NTCA Guidelines for Respiratory Isolation and Restrictions to Reduce Transmission of Pulmonary Tuberculosis in Community Settings

Executive Summary

Background (Abridged)

Mycobacterium tuberculosis is a globally prevalent infection that spreads person-to-person via airborne transmission and warrants concerted treatment and prevention efforts. The plan for “Controlling Tuberculosis in the United States” set forth by the CDC, American Thoracic Society (ATS), and the Infectious Diseases Society of America (IDSA) in 2005 included 4 principles to prevent and control TB, covering topics such as prompt reporting, evaluation of contacts, testing and treatment, and transmission prevention in high-risk settings [4]. Within that document it is noted that institutional infection-prevention measures developed in the 1990s were successful in reducing transmission in healthcare settings [4]. The plan did not articulate specific national recommendations for isolation in community settings as a core infection-control measure, but discussed general guidelines to reduce infectivity, which includes prompt and effective anti-tuberculosis therapy (ATT). More recently, the CDC released the Strategic Plan 2022–2026 from the National Center for HIV, Viral Hepatitis, STD and TB Prevention (NCHHSTP) [5]. This Strategic Plan establishes a goal to reduce morbidity and mortality from TB infections, with specific indicators related to latent TB treatment initiation among diagnosed close contacts (of smear-positive cases), without specific metrics related to respiratory isolation or other public health restrictions [5]. The CDC's Division of Tuberculosis Elimination (DTBE) also released a 2022–2026 Strategic Plan that aligns with the goals of the plan from the NCHHSTP but also does not specifically address community-based RIR practices [6].

Nonetheless, for several decades, respiratory isolation of PWTB residing in the community has been used with a goal of preventing the transmission of TB in the United States, with the passage of state and local laws to grant public health officers the authority to implement restrictions for PWTB. Consequently, in 2009, a Handbook for Public Health and Legal Practitioners was prepared by the NTCA and ACET for the CDC, which articulated principles surrounding public health interventions that may encroach on individual rights. Public health authorities must balance the magnitude of public health risk against the rights of individuals and ensure provisions for substantive and procedural due process [1].

The widespread use of prolonged quarantine, isolation, and social-distancing measures to limit transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) during the recent coronavirus disease 2019 (COVID-19) pandemic increased awareness of the potential harms these practices can have on individuals [7, 8]. There is increased recognition of the impact on individuals being placed under strict respiratory isolation for prolonged durations, separated from their friends and families and being restricted from attending school, work, or other activities [9, 10]. Preliminary survey data collected by NTCA further demonstrated heterogeneity in the range of approaches to and decisions around home-based isolation across US public health departments [11]. The NTCA leadership decided there was a need for an ethics-informed framework based on current scientific evidence to guide community-based RIR practices for TB. Consequently, in 2022, the NTCA initiated the process of developing evidence-based guidelines for community-based RIRs for persons with TB of the lungs and respiratory tract (referred to broadly as “pulmonary TB” throughout the rest of this document) [12, 13].

To view the entire guideline, please visit the Clinical Infectious Diseases journal online.