risk populations based on local TB epidemiology. 1
Patient and Community Education
Design all patient education programmes with input from the targeted community to address cultural beliefs and neutralize TB-related stigma, particularly among foreign-born populations. 1
Programme Infrastructure Requirements
Data Management and Surveillance
Establish recording and reporting systems: Maintain systematic data collection with evaluation of treatment outcomes to monitor programme effectiveness 1, 4
Evaluate programme performance: Routinely assess effectiveness and impact of contact investigations, case detection activities, and LTBI programmes, developing interventions to improve performance when indicated 1
Legal and Confidentiality Framework
Develop guidelines in conjunction with legal offices and in compliance with HIPAA regulations for release of confidential information during contact investigations. 1
Context-Specific Adaptations
Low-Incidence Countries (Europe, North America)
In low-incidence settings, implement a broader spectrum of interventions beyond the basic DOTS strategy, including risk-group management, institutional transmission prevention, outbreak management, and preventive therapy for specified groups. 1
Follow American Thoracic Society/CDC/IDSA guidelines for high-resource, low-incidence settings with sophisticated diagnostics 5
Use WHO/IUATLD/KNCV framework for European low-incidence countries addressing technical sophistication available in industrialized nations 1, 5
High-Burden Settings
For high-burden, resource-limited settings, follow WHO guidelines directly as they are designed for countries with high TB incidence and variable resource availability. 5
- Sub-Saharan Africa (356 cases/100,000/year) and former Soviet Union countries (>100 cases/100,000/year) require WHO-adapted approaches 6
Critical Implementation Pitfalls
Inadequate staffing and funding: TB programmes weakened by insufficient resources cannot provide core control activities 4
Poor adherence to preventive therapy: Use monetary incentives to improve TB identification and management among drug users and homeless populations 7
Delayed diagnosis: Mobile chest radiography screening improves coverage, reduces diagnostic delay, and is cost-effective in hard-to-reach populations 7
Premature LTBI programme development: Do not establish LTBI testing and treatment programmes until active TB case detection and contact investigation objectives are met 1