TB Manual

The components recommended for TB outbreak response are similar to those for site-based screening in congregate settings, but much expanded in scope and duration:

• An identified outbreak manager, appointed for the duration, with overall responsibility for management and coordination of the outbreak response.

• Public health/TB program nursing staff to coordinate initial work-up and case-management for patients with TB, define infectiousness, coordinate contact investigation and active case finding clinics and provide consultation and communication with others in the field.

• Sufficient field staff to carry out the contact investigation and follow-up, and active case-finding clinics; for outbreaks involving multiple remote communities, mobile specialized teams may be an effective strategy to support local staff.

• Information technology (IT)/database and epidemiologic support. Contact investigation and management in a TB outbreak is very data-intensive. Dedicated epidemiology support is essential for development of effective data-collection strategies and rapid, thoughtful evaluation of the aggregate results as they become available. Tracking hundreds of contacts, often through multiple sites and assessments, demands electronic data collection tools, a good database and IT support.

• Timely WGS is strongly recommended for all TB outbreaks, to confirm case linkages and thereby help focus the response on high-risk locations/populations; analysis of these results and interpretation alongside the epidemiologic investigation data requires strong ongoing collaboration with the supporting laboratory.

• Clear written protocols for all components of the public health outbreak response, including contact investigation, screening clinics, contact management and referral. Clinical protocols for suspected or confirmed TB disease and for contacts should be agreed on by all participating health care partners.

• Training and education on TB for public health staff redeployed to help with outbreak response.

• Education and outreach to health care and social-services partners:

  • Staff in partner organizations may not be experienced in TB work; training and education about TB and TB-related infection control, presentation at medical rounds, etc., at all the organizations involved in the response plan is helpful. In outbreaks among homeless and other marginalized populations, this should include staff at shelters and other homeless services and other low-threshold types of care as they are often critical for early detection of individuals with TB.

  • Ongoing communication to the partner organizations/sectors will help to raise the index of clinical suspicion for TB, provide up-to-date information about the outbreak and help decrease barriers to care, including early hospitalization for individuals being investigated for active TB when necessary. These patients should not return to congregate settings until infectious TB has been ruled out.

• Consistent, coordinated clinical and diagnostic supports with expertise in TB:

  • Prompt, local access to good-quality chest radiography.

  • Identified medical consultants with expertise in TB to review chest radiology, evaluate patients for TB, hospitalize patients if necessary and manage active TB and contact follow-up in a consistent, timely manner; for remote communities, telemedicine links (including review of digital radiology) can be extremely effective.

  • Hospital facilities that can provide airborne isolation rooms, diagnostic examinations and treatment without delay.

  • Links to public health laboratories for specialized supports and consultation (arrangements to handle larger numbers of specimens; genotyping and interpretation, etc.).

  • Rapid and safe transportation of specimens and, if necessary, patients.

  • Written protocols for clinical work-up and management of active TB patients and contacts to ensure a consistent approach across all partners.

• Active case-finding: In outbreaks in congregate settings such as shelters, long-term care facilities or prisons, ongoing symptom screening and cough logs may be useful case detection tools.¹²⁸ As discussed in the main chapter, screening should ideally be on-site for congregate settings (via sputum and/or chest x-ray) to maximize access and participation. If the outbreak involves transient or highly mobile individuals, active case-finding on an ongoing basis over an extended period of time may be the only way to ensure that most contacts are identified and screened. It may be possible to follow infected contacts who refuse or are not eligible for treatment of LTBI through periodic clinical assessment for two years after exposure, in order to detect early TB disease.

  • Outreach plan and staff to carry it out: information about TB, the outbreak response and TB screening should be in languages, formats and venues that are easily accessible to the at-risk community. Standard materials may need to be adapted to the cultural and practical setting, ideally with input from community members. Consider posters, videos, internet, local radio or other media, as well as community meetings and presentations through local community groups or services. Community champions and peer outreach may be helpful to reduce the level of anxiety and enhance participation in screening.

  • Sufficient TB case-management and treatment support staff to provide complete treatment for all patients with active TB disease and LTBI. At least one year’s additional staffing after the outbreak is over may be required. For outbreaks involving patients who move between communities, extra effort should be made to coordinate ongoing TB care between jurisdictions and ensure treatment completion.

