ProposedTemplateTBOutbreakResponsePlans.doc

1、model tuberculosis outbreak response planfor low-incidence areas- a customizable template -august 2006revised august 15, 2007prepared bykaren r steingart, md, mph, medical advisorfrancis j. curry national tuberculosis center a project of task order #6, regional capacity-building in low-incidence are

2、as,funded and supported by the tuberculosis epidemiologic studies consortium, centers for disease control and preventionfrancis j. currynationaltuberculosiscenter2acknowledgmentswe wish to thank dr. charles nolan and representatives from idaho, montana, utah, andwyoming state tb programs; central di

3、strict health department, boise, idaho; and the centers for disease control and prevention division of tuberculosis elimination for their vitalcontributions in the preparation of this plan. we also thank phil griffin, denise ingman,evelyn lancaster, masa narita, carol pozik, dawn tuckey, ruth west,

4、and jan young fortheir help in launching this project. about the coveradvances in molecular epidemiology and an increasing focus on hard-to-reach, high-riskgroups have required new ways of thinking about outbreaks. social network models arebeing explored for the potential to reveal hidden routes of

5、transmission, to prioritize contactinvestigations, and to portray the scope of outbreaks. in this fictitious network, cases oftuberculosis (dark grey) share connections to contacts (white), while both share connectionsto homeless shelters.abbreviations centers for disease control and prevention (cdc

6、); contact investigation (ci); directly observed therapy (dot); division of tuberculosis elimination (dtbe); human immunodeficiency virus (hiv); latent tuberculosis infection (ltbi); tb outbreak response plan (orp); tb outbreak response team (tort); quantiferon-tb gold (qft-g); tuberculin skin test

7、(tst); tuberculosis (tb)tips for customizing and printing1. the entire template was created using microsoft word 2003. it is an “un-protected” word document.2. suggested sections for jurisdictional customization are highlighted in yellow and bracketed.3. all body text fonts are set in “normal” style

8、 and font size is 12 (notes and sources 10; urls 9). 4. the exceptions from the “normal” style are with the sections top headings (in roman numerals), sub-headings (in letters), and appendices. 5. the template is viewed as an 8.5x11 document and can be printed as such.6. to print in booklet format,

9、set your printers setting to the following: double-sided, booklet format, left legal binding, and legal size paper (8.5x14). we welcome your feedback; please send comments and suggestions to: karen r steingart, md, mph 3table of contentspurpose and definition for tb outbreak.

10、4initiating the outbreak response plan.5goals of outbreak response.5legal authority.5composition of the tb outbreak response team.5notification and request for assistance8local and state public health responsibilities.9data management.10internal and external communication.10training and education.11

11、community partnerships11evaluation.11de-activation of the tb outbreak response plan11glossary of terms for tb outbreak and contact investigation. 12references.16appendix a ten steps to take when a tb outbreak is suspected.17appendix b exceptional tb circumstances.18appendix c state and local laws an

12、d regulations19appendix d risk communication checklist20appendix e evaluation checklist.22appendix f de-activation checklist.234the tuberculosis (tb) outbreak response plan (orp) includes the following sections: purpose, indications for initiating the response plan, legal authority, composition of t

13、he response team, notification procedures, local and state public health responsibilities, data management, communication, training and education, community partnerships, evaluation, de-activation, and glossary. guidelines for contact investigations (cis) are provided in the tb manual, another proje

14、ct of task order 6.i. purposethe purpose of the orp is to ensure comprehensive and timely response to a tb outbreak. a. definition for tb outbreakdefinitions for tb outbreak are relative to the local context. outbreak cases can be distinguished from other cases only when certain associations in time

15、, location, patient characteristics, or mycobacterium tuberculosis attributes (e.g., drug resistance or genotype) become apparent. in low-incidence jurisdictions, any temporal cluster of cases is suspicious for an outbreak. a working definition for a potential tb outbreak is helpful for planning and

16、 response and may include any of the following six criteria: criteria based on surveillance* and epidemiology: an increase has occurred above the expected number of tb casesduring and because of a contact investigation (ci), two or more contacts are identified as having tb disease, regardless of the

17、ir assigned priority, (i.e., high-, medium-, or low-priority)any two or more cases occurring within one year of each other are discovered to be linked, and the linkage is established outside of a ci (e.g., two patients who received a diagnosis of tb disease outside of a ci are found to work in the s

18、ame office and only one or neither of the persons was listed as a contact to the other)a genotyping cluster leads to discovery of one or more verified transmission links which were missed during a ci within the prior two yearsnote: a protocol for investigating a genotyping cluster is under developme

19、nt and will be added as an appendix when available.criteria based on program resources: transmission is continuing despite adequate control efforts by the tb control program ci associated with increased cases requires additional outside help*surveillance is the ongoing, systematic collection, analys

