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Like many communities across the United States, St. Louis, Missouri, faces stark inequities in health outcomes, including wellness, quality of life, and life expectancy. These inequities are the result of social systems and policies that have robbed generations of St. Louisans of opportunity. BJC HealthCare's (BJC's) commitment to becoming a catalyst for community health by helping to eliminate health disparities led to the launch of its community health improvement strategy. This article details the community-driven and evidence-informed process that BJC used to create a multiyear, proactive approach to addressing the social and economic factors that are the root causes of health inequities. It examines areas of opportunity through which the strategy will drive change and explores lessons learned and promising practices for other healthcare institutions to consider as they advance health equity., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2022 Foundation of the American College of Healthcare Executives.)

Background: For a regional project in four low-incidence states, we designed a customizable tuberculosis outbreak response plan. Prior to dissemination of the plan, a tuberculosis outbreak occurred, presenting an opportunity to perform a field assessment of the plan. The purpose of the assessment was to ensure that the plan included essential elements to help public health professionals recognize and respond to outbreaks., Methods: We designed a semi-structured questionnaire and interviewed all key stakeholders involved in the response. We used common themes to assess validity of and identify gaps in the plan. A subset of participants provided structured feedback on the plan., Results: We interviewed 11 public health and six community stakeholders. The assessment demonstrated that (1) almost all of the main response activities were reflected in the plan; (2) the plan added value by providing a definition of a tuberculosis outbreak and guidelines for communication and evaluation. These were areas that lacked written protocols during the actual outbreak response; and (3) basic education about tuberculosis and the interpretation and use of genotyping data were important needs. Stakeholders also suggested adding to the plan questions for evaluation and a section for specific steps to take when an outbreak is suspected., Conclusion: An interactive field assessment of a programmatic tool revealed the value of a systematic outbreak response plan with a standard definition of a tuberculosis outbreak, guidelines for communication and evaluation, and response steps. The assessment highlighted the importance of education and training for tuberculosis in low-incidence areas.

During 1993-2003, incidence of tuberculosis (TB) in the United States decreased 44% and is now occurring at a historic low level (14,874 cases in 2003). The Advisory Council for the Elimination of Tuberculosis has called for a renewed commitment to eliminating TB in the United States, and the Institute of Medicine has published a detailed plan for achieving that goal. In this statement, the American Thoracic Society (ATS), CDC, and the Infectious Diseases Society of America (IDSA) propose recommendations to improve the control and prevention of TB in the United States and to progress toward its elimination. This statement is one in a series issued periodically by the sponsoring organizations to guide the diagnosis, treatment, control, and prevention of TB. This statement supersedes the previous statement by ATS and CDC, which was also supported by IDSA and the American Academy of Pediatrics (AAP). This statement was drafted, after an evidence-based review of the subject, by a panel of representatives of the three sponsoring organizations. AAP, the National Tuberculosis Controllers Association, and the Canadian Thoracic Society were also represented on the panel. This statement integrates recent scientific advances with current epidemiologic data, other recent guidelines from this series, and other sources into a coherent and practical approach to the control of TB in the United States. Although drafted to apply to TB control activities in the United States, this statement might be of use in other countries in which persons with TB generally have access to medical and public health services and resources necessary to make a precise diagnosis of the disease; achieve curative medical treatment; and otherwise provide substantial science-based protection of the population against TB. This statement is aimed at all persons who advocate, plan, and work at controlling and preventing TB in the United States, including persons who formulate public health policy and make decisions about allocation of resources for disease control and health maintenance and directors and staff members of state, county, and local public health agencies throughout the United States charged with control of TB. The audience also includes the full range of medical practitioners, organizations, and institutions involved in the health care of persons in the United States who are at risk for TB.

Beginning in mid-2002, a large tuberculosis outbreak occurred among homeless persons in King County, Washington. In order to further monitor the outbreak following its peak in 2003, Mycobacterium tuberculosis isolates from all new King County tuberculosis (TB) patients in 2004 and the first half of 2005 (n = 220) were genotyped by using a rapid comparative genomics-based (genomic deletion-typing) approach, with confirmation by mycobacterial interspersed repetitive units and repetitive-sequence-based PCR (rep-PCR). Results were compared to retrospective genotypic data from 1995 to 2003. The outbreak strain SBRI9, which was not seen among King County homeless persons prior to 2002, accounted for 16 out of 30 TB cases (53%) within this population in 2002. This trend continued with 27 out of 35 cases (77%) caused by the outbreak strain in 2003, 11 out of 13 cases (85%) caused by the outbreak strain in 2004, and 4 out of 10 cases (40%) caused by the outbreak strain in the first 5 months of 2005. Thus, the outbreak strain remained well established within this homeless population throughout the study period. At least four SBRI9 cases were in people who had previously been infected by other strains. The novel PCR-based strain-typing approach used in this investigation proved to be cost-effective and very rapid. In most cases, it was possible to analyze DNA extracted directly from primary isolation (Mycobacterium growth indicator tube) cultures submitted by clinical laboratories, a feature that markedly reduced the delay between diagnosis and strain typing results. This rapid turnaround facilitated public health efforts to prevent new outbreaks involving this strain.

