Emerging and re-emerging infectious diseases continue to test the agility and resilience of public health systems. Whether it's COVID-19, hepatitis A, mpox, or novel fungal infections, the ability to detect and mitigate outbreaks requires innovative, scalable, and equitable strategies. Tuberculosis (TB), a long-standing public health threat with complex clinical and social implications, offers a powerful lens through which we can examine and strengthen outbreak response systems. These innovations provide a powerful blueprint for preparing and responding not only to TB, but to other infectious disease threats.
Best practices and lessons learned from TB readiness shared in this module, particularly in provider readiness, understanding transmission patterns, and scaling response infrastructure, can guide preparedness and response strategies for a wide range of infectious threats.
Despite progress in TB prevention and treatment, outbreaks remain a persistent threat. Many challenges faced in TB control, such as delayed diagnosis, supply chain limitations, and workforce gaps, mirror those encountered across other infectious diseases. Through learning innovative approaches to these issues in the context of TB, health agencies can apply tested solutions to a broader set of emerging threats.
Clinical Guidance and Provider Readiness
TB diagnosis and treatment requires specialized knowledge. Providers unfamiliar with less frequent clinical presentations, drug-resistant TB, or alternative regimens may unintentionally delay effective treatment — a challenge that also applies to emerging diseases with evolving clinical guidance.
Emerging and zoonotic diseases may be incredibly rare until there’s an outbreak. How do we equip providers with the knowledge they need to act quickly and appropriately?
Hear more about approaches to provider education:
José Romero, MD
Former Secretary of Health, Arkansas Department of Health
"We need to re-educate … all healthcare providers, so they can consider this as a possibility in their diagnostic scheme"
Listen to the full quote by pressing play below.
Philip LoBue, MD, FACP, FCCP
Former Director, Division of Tuberculosis Elimination, CDC
"People don’t wake up one morning and think, 'Oh I’m at risk for TB, I should go to the health department and get treated,' but they do go and see their primary care provider for physicals, diabetes, blood pressure…"
Listen to the full quote by pressing play below.
Jason Cummins, MPH
President, National Tuberculosis Coalition of America; and Director, TB Elimination Program, Tennessee Department of Health
"… we can reach out to our private healthcare providers, that sometimes are the first line of defense…"
Listen to the full quote by pressing play below.
TB-specific strategies and resources developed for providers include:
- Virtual Case Consultation Support
Tuberculosis Centers of Excellence for Training, Education, and Medical Consultation funded by the Centers for Disease Control and Prevention (CDC), provided virtual case consultation support to TB providers. The primary areas of consultation included active infections, testing, and contact tracing and disease transmission, with a significant proportion of consultations focused on pediatric patients. - Provider Fact Sheets
The University of Southern California’s Curry International TB Center developed Drug-Resistant Tuberculosis: A Survival Guide for Clinicians, which includes resources on diagnosing TB, medication fact sheets, co-morbidities, and more.
Medication Access and Supply Chain Visibility
TB medications have been in shortage in recent years due to complex international pharmaceutical markets and procurement processes. Medication and supply procurement is not a barrier unique to TB; similar issues affect access to antivirals for flu and antimicrobial drugs.
"It just takes one outbreak with higher numbers or an MDR [multi-drug resistant TB] patient that is not predictable, not forecastable, and it blows totally out of the water any kind of stock or inventory… For TB, ultimately, the forecasting of how much meds you're going to need for the active cases or LTBI [latent TB infection] is incredibly challenging and very unpredictable."
Improving Access to Critical Medications: A Policy Toolkit for Health Agency Program Leadership | ASTHO
Understanding Nuance in Defining an Outbreak
In infectious disease preparedness and response, not all increases in case counts indicate outbreaks. TB provides an example of this nuance. An uptick in reported TB cases may result from factors unrelated to an outbreak, such as improved detection or demographic shifts in populations. These scenarios (often referred to as pseudo-outbreaks) underscore the importance of context-specific interpretation of surveillance data.
Scenarios that may mimic outbreaks include:
- Population changes, such as the arrival of individuals from high TB-burden areas.
- False-positive TB diagnoses, such as those from laboratory contamination or errors.
- Enhanced screening or diagnostic practices, which improve case detection but do not necessarily indicate increased transmission.
- Clinician variability, where a new provider may identify more cases based on differing diagnostic thresholds.
These TB-specific considerations are widely applicable to other emerging infectious diseases. For example, an increase in diagnosed new rare respiratory viruses may stem from heightened clinical awareness or more testing supply availability rather than true transmission events. Surveillance data provide the foundation for understanding disease transmission; however, they only tell a piece of the picture.
Using Genotyping and Surveillance Data to Clarify Transmission Patterns
Molecular genotyping provides information about infection relatedness by helping distinguish between isolated cases and true outbreaks. Indicators of a likely outbreak include:
- Clusters of cases with the same genotype in a localized area.
- The emergence of a new or rare genotype.
- A sudden increase in a previously stable genotype.
- Recurrence of a genotype linked to a past outbreak.
- Genotype clustering in populations with shared risk factors (e.g., incarceration, homelessness, substance use).
Applying this level of genomic surveillance and contextual interpretation can help guide public health response in emerging infectious diseases — particularly where molecular epidemiology is evolving, such as in hepatitis, COVID-19 variants, or fungal infections.
