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## Complete Summary

#### GUIDELINE TITLE

Controlling tuberculosis in the United States. Recommendations from the
American Thoracic Society, CDC, and the Infectious Diseases Society of
America.

#### BIBLIOGRAPHIC SOURCE(S)

Taylor Z, Nolan CM, Blumberg HM. Controlling tuberculosis in the United
States. Recommendations from the American Thoracic Society, CDC, and the
Infectious Diseases Society of America. MMWR Recomm Rep 2005 Nov
4;54(RR-12):1-81. \[441 references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16267499)

#### GUIDELINE STATUS

This is the current release of the guideline.

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Tuberculosis

#### GUIDELINE CATEGORY

Diagnosis\
Prevention\
Risk Assessment\
Screening\
Treatment

#### CLINICAL SPECIALTY

Family Practice\
Infectious Diseases\
Internal Medicine\
Pediatrics\
Preventive Medicine\
Pulmonary Medicine

#### INTENDED USERS

Advanced Practice Nurses\
Allied Health Personnel\
Health Care Providers\
Nurses\
Physician Assistants\
Physicians\
Public Health Departments\
Respiratory Care Practitioners\
Utilization Management

#### GUIDELINE OBJECTIVE(S)

To improve the control and prevention of tuberculosis in the United
States and to progress towards its elimination

#### TARGET POPULATION

People in the United States who are at risk for tuberculosis

#### INTERVENTIONS AND PRACTICES CONSIDERED

**Diagnosis**

1.  Chest radiograph

2.  Tuberculin skin test

3.  Acid-fast bacilli (AFB) smear/culture

4.  *Mycobacterium tuberculosis* genotyping

5.  Laboratory services and testing

**Prevention/Screening/Risk Assessment**

1.  Identification of persons at high risk for tuberculosis, contacts,
    and persons with latent tuberculosis infection (LTBI)

2.  Contact investigation

3.  Infection-control measures in high risk settings

4.  Tuberculosis training and education

5.  Targeted testing and timely reporting

6.  Human immunodeficiency virus (HIV) testing

**Treatment**

1.  Chemotherapy (isoniazid, rifampin, ethambutol, and pyrazinamide)

2.  Directly observed therapy

**Management**

Planning for TB control among specific populations, including children
and adolescents, foreign-born persons, HIV-infected persons, homeless
persons, and detainees and prisoners, and in high-risk settings,
including health-care facilities

#### MAJOR OUTCOMES CONSIDERED

-   Cases of tuberculosis detected through screening

-   Rates of tuberculosis

-   Morbidity and mortality caused by tuberculosis

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

Not stated

#### NUMBER OF SOURCE DOCUMENTS

Not stated

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Weighting According to a Rating Scheme (Scheme Given)

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

**Quality of Evidence**

I.  Evidence from at least one randomized, controlled trial

II. Evidence from 1) at least one well-designed clinical trial, without
    randomization; 2) cohort or case-controlled analytic studies; 3)
    multiple time-series; or 4) dramatic results from uncontrolled
    experiments

III. Evidence from opinions of respected authorities, on the basis of
     cumulative public health experience, descriptive studies, or
     reports of expert committees

#### METHODS USED TO ANALYZE THE EVIDENCE

Review of Published Meta-Analyses\
Systematic Review

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

Not stated

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

This statement was drafted, after an evidence-based review of the
subject, by a panel of representatives of the three sponsoring
organizations. The American Academy of Pediatrics (AAP), the National
Tuberculosis Controllers Association (NTCA), and the Canadian Thoracic
Society were also represented on the panel.

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

**Strength of Recommendation**

A.  Highly recommended in all circumstances

B.  Recommended; implementation might be dependent on resource
    availability

C.  Might be considered under exceptional circumstances

**Note**: No rating was assigned to recommendations that are considered
to be standard practice **(SP)** (i.e., medical or administrative
practices conducted routinely by qualified persons who are experienced
in their fields).

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

External Peer Review\
Internal Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

Not stated

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

Definitions of the strength of the recommendations (A-C) and quality of
evidence (I-III) are provided at the end of the \"Major
Recommendations\" field.

**Note**: No rating was assigned to recommendations that are considered
to be standard practice (**SP**) (i.e., medical or administrative
practices conducted routinely by qualified persons who are experienced
in their fields).

**[Recommendations for Tuberculosis (TB) Laboratory
Services]{.underline}**

-   Laboratorians, clinicians, and public health officials should work
    together to develop an integrated system that ensures timely
    laboratory testing and flow of information among laboratorians,
    clinicians, and TB controllers **(AIII)**.

-   Public health laboratorians should take a leadership role to develop
    the laboratory system and assure that essential laboratory tests for
    TB control are available, accessible, standardized, reproducible,
    and with high sensitivity and specificity **(AII)**.

-   Public health laboratories should educate laboratory staffs,
    health-care providers, and public health officials about the most
    effective uses of clinical microbiologic laboratory services. Such
    activities might include education programs, development of
    web-based or written materials, or direct consultation (standard
    practice \[**SP**\]).

-   All microbiology laboratories should subscribe to specified
    turnaround times (Box 2 in the original guideline document) from
    date of specimen collection to date when the following results are
    reported:

    -   Acid-fast microscopy: [\<]{.underline}24 hours

    -   Growth detection of mycobacteria in culture: [\<]{.underline}14
        days

    -   Identification of *Mycobacterium tuberculosis* complex:
        [\<]{.underline}21 days

    -   Drug susceptibility testing: [\<]{.underline}30 days (**AII**)

-   The following laboratory results should be reported immediately
    (preferably by electronic or fax transmission) by the testing
    laboratory to the responsible clinician and to the jurisdictional TB
    control program:

    -   A positive smear for acid-fast bacilli (AFB) and the subsequent
        growth detection (culture) result of that specimen

    -   Identification of *M. tuberculosis* complex in any specimen

    -   Drug susceptibility test results, especially when isolates are
        drug resistant **(AII)**; and

-   Clinical microbiologic laboratories should include, as part of
    quality improvement, a plan for identification and review of
    possible false-positive results. Any false-positive result should
    trigger an inquiry and a plan of correction (Maurer et al., 1984)
    **(SP)**.