The N and W-Beijing families of Mycobacterium tuberculosis are phylogenetically closely related. The ability of the W-Beijing family to rapidly cause widespread disease is well described; however, few outbreaks involving the N family have been reported outside the New York City, N.Y., area. During 2002 to 2003, Seattle, Wash., experienced a rapidly expanding tuberculosis outbreak involving 38 persons in a 23-month period. The outbreak strain, SBRI9, exhibited the genotypic properties of the N family. Its IS6110 restriction fragment length polymorphism pattern was identical or nearly identical to those of two N family strains that were responsible for clusters of tuberculosis cases, including a large nosocomial outbreak, in New York City and New Jersey from 1989 to 1990. It was also identical to strains involved in late 1990s tuberculosis cases in Michigan, Maryland, and Arkansas. Further monitoring of the N family may show that it shares with the W-Beijing family the propensity to spread rapidly, suggesting that this characteristic evolved prior to the divergence of the two genetic lineages.

Setting: The proportion of tuberculosis (TB) among foreign-born individuals in the United States is steadily increasing. Treatment of latent TB infection can prevent future cases of disease, although generally only 60% of patients who start a 6-month regimen of isoniazid complete therapy., Objective: Cultural case management--employing case manager cultural mediators who serve patient-defined needs in addition to performing TB control functions--may improve results of testing and treatment in one high-risk group, new refugees., Design: A cultural case management approach was established for finding and treating latent TB infection among three groups of new refugees: from the former Soviet Union (FSU), former Yugoslavia (FY), and Somalia., Results: From July 1999 through December 2000, treatment was offered to 442 refugees, of whom 389 (88%) started and 319 (82%) completed therapy. The completion rate among starters from the FSU was 76%, for those from FY it was 94% and for those from Somalia it was 88%. Among all refugees to whom treatment was offered, 319/442 (72%) completed therapy., Conclusion: Cultural case management may be a useful tool for expanding treatment of latent TB infection among foreign-born individuals.

As we approach 2010, the year by which we were to have eliminated TB, we find this ancient disease is making a comeback. This comeback is due to many factors, but the role of HIV infection is clearly important. HIV infection can result in changes in the pathogenesis and presentation of infection with the tubercle bacillus. Consequently, as health care providers, we must respond with changes in our usual methods of prevention, treatment, and infection control. Whereas the increase in TB is currently limited to certain geographic areas, it is likely to spread more widely. All health care providers should be aware of the changing face of TB and have a high clinical index of suspicion for this disease.

During a two-year period, from January 1984 through December 1985, six cases of intentional overdosage with isoniazid were reported in young Southeast Asian refugee women. The patients were aged 14 to 23 years, had all immigrated within one year and were receiving isoniazid preventive therapy for tuberculosis infection without disease. Clinically, all patients experienced generalized seizures, and three sustained moderate metabolic acidosis. All recovered uneventfully. Psychiatric evaluations revealed that two patients had major depression; two, adjustment disorders with depressed mood; and two, no psychiatric illness. The latter two patients and two others ingested an excessive amount of isoniazid immediately following an argument with a family member. Because tuberculosis infection is prevalent in refugees immigrating from Southeast Asia, isoniazid, given for six months to one year as preventive therapy, is one of the most frequently prescribed drugs during the early resettlement period. There may be an increased risk of intentional isoniazid overdosage during preventive therapy of young refugee women.

Morbidity caused by tuberculosis was determined in a cohort of 9,328 refugees from Southeast Asia during the first 5 yr after their immigration to the United States. The entire cohort was screened at the time of entry, and isoniazid preventive therapy was offered according to ATS-CDC guidelines. During the period of study, 25 cases of tuberculosis were reported from the cohort. The 5-yr cumulative incidence of tuberculosis (26.8 cases per 10,000 in the entire cohort) was greatest in tuberculin-positive refugees who had abnormal screening chest roentgenograms (324.3 cases per 10,000) and least in those with nonsignificant tuberculin reactions (5.0 cases per 10,000). The annual incidence of tuberculosis in the cohort decreased from an estimated 30.6 cases per 10,000 at the time of immigration to less than 5 cases per 10,000 during the fourth and fifth years. The prevalence of resistance to isoniazid was greater in culture-positive cases arising after immigration (7 of 22, 32%) than in those diagnosed at the time of immigration (5 of 36, 14%), probably because of a reduction in isoniazid-susceptible cases by isoniazid preventive therapy. Currently recommended screening and preventive services may be favorably impacting tuberculosis morbidity in newly arriving refugees from Southeast Asia.