20、is, and interpretation of data essential to the planning, implementation, and evaluation of public health practice, closely integrated with the timely dissemination of these data to those responsible for prevention and control. tb surveillance includes regular review of cases; epidemiologic, program

21、, and genotyping data; and findings from cis. surveillance is an essential component of tb outbreak planning.5b. suspected tb outbreaka tb outbreak may be suspected on the basis of information from diverse sources, including tb case reports, cis, routine surveillance, and genotyping data. because of

22、 the possibility of uncertainty as to whether an outbreak has occurred, it is helpful to define some initial activities which can be put into place while seeking additional information. appendix a suggests ten initial steps to take when a tb outbreak is suspected.ii. initiating the outbreak response

23、 plan the state tb program manager/controller after consultation with and the local tb controller will declare a tb outbreak and initiate the orp. the decision to declare a tb outbreak and initiate the orp will be based on the criteria for tb outbreak above. note: every situation involving ongoing t

24、b transmission has its unique set of special factors. therefore, although all situations meeting criteria for “tb outbreak” merit increased scrutiny and consideration, they may not require initiation of the orp. some situations meeting criteria for “tb outbreak” may be resolved by standard program o

25、perations. appendix b lists examples of “exceptional tb circumstances,” defined as situations that merit additional scrutiny and discussion, but are not specifically addressed in the above criteria for tb outbreak. an exceptional tb circumstance may prompt initiation of the orp. alternatively, an ex

26、ceptional tb circumstance may be resolved by standard program operations and not require initiation of the orp.iii. goals of outbreak repsonse identify all tb casesinitiate ci in a timely manneridentify infected persons for evaluation (for disease and treatment of latent tuberculosis infection ltbi)

27、 and ensure appropriate follow-upiv. legal authority authority will remain with the local tb controller see appendix c, “state and local laws and regulations”.note: in the event of a tb outbreak, authority for local tb control efforts should be established based on availability of resources and abil

28、ity of the local tb program to implement activities and programmatic changes needed to interrupt tb transmission. such decisions will be made after discussion between state and local public health authorities. v. composition of the tb outbreak response team (tort) a. state tb program manager/control

29、ler - makes decision to initiate orp provides leadership and overall management of activities of tortprovides, along with local tb controller, recommendations related to tb response, including decisions about legal issuesprovides clinical and public health guidance (e.g., guidance for ci, isolation,

30、 and infection control) to tort, local public health staff, and community providersreviews all reports, publications, and other documents related to tb response prior to use or distributionconvenes team for evaluation of outbreak responsemaintains communication with coordinates inter-jurisdictional

31、communication, including provider alerts and advisoriesmay serve as primary media spokespersonb. local tb controllermakes decision along with local tb program staff to request assistance from state provides final decisions related to tb response, including legal issues provides clinical and public h

32、ealth guidance (e.g., guidance for ci, isolation, and infection control) to local public health staff and community providers reviews all reports, publications, and other documents related to tb response prior to use or distributionmaintains communication with coordinates intra-jurisdictional commun

33、ication, including provider alerts and advisories may serve as primary media spokespersonc. state public health laboratory representative conducts routine and specialized testingprovides collection kits and forms for clinical specimens as neededanalyzes samplessends isolates to california department

34、 of health services genotyping laboratoryreports test results to state tb program manager/controller, local tb controller, and primary health care providermaintains communication with state tb program manager/controllernote: a representative from the state public health laboratory is a vital member

35、of the tort. the state publichealth laboratory can ensure that clinicians and public health agencies within their jurisdiction have readyaccess to reliable laboratory tests for diagnosis and treatment of tb. 7d. state epidemiologist requests assistance from the centers for disease control and preven

36、tion (cdc) provides guidance for data management of tb cases and contacts (e.g., oversees epidemiologic analysis) and evaluation of outbreak responseensures quality of ongoing tb surveillance and genotyping dataprepares communications and written reports related to outbreak responsemaintains communi

37、cation with state tb program manager/controllere. state epidemiology program specialist (idaho)ensures quality of ongoing tb surveillance and genotyping dataprovides recommendations to local public health on tb case management and cifacilitates tb education and training prepares communications and w

38、ritten reports related to outbreak responsemaintains communication with state tb controllerf. local epidemiologist investigates and reports suspected and confirmed tb cases to stateconducts cis (see “l(fā)ocal public health nurse” below)manages data for tb cases and contactsmay serve as liaison to commu

39、nity providersprepares communications and written reports related to outbreak responsemaintains communication with local tb controller g. state tb nurse consultant serves as primary liaison with local public health staff involved in outbreak responseprovides recommendations to local public health st

40、aff on tb case management, cis, infection control, and legal issues facilitates tb education and training prepares communications and written reports related to outbreak responsemaintains communication with state tb program managerh. local public health nurseinvestigates and reports suspected and co

