Disclaimer: The activities and data presented in this document are fictional and intended for example purposes only. The actual activities 

implemented as part of TB program evaluation should be identified by state or local TB program officials in collaboration with other 

stakeholders. The example provided here is not intended to be applied directly to any specific TB program.

1

Program Evaluation Topic/Focus Area: Tuberculosis Infection Identification Among Persons with Diabetes Mellitus in Community 

Health Centers

Background 

The purpose of this section is to provide background, or rationale, and intended use of your evaluation results. What are the expected 

outcomes and impact if successful?

Diabetes mellitus (DM) can significantly increase the risk of developing tuberculosis (TB) and adversely affect TB treatment 

outcomes.1,2 Undiagnosed and untreated latent tuberculosis infection (LTBI) that progresses to TB disease accounts for approximately

80% of TB cases diagnosed in the US.

3 Both DM and LTBI disproportionately affect some population groups, including Hispanic, 

Asian, African American, and non-US–born persons.

1,2 Community Health Centers (CHCs) can play a vital role in reaching 

populations at higher risk for these conditions by providing health screening services as part of the critical primary care services they 

provide.

4 Strategies implemented by CHCs to test and treat LTBI can help public health programs improve TB prevention and control 

in the communities they serve. 

*Scenario:

During October 1, 2022-June 30, 2023, one TB program partnered with 3 CHCs serving primarily non-US–born patients to pilot a TB 

infection screening program among patients being treated for preexisting DM. All patients with DM over the age of 15 years were 

screened the first time they visited the CHC for DM care and treatment during the project period to determine if they met the criteria 

to be tested for TB infection. The criteria to conduct TB infection testing were based on the state’s standard TB risk assessment form.

Individuals who answered yes to any of the risk assessment questions were considered eligible for TB infection testing. The TB 

program sought to evaluate this screening process to assess its ability to identify eligible persons. The clinic also sought to determine 

if the screening and testing process is more likely to identify individuals with TB infection if it prioritizes persons newly diagnosed

(<2 months) with DM as compared with persons who have been living with diabetes long term (>2 months).

Goal: Improve TB infection identification among individuals with DM.

Objectives

Should be specific, measurable, attainable, realistic, and time-bound (SMART).
Disclaimer: The activities and data presented in this document are fictional and intended for example purposes only. The actual activities 

implemented as part of TB program evaluation should be identified by state or local TB program officials in collaboration with other 

stakeholders. The example provided here is not intended to be applied directly to any specific TB program.

2

1. By July 31, 2023, describe the number and percentage of all persons with DM referred for TB infection testing and the 

numbers who were tested.

2. By July 31, 2023, the program will complete TB infection testing in 75% of the DM patients referred for TB infection

testing. 

3. By July 31, 2023, describe the number of patients who tested positive for TB infection stratified by newly diagnosed (<2 

months) with DM or long-term (>2 months) management of DM.

4. By August 31, 2023, use findings related to objectives 1 and 3 to identify new or improved strategies that might help 

increase LTBI identification among persons with DM. 

Expected Outcome: Improved or new strategies to increase the detection of LTBI among persons with DM.

Corresponding National Tuberculosis Indicator Project Indicator

Program evaluation should ideally reflect the National Tuberculosis Indicator Project (NTIP). Please specify the NTIP indicator 

addressed by this evaluation. If the evaluation is not linked to an NTIP indicator, please provide an explanation regarding how the 

evaluation relates to your scope of work.

Corresponding NTIP indicator: Decrease incidence of TB disease 

Evaluation Plan Questions, Measures, Analysis, and Timeline
Disclaimer: The activities and data presented in this document are fictional and intended for example purposes only. The actual activities 

implemented as part of TB program evaluation should be identified by state or local TB program officials in collaboration with other 

stakeholders. The example provided here is not intended to be applied directly to any specific TB program.

3

Evaluation 

Question

(Objectives 1-3)

Measure Data Source Method of Analysis Target Timeline of Activities and 

Person

Responsible

A. How well did 

the program 

perform in 

identifying DM 

patients eligible 

for TB 

infection 

testing?

B. How well did 

the program 

perform in 

testing referred 

DM patients?

C. What

proportion of 

those tested, 

received a 

positive TB 

infection result?

D. Were patients 

newly 

diagnosed with 

DM (<2 

months) more 

likely to be 

diagnosed with 

LTBI than

A. Number of persons 

with DM eligible for

TB infection testing

and number of persons

referred for testing.

B. Proportion of eligible 

persons with DM 

referred for TB 

infection testing who 

received testing.

C. Proportion of persons 

testing positive for TB 

infection among those 

who were tested.

