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Tuberculosis in the Workplace G Recommendations of the Institute of Medicine Committee on Eliminating Tuberculosis in the United States1 Recommendation 3.1 To permanently interrupt the transmission of tuberculosis and prevent the emergence of multidrug-resistant tuberculosis, the committee recommends that All states have health regulations that mandate completion of therapy (treatment to cure) for all patients with active tuberculosis. All treatment be administered in the context of patient-centered programs that are based on individual patient characteristics. Such programs must be the standard of care for patients with tuberculosis in all settings. Recommendation 3.2 To ensure the most efficient application of existing resources, the committee recommends that New program standards be developed and used by CDC [Centers for Disease Control and Prevention] and state and local health departments to evaluate program performance. Standardized, flexible case management systems be developed to provide the information needed for the evaluation measurements. These systems should be integrated with existing case management systems and other automated public health data systems whenever possible. 1 Institute of Medicine. Ending Neglect: The Elimination of Tuberculosis in the United States Geiter L, ed. Washington DC: National Academy Press, 2000, pp. 6–12.
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Tuberculosis in the Workplace Recommendation 3.3 To make further progress toward the elimination of tuberculosis in regions of the country experiencing low rates of disease, the committee recommends that Tuberculosis elimination activities be regionalized through a combination of federal and multistate initiatives to provide better access to and more efficient utilization of clinical, epidemiological, and other technical services. Protocols and action plans be developed jointly by CDC and the states for use by state and local health departments to enable planning for the availability of adequate resources. State and local health departments develop case management plans to ensure a uniform high quality of care for patients with tuberculosis and tuberculosis infection in their jurisdictions. Recommendation 3.4 To maintain quality in tuberculosis care and control services in an era of increased use of managed care systems and privatization of services, the committee recommends that When it is determined that tuberculosis diagnosis and treatment services can be provided more efficiently outside of the public health department, the delivery of such services be governed by well-designed contracts that specify performance measures and responsibilities. Federal categorical funding for tuberculosis control be retained. Funding at the local level should provide sufficient dedicated resources for tuberculosis control but should be structured to provide maximum flexibility and efficiency. Both public and private health insurance programs be billed for tuberculosis diagnostic and treatment services whenever possible, but tuberculosis services should never be denied due to a patient’s inability to make a co-payment. Recommendation 3.5 To promote a well-trained medical (in a broad sense) workforce and educated public, the committee recommends that The Strategic Plan for Tuberculosis Training and Education, which contains the blueprint that addresses the training and educational needs for tuberculosis control, be fully funded. Programs for the education of patients with tuberculosis be developed and funded. Funding be provided for government, academic, and nongovernmental agencies to work in collaboration with international partners to develop training and educational materials. Recommendation 4.1 To limit the spread of tuberculosis from infectious patients to their contacts, the committee recommends that more
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Tuberculosis in the Workplace effective methodologies for the identification of persons with recently acquired tuberculosis infection, especially persons exposed to patients with new cases of tuberculosis, be developed and efforts be increased to evaluate appropriately and treat latent infection in all persons who meet the criteria for treatment for such infections. Recommendation 4.2 To prevent the development of tuberculosis among individuals with latent tuberculosis infection, the committee recommends that Tuberculin skin testing be required as part of the medical evaluation for immigrant visa applicants from countries with high rates of tuberculosis, a Class B4 immigration waiver designation be created for persons with normal chest radiographs and positive tuberculin skin tests, and all tuberculin-positive Class B immigrants be required to undergo an evaluation for tuberculosis and, when indicated, complete an approved course of treatment for latent infection before receiving a permanent residency card (“green card”). Implementation should be in a step wise fashion, and pilot programs should evaluate strategies and assess costs. Tuberculin testing be required of all inmates of correctional facilities and completion of an approved course of treatment, when indicated, be required, with referral to the appropriate public health agency for all inmates released before completion of treatment. Programs of targeted tuberculin skin testing and treatment of latent infection be increased for high-incidence groups, such as HlV-infected individuals, undocumented immigrants, homeless individuals, and intravenous drug abusers, as determined by local epidemiological circumstances. Recommendation 5.1 To advance the development of tuberculosis vaccines, the committee recommends that the plans outlined in the Blueprint for Tuberculosis Vaccine Development, published by NIH [National Institutes of Health] in 1998, be fully implemented. Recommendation 5.2 To advance the development of diagnostic tests and new drugs for both latent infection and active disease, action plans should be developed and implemented. CDC should then exploit its expertise in population-based research to evaluate and define the role of promising products. Recommendation 5.3 To promote better understanding of patient and provider nonadherence with tuberculosis treatment recommendations and guidelines, a plan for a behavioral and social science research agenda should be developed and implemented.
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Tuberculosis in the Workplace Recommendation 5.4 To encourage private-sector product development, the global market for tuberculosis diagnostic tests, drugs, and vaccines should be better characterized and access to these markets for these new products should be facilitated. Recommendation 5.5 To define the applicability of any new tools to the international arena and facilitate their development, the U.S. Agency for International Development (AID), NIH, and CDC should build upon international relationships and expertise to conduct research. Recommendation 6.1 To decrease the number of foreign-born individuals with tuberculosis in the United States, to minimize the spread and impact of multidrug-resistant tuberculosis, and to improve global health, the committee recommends that The United States expand and strengthen its role in global tuberculosis control efforts, contributing to these efforts in a substantial manner through bilateral and multilateral international efforts. The United States contribute to global tuberculosis control efforts through targeted use of financial, technical, and human resources and research, all guided by a carefully considered strategic plan. The United States work in close coordination with other government and international agencies. In particular, the United States should continue its active role in and support of the Stop TB Initiative. AID, CDC, and NIH should jointly develop and publish strategic plans to guide U.S. involvement in global tuberculosis control efforts. Recommendation 7.1 To build public support and sustain public interest and commitment to the elimination of tuberculosis, the committee recommends that CDC significantly increase resources for activities to secure and sustain public understanding and support for tuberculosis elimination efforts at the national, state, and local levels, including programs to increase knowledge among targeted groups of the general public. Recommendation 7.2 To increase the effectiveness of mobilization efforts the committee recommends that the National Coalition for the Elimination of Tuberculosis continue to provide leadership and oversight and that CDC continue to work in collaboration with the coalition to secure the support and participation of nontraditional public health partners, ensure the development of state and local coalitions, and evaluate public understanding and support for tuberculosis elimination efforts with the assistance of public opinion research experts.
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Tuberculosis in the Workplace Recommendation 7.3 To assess the impacts of these recommendations and to measure progress toward accomplishing the elimination of tuberculosis, the committee recommends that, 3 years after the publication of this report and periodically thereafter, the Office of the Secretary of Health and Human Services conduct an evaluation of the actions taken in response to the recommendations in this report.
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