**[Recommendations for TB Case Detection]{.underline}**

-   Steps recommended by Institute of Medicine (IOM, 2000) to improve
    public knowledge and awareness about the risk factors for TB,
    symptoms of TB, and the implications of the diagnosis of latent
    infection should be undertaken by TB-control programs,
    community-based organizations representing populations at high risk,
    and academic health sciences institutions. Targeted education of
    populations at high risk might be particularly effective in
    neutralizing the stigma associated with TB among foreign-born
    populations on the basis of cultural beliefs in their country of
    origin. Programs for patient education should always be designed
    with input from the targeted community **(AII)**.

-   Because nonpublic health medical practitioners most often conduct
    the initial evaluation on persons who have symptoms related to TB,
    health departments, academic institutions, and medical professional
    organizations should provide continuing education about TB to their
    constituent health-care providers. These efforts should be focused
    on clinicians serving populations at high risk for TB on the basis
    of local or regional trends in TB epidemiology **(AIII)**.

-   Jurisdictional public health agencies should ensure that clinicians
    who evaluate persons with suspected TB have access to current,
    accurate, and timely diagnostic services **(SP)**.

-   Guidelines for detection of TB cases in clinical settings should be
    followed by primary care, emergency department (ED), and
    hospital-based practitioners (see table below titled \"Guidelines
    for the Evaluation of Pulmonary Tuberculosis (TB) in Adults in Five
    Clinical Scenarios\").

-   Screening for TB cases during contact and outbreak investigations
    and during the evaluation of immigrants and refugees with Class
    A/B1/B2 TB notification status has a high yield of finding cases
    (Table 6 in the original guideline document) and should be given
    high priority as a method for TB case detection **(AII)**.

-   Public health programs should identify other opportunities for
    screening for TB disease on the basis of the local epidemiology of
    TB, such as in congregate settings, homeless shelters, and
    correctional facilities in which the consequences of an undiagnosed
    case are severe. All case detection activities should be evaluated
    periodically to determine their usefulness **(AII)**.

**Table. Guidelines for the Evaluation of Pulmonary Tuberculosis (TB) in
Adults in Five Clinical Scenarios**

  --------------------------------------------------------------------------
  **Patient and Setting**        **Recommended Evaluation**     **Evidence
                                                                Rating**
  ------------------------------ ------------------------------ ------------
  Any patient with a cough of    Chest radiograph: if           **AII**
  [\>]{.underline}2 to 3 weeks\' suggestive of TB\*, collect    
  duration, with at least one    three sputum specimens for     
  additional symptom, including  acid-fast bacilli (AFB) smear  
  fever, night sweats, weight    microscopy and culture         
  loss, or hemoptysis                                           

  Any patient at high risk for   Chest radiograph: if           **AIII**
  TB\*\* with an unexplained     suggestive of TB, collect      
  illness, including respiratory three sputum specimens for AFB 
  symptoms of [\>]{.underline}2  smear microscopy and culture   
  to 3 weeks\' duration                                         

  Any patient with HIV infection Chest radiograph, and collect  **AII**
  and unexplained cough and      three sputum specimens for AFB 
  fever                          smear microscopy and culture   

  Any patient at high risk for   Chest radiograph, and collect  **AIII**
  TB with a diagnosis of         three sputum specimens for AFB 
  community-acquired pneumonia   smear microscopy and culture   
  who has not improved after 7                                  
  days of treatment                                             

  Any patient at high risk for   Review of previous chest       **AII**
  TB with incidental findings on radiographs if available,      
  chest radiograph suggestive of three sputum specimens for AFB 
  TB even if symptoms are        smear microscopy and culture.  
  minimal or absent\*\*\*                                       

  \*Infiltrates with or without                                 
  cavitation in the upper lobes                                 
  or the superior segments of                                   
  the lower lobes. SOURCE: Daley                                
  CL, Gotway MB, Jasmer RM.                                     
  Radiographic manifestations of                                
  tuberculosis: a primer for                                    
  clinicians. San Francisco, CA:                                
  Francis J. Curry National                                     
  Tuberculosis Center: 2003;                                    
  1-30.\                                                        
  \*\* Patients with one of the                                 
  following characteristics:                                    
  recent exposure to a person                                   
  with a case of infectious TB;                                 
  history of a positive test                                    
  result for *M. tuberculosis*                                  
  infection; HIV infection;                                     
  injection or noninjection drug                                
  use; foreign birth and                                        
  immigration in                                                
  [\<]{.underline}5 years from a                                
  region in which incidence is                                  
  high; residents and employees                                 
  of high-risk congregate                                       
  settings; membership in a                                     
  medically underserved,                                        
  low-income population; or a                                   
  medical risk factor for TB                                    
  including diabetes mellitus,                                  
  conditions requiring prolonged                                
  corticosteroid and other                                      
  immunosuppressive therapy,                                    
  chronic renal failure, certain                                
  hematological malignancies and                                
  carcinomas, weight \>10% below                                
  ideal body weight, silicosis,                                 
  gastrectomy, or jejunoileal                                   
  bypass.\                                                      
  \*\*\* Chest radiograph                                       
  performed for any reason,                                     
  including targeted testing for                                
  latent TB infection and                                       
  screening for TB disease.                                     
  --------------------------------------------------------------------------

**[Recommendations for Contact Investigations and for Outbreak
Prevention and Response]{.underline}**

-   Contact investigations are a critical component of TB control,
    following only TB case detection and treatment in priority
    **(AIII)**.

-   State and local health departments should establish a comprehensive
    contact investigation program to ensure that contacts of infectious
    TB cases are identified, access to adequate care is provided, and
    therapy is completed **(AIII)**.

-   TB-control programs should develop a protocol for conducting contact
    investigations that identifies persons responsible for each step of
    the investigation and outline processes to maximize the efficiency
    of the process within the framework of available resources
    **(AIII)**.

-   TB-control programs should have procedures for voluntary human
    immunodeficiency virus (HIV) counseling and testing of contacts.
    Those procedures should set priorities for HIV counseling and
    testing of contacts on the basis of locally derived data on the risk
    for HIV infection among contacts or, alternatively, on the local
    epidemiology of TB and HIV infection **(BIII)**.

