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Ohio Tuberculosis Program Manual

Table of Contents

Chapter 1: Introduction

TB Manual Chapter 1: Introduction contains information outlining the Ohio Tuberculosis (TB) Program Manual. This includes the purpose, objectives, standards and contact information for the state TB Program staff. The introduction also contains a legend for the keys seen throughout the manual and the abbreviations commonly used.

Chapter 2: Surveillance

TB Manual Chapter 2: Surveillance outlines the importance of surveillance in tuberculosis (TB) control and prevention. It discusses the report of suspect and confirmed cases of TB and the required data collection necessary to do so. Local health departments are required to send reports to the Ohio TB Program, including the Report of Verified Case of Tuberculosis (RVCT) forms which are then entered into the Ohio Disease Reporting System (ODRS). These are entered by the local TB control unit and the ODH TB Program then transferred electronically to the CDC. This chapter also outlines the state TB program’s computerized TB registry as well as the use and importance of genotyping.

Chapter 3: Targeted Testing for LTBI

TB Manual Chapter 3: Targeted Testing for LTBI covers the fact that reducing latent tuberculosis infection (LTBI) in high-risk populations is an important strategy to control TB. This chapter discusses targeted testing for LTBI, a strategic component of TB control that identifies persons who are at high risk for developing TB and who would benefit by treatment of LTBI, if detected. This chapter also identifies approaches to increase targeted testing and screening for TB infection in facilities such as hospitals, long-term care facilities, and prisons.

Chapter 4: TB Notifications

TB Manual Chapter 4: TB Notifications outlines the notification system, evaluation, and treatment of immigrants and/or refugees entering the United States with Class A or B conditions, specifically medical screenings of persons with tuberculosis (TB) classifications after their arrival at ports of entry to the United States. They are reported to CDC’s Division of Global Migration and Quarantine (DGMQ). The DGMQ notifies state and local health departments of refugees and immigrants with TB classifications who are moving to their jurisdictions. This chapter outlines the different classifications of applicants for immigration: No TB Classification, Class A TB with wavier; Class B1 TB, Pulmonary; Class B1 TB, Extrapulmonary; Class B2 TB, LTBI Evaluation, Class B3 TB, Contact Evaluation. It also includes patient follow-up and treatment after the immigration paperwork so that complete evaluation for TB disease is done as well as the evaluation activities/tasks that should be done for B1 and B2 arrivals.

Chapter 5: Diagnosis of TB Disease

TB Manual Chapter 5: Diagnosis of TB Disease can be used to classify patients with tuberculosis (TB) and latent tuberculosis infection (LTBI) and detect suspect cases of TB. It also provides information on knowing when to report suspect or confirmed cases of TB and diagnose TB disease. For detecting suspected cases of TB, it utilizes signs and symptoms typical of TB, as well as the difference in chest radiograph (x-ray) of immunocompetent patients vs. immunocompromised patients, and those with advanced human immunodeficiency virus (HIV) infection. For diagnosis of TB, the requirement of a complete medical evaluation includes medical history, HIV screening, physical examination, Tuberculin skin test (TST) or interferon gamma release assay (IGRA), chest radiography, and bacteriologic examination. Bacteriologic tests, Acid-Fast Bacilli (AFB) smear, Nucleic Acid Amplification (NAA) assay, culture, and drug susceptibility are all outlined. This chapter includes scenarios for different TB patients and recommended course of action. It also outlines the Ohio policies, state laws and regulations regarding tuberculosis.

Chapter 6: Treatment of TB Disease

TB Manual Chapter 6: Treatment of Disease outlines the overall goal for treatment of tuberculosis (TB): to cure the patient and minimize transmission to others. This chapter outlines the basic treatment principles for TB disease. It provides guidance on the appropriate treatment regimens, first-line drugs like Isoniazid (INH), Pyrazinamide (PZA), Ethambutol (EMB), and Rifampin (RIF), dosages, and duration for patients, assessing the patients’ response to treatment and any side effects or adverse reactions. It allows for determination of therapy completion, the need for post-treatment evaluation. The chapter also provides treatment in special situations, such as when a patient has drug-resistant TB or TB–human immunodeficiency virus (HIV) coinfection.

Chapter 7: Diagnosis of LTBI

TB Manual Chapter 7: Diagnosis of LTBI provides information on the classification and diagnosis of patients with latent tuberculosis infection (LTBI) via tuberculin skin testing (TST) or interferon gamma release assays (IGRA). Administration and interpretation of TST and IGRA are outlined here also. Certain factors identify persons at high risk for tuberculosis (TB) infection and/or for progression to TB disease such as being a contact of a smear-positive TB case, persons with HIV infection or other immunocompromising conditions, infants and children under age five, recent immigrants from countries with high incidence of TB, etc.

Chapter 8: Treatment of LTBI

TB Manual Chapter 8: Treatment of LTBI discusses who to treat for latent tuberculosis infection (LTBI), including people in high-risk groups, susceptible contacts, and those with positive tuberculin skin test (TST) results. Treatment regimens and dosages are identified, including the importance of directly observed therapy (DOT) for those at high risk for TB, or those at risk of nonadherence or on an intermittent dosing regimen. This chapter provides side effects and adverse reactions to anti-TB medications that should garner additional attention. It also addresses the importance of monitoring patients for adherence to treatment, since effectiveness of the regimen decreases with non-adherence. Lastly, it includes completion of therapy as well as treatment for special situations, HIV infection, alcoholism, and pregnancy and breastfeeding.