Scaling Response Infrastructure in Real Time
Effective TB outbreak response also provides key operational takeaways that apply to other infectious disease emergencies. Public health departments responding to TB outbreaks may:
- Extend clinic hours and offer offsite services to reach affected populations.
- Provide transportation, incentives, and other opportunities to enable participation in follow-up care and treatment adherence.
- Deliver directly observed therapy not just for cases, but for high-risk contacts.
These same strategies are critical in other infectious scenarios requiring rapid scaling of services, such as during an uptick in hepatitis A among persons who use drugs or contact tracing for novel respiratory pathogens.
Ensuring Adequate Resources and Staff Capacity
Another lesson from TB outbreak response is the emphasis on surge capacity. TB responses have relied on:
- Reassigning and training existing staff to support outbreak activities.
- Bringing in clinicians with specialized expertise.
- Hiring outreach workers with linguistic, cultural, and clinical skills to engage affected communities.
Other infectious disease responses can similarly benefit from this flexible, resource-conscious approach to workforce mobilization, especially in jurisdictions with limited public health capacity.
States are implementing scalable, equity-centered strategies that respond to TB while building infrastructure to support broader infectious disease preparedness.
Innovation in Pharmaceutical Access
Several state health departments are exploring the development of a reserve supply of pharmaceuticals managed by a commercial supplier. This strategy is designed to address critical drug shortages during infectious disease outbreaks that may not be covered by the Strategic National Stockpile formulary. The reserve supply model works by having states identify specific pharmaceuticals essential for managing outbreaks of diseases, which may face intermittent supply disruptions. Examples of how this strategy can be deployed include:
- Pharmaceutical Reserve System: Under this model, a state health department works with a wholesaler to procure and store a bolus of key medications. These medications are stored in a commercial supply chain, ensuring they are readily available during emergencies.
- Stock Rotation and Management: States allocate funding for additional staffing and infrastructure to manage these reserves. A critical feature of this system is stock rotation, where medications are integrated into the wholesaler’s regular business operations. This minimizes waste due to expired medications, ensuring a continual, efficient flow of essential drugs.
- Applicability to Other Diseases: This system can be applied to other infectious diseases, ensuring preparedness for shortages of treatments for respiratory infections, antivirals for hepatitis C, or medications for post-exposure prophylaxis during mpox outbreaks.
As states continue to examine funding options and logistics, the broader goal is to increase resilience across multiple infectious disease threats. This pharmaceutical reserve model can be a flexible, scalable solution to meet the evolving needs of public health during diverse disease outbreaks.
State and Local Coordination: A Collaborative Approach
Effective state and local coordination is crucial before, during, and after infectious disease emergencies. To help establish relationships, states have established working groups that include representatives from local jurisdictions, hospitals, health agencies, and other key community partners. For example, the California TB Controllers Association supports coordination between health agencies and others working to prevent and treat TB in California.
- Working Group Approach: The working group serves as a platform for state health agency staff and local representatives to communicate and monitor updates on medication availability, and other time sensitive topics. When new data or actionable information becomes available, such as shifts in disease spread or resource availability, this group ensures the information is rapidly disseminated to the right partners.
- Medical Mutual Aid Systems: Many states have adopted a medical mutual aid system. In California, the state’s Standardized Emergency Management System provides the fundamental structure for emergency response in the state. Within the public health and medical system, the medical health operational area program coordinates functions at the operational area or county, and the regional disaster medical health coordinator program coordinates functions within the states six mutual aid regions. This system enables local organizations to share information and resources, enhancing the collective response to infectious disease outbreaks. Mutual aid systems can be particularly effective for diseases that require rapid mobilization of resources, such as disease with high infectiousness, or where access to specialized drugs must be ensured for those at highest risk.
Partnerships: Strengthening Access to Critical Medications
Effective partnerships are vital in addressing challenges related to medication shortages, particularly for diseases like TB. The ASTHO blog "Partnering to Increase Access to Tuberculosis Medications" highlights several key collaborations that have proven instrumental in ensuring consistent access to essential treatments:
- National Organizations
- Pharmacists
- Health Care Providers
- Community Members
- Departments of Corrections
- Universities
These collaborations underscore the importance of a multifaceted approach to public health challenges, where diverse stakeholders work together to ensure that essential medications remain accessible to those in need.
Storytelling to Change Narratives
Health agencies may also consider working with people affected by the disease to use storytelling to amplify their message. Storytelling helps add humanity to public health communication, helping partners better understand the realities behind the data. Incorporating voices of people with lived experience may:- Reduce Stigma: Infectious diseases like TB, mpox, hepatitis, Ebola, and even COVID-19 may carry stigma. Personal stories can shift public perception by putting a face to the diagnosis and challenging harmful stereotypes.
- Build Trust and Empathy: Hearing directly from someone who has navigated an illness (particularly if they look and sound like those at greatest risk) builds a sense of connection and trust that purely clinical messages may miss. This can be especially powerful in communities that are hesitant to engage with public health systems.
- Encourage Engagement and Action: Survivors and their loved ones can share firsthand how testing, treatment, and prevention services made a difference. These testimonials can encourage others to seek care, complete treatment, or support public health recommendations.
Whether through videos, quotes, or community forums, incorporating voices of those with lived experience can strengthen outbreak response across emerging infectious diseases.
Here’s an example:
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