-   Tuberculin skin testing of contacts should establish as first
    priorities those contacts who are at highest risk for progressing
    from latent tuberculosis infection (LTBI) to TB disease on the basis
    of transmission risk assessment and the presence in contacts of risk
    factors for progression (e.g., age \<5 years, HIV infection, and
    other immunocompromising conditions (\"Targeted tuberculin
    testing,\" 2000) **(AII)**.

-   Directly observed therapy (DOT) for LTBI should be considered for
    all contacts. High risk contacts should receive highest priority for
    directly observed treatment **(AIII)**.

-   TB-control programs should apply existing communicable disease laws
    that protect the health of the community to contacts who fail to
    comply with the examination requirements **(BIII)**.

-   TB-control programs should develop guidelines, in conjunction with
    the program legal office and in compliance with Health Insurance
    Portability and Accountability Act (HIPAA) rule, for release of
    confidential information related to conducting contact
    investigations **(BIII)**.

-   TB-control programs should evaluate the effectiveness and impact of
    contact investigations and develop interventions to improve
    performance when indicated **(BIII)**.

-   TB-control programs should develop outbreak response plans for their
    jurisdictions. These plans should include indications for initiating
    the plan, notification procedures, composition of the response team,
    source of staffing, plan for follow-up and treatment of contacts,
    indications for requesting assistance from CDC, and a plan for
    evaluating the outbreak response **(BIII)**.

**[Recommendations for the Public Health Aspects of Targeted Testing and
Treatment of LTBI]{.underline}**

-   When a TB-control program is prepared to develop strategies for
    targeted testing and treatment of LTBI (i.e., the program satisfies
    national objectives for management of TB cases and contacts \[Table
    4 in the original guideline document\]), it should begin by
    identifying populations and communities at high risk for LTBI within
    its jurisdiction and establish priorities for intervention
    **(AIII)**.

-   Populations and communities should be categorized on the basis of
    the expected impact and efficacy of targeted testing in the setting.
    Tier 1 groups (see \"Priority Population Subpopulations and Sites
    for Targeted Testing and Treatment of Latent Tuberculosis \[TB\]
    Infection\" below) should receive the highest priority, followed by
    groups in Tier 2 and Tier 3 **(AII)**.

-   Once the targeted population or community has been identified,
    strategic and operational decisions should be made on how best to
    establish the targeted testing and treatment program. Questions to
    decide include where to locate the program, how to identify and
    allocate resources, what training is needed for practitioners and
    patients, and what data-management needs exist. Focus groups,
    influential community leaders, associations and community action
    agencies, religious organizations, coalitions, block organizations,
    and informal community groups all can contribute to these decisions
    **(AII)**.

-   Public health agencies that establish targeted testing and treatment
    programs should maximize patient convenience and acceptance through
    strategies such as employing, when possible, staff members from the
    populations being served, medical translation, cultural awareness
    and sensitivity, flexible clinic hours, outreach services for
    patient transport, and the use of incentives and enablers. All
    services should be free of cost to patients **(AII)**.

-   Targeted testing programs established in the community (e.g., at
    community health centers, schools, prisons, jails, substance abuse
    centers, and homeless shelters) should receive full support from the
    jurisdictional public health agency. Such support might be decisive
    in the success of nonpublic health targeted testing and treatment
    programs. Types of support should include training and education of
    providers, patient education materials, provisions of medication,
    radiographs and other laboratory services, clinical consultation,
    and design of tracking and data management systems **(AII)**.

-   Targeted testing programs should be routinely and systematically
    evaluated for their effectiveness, efficiency, and impact. Programs
    that are not effective should be improved or discontinued
    **(AIII)**.

**Priority Population Subpopulations and Sites for Targeted Testing and
Treatment of Latent Tuberculosis (TB)**

+-----------------------------------------------------------------------+
| **Tier 1**                                                            |
|                                                                       |
| -   Persons working in or served by clinics or community health       |
|     organizations providing care to HIV-infected persons              |
|                                                                       |
| -   Prisoners                                                         |
|                                                                       |
| -   Legal immigrants and refugees with Class B1 and B2 TB             |
|     notification status                                               |
|                                                                       |
| -   Recently-arrived refugees                                         |
|                                                                       |
| -   Other well-defined groups in congregate living facilities         |
|                                                                       |
| -   Persons enrolled in substance abuse treatment programs\*          |
|                                                                       |
| **Tier 2**                                                            |
|                                                                       |
| -   Jail detainees                                                    |
|                                                                       |
| -   Persons working or living in homeless shelters                    |
|                                                                       |
| -   Immigrants reporting for adjustment of status                     |
|                                                                       |
| **Tier 3**                                                            |
|                                                                       |
| -   Other foreign-born persons at high risk (i.e., those that         |
|     immigrated [\<]{.underline}5 years from countries with a high     |
|     incidence of TB)                                                  |
|                                                                       |
| \*Persons enrolled in substance abuse treatment programs should be    |
| considered a transition group between Tier 1 and Tier 2, depending on |
| the local epidemiology of tuberculosis.                               |
+-----------------------------------------------------------------------+

**[Recommendations for TB Control Among Children and
Adolescents]{.underline}**

**Case Detection and Primary Prevention Strategy**

-   Timely reporting of suspected cases of infectious TB is crucial to
    the prevention of TB among children **(AII)**.

-   Contact investigation of adults with infectious TB is the most
    important activity for early detection of TB among children,
    identification of children with LTBI who are at high risk for
    progressing to primary TB and its sequelae, and determination of the
    drug susceptibility pattern of the *M. tuberculosis* isolate causing
    TB disease or LTBI in a child. Contact investigations should be
    timely and thorough, and adequate resources for them should be made
    available. This should be one of the highest priority goals of any
    TB-control program **(AII)**.

-   Children aged \<5 years who have been identified as contacts of
    persons with infectious TB should receive a clinical evaluation,
    including a tuberculin skin test and chest radiograph, to rule out
    active TB. Once active TB has been ruled out, children with positive
    tuberculin skin test results should receive a full course of
    treatment for LTBI. Those who have negative skin test results should
    also receive treatment for presumed LTBI. This intervention is
    especially critical for infants and toddlers aged \<3 years but is
    recommended for all children aged \<5 years. A second tuberculin
    test is then placed at least 3 months after exposure to infectious
    TB has ended. If the second test result is positive, treatment
    should be continued for a full course of treatment for LTBI. If the
    second test result is negative, treatment may be stopped **(AII)**.