  • Logistical support for staffing, supplies, transportation, etc.

  • Communications personnel to provide regular updates to the media and community on the status of the investigation.

  • Program and epidemiology staff and resources to carry out evaluation of outxbreak response.

Community-wide screening seeks to rapidly reduce prevalent infectious TB via active case-finding in an entire population, and usually also to identify and treat the pool of recent contacts with LTBI. It can also help reduce individual stigma, which can be a real stumbling block for contact investigation and follow-up in smaller communities. As an outbreak-response strategy, it is only practical in small, well-defined populations such as remote northern communities, closed settings or more loosely in homeless outbreaks. It is usually done as a single high-intensity event over 6-8 weeks as a “catch-up” effort, particularly in situations where it is difficult to rapidly assess individual level of contact in a close-knit community, or a majority of the community has already been identified as contacts. It has also been used in repeated lower-intensity cycles (eg, annually) as part of a TB elimination strategy in communities with ongoing high TB rates or repeated outbreaks. This approach needs fewer outside staff and smaller working space, but for a longer commitment.^129,130 A recent study using Nunavik data found both single and repeated community-wide screening strategies to be cost-effective in high-incidence remote communities with frequent outbreaks.¹³¹

Community-wide screening takes considerable planning and resources beyond usual program operations; the decision to proceed should be made only after consideration of the broad local health and community context. TB programs should first consider the healthcare capacity and effectiveness of the current outbreak response. Local staff turnover and lack of TB expertise may be a contributing factor and are common challenges in remote communities; it may be sufficient to supplement the local health care team with additional TB-specific nurses, epidemiologic support, among others, for an extended period to manage the increased TB case/contact needs. If this is neither feasible nor sufficient, then community-wide screening may be a realistic strategy.

Community-wide screening should not be undertaken without consultation with and agreement of community leaders, and all components of the healthcare system (local health center, referral hospital, regional health authority, etc). It is essential to ensure that resources are adequate to balance TB and LTBI care needs resulting from the community-wide screening with other healthcare needs in the community; a community-wide screening almost always means pulling TB resources from elsewhere in the system and diverting local healthcare resources from other conditions, some of which may also be in crisis (eg, mental health, addictions, other outbreaks).

In addition to the general outbreak response components recommended above, community-wide screening in remote communities requires consideration of additional logistics:

• Lead time for a community-wide screening in a remote community is generally 3-6 months. An advance team may be needed to arrange/negotiate logistics.

• Accommodation and workspace for visiting staff are usually constrained in small remote communities.

• Clinic site arrangements and set-up: there is usually not enough room in the local health center or hospital; try community centers, school gyms, sewing centers or other large spaces that can be converted to clinic space for several weeks/months. Screening clinic locations need to have adequate ventilation (especially considering there may be active TB cases), running water and toilets, electricity, phone and, ideally, internet access. If a clinic site has to be renovated – which may be a longer-term investment for the community – then construction personnel, building supplies, temporary barriers and office equipment have to be sourced and transported if not locally available.

• Purchasing, transportation, and inventory systems for clinic equipment are needed. These include infection prevention and control supplies, testing equipment and supplies, such as chest x-ray equipment, GeneXpert (a rapid molecular test), TST/IGRA supplies, sputum-induction supplies, etc. Comprehensive planning is critical. In remote communities, use of GeneXpert may shorten time to diagnosis dramatically compared to transporting of sputum specimens to a lab for smear and culture, though both approaches are necessary. Make independent arrangements so as not to stress the local health center’s supply chain. Confirm arrangements for transport of specimens and lab/radiology support, calibration of equipment on set-up and disposal of medical waste.

• Data collection and management: arrange computers and IT support, internet access if possible, connectivity/access to other essential healthcare databases/EMR, radio, phones. Paper versions of forms and records should be available if internet connectivity is unreliable.

• Clinic timing: aim for a period when the largest number of people will be in community; this is often winter.

• Outreach: since the goal is complete community coverage, accurate denominator information is needed; in remote communities this is generally available through the community mayor or housing office. Extensive outreach prior to and during the screening is vital for success, including local champions, local radio/social media, community meetings and door-to-door campaigns providing information and invitations to participate.

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