Chapter 9: TB Case Management

TB Manual Chapter 9: TB Case Management describes the activities assigned to the local TB Control Unit, specifically the responsibilities of the employee assigned to the case to regularly review patient progress and address any barriers to adherence. This ensures the successful completion of tuberculosis (TB) treatment and the subsequent cure of the patient. It outlines the recommendations and guidance for conducting initial assessments, developing treatment plans for case management activities, including the plan for directly observed therapy (DOT), and conducting monthly ongoing assessments with a physician. Included amongst the monitoring is watching for side effects and adverse reactions to medication while monitoring bacteriologic and clinical improvement as a response to medication. The last of the steps outlined are following treatment completion: verify completion of therapy and evaluate case management activities. For unique situations of non-adherence or push back, the use of incentives and enablers to improve adherence to therapy, and if necessary, when and how to use legal orders for the patient to adhere to therapy are discussed as well.

Chapter 10: Contact Investigation

A contact investigation is the process of identifying, examining, evaluating, and treating all persons who are at risk for infection with tuberculosis (TB) due to recent exposure to a newly diagnosed or suspect case. TB Manual Chapter 10: Contact Investigation provides guidelines for when to initiate a contact investigation, the time frames for key activities, estimation of infectious period, conducting index patient interviews, and if necessary, an outbreak investigation. It also provides guidance on management of data, evaluation of investigations, and assigning priorities to contacts after data is collected via index patient interviews.

Chapter 11: Lab Services

The diagnosis, management and control of tuberculosis (TB) relies on accurate laboratory tests, as they provide key information to clinicians (for patient care) and public health agencies (for disease control services). TB Manual Chapter 11: Lab Services outlines the available laboratory tests and their turnaround time for results including: Acid-Fast Bacilli (AFB) smear, culture, drug susceptibility, Nucleic Acid Amplification (NAA) assay, identification of Mycobacteria by high performance liquid chromatography (HPLC) or DNA Probe, and genotyping. Directions for specimen collection of sputum at a healthcare facility and at home are provided, as well as collection of gastric aspirates and bronchoscopy or collection of extrapulmonary specimens. This chapter also provides information on specimen shipment.

Chapter 12: Patient Education

An important part in helping patients to adhere to treatment plans is to educate them about tuberculosis (TB). Patients cannot be expected to adhere to treatment recommendations if they are not educated about TB and how it is treated, and patients who understand these concepts are more likely to adhere to treatment. TB Manual Chapter 12: Patient Education provides guidance on what information to cover in education sessions with patients. It includes links to resources to provide to patients in addition to the approach to take in addressing TB and latent tuberculosis infection (LTBI), as well as anything that may come up during treatment such as non-adherence to medication, adverse side effects, contact investigation, and isolation. This chapter also addresses language and comprehension barriers during assessment.

Chapter 13: Confidentiality

TB Manual Chapter 13: Confidentiality outlines what information and records should be treated with confidentiality under HIPAA, as it identifies the state and national policies that maintain patient confidentiality. Measures should be taken to ensure tuberculosis (TB) patients’ confidentiality, while understanding what information is permissible for sharing due to public health reasons.

Chapter 14: Transfer Notifications

TB Manual Chapter 14: Transfer Notifications provides notification information in the event a tuberculosis (TB) case, a contact, and/or a latent tuberculosis infection (LTBI) case with initiated treatment moves to another TB Control Unit’s jurisdiction. Some patients receiving treatment for TB disease in the United States move from one jurisdiction to another before completing treatment. Notifying the receiving local and/or state jurisdiction of a patient’s impending arrival will prevent interrupted treatment and improve public health outcomes. In Ohio, the Ohio Department of Health (ODH) TB Program is responsible to for coordination of transfer notification between states and other local jurisdictions within the state. An interjurisdictional TB notification system (IJN) has been set up by the National Tuberculosis Controllers Association (NTCA) to facilitate and standardize communication between states. For those cases transferring outside the United States, an International Tuberculosis Notification Form is completed through ODH and TBNet is used for patient tracking. If the patient is transferring to Mexico, CURE-TB is used.

Chapter 15: Supplies, Materials, and Services

TB Manual Chapter 15: Supplies, Materials, and Services outlines the resources available for effective tuberculosis (TB) treatment and how to access them. Local agencies can use the Ohio Department of Health (ODH) TB Program for technical assistance, for incentives and enablers, to arrange for medical consultation services in the event of difficult cases, and healthcare staff training and education based on the needs of a health agency and their population. Also included is information for the arrangement of specimen collection and shipment via ODH Laboratory without cost to the local agency.

Chapter 16: Infection Control

TB Manual Chapter 16: Infection Control outlines infection control measures that are fundamental to reducing the spread of communicable diseases like tuberculosis (TB). This chapter outlines the hierarchy of infection control measures: administrative controls, environmental controls, and personal respiratory protection. It provides direction and guidance on the difference between masks and respirators, the importance of two-step Tuberculin skin testing (TST), isolation of a patient with TB to reduce transmission, and determining infectiousness. Further, negative air pressure rooms, a form of airborne infection isolation (AII) is outlined for hospitals, as well as hospital discharge for drug-susceptible TB and multidrug-resistant TB (MDR-TB). This chapter also applies the hierarchy of infection control measures to a patient’s home, and residential settings. It also provides guidance on return to work, school, and other social settings, directions for close contacts of TB patients depending on their transportation vehicles, and infection control in patient care facilities.

Chapter 17: Glossary

TB Manual Chapter 17: Important terms, phrases and abbreviations used throughout the Tuberculosis (TB) Manual for reference.