**Case Management**

-   DOT should be the standard of care for treatment of TB disease among
    children and adolescents **(AII)**.

-   As adherence to treatment is no better for children than for adults,
    all efforts should be made to support children and families through
    treatment of TB through comprehensive case management **(AIII)**.

**Contact Investigation**

-   Infants and younger children with primary TB disease are rarely if
    ever contagious. They do not need to be excluded from activities or
    isolated in health-care settings **(AII)**.

-   Children and adolescents of any age with characteristics of
    adult-type TB (i.e., productive cough and cavitary or extensive
    upper lobe lesions on chest radiograph) should be considered
    potentially contagious at the time of diagnosis **(AII)**.

-   Infants with suspected or proven congenital pulmonary TB should be
    considered contagious and effective infection-control measures
    should be undertaken **(AII)**.

-   Adults who accompany and visit children with TB in health-care
    settings should be evaluated for TB disease as soon as possible to
    exclude the possibility that they are the source case for the child.
    These adults should have a chest radiograph to rule out pulmonary TB
    and to prevent the possibility of transmission within the healthcare
    setting **(AII)**.

-   Testing of the contacts of children aged \<4 years with LTBI is
    recommended for persons sharing a residence with the child or those
    with equally close contact. Such investigations may be performed by
    public health agencies or primary health-care providers **(BII)**.

**Targeted Testing and Treatment of LTBI**

-   Contact investigations of adults with TB and targeted tuberculin
    skin testing of foreign-born children from countries with a high
    incidence of TB are the best and most efficient methods for finding
    children with LTBI **(AII)**.

-   Because foreign birth in a country with a high prevalence of TB is
    the greatest attributable risk factor for LTBI, children born in or
    with extensive travel to such countries should be targeted for
    testing for LTBI. This includes foreign-born adopted children.
    Testing for LTBI among children with low risk for infection should
    be avoided **(AII)**.

-   A risk assessment questionnaire can be used to identify children
    with risk factors for LTBI who should undergo a tuberculin skin test
    **(AI)**.

-   A decision to place a tuberculin skin test is a commitment to
    arrange evaluation and treatment for LTBI **(SP)**.

-   A tuberculin skin test should always be placed, read, and
    interpreted by specifically trained persons **(SP)**.

-   In general, foreign-born children with LTBI should be treated with
    isoniazid unless information exists linking them to a specific case
    of isoniazid-resistant TB **(AIII)**.

-   DOT should be considered strongly as the means of treatment for
    newborns and infants, contacts of persons with recent cases, and
    immune-compromised children and adolescents with LTBI because they
    are at greatest risk for progression to TB disease **(AIII)**.

**[Recommendations for TB Control Among Foreign-Born
Persons]{.underline}**

**Surveillance**

-   Public health agencies in states and communities with a substantial
    number of TB cases among foreign-born persons should develop
    enhanced surveillance methods in order to gain a detailed
    understanding of the local epidemiology of TB among foreign-born
    persons. This is important for program planning and to ensure that
    recently arrived immigrants, refugees, and other foreign-born
    persons at high risk have access to medical and public health
    services **(AIII)**.

-   Imported cases of TB present at the time of entry should be
    distinguished from incident cases, i.e., those that arise during
    residence in the United States **(AIII)**.

-   Cases of TB among persons granted temporary entry to the United
    States as visitors, students, and temporary workers and unauthorized
    aliens (see Table 7 in the original guideline document) should be
    distinguished from those among foreign-born permanent residents
    **(AIII)**.

-   Cases identified as a result of targeted testing activities should
    be distinguished from those identified by noting symptoms of active
    TB **(AIII)**.

-   For TB control along the U.S.-Mexico border to be facilitated, a
    binational TB case definition and TB registry system should be
    adopted and evaluated **(AIII)**.

**Case Detection**

-   Jurisdictional public health agencies responsible for TB control
    should undertake or engage community groups to undertake education
    campaigns for foreign-born persons at high risk. These campaigns
    should communicate the importance of TB as a personal and public
    health threat, the symptoms to look for, how to access diagnostic
    and targeted testing services in the community, and the concept of
    LTBI. The purpose of this education is to destigmatize the
    infection, acquaint the population with available medical and public
    health services, and explain the approaches used to treat, prevent,
    and control TB **(AIII)**.

-   Public health agencies conducting TB-control programs should
    establish liaisons with primary care physicians, community health
    centers, hospital emergency departments, and other organizations
    that provide health care for foreign-born populations at high risk
    to provide TB publications and guidelines and education about the
    local epidemiology of TB **(AIII)**.

-   Public health agencies conducting TB-control programs should
    establish liaisons with civil surgeons within their jurisdictions.
    They should also ensure that civil surgeons have access to recent TB
    publications and guidelines and that they promptly report all
    suspected cases of TB **(AIII)**.

-   CDC should provide standardized education and training programs with
    a formal certification process for panel physicians and civil
    surgeons. As part of the certification, continuing education
    programs should be required **(AIII)**.

-   Federal, state, and local public health agencies should assign high
    priority to the follow-up of immigrants with a Class A TB waiver and
    Class B1 and B2 TB notification status **(AII)**.

**Case Management**

-   Culturally appropriate case management should be instituted,
    including readily available professional translation and
    interpretation services, for all foreign-born persons. If possible,
    outreach workers should be from the patient\'s own cultural
    background **(AII)**.

**Contact Investigation**

-   Local and state jurisdictions should assign high priority to contact
    investigations of foreign-born persons with TB because of the high
    likelihood of identifying persons with LTBI as well as secondary TB
    cases **(AII)**.

-   Culturally sensitive and appropriate contact investigation protocols
    should be established **(AIII)**.

**Targeted Testing and Treatment of LTBI**

-   In jurisdictions where foreign-born persons constitute a major
    proportion of the TB burden, targeted testing and treatment of LTBI
    for foreign-born persons at high risk (\"Targeted tuberculin
    testing,\" 2000) should be implemented as a primary means of
    preventing TB in the community. The tiered approach (see \"Priority
    Population Subpopulations and Sites for Targeted Testing and
    Treatment of Latent Tuberculosis \[TB\],\" above), which is based on
    access to the target populations and likelihood of implementing a
    successful program, should be employed **(AII)**.