41、nfirmed tb cases to state. provides tb case management and directly observed therapy (dot); documents all laboratory reports (e.g., smear, culture, susceptibility, nucleic acid amplification tests, hiv status, genotyping)conducts cis, specifically: identifies, interviews, and evaluates contacts by p

42、erforming symptom screen and initial and follow-up tests for tb infection (i.e., tuberculin skin test tst or interferon-gamma release assay); obtains chest x-ray if contact has symptoms and/or positive test for tb infection; determines contacts eligible for 8treatment of ltbi and window prophylaxis;

43、 and ensures safe treatment for persons with ltbi (see ci guidelines in the tb program manual) note: cdc recommends quantiferon-tb gold (qft-g) may be used in all circumstances in which the tst is currently used, including ci. for a person with recent contact with an infectious tb case, a negative q

44、ft-g result should be confirmed with a repeat test 8-10 weeks after the end of exposure, as is recommended for a negative tst result.provides incentives/enablers for tb cases and persons with ltbiadvises about infection controlprovides education to other public health staff and the communitymay assi

45、st with media communicationmaintains communication with local tb controlleri. public information officer (state and local; see section viii and appendix d)coordinates all public information activitiesmay assist with provider alerts and advisoriesmay assist with internal communicationmaintains commun

46、ication with state tb program manager/controller and local tb controllerj. support personnelprovide logistical and administrative support to tortarrange for acquisition and delivery of additional supplies and servicesk. sources of additional staffing additional personnel from other state and local p

47、ublic health programs may be required to support the functions listed above. examples of positions include: outbreak coordinator; nurse to oversee ci, testing for tb infection, and treatment for ltbi; outreach workers; and health education specialists. staff may be needed to fill above roles when ot

48、hers involved in outbreak response become overwhelmed note: state and local jurisdictions should consider planning in advance for additional personnel and providing the appropriate education and training.vi. notification and request for assistancea. local public health notification to state public h

49、ealth will notify state tb program manager/controller or designee by phone immediately when tb outbreak is suspected. b. state public health notification to cdc will notify area cdc tb program specialist by phone, email or fax when a tb outbreak is suspected or 9confirmed . c. request for assistance

50、 from cdcassistance from cdc division of tb elimination (dtbe) is available at three levels:telephone consultationprogram management with on-site assistanceon-site outbreak investigation (epi-aid); the request for an epi-aid must be made by the state epidemiologistnote: notification to dtbe is impor

51、tant for documenting tb outbreaks as the u.s. moves toward the goal of tb elimination. in addition to providing assistance for tb outbreaks within a state or local jurisdiction, the dtbe is experienced in conducting tb outbreak investigations that cross geographic and political boundaries (e.g., dom

52、estic outbreaks that involve multiple states, domestic outbreaks that involve other countries, and outbreaks that occur in u.s. government facilities).vii. local and state public health responsibilitiesa. local public health agency responsibilitiesestablish authority, in collaboration with state pub

53、lic health agencies, for responsebuild consensus with state and other tb control advisors regarding responseestablish accountable systems of communication, evaluation, response and tracking of tb cases and contactsnotify appropriate state officialsdesignate media spokespersonensure sufficient number

54、 of trained staff for response as resources ensure the following response activities: ci; data management; collection and transport of laboratory specimens; tests for tb infection; infection control; education and training for community health providers and affected groups (e.g., parents, employees,

55、 employers, schools, organizations) request assistance from state provide a list of available isolation resources if needed, including list and location of airborne infection isolation rooms in the local jurisdiction facilitate education and training for community health providers and affected group

56、s (e.g., parents, employees, employers, schools, organizations)designate liaison to local law enforcementdesignate liaison for logisticsb. state public health agency responsibilities establish authority, in collaboration with local public health agencies, for responsebuild consensus with local and o

57、ther tb control advisors regarding responsemonitor response activitiesnotify appropriate cdc officials10provide periodic epidemiologic and other response-related reportsdesignate media spokespersonensure appropriate laboratory testing, including genotyping, and specimen transportprovide consultation

58、 and onsite assistance to local public health, as resources allow, for the following response activities: ci; data management; collection and transport of laboratory specimens; tests for tb infection; infection control; education and training for community health providers and affected groups (e.g.,

59、 parents, employees, employers, schools, organizations) assist local public health in procuring resources needed for outbreak response (e.g., personal protective equipment, interpreters, translated patient education materials, isolation facilities, laboratory resources, drugs) request assistance fro

60、m cdc or assist in finding additional resources needed for outbreak response activitiesimplement other activities as recommended by cdcviii. data managementmaintenance of data is crucial to all aspects of the outbreak response and cis. data should be collected for cases and contacts by using standar