TB outbreak response involves ongoing assessment for transmission patterns via detailed social network interviews and genotyping/WGS; managing multiple, often overlapping, contact investigations; and active case finding and outreach with the at-risk population.67,116,117 At the same time, caseloads for TB patients and for medical follow-up and LTBI treatment of contacts are increased during outbreaks. See Appendix 4 for a more detailed discussion of the recommended components of outbreak response and community-wide screening.
6.3.1. Organization and resources
Assistance from beyond the TB program is usually necessary. Outbreak response within the public health/TB program is often most efficiently organized using an Incident Management System-type structure, with well-defined roles for all those involved. An outbreak coordinating group, chaired by key individuals from the public health/TB program, and including clinical TB experts, hospitals, laboratory and the affected community, is strongly advised.
Good practice statement
Given the scale and duration of most TB outbreaks, it is critical that there be adequate organization, staffing and resources for investigation and management from the beginning of the response efforts.
6.3.2. Community outreach and education
TB outbreaks are anxiety-provoking and may be stigmatizing. Often, they take place in a context of limited or inaccurate information about TB and sometimes, negative cultural/historical associations. All these can prolong the outbreak, as lack of recognition of the significance of their symptoms or fear of receiving a diagnosis of TB among individuals can lead to delay in seeking medical care. It is crucial to begin outreach to the affected community and coordinated media communications as early as possible, with information about TB and the outbreak response.118
6.3.3. Community-wide screening
In small remote communities, or sometimes in closed settings/well-defined sub-populations, screening the entire affected community may be a useful strategy to consider when local TB resources are not able to manage multiple overlapping cases and contact investigations in an escalating outbreak. It may also be more efficient if a large proportion of the community has already been identified as contacts. This approach has been used recently in Nunavut and Nunavik, and more loosely in urban homeless populations.
6.3.4. Evaluating the outbreak response and identifying fundamental causes
Ongoing evaluation of process and outcomes will help to refine the outbreak response and ensure adequate resources. Both outbreak response and final policy recommendations should address the specific challenges in social determinants of health and/or behavioral risks that fueled the outbreak. In facility-based outbreaks a systematic assessment of conditions (including ventilation) and infection-control policies and practices may also identify concrete areas for improvement (see also Chapter 14: Prevention and Control of Tuberculosis Transmission in Healthcare Settings). Individual cases can be treated and cured, but it is difficult to contain outbreaks or reduce endemically high rates of TB without addressing the fundamental causes.1,108
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