D. Stratify measures 

above (A, B, and C) by 

newly diagnosed (<2 

months) and longerterm DM patients (>2 

months).

Clinic logs, 

medical records

A. Number of persons with 

DM eligible for TB infection

testing October 1, 2022–June 

30, 2023, and the number 

referred for testing.

B. Number of persons with 

DM referred for TB infection

testing who received testing 

divided by the number of 

persons with DM who were 

referred for testing. 

C. Number of patients testing 

positive for TB infection

divided by the number of 

patients who were tested for

TB infection. 

D. Stratify analyses above (A, 

B, and C) by newly diagnosed 

with DM

(<2 months) and longer-term 

DM patients (>2months).

A. All eligible DM 

patients will be

referred for

testing and

grouped as newly 

diagnosed

(<2 months) or 

longer-term (>2 

months) DM for 

this evaluation.

B. 75% of DM

patients referred 

for TB infection

testing will have 

testing 

completed.

TB program evaluation staff

will review charts for all 

patients seen between October 

1, 2022, and June 30, 2023,

grouping patients with DM as 

newly diagnosed (<2 months)

or longer-term (>2 months) 

DM; recording whether each 

patient was referred for TB 

infection testing, evaluated for 

LTBI or TB and documenting

testing results. The medical 

record review will be 

completed by July 15, 2023, 

and data analysis will be 

completed by August 15, 2023.
Disclaimer: The activities and data presented in this document are fictional and intended for example purposes only. The actual activities 

implemented as part of TB program evaluation should be identified by state or local TB program officials in collaboration with other 

stakeholders. The example provided here is not intended to be applied directly to any specific TB program.

4

Evaluation Findings and Conclusions Updates to this section should be included in the annual progress report.

patients who 

have been 

managing DM

for >2 months?

.

(Objective 4)

A. What changes 

to the current 

strategy or what 

new strategies 

might increase 

LTBI 

identification 

among persons 

with DM?

A 1. Facilitators to 

screening service

implementation. 

A 2. Recommendations 

for improved or new 

strategies.

Meeting with 

health department 

program 

evaluation staff, 

TB control 

program staff,

and clinical and 

management 

representatives 

from each CHC

to discuss 

findings and next 

steps.

Identify at least 3 activities

that worked well with the 

current strategy and at least 3 

recommendations for strategy 

modifications or ideas for new 

strategies.

Meeting agenda:

• review results of 

analysis

• identify 

facilitators for 

increasing 

screening services 

at CHC

• develop

recommendations 

for improved and 

new strategies 

Meeting agenda and discussion 

summary completed by TB 

PEN Focal Point. The meeting 

will take place by August 25, 

2023, and a follow-up plan will 

be drafted by August 31, 2023. 

Evaluation Question and Related Findings

Target

Met or Not 

Met

A. How well did the program perform in identifying and referring eligible patients?

By June 2023, a total of 500 patients with DM were seen by the 3 CHCs, 200 of whom met the TB infection testing criteria and were 

referred for testing. 60 were newly diagnosed with DM (<2 months), and 140 were longer-term DM patients (>2 months)

Met

(Target 100%)

B. How well did the program perform in testing referred DM patients?

200 patients met the screening criteria and were referred for testing; 100 (50%) completed TB infection testing

[30 were newly diagnosed with DM (<2 months), 70 were longer-term DM patients (>2 months)]. 

Not Met

(Target 75%)

C. What proportion of those receiving testing were positive for TB infection?

Of the 100 patients tested 4 (4%) were identified as having TB infection. 

[All 4 that tested positive were newly diagnosed with DM (<2 months), none of the longer-term DM patients (>2 months) tested positive]

N/A
Disclaimer: The activities and data presented in this document are fictional and intended for example purposes only. The actual activities 

implemented as part of TB program evaluation should be identified by state or local TB program officials in collaboration with other 

stakeholders. The example provided here is not intended to be applied directly to any specific TB program.

5

 

Deliverables, Products, and Dissemination Plan (For further information on sharing your program evaluation findings, please refer 

to Sharing Your TB Program Evaluation Findings on our DTBE Program Evaluation Tools website) Please provide a list of final 

D. Were patients newly diagnosed with DM more likely to be diagnosed with LTBI than patients who have been managing DM for a 

long time?

All 4 DM patients that tested positive for TB infection were diagnosed with LTBI. These 4 patients were newly diagnosed with DM and had 

their initial visit to the clinic within the last 2 months. 

N/A

Additional Findings:

During October 1, 2022-June 30, 2023, 28 persons in the communities served by these CHCs were admitted to a local hospital with uncontrolled 

DM, 3 of whom tested positive for TB infection. This leads the program to believe that some persons in the community are not seeking care at 

local CHCs, and further efforts are needed to identify and ensure these individuals are screened for TB infection.