-   In developing the plan for targeted testing and treatment of LTBI
    among foreign-born persons at high risk, TB-control programs should
    collaborate with health-care providers, neighborhood health centers,
    and community advocacy groups that serve and work with the target
    populations **(AII)**.

-   The testing of immigrants and refugees with a Class A TB waiver and
    Class B1 and B2 TB notification status for LTBI as well as for
    active TB should always be prioritized **(AII)**.

-   Targeted testing and treatment of foreign-born children at high risk
    aged \<15 years should be a priority **(SP)**.

-   When resources permit, DOT for LTBI should be used to ensure high
    completion rates **(BII)**.

-   Jurisdictional public health agencies should work with local
    colleges and universities to develop targeted testing protocols for
    foreign-born students at high risk and assist with treatment of LTBI
    **(BIII)**.

**[Recommendations for TB Control Among HIV-Infected
Persons]{.underline}**

**HIV Counseling and Testing**

-   Voluntary HIV counseling and testing is recommended for all patients
    with TB and should be considered the standard of care. In extreme
    circumstances, if establishing priorities is necessary as a result
    of resource constraints, patients aged 25-44 years should receive
    highest priority **(SP)**.

-   Clinic staff members at sites where patients with TB are followed
    should receive up-to-date education and training on the most current
    concepts and methodology of voluntary HIV counseling, testing, and
    referral. If on-site HIV testing is not feasible, TB facilities
    should have well-established arrangements for referral to other
    testing sites **(SP)**.

-   Voluntary HIV counseling and testing should be offered routinely to
    contacts of HIV-infected TB cases **(AII)**.

-   Voluntary HIV counseling and testing should be offered to all
    contacts that are members of populations with a prevalence of HIV
    infection [\>]{.underline}1% (CDC, 2001). In other communities and
    settings, the decision of whether to routinely offer voluntary HIV
    counseling and testing to contacts of persons with infectious TB
    should be based on the local epidemiology of HIV infection and TB.
    In communities or settings where populations at risk for TB are also
    known to have high rates of HIV infection (e.g., injection drug
    users \[IDUs\] in inner cities \[Selwyn et al., 1989\]), all
    contacts should be routinely offered voluntary HIV counseling and
    testing. In communities and settings in which the HIV seroprevalence
    likely approaches that of the general U.S. population (\<0.1%), a
    risk-factor assessment for HIV infection should be included in the
    evaluation of contacts of infectious cases, and contacts with
    clinical or behavioral risk factors for HIV infection (CDC, 2001)
    should receive voluntary HIV counseling and testing **(AII)**.

-   Persons with LTBI who are members of populations with a prevalence
    of HIV infection \>1% should be routinely offered voluntary HIV
    counseling and testing (CDC, 2001). Otherwise the decision of
    whether to routinely offer HIV counseling and testing to persons
    with LTBI should based on the local epidemiology of HIV infection
    and TB. In communities or settings where populations at risk for TB
    are also known to have high rates of HIV infection (e.g.,
    intravenous drug users in inner cities), routine counseling and
    testing among patients with LTBI is indicated. In other communities
    and settings the HIV seroprevalence is likely to approach that of
    the general U.S. population (\<0.1%), a risk-factor assessment for
    HIV infection should be included as a standard part of the initial
    evaluation for all persons diagnosed with LTBI. Persons with
    clinical or behavioral risk factors should receive HIV counseling
    and testing **(AII)**.

-   Routine periodic cross-matches of jurisdictional HIV and TB case
    registries should be conducted to ensure completeness of reporting
    of both diseases **(SP)**.

**Case Detection**

-   Physicians who provide primary care to persons with HIV infection or
    populations at increased risk for HIV infection should maintain a
    high index of suspicion for TB. Every patient in whom HIV infection
    has been newly diagnosed should be assessed for the presence of TB
    or LTBI. This should include a history for symptoms compatible with
    TB (e.g., cough of [\>]{.underline}2 to 3 weeks\' duration, fever,
    night sweats, weight loss, or hemoptysis, or unexplained cough and
    fever \[see table above titled \"Guidelines for the Evaluation of
    Pulmonary Tuberculosis (TB) in Adults in Five Clinical
    Scenarios\"\]) and of exposure to persons with TB. Physical
    examination should include examination of extrapulmonary sites such
    as lymph nodes, and a chest radiograph should be taken to check for
    findings of current or previous TB. Testing for *M. tuberculosis*
    infection by using the tuberculin skin test should be conducted, and
    patients with [\>]{.underline}5 mm of induration be considered to
    have a positive test and should receive, in addition to chest
    radiography, a clinical evaluation to rule out TB (\"Targeted
    tuberculin testing,\" 2000) **(SP)**.

-   Public health agencies conducting TB-control activities should
    maintain close contact with HIV control programs, medical
    practitioners and clinics, community-based organizations, homeless
    shelters, correctional facilities, and housing facilities that serve
    persons with HIV infection to ensure that a high index of awareness
    of TB is maintained by persons who provide services at those sites
    and by their HIV-infected patients **(AIII)**.

-   Health-care facilities, social service agencies, and work sites that
    serve patients with HIV infection should establish firm lines of
    referral for patients with respiratory symptoms **(AIII)**.

**Case Management**

-   Public health agencies conducting TB-control activities should have
    access to consultants with expertise in managing HIV related TB
    **(SP)**.

-   Management of TB and HIV infection should be effectively integrated
    and should include a multidisciplinary team of providers and
    supportive care **(AIII)**.

-   Comprehensive case management, including DOT, is strongly
    recommended for persons with HIV infection who have TB **(AII)**.

-   HIV-infected patients with TB and a CD4 count \<100 cells/microliter
    should receive DOT daily or three times per week **(AI)**.

**Contact Investigation**

-   Contact investigations of persons with TB and known or suspected HIV
    infection and those conducted in any circumstance in which
    HIV-infected persons could have been exposed to a person with
    infectious TB should have the highest priority and be completed
    without delay **(AII)**.

-   Persons with known or suspected HIV infection who have contact with
    a patient with infectious pulmonary TB should be offered a full
    course of treatment for LTBI regardless of the initial result of
    tuberculin skin testing once active TB has been ruled out **(AII)**.

**Targeted Testing and Treatment of LTBI**

-   Targeted testing and treatment for LTBI are strongly recommended at
    the time the diagnosis of HIV infection is established **(AII)**.

