Proponents say reporting infections may wipe out TB in low-prevalence areas
Mandatory registries may find reservoirs of infection
Making TB infection a reportable condition isn’t commonplace among TB control programs in the United States — not yet, anyway. But in low-prevalence areas, where there are fewer actual cases to report, boosters of the idea say mandating reporting of TB infection offers some big advantages.
"If we’re serious about eliminating this disease, we certainly need to start looking harder at the reservoirs of infection," says Vic Tomlinson, chief of TB control for the Missouri Department of Health in Jefferson City.
Plenty of states and counties already keep infection registries based on voluntary names reporting. In addition, many jurisdictions require reporting for children under age 14. In a low-incidence era, extending the reporting requirement to all positive reactors is the logical next step toward elimination, proponents argue.
For one thing, having a law on the books about infection reporting helps increase awareness of an increasingly low-profile disease, says Jim Pruitt, assistant section chief of Missouri’s Division of Vaccine-Preventable and Tuberculosis Disease Elimination. "We really don’t see that many cases anymore, except in places like St. Louis and Kansas City," he says. "This is a good way to keep people thinking TB.’"
That goes for the public as well. "Legislators and funders often have trouble understanding why you need more money for TB when cases are down," says Tomlinson. "It makes a big difference if you can show them some data."
In Washington state’s Tacoma/Pierce County, where a new infection reporting requirement went into effect March 1, health department officials are gung-ho about the new policy. "A lot of this is about raising awareness and teaching [providers] about the importance of screening," says Dian Sharma, PhD, senior epidemiologist for the Pierce County health department. "This is about how to apply a PPD and how to read it. It’s about helping providers understand why, if someone needs isoniazid, seeing they get it and monitoring for complications [is crucial]."
When it comes to establishing stronger ties to the community, Pierce County has a bigger stake than most places do. In 1996, as part of a cost-savings decision, the county health department shut down all its categorical TB clinics, contracting for services with private clinics and a local infectious disease group.
Redefining role of public health
As a result, the role of the public health department has shifted dramatically, Sharma says. "We were so busy sticking needles in peoples’ arms that we’d lost site of our true mission," she says. "Now that we’ve come down out of our ivory towers, we’re finding there’s clinical care taking place in hundreds of doctors’ offices. It was foolish for us to have thought we were the center of all that."
That’s not to say the notion of making TB infection reportable strikes everyone as a terrific idea. "In Florida, there are probably tens of thousands of people found infectious each year," says Heather Duncan, senior public health adviser for Florida’s Bureau of TB and Refugee Health. "Our state system couldn’t handle that. If it were some tiny county without many cases, and the resources to do it — well, maybe then it would make sense."
Charles DeGraw, head of the Louisiana TB control section, agrees. "There are 250,000 people in this state who are infected," he says. Processing the extra volume "would be physically impossible," he adds. "We absolutely couldn’t do it."
In Indiana, the state health department has decided to ditch its reporting requirement for TB infections. "Asymptomatic TB infection isn’t a public health threat, and few of these individuals go on to develop disease," says Paul Britton, state TB controller.
Plus, a lot of reactions reported are false positives, he says. "The data mostly just sits there," he says. "We decided the administrative burden wasn’t justified by what we gained in epidemiology."
As for Duncan and DeGraw’s concerns, Tomlinson points out that not everyone starts reporting at the same time. "Here, it’s been an evolving process," he explains. "Not everyone reports just because it’s reportable. But the more we get out the word, the better reporting has become."
In 1994, for example, 4,300 instances of infection were reported. Numbers have been rising more or less steadily so that by the end of 1999, they had reached 6,000. "It is some work," says Lynelle Phillips, RN, MPH, nurse consultant to the state TB program. "But local and district health departments have nothing but good things to say about [the reporting requirement]. They like to know what’s going on."
As far as epidemiology and surveillance, Missouri TB controllers predict a future in which keeping track of infections assumes increasing importance. "As disease continues to decline, and cases become harder to find, TB infection more and more will become a sentinel event," says Phillips. "Keeping a registry is the way to find out where those reservoirs of infection are, so we can target populations at risk."
Just as some TB controllers worry about having to enter so much data, physicians and health care providers fret at the prospect of yet another form to fill out. When Pierce County public health officials asked physicians to name potential obstacles to compliance, most replied: "paperwork." So Pierce County TB controllers are determined to that keep that part to a minimum; physicians need only phone or fax in the patient’s name, at which point a nurse practitioner will call back and gather the rest of the information.
Missouri health care providers don’t have it so cushy. They have to fill out two sides of a form: the front upon discovery of the infection, and the back upon completion of treatment.
Fears for privacy, not paperwork
In Pierce County, protests, not paperwork, have claimed the spotlight lately. A group of Seattle-based activists calling themselves "Resist the List" say they’re afraid the new reporting requirement will scare people away from seeking treatment or be used unfairly to target immigrants and people with AIDS.
Sharma tells them the new law won’t mean an invasion of patients’ privacy, just better care. "No," she told one anxious caller, "this law doesn’t mean someone will call you or come to your house." All that would happen is a nurse practitioner would call the reporting physician and run through a checklist:
• Why did you decide to screen this person for infection?
• How did you read the skin test?
• If it was positive, did you do a history and physical?
• Based on the results, have you determined whether to provide prophylaxis?
As much as reporting infections now helps with case management, Tomlinson thinks it will help more in the future. "We’re still working on ways to better prioritize our data and to improve follow-up. As our incidence of cases continues to drop, this is where we’ll be spending more time."
If, as state officials are considering, Washington follows Pierce County’s lead and makes infection reportable statewide, the concept certainly will get a good workout. Estimates put the number of latent infections in the state at more than 300,000.
That thought doesn’t faze Sharma. "Our approach has always been to say that if you never ask the questions, you’ll never know what the workload truly is, and you’ll never get the information," she says. "This is the way we go ahead and ask."
You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content