Tuberculosis

Tuberculosis (TB) Forms and Documents

Completion of Active Treatment Letter

Completion of TB Infection (LTBI) Treatment Letter

Contact Investigation Report

Contact Investigation Summary

Directly Observed Therapy (DOT) Agreement

DOT/Active TB Treatment Record

Facility Risk Assessment

Formulary

Home Evaluation Form

Home Isolation Agreement

Interjurisdictional TB Notification Form

Monthly Clinical and Medication Monitoring

Patient Medication List

Prior Authorization Form

Patient Education – ACTIVE

Patient Education – LATENT

Patient Assistance Guidance

Patient Tuberculosis Risk Assessment

TB Skin Test Not Indicated – Letter

TB Infection Treatment Record

TST Supply Order Form

Use & Disclosure Authorization

Targeted Tuberculosis (TB) Screening Guidelines

Evaluación de riesgo di tuberculosis del paciente (Patient TB Risk Assessment)

Acuerdo de terapia observada directamente (DOT Agreement)

Acuerdo de aislamiento en el hogar (Home Isolation Agreement)

Tratamiento de la infección con tuberculosis (TB Infection Patient Education Form)

Tratamiento de la enfermedad de tuberculosis (TB Disease Patient Education Form)

TUBERCULOSIS STATISTICS IN WYOMING

CLICK HERE to view the Department of Health 2016 Wyoming Tuberculosis Report. This report includes individual county rates. The Wyoming TB rate for 2016 was 0.2 cases per 100,000 people. The national TB rate was 2.9 cases per 100,000 people.

TUBERCULOSIS MANUAL

PUBLICATION COVER: Program information and publication date.

TITLE PAGE AND CONTENTS

CHAPTER 1: INTRODUCTION TO MANUAL AND TB CONTROL Including Wyoming laws ans rules regarding TB control, objectives and standards, roles and responsibilities (program staff, consultants, public health agencies, private providers and laboratories).

CHAPTER 2: TB SURVEILLANCE Introduction to surveillance (purpose, policies, laws and rules), TB classification system, how to report TB, data collection forms, registry and document retention, genotyping, dissemination, evaluation.

CHAPTER 3: TARGETED TESTING FOR LATENT TB INFECTION Introduction including the purpose and policies surrounding targeted testing for latent TB, when to do targeted testing, how to increase targeted testing and treatment, screening in facilities.

CHAPTER 4: TB NOTIFICATIONS Introduction to notifications including purpose, pre-arrival medical screenings and policies, evaluation and follow-up of B1/B2 TB arrivals (including division of global migration and quarantine forms, patient follow-up, evaluation activities and treatment).

CHAPTER 5: DIAGNOSIS OF TB DISEASE Purpose, policy and forms for the diagnosis of TB disease, identification and follow-up of suspected TB cases, diagnosis of TB disease including medical history review, HIV screening, physical examinations, TB skin test and IGRA testing, radiography and bacteriologic examinations.

CHAPTER 6: TREATMENT OF TB DISEASE Purpose, policy and forms for the treatment of TB disease, basic treatment principles, regimens, dosages and durations of treatment, side effects and adverse reactions (monitoring, reporting), response to treatment, completion of therapy, post-treatment evaluation, treatments in special situations (including drug-resistant TB, HIV infection, alcohol use, liver disease, renal insufficiency and end-stage renal disease, TB associated with tumor necrosis factor-alpha antagonists, culture-negative pulmonary TB, extrapulmonary TB, pregnancy and breastfeeding, TB in children).

CHAPTER 7: DIAGNOSIS OF LATENT TB INFECTION Purpose, policy and forms for diagnosis of latent TB infection, high-risk groups, diagnosis through interferon-gamma release assays (IGRA) and Mantoux TB skin testing, candidates for mantoux TB skin testing, administration/ measurement/ interpretation of the TB skin test, HIV screening, follow-up activities and chest radiography.

CHAPTER 8: TREATMENT OF LATENT TB INFECTION Introduction, whom to treat (susceptible/ vulnerable contacts, TB skin test results of 5mm/ 10mm/ 15mm or more, treatment regimens and dosages, side effects and adverse reactions (monitoring and reporting). Adherence to treatment (monthly assessment and directly observed therapy), completion of therapy and special situations (including HIV/ Latent TB infection, alcohol use, pregnancy, breastfeeding.

CHAPTER 9: CASE MANAGEMENT Introduction (including purpose, policy, forms, acknowledgments), initial assessment (cultural sensitivity, language issues, patient’s medical records, assessment site, discharge planning, initial assessment activities), treatment plan components, activities and implementation. Ongoing assessment activities, monitoring for side effects/ adverse reactions/ bacterial/ and clinical improvements. Verifying completion of therapy, adequate course of treatment, calculating completion of therapy and closures other than completion. Evaluation activities, directly observed therapy (candidates, how to deliver, adherence to), incentives and enablers (eligible patients, available incentives), progressive interventions, types of legal orders and how to process them.

CHAPTER 10: CONTACT INVESTIGATION Introduction, basic steps and planning for contact investigation, factors predicting transmission and the decision to initiate contact investigation, index patient and transmission site information, contact evaluation and treatment, ongoing management activities and time frame of contact investigation activities. Infection period, index patient pre-interview preparation and general guidelines. Field investigation, contact priorities, evaluation, treatment and follow-up. When to expand contact investigation and low-priority contacts. Data management and evaluation of contact investigations, outbreak investigations and Wyoming TB outbreak response plan.

CHAPTER 11: LABORATORY SERVICES Introduction, available lab tests, specimen collection and shipment.

CHAPTER 12: PATIENT EDUCATION Introduction, general guidelines, language and comprehension barriers, education topics (diagnosis, contact investigation, isolation, side effects, adverse reactions, adherence), patient education materials.

CHAPTER 13: CONFIDENTIALITY Introduction, CDC guidance on HIPAA, Wyoming HIPAA policies, national confidentiality guidelines.

CHAPTER 14: TRANSFER NOTIFICATIONS Introduction, when and how to initiate/ issue a notification (both within and outside of the United States),

CHAPTER 15: SUPPLIES, MATERIALS, AND SERVICES Introduction, Mantoux TB skin testing supplies, Interferon Gamma Release Assay supplies, chest radiographs, specimen collection and shipment supplies, anti-tuberculosis medications, incentives and enablers, medical interpretation services, healthcare staff training and education.

CHAPTER 16: INFECTION CONTROL Introduction, Infection Control Measures (Administrative, Environmental, Personal respiratory protection), two-step TB skin testing, estimating infectiousness and determining non-infectiousness, airborne infection isolation,hospital discharge determinations, residential setting infection control measures, social settings (school, work, other), TB infection control inpatient care facilities and transportation vehicles (self-transport, healthcare workers, emergency medical services).

CHAPTER 17: GLOSSARY