-   For HIV-infected persons whose initial tuberculin skin test is
    negative, repetitive testing is recommended (at least yearly) if the
    local epidemiologic setting indicates an ongoing risk for exposure
    to TB **(AII)**.

-   An HIV-infected patient who is severely immunocompromised and whose
    initial tuberculin skin test result is negative should be retested
    after the initiation of antiretroviral therapy and immune
    reconstitution, when CD4 cell counts are greater than 200
    cells/microliter) **(AII)**.

-   HIV-infected persons who receive a diagnosis of LTBI should receive
    high priority for DOT **(BIII)**.

**Institutional Infection Control**

-   HIV-infected persons should be advised that certain occupations and
    activities increase the likelihood of exposure to TB. These include
    employment and volunteer work in certain health-care facilities,
    correctional institutions, and shelters for the homeless, as well as
    in other high-risk settings identified by jurisdictional health
    authorities. The decision about continuing employment or volunteer
    activities in a high-risk setting should be made in consultation
    with a health-care professional and be based on factors such as the
    person\'s specific duties in the workplace, prevalence of TB in the
    community, and the degree to which precautions are taken to prevent
    TB transmission in the workplace **(AIII)**.

**[Recommendations for TB Control Among Homeless Persons]{.underline}**

**Surveillance and Case Detection**

-   Information on whether the person is homeless should be included for
    each reported TB case to determine the importance of homelessness in
    the TB morbidity in the state or community. This is particularly
    important for communities that provide shelters or other congregate
    living facilities that are conducive to the transmission of TB
    **(AII)**.

-   In designing programs for control and prevention of TB in homeless
    persons, public health agencies should work closely with providers
    of shelter, housing, primary health care, treatment for alcoholism
    or substance abuse, and social services to ensure a comprehensive
    approach to improving the health and welfare of this population
    **(AIII)**.

-   Public health agencies should closely monitor the location, mode
    (i.e., screening or symptomatic presentation), and timeliness of
    diagnosis of TB in homeless persons in their community and use such
    data to develop more effective control strategies **(AIII)**.

-   Public health agencies should identify providers of medical care for
    homeless persons and facilities that serve homeless persons (e.g.,
    hospital emergency departments and correctional institutions) to
    ensure that practices and procedures are implemented to readily
    detect and report suspected cases of TB **(AIII)**.

-   Providers of primary health care for homeless persons should be
    knowledgeable about how to diagnose (see table above titled
    \"Guidelines for the Evaluation of Pulmonary Tuberculosis \[TB\] in
    Adults in Five Clinical Scenarios\"), isolate, and report suspected
    cases of TB **(AIII)**.

-   Public health agencies should have ready access to an inpatient
    facility for the isolation and induction phase of therapy of
    homeless patients with infectious TB **(AII)**.

-   Public health agencies should be prepared to conduct activities to
    detect TB among persons without symptoms and enhance TB case
    detection as part of a plan for TB control among homeless persons
    (see Table 6 in the original guideline document). Indications for
    screening for TB disease include 1) a documented outbreak, 2) an
    increase in incidence of TB in the homeless population, and 3)
    evidence of current transmission of TB in the population. Shelters
    should always be suspected as sites of transmission **(AII)**.

**Case Management**

-   Case management for homeless persons with TB should be structured to
    encourage adherence to treatment regimens by making TB treatment a
    major priority for the patient. It should include provision of
    housing, at least on a temporary basis; an increasing number of
    models have demonstrated the importance of a housing incentive in
    successful treatment of TB in homeless persons. Case management
    should also include establishing linkages with providers of alcohol
    and substance treatment services, mental health services, and social
    services **(AII)**.

**Contact Investigation**

-   Health departments should regularly evaluate their methods for
    contact investigation for cases of TB among homeless persons to
    identify barriers and develop alternative strategies, such as
    shelter- or other location-based contact investigations oriented to
    possible sites of transmission. Factors to evaluate should include
    timeliness of completing contact investigations, number of contacts
    identified and evaluated per case, proportion of evaluated contacts
    with LTBI and TB disease, and completion of treatment of LTBI among
    contacts **(AII)**.

**Targeted Testing and Treatment of LTBI**

-   Targeted testing and treatment of LTBI should be a priority for
    homeless populations because studies from throughout the United
    States have demonstrated high rates of transmission of *M.
    tuberculosis* in this group. This epidemiologic situation, causing a
    high ongoing risk for acquiring LTBI and TB disease, might
    necessitate repetitive testing for *M. tuberculosis* infection among
    homeless persons **(AII)**.

-   When high rates of transmission of *M. tuberculosis* are documented
    among homeless persons, those with a positive test for *M.
    tuberculosis* infection should be presumed to be recently infected
    and treated for LTBI **(AIII)**.

**Institutional and Environmental Controls**

-   Organizations that provide shelter and other types of emergency
    housing for homeless persons should develop institutional TB-control
    plans. Guidelines to facilitate this process are available from CDC
    (Kaplan, Masur, & Holmes, 2002) and the Francis J. Curry National TB
    Center (Hammett, Harmon, & Rhodes, 1997) **(AII)**.

**[Recommendations for TB Control Among Detainees and
Prisoners]{.underline}**

**Case Detection and Case Management**

-   All jails and prisons should conduct a TB case detection program for
    detainees and prisoners entering the facility as well as for those
    who become ill during incarceration to ensure prompt isolation of
    contagious cases of TB **(AII)**.

-   Strategies for case detection for incoming detainees and prisoners
    include symptom surveys **(BIII)**, testing for *M. tuberculosis*
    infection followed by chest radiography **(BIII)** for those with a
    positive test, and universal chest radiography in jails **(BII)**.
    In each setting, the adopted strategy should receive ongoing
    evaluation.

-   Each correctional facility\'s health-care program for inmates and
    staff should ensure that training in the clinical and public health
    aspects of TB and other diseases of public health significance is
    provided in an ongoing manner **(SP)**.

-   Detainees and prisoners with signs and symptoms of TB should be
    placed in respiratory isolation on-site or off-site until infectious
    TB is ruled out **(SP)**.

-   Case-management strategies including DOT and incentives should be
    used to assure completion of therapy of detainees and prisoners with
    TB **(BII)**.

