Alaska Tuberculosis Program Manual - Epidemiology - State of Alaska

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Ongoing Assessment and Monitoring Conduct ongoing assessments and monitor patients at least monthly either in an ambulatory clinic setting, local public health agency, or private physician’s office. When itinerant PHNs provide case management for patients in villages, monthly monitoring can be done by teleconference in conjunction with the CHAP or DOT aide, by phone with the patient, or may be done by the patients’ provider. Schedule additional assessments throughout the month for patients experiencing problems in their tuberculosis (TB) treatment, or for those patients who are nonadherent to directly observed therapy (DOT) or follow-up appointments. 37 There are countless stories from nurses and outreach workers reinforcing the fact that not all information is obtained from the patient or family at one time. Therefore, the case manager must ensure that the list of contacts is updated from time to time and determine the need for further testing. It is also important to review the status of the contact investigation to ensure that timelines and standards are followed. Also, checking for the accuracy of previously gathered information should occur throughout the patient’s TB treatment. 38 See the “Alaska TB Program: Timeline for the Case Management of TB Treatment” (10.5) in this section for more information. Ongoing Assessment Activities To complete an ongoing assessment, perform the following activities: Monitor the clinical response to treatment Determine human immunodeficiency virus (HIV) status and the risk factors for HIV disease, and refer the patient for treatment, if indicated Review the treatment regimen Ensure that medications are ordered and given at the correct time, and in the correct dosage Monitor for side effects and adverse reactions to medication Assess adherence daily and monthly, and identify positive and negative motivational factors influencing adherence Address the unmet educational needs of the patient Educate the patient about the TB disease process Advocate for the patient with team members and other service providers A L A S K A T B P R O G R A M M A N U A L Case Management 10. 20 R e v i s e d N o v e m b e r 2 0 1 2
Review the status of the contact investigation, if one was started Monitor the clinical response to treatment by reviewing TB symptoms, bacteriology reports, radiographic results, weight, vital signs, drug susceptibility results, and comparing them to previous documented findings. This review is an important measurement of clinical improvement, worsening, or stabilization of the patient’s condition. The case manager should collect three (3) sputa for acid-fast bacilli (AFB) sputum smear and culture at least every two (2) weeks until sputum smears are negative. Thereafter, three (3) sputa should be collected monthly until there are three negative cultures. If a patient is on DOT, no further specimen collected is indicated unless the patient becomes symptomatic again. A clinician should complete a medical evaluation at the time of diagnosis and periodically based on patient condition or review of diagnostic information, patient chart, and chest radiographs. If the patient’s condition is worsening, interview the patient to determine the potential cause(s) for the worsening condition. List all bacteriological reports in chronological order, and correlate them with the patient’s current symptoms history and chest radiograph report to ensure accuracy. Also, conduct this review at conversion as evidence for the improving condition of the patient. 39 Inconsistencies should trigger additional questions, such as the possibility of laboratory contamination. Bring these questions immediately to the attention of the health care provider, case manager and Alaska TB Program (907) 269-8000. Determine HIV status and the risk factors for HIV disease, and refer the patient for treatment, if indicated. It is important for patients to understand the correlation between TB and HIV disease. The case manager should ensure that HIV counseling and testing are done at the beginning of TB treatment, if the HIV status is not previously known. If the patient refuses HIV testing, an assessment of the risk factors for HIV should be completed. 40 If a patient refuses, voluntary HIV testing and counseling should continue to be offered periodically throughout treatment. If the parents of a young child with TB refuse to permit the child to be HIV tested, the parents should be interviewed regarding the child’s risk of HIV disease, including neonatal transmission. 41 Review the treatment regimen to verify that the physician’s orders are clear and that dosages are correct for the patients’ age and weight. One of the case manager’s primary responsibilities is to ensure that the patient completes treatment according to the physician’s orders. It is also important to ensure that the plan is specific for the individual patient and follows the principles of TB treatment. 42 For consultation regarding the treatment of TB, contact the Alaska TB Program at 907-269-8000. A L A S K A T B P R O G R A M M A N U A L Case Management 10. 21 R e v i s e d N o v e m b e r 2 0 1 2
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Alaska Tuberculosis Program Manual
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Purpose............................
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Monthly assessment of adherence ...