Outcome from meeting between health department and CHC staff

A 1. Facilitators to TB infection screening and testing of patients with DM

• Written guidelines on the staff bulletin board regarding TB infection screening and testing.

• Reminders from the nursing supervisor at weekly staff meetings to implement TB infection screening strategy 

• Use of IGRA testing, which requires a single visit to complete the test 

• TB infection testing available in the same location and on the same day as the patient visit for DM 

• Frequent information sharing between DM staff and TB staff 

A 2. Meeting participants’ recommendations for new strategies 

• Increase focus on screening for LTBI among individuals with uncontrolled diabetes, including both those seen at CHCs and those 

not seeking health care until their illness is critical. CHC staff noted that all patients testing positive for TB infection were newly 

diagnosed DM patients. Individuals who were newly diagnosed with DM tended to have fewer, if any, prior visits to the CHC and 

therefore did not have the opportunity for TB infection screening. Individuals who were newly diagnosed were also less likely to return 

for future appointments, so screening for TB infection should occur during their first visit or as quickly as possible.

• Implement adequate staff training for TB infection screening and testing. CHC staff should be able to identify TB symptoms and risk 

factors, extract relevant patient information, accurately record information in patient charts, and accurately answer patient questions.

• Develop educational messages for private providers regarding the increased risk of TB infection among DM patients.

A.
Disclaimer: The activities and data presented in this document are fictional and intended for example purposes only. The actual activities 

implemented as part of TB program evaluation should be identified by state or local TB program officials in collaboration with other 

stakeholders. The example provided here is not intended to be applied directly to any specific TB program.

6

deliverables and describe how you plan to disseminate to stakeholders.

• A one-pager highlighting the evaluation results will be distributed to stakeholders and CHC staff by email.

• A brief presentation will be provided at a clinic staff meeting, followed by an open discussion to get feedback on the next steps for

reaching and testing the newly diagnosed DM population for TB infection.

Remediation Plan based on Findings

(For further information on developing and implementing a remediation plan, please refer to Program Evaluation: Developing and 

Implementing a Remediation Plan for detailed steps)

All remediation plan results and progress will be shared periodically with relevant CHC and State TB Program leadership through 

presentations. They will also be shared with the CDC Division of TB Elimination in the Annual Progress Report. 

• Findings indicated some newly diagnosed DM patients did not seek care from CHCs; rather, new diagnoses for DM were often 

received during emergency room and hospital visits among people in this community. To promote testing for TB infection among 

this population, the health department’s TB control program staff will work with area hospitals to develop a program to flag

patients newly diagnosed with DM for TB infection screening.

• To increase reach within the community and ensure there is an event for screening eligible individuals, the health department’s TB 

control program will organize an annual community health fair. The health fair will provide DM and TB infection screening and 

testing services. The health department will follow up with individuals regarding their testing results to encourage and coordinate 

treatment efforts. 

• One of the outcomes from the meeting with the health department and CHC staff indicated that CHC staff would benefit from 

additional training regarding TB infection screening and testing. CHCs will develop an additional section in their new employee 

orientation course regarding screening and testing. 
Disclaimer: The activities and data presented in this document are fictional and intended for example purposes only. The actual activities 

implemented as part of TB program evaluation should be identified by state or local TB program officials in collaboration with other 

stakeholders. The example provided here is not intended to be applied directly to any specific TB program.

7

Resources

1. Haddad MB, Lash TL, Castro KG, et al. Tuberculosis infection among people with diabetes: United States population 

differences by race/ethnicity. Am J Prev Med 2020;58(6):858–63.

2. Armstrong LR, Kammerer JS, Haddad MB. Diabetes mellitus among adults with tuberculosis in the USA, 2010–2017. BMJ 

Open Diabetes Res Care 2020;8(1):e001275.

3. Shea KM, Kammerer JS, Winston CA, Navin TR, Horsburgh CR Jr. Estimated rate of reactivation of latent tuberculosis 

infection in the United States, overall and by population subgroup. Am J Epidemiol. 2014;179(2):216-25. 

4. Centers for Disease Control and Prevention. Community tuberculosis control. In: Core Curriculum on Tuberculosis: What the 

Clinician Should Know. 6

th ed. Centers for Disease Control and Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, 

and TB Prevention, Division of Tuberculosis Elimination; 2013:227–248. 

https://www.cdc.gov/tb/education/corecurr/pdf/chapter8.pdf

*We would like to acknowledge Palau for providing the idea and inspiration behind the development of this program evaluation 

and improvement plan.