-   When detainees and prisoners receiving therapy for TB are
    transferred to another facility or released from detention,
    responsibility for continuation of the treatment plan should be
    transferred to the appropriate facility or agency, and the
    jurisdictional TB-control program should be notified **(SP)**.

**Contact Investigation**

-   Contact investigations of infectious TB cases in corrections
    facilities should receive equal priority as effective case detection
    as the primary means of aborting TB outbreaks. Facilities should
    have written procedures for contact investigations and have adequate
    staff to ensure prompt and thorough contact investigations. They
    should also consult with the jurisdictional public health TB-control
    program **(AII)**.

**Targeted Testing and Treatment of LTBI**

-   Prisons should implement a treatment program for prisoners with LTBI
    as part of the effort to prevent the transmission of *M.
    tuberculosis* within their walls and to contribute to the overall
    goal of TB elimination **(AII)**.

-   Treatment programs for LTBI in jail detainees should be undertaken
    only if it is possible to develop a successful plan for community
    follow-up of released persons on treatment **(AII)**.

-   Reducing the length of treatment for LTBI is more likely to lead to
    completion of treatment in correctional facilities; 4 months of
    rifampin is recommended as an alternative for the treatment of LTBI
    (\"Targeted tuberculin testing,\" 2000; CDC & American Thoracic
    Society, 2003). Correctional health providers need to consider the
    costs and benefits of this regimen compared with the standard
    9-month course of isoniazid in each individual case **(BIII)**.

**Institutional Infection Control**

-   Jails and prisons should implement effective infection-control
    programs including risk assessment, staff training, screening and
    treatment of LTBI, isolation of inmates with infectious forms of TB,
    treatment and discharge planning, and contact investigation
    **(AII)**.

-   HIV-infected detainees and prisoners should not be housed together
    in a separate facility unless institutional control programs
    following current guidelines have been established and proved to be
    effective in preventing the transmission of *M. tuberculosis*
    **(AIII)**.

**[Recommendations for TB Control in Health-Care Facilities and Other
High-Risk Settings]{.underline}**

-   All health-care institutions and other sites at high risk for
    transmission of *M. tuberculosis* should have in place a TB
    infection control program; they should implement and enforce
    procedures to promptly identify, isolate, and either manage or refer
    persons with suspected and confirmed infectious TB **(AII)**.

-   All health-care institutions that care for persons with TB and other
    sites that are at risk for transmission should implement TB
    infection-control measures based on a hierarchy of administrative
    controls, engineering controls, and respiratory protection.
    Administrative controls and early recognition of persons with TB are
    the most important parts of an airborne infection control program
    for TB **(AII)**.

-   Employees who have first contact with patients in settings that
    serve populations at high risk for TB should be trained to detect
    persons who could have infectious TB. Patients should be routinely
    asked about exposure to *M. tuberculosis*, previous TB infection or
    disease, current symptoms suggestive of TB, and medical conditions
    that increase the risk for TB. The medical evaluation should include
    an interview conducted in the patient\'s primary language, with the
    assistance of a medical interpreter if necessary **(AIII)**.

-   The index of suspicion for TB should be very high in health-care
    settings located in geographic areas where TB is prevalent and those
    serving patients at high risk for TB. Guidelines exist for
    conducting an evaluation for suspected pulmonary TB in adults at
    high risk (see table above titled \"Guidelines for the Evaluation of
    Pulmonary Tuberculosis \[TB\] in Adults in Five Clinical
    Scenarios\") **(AIII)**.

-   Among persons suspected of having TB, arrangements should be
    available for the diagnosis to be promptly established and standard
    therapy initiated **(AII)**.

-   Health-care workers (HCWs) and employees in other high-risk settings
    should be tested for *M. tuberculosis* infection upon employment.
    Subsequent testing should be based on risk assessment **(AIII)**.

-   Health-care facilities and other high-risk institutions should
    conduct a risk assessment to determine the frequency of testing for
    *M. tuberculosis* infection among employees, as a component of the
    proper level of TB infection control measures **(AIII)**.

-   For health-care workers and employees in other high-risk settings
    with no other risk factors for TB, a cut-off of 15 mm of induration
    (rather than 10 mm) on the tuberculin skin test should be used to
    define a positive baseline test at the time of initial employment.
    An increase of [\>]{.underline}10 mm in reaction size is generally
    accepted as a positive test result on subsequent testing unless the
    worker is a contact of a TB case or has HIV infection or is
    otherwise immunocompromised, in which case a result of
    [\>]{.underline}5 mm is considered positive **(AIII)**.

-   Employees with *M. tuberculosis* infection should have a chest
    radiograph performed to exclude TB disease and should be evaluated
    for treatment of LTBI, based on current recommendations **(AII)**.

-   Health-care workers and employees in other high risk settings with
    an indication for treatment of LTBI should be encouraged to initiate
    and complete treatment **(AII)**.

-   Residents admitted to long-term care facilities should be tested for
    *M. tuberculosis* infection upon admission (with a two-step test if
    using tuberculin skin testing) and should receive a history and
    physical examination to detect symptoms and signs of TB. Residents
    with *M. tuberculosis* infection should be offered treatment if
    indicated (\"Targeted tuberculin testing,\" 2000; CDC & American
    Thoracic Society, 2003), with careful monitoring for drug toxicity
    **(BII)**.

-   Jails and prisons should develop and implement effective
    infection-control programs including risk assessment, staff
    training, screening for TB among incoming detainees and prisoners,
    isolation of inmates with infectious forms of TB, treatment and
    discharge planning, and prompt and thorough contact investigations
    **(AII)**.

-   In jails and prisons, HIV-infected inmates should not be housed
    together in a separate housing unit unless institutional control
    programs following current guidelines have been established and
    proved to be effective in preventing the transmission of *M.
    tuberculosis* **(AII)**.

-   Organizations that provide shelter and other types of emergency
    housing for homeless persons should develop institutional TB-control
    plans. Guidelines to facilitate this process are available from the
    Francis J. Curry National TB Center (Hammett, Harmon, &
    Rhodes, 2002) **(AII)**.

-   TB-control programs should remain aware of the possibility of TB
    disease as a result of current transmission when conducting
    epidemiologic surveillance and contact investigations. *M.
    tuberculosis* genotyping should be immediately available to any
    program that is investigating possible transmission of *M.
    tuberculosis* **(AII)**.