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When to Expand a Contact Investigat
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Introduction CONTENTS About the Ala
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How to Use This Manual Portable Doc
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Printing To access the print dialog
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Abbreviations Refer to the list bel
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QFT QuantiFERON ® -TB test QFT-G Q
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Alaska Statutes and Regulations on
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National and State Program Objectiv
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Indicator 3 Thorough contact invest
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National Standards and Recommendati
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Roles and Responsibilities Contact
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Local Public Health Agencies Table
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Resources and References Resources
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Introduction Purpose Use this secti
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Contact investigation: Collecting,
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Reporting Tuberculosis Detecting an
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Prompt reporting (prior to culture
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Use the Infectious Disease Report F
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Data Collection Forms The following
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Genotyping Genotyping is a useful t
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References 1 ATS, CDC, IDSA. Contro
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child or a person acting on behalf
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When to Conduct Targeted Testing Al
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Alaska Program Standards for Health
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B Notifications CONTENTS Introducti
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Table 1: NUMBERS OF FOREIGN-BORN PE
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chest radiograph and if sputum AFB
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Follow-up of B1 and B2 Tuberculosis
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Evaluation of B1, B2, and B Tubercu
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Treatment Prescribe medications as
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12 Centers for Disease Control and
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Tuberculosis Classification System
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Table 2: PERSONS AT HIGH RISK FOR T
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Table 3: WHEN TO SUSPECT PULMONARY
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Diagnosis of Tuberculosis Disease T
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1. Exposure to Infectious TB: Ask p
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Physical Examination A physical exa
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For more information on chest radio
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Laboratories should report positive
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Guidelines for preventing the trans
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50 CDC. National plan for reliable
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Introduction Purpose The overall go
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Basic Treatment Principles Follow t
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Treatment Regimens and Dosages Use
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Table 3: FOUR TREATMENT REGIMENS FO
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† 4 Table 4: DOSES*OF FIRST-LINE
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Figure 1:TREATMENT ALGORITHM FOR DR
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a. In remote locations in Alaska, m
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Antituberculosis Drug Rifampin (RIF
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Antituberculosis Drug Rifapentine (
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Reporting Reactions The table below
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Response to Treatment For consultat
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Figure 2: MANAGEMENT OF TREATMENT I
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Post-Treatment Evaluation Routine f
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Treatment in Special Situations Tre
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Resources For consultation regardin
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with an increase in overall complet
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Liver Disease Management of TB in p
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After the initial phase (first two
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Extrapulmonary Tuberculosis The bas
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Diagnosis of Latent Tuberculosis In
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Forms All required and recommended
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High-Risk Groups Certain factors id
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Diagnosis of Latent Tuberculosis In
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continually exposed to populations
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Administration of the Tuberculin Sk
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See “Two-Step Tuberculin Skin Tes
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See “Live-Virus Vaccines” under
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For more information on IGRAs and t
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Table 5: TARGETED TESTING FOR LATEN
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Treatment of Latent Tuberculosis In
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Policy Detailed information on the
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Window period prophylaxis is treatm
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Regimens Identify an appropriate re
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Dosages Once the appropriate regime
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Side Effects and Adverse Reactions
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If a patient reports to a healthcar
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Antituberculosis Drug Rifampin (RIF
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DOT is strongly encouraged for thos
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Table 7 describes the duration of t
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Alcoholism Alcohol-Related Treatmen
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Medication Administration and Pharm
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National Tuberculosis Controllers A
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24 CDC . “Recommendations for Use
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Diagnosis and Treatment of Latent T
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All children suspected or diagnosed
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Page 189 and 190: History of BCG vaccination is not a
Page 191 and 192: Because of their higher specificity
Page 193 and 194: Table 3: COUNTRIES AND AREAS WITH A
Page 195 and 196: Treatment of Latent TB Infection (L
Page 197 and 198: For consultation regarding the trea
Page 199 and 200: Monitoring DOT is mandatory for INH
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Page 203 and 204: TABLE 8: SIGNS AND SYMPTOMS OF PULM
Page 205 and 206: Treatment of Tuberculosis Basic pri
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Page 219 and 220: Case Management CONTENTS Introducti
Page 221 and 222: patient-centered approach to case m
Page 223 and 224: Alaska TB Program: Timeline for the
Page 225 and 226: For assistance with language issues
Page 227 and 228: Ascertain the extent of TB illness
Page 229 and 230: medical/health problem. The date of
Page 231 and 232: necessary to teach people how to ta
Page 233 and 234: Treatment Plan Components Recommend
Page 235 and 236: Implementation Activities To begin
Page 237: o Indicate the number of doses prov
Page 241 and 242: For more information, see the “Di
Page 243 and 244: importance of continued treatment a
Page 245 and 246: 5. Review information with the prov
