Population growth and changing demographics in Commonwealth.

Larger number of foreign born residents; newcomers increasingly from countries with high TB rates.

Newcomers settling in areas of the state where local support services are limited.

Significant numbers of international visitors, students, undocumented aliens – i.e., non-citizen, non-
permanent residents with limited eligibility for services - are entering state.

Virginia residents (permanent and non-permanent) increasingly travel between US and high TB prevalence countries, so have repeated opportunities for exposure to TB.
TB in usually productive, employed adults may result in loss of job, sudden poverty, loss of housing, lack of funds for necessities (e.g., groceries) for patient and family. Support services are limited or unavailable for other than citizens and legal permanent residents.

Persons with serious underlying medical conditions (HIV infection, diabetes, end stage renal disease,
collagen-vascular diseases) are surviving longer, so have more years at risk for re-activating latent TB infection or progressing to active TB if newly infected. Immunocompromised patients with TB may be more difficult to diagnose (increasing opportunities for transmission to others) and are more difficult to manage.

National and state standards for the management of TB cases and their contacts are increasingly effective
in curing patients and limiting transmission, but are also increasingly labor intensive and costly.

The majority of TB patients are underinsured or uninsured, limiting access to health care services in the
private sector.

Public health services at the district and local level are uneven across the Commonwealth and very limited
in several districts.

Fewer Public Health Nurses and other local health department personnel with TB management experience.

Few regional TB clinics remain.

Few private sector health care providers with experience or interest in TB.

English speaking clients with limited literacy and non-English speaking clients make case management and patient education difficult.

Some re-centralization of TB prevention and control services (i.e., return of some consultation,
involvement in contact investigations, assistance to districts in collecting data for surveillance systems) is
occurring. Balancing local needs and resources with state requirements and resources is and will be an
ongoing activity at both the central office and in the districts.

Federal funding is likely to remain level or decrease, and Cooperative Agreement funds are increasingly
categorical – i.e., with very specific requirements or restrictions on activities for which the funds may be used.

Greater need for services to be ethnically and linguistically diverse.

Greater emphasis on program evaluation.

Changing public health workforce (e.g., smaller numbers of workers, fewer physicians and nurses) at a time of increasing pressure to meet standards of care will force re-evaluation of how and by whom TB prevention and control services are provided.

The public health workforce has increasing and diverse responsibilities. TB prevention and control services at the local level must compete with other mandated/high priority activities.

• Consultation and Technical Assistance Consultation on TB prevention, diagnosis and treatment for health departments and health care providers in the public and private sector Consultation on health screening of refugees and asylees Development of guidelines and procedures related to core mission – examples include contact investigation and sputum collection guidelines Development of products to facilitate service delivery – examples include TB record forms, risk assessment tools, investigation and evaluation algorithms Technical assistance to hospitals, clinics, long term care facilities, congregate living facilities, health departments and other facilities on matters related to facility design and maintenance, TB screening of employees and clients, and investigation of exposures Implementation of statutory and regulatory requirements by development and publication of policies, procedures, and guidelines
• Direct Assistance Direct assistance to health departments to assess possible outbreaks and facilitate large contact investigations Coordination of referrals and information exchange for cases, suspected cases, contacts and other clients who move in or out of Virginia. Facilitate communication between local health districts for those moving within Virginia Support (personnel and financial) for health departments to ensure that CDC mandated activities are carried out at the local level Support (personnel and financial) for health departments experiencing increased numbers of TB cases Direct assistance in management of difficult cases with complicating factors such as homelessness
• Education and Training Activities Provision of training for health care providers in public and private sectors Development and dissemination of educational materials for patients and the public – English and other languages to meet needs of patients and the public. Examples include pamphlets, fact sheets, web site, media presentations. Preparation of informational materials for elected officials and other decision-makers. Serve as speakers at conferences and meetings on matters related to TB prevention and control and refugee health conditions of public health importance. Development of fact sheets, press releases, interviews, other products as required to address media requests.
• Planning and Evaluation Periodic evaluation of local district TB prevention and control activities. Production of reports for local, regional and national use in TB program planning and evaluation. Participation in local, regional and national TB control planning activities. Participation in local, regional and national refugee resettlement planning and evaluation activities.
• Surveillance and Data Analysis Collection of TB case reports and other surveillance data from health departments; verification of data; data analysis; transmission of data for inclusion in the national TB registry. Collection of data on health screening of refugees and asylees from local health departments; verification of data; data analysis; production of reports for local, regional and national use in program planning and evaluation.

Objective Description

Reducing the incidence of TB disease is critical to achieving eventual elimination of the disease. TB is an airborne disease that is transmitted from person to person. Transmission can occur when a patient with TB disease of the lungs coughs TB bacteria into the air. A person in close contact with the patient can breathe the TB bacteria into his lungs and become infected. That person may also develop active TB, and may transmit infection to others, or may develop latent infection – i.e., TB infection that is limited so the person is not sick. The person with latent infection may develop active (and potentially infectious TB) later in life.

Objective Strategies

Objective Measures