-   In an era of declining rates of TB in the United States, expertise
    in the recognition, diagnosis and treatment of TB is likely to
    decline, especially in areas in which incidence is low (Jereb,
    2002). Because the risk for spread of *M. tuberculosis* increases
    when the diagnosis is not promptly made, institutional education
    programs for health-care workers, including physicians in training,
    should be made a continuing priority **(AIII)**.

**[Definitions]{.underline}**:

**Strength of Recommendation**

A.  Highly recommended in all circumstances

B.  Recommended; implementation might be dependent on resource
    availability

C.  Might be considered under exceptional circumstances

**Quality of Evidence**

I.  Evidence from at least one randomized, controlled trial

II. Evidence from 1) at least one well-designed clinical trial, without
    randomization; 2) cohort or case-controlled analytic studies; 3)
    multiple time-series; or 4) dramatic results from uncontrolled
    experiments

III. Evidence from opinions of respected authorities, on the basis of
     cumulative public health experience, descriptive studies, or
     reports of expert committees

#### CLINICAL ALGORITHM(S)

None provided

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### REFERENCES SUPPORTING THE RECOMMENDATIONS

[References open in a new
window](http://www.guideline.gov/summary/select_ref.aspx?doc_id=8328)

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of supporting evidence is identified and graded for each
recommendation (see \"Major Recommendations\" field).

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

Reduced morbidity and mortality caused by tuberculosis (TB) by 1)
preventing transmission of *Mycobacterium tuberculosis* from persons
with contagious forms of the disease to uninfected persons and 2)
preventing progression from latent tuberculosis infection (LTBI) to
tuberculosis disease among persons who have contracted *M. tuberculosis*
infection

#### POTENTIAL HARMS

Not stated

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

References to non-Centers for Disease Control (CDC) sites on the
Internet are provided as a service to Morbidity and Mortality Weekly
Report (*MMWR)* readers and do not constitute or imply endorsement of
these organizations or their programs by CDC or the U.S. Department of
Health and Human Services. CDC is not responsible for the content of
these sites. URL addresses listed in *MMWR* were current as of the date
of publication.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

The original guideline document contains detailed recommendations on the
implementation of measures for tuberculosis (TB) control and prevention,
including:

-   Principles and practice of TB control

-   Recommended roles and responsibilities for TB control

-   Essential components of TB control in the United States

-   Control of TB among populations at high risk

-   Control of TB in health-care facilities and other high-risk
    environments

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Getting Better\
Staying Healthy

#### IOM DOMAIN

Effectiveness\
Patient-centeredness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Taylor Z, Nolan CM, Blumberg HM. Controlling tuberculosis in the United
States. Recommendations from the American Thoracic Society, CDC, and the
Infectious Diseases Society of America. MMWR Recomm Rep 2005 Nov
4;54(RR-12):1-81. \[441 references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16267499)

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

2005 Nov 4

#### GUIDELINE DEVELOPER(S)

American Thoracic Society - Medical Specialty Society\
Centers for Disease Control and Prevention - Federal Government Agency
\[U.S.\]\
Infectious Diseases Society of America - Medical Specialty Society

#### SOURCE(S) OF FUNDING

United States Government

#### GUIDELINE COMMITTEE

Joint Subcommittee of the American Thoracic Society (ATS), the
Infectious Diseases Society of America (ISDA), and CDC

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Committee Members*: Charles M. Nolan, MD (*Chair*), Seattle-King County
Department of Public Health, Seattle, Washington (American Thoracic
Society); Henry M. Blumberg, MD (*Co-Chair*), Emory University School of
Medicine, Atlanta, Georgia (Infectious Diseases Society of America);
Zachary Taylor, MD (*Co-Chair*), National Center for HIV, STD, and TB
Prevention, CDC, Atlanta, Georgia; John Bernardo, MD, Boston University
School of Medicine, Boston, Massachusetts; Patrick J. Brennan, MD,
University of Pennsylvania School of Medicine, Philadelphia,
Pennsylvania; Nancy E. Dunlap, MD, PhD, University of Alabama at
Birmingham, Birmingham, Alabama; Charles L. Daley, MD, National Jewish
Medical and Research Center, Denver, Colorado; Wafaa M. El-Sadr, MD,
Harlem Hospital and Columbia University, New York City, New York; Sue
Etkind, MS, Massachusetts Department of Public Health, Jamaica Plain,
Massachusetts; Mark FitzGerald, MD, University of British Columbia,
Vancouver, British Columbia, Canada; James B. McAuley, MD, Rush Medical
College, Chicago, Illinois; Marisa Moore, MD, Centers for Disease
Control and Prevention, Atlanta, Georgia; Noreen L. Qualls, DrPH,
Centers for Disease Control and Prevention, Atlanta, Georgia; Randall R.
Reves, MD, Denver Public Health, Denver, Colorado; Sarah E. Royce, MD,
California Department of Health Services, Berkeley, California; Max
Salfinger, MD, Wadsworth Center, New York State Department of Health,
Albany, New York; Jeffrey R. Starke, MD, Texas Children\'s Hospital and
Baylor College of Medicine, Houston, Texas; Wanda Walton, PhD, Centers
for Disease Control and Prevention, Atlanta, Georgia; Stephen E. Weis,
DO, University of North Texas Health Science Center at Fort Worth, Fort
Worth, Texas; and Jan Young, MS, California Department of Health
Services, Berkeley, California

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Not stated

#### GUIDELINE STATUS

This is the current release of the guideline.

#### GUIDELINE AVAILABILITY

Electronic copies: Available from the [Centers for Disease Control and
Prevention (CDC) Web
site](http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5412a1.htm).

Print copies: Available from the Centers for Disease Control and
Prevention, MMWR, Atlanta, GA 30333. Additional copies can be purchased
from the Superintendent of Documents, U.S. Government Printing Office,
Washington, DC 20402-9325; (202) 783-3238.

#### AVAILABILITY OF COMPANION DOCUMENTS

None available

#### PATIENT RESOURCES

None available

#### NGC STATUS

This NGC summary was completed by ECRI on December 28, 2005.

#### COPYRIGHT STATEMENT

No copyright restrictions apply.

### DISCLAIMER

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