Page 247 and 248: Completion of Therapy The case mana
Page 249 and 250: Case Closures Other than Completion
Page 251 and 252: Conduct a case management meeting o
Page 253 and 254: Biweekly (BIW) doses of TB medicati
Page 255 and 256: Use DOT with other measures such as
Page 257 and 258: It is important not to send a mixed
Page 259 and 260: Medical Orders Progressive Interven
Page 261 and 262: CDC. Module 9: “Patient Adherence
Page 263 and 264: 36 New Jersey Medical School Nation
Page 265 and 266: 75 CDC. Module 9: patient adherence
Page 267 and 268: Introduction Purpose A contact inve
Page 269 and 270: For roles and responsibilities, ref
Page 271 and 272: Decision to Initiate a Contact Inve
Page 273 and 274: chest radiographic findings that ar
Page 275 and 276: In general, a contact investigation
Page 277 and 278: Time Frames for Contact Investigati
Page 279 and 280: Circumstances unique to Alaska may
Page 281 and 282: Circumstances unique to Alaska may
Page 283 and 284: Activity Purpose Maximum Time Inter
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General Guidelines for Interviewing
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Healthcare workers should remember
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Index Patient with Positive Acid-Fa
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Index Patient with Negative Acid-Fa
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Contact Evaluation, Treatment, and
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Definition of abbreviations: HIV =
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Note: An IGRA may be used in place
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When to Expand a Contact Investigat
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Figure 7: EVALUATION, TREATMENT, AN
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CDC’s “Framework of Program Eva
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Definitions of abbreviations: AIDS
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elease assay; LTBI = latent tubercu
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officials to distinguish between di
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References 1 ATS, CDC, IDSA. Contro
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44 CDC, NTCA. Guidelines for the in
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Available Laboratory Tests Table 2:
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Table 3: PCR Testing Algorithm and
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Table 4: SPECIMEN COLLECTION METHOD
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5. If possible, send the specimen o
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Specimen Shipment There are three m
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Patient Education CONTENTS Introduc
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treatment, common side-effects of m
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Education Topics During the initial
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10. Explain the signs and symptoms
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Patient Education Materials Get th
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References 1 CDC. Module 4: treatme
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National Guidelines The following g
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Transfer Notifications CONTENTS Int
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For roles and responsibilities, ref
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Follow-Up Type When to Initiate Not
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Action Transfers Within Alaska Tran
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Provide the patient with a. A copy
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References 1 CDC. International not
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Infection Control CONTENTS Introduc
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of TB infection control principles
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Administrative Activities 13 Key ac
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Personal Respiratory Protection Alt
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For regulations in your area, refer
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Employee Health All employees, phys
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Figure 1: TWO STEP TESTING AND FOLL
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Isolation To reduce disease transmi
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Table 4: CRITERIA FOR PATIENTS TO B
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When to Initiate Airborne Infection
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Confirmed Tuberculosis Disease A pa
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Multidrug-Resistant Tuberculosis Di
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Environmental Controls in the Patie
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Return to Work, School, or Other So
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Tuberculosis Infection Control in P
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Transportation Vehicles To prevent
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7 CDC. Guidelines for preventing th
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Forms: Alaska State Public Health L
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ALASKA STATE PUBLIC HEALTH LABORATO
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Anchorage Alaska State Public Healt
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INDEX CASE INFORMATION Name: DOB: /
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CONTACT Name: Tuberculosis Contact
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Directly Observed Therapy (DOT) Cal
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B. Documents patient care activitie
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Alaska TB Program Section of Epidem
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Treatment Summary for Active TB Nam
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Interjurisdictional Tuberculosis No
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Latent Tuberculosis Infection (LTBI
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Alaska Tuberculosis Program 9210 Va
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Instructions for Collecting Sputum
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TB Case Management Information Requ
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Table 1: First-line anti-tuberculos
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Return the fax to the Drug Room (90
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Stock Orders: A small supply of
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TB/LTBI Medication Return Form Reas
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TB/LTBI Stock Medication Request FA
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TB Medication Dose Monitoring Regim
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TB Medication Dose Monitoring Regim
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ALASKA DEPARTMENT OF HEALTH AND SOC
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Tuberculosis Discharge Planning Che
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PART 2: 8. Have you ever been told
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Tuberculosis Treatment Contract Dep
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Statutes and Regulations Contents I
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Regulations Infection Control 7 AAC
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place of work is remote from patien
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(2) the child or a person acting on
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Glossary acid-fast bacilli (AFB): M
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eaction size on a later test, which
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disseminated TB: See miliary TB. dr
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immunocompromised and immunosuppres
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include medical history and TB symp
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thousands to millions of copies of
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secondary (TB) case: A new case of
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eproducing TB organisms from respir
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Alaska Tuberculosis Program Manual - Epidemiology - State of Alaska

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