Alaska Tuberculosis Program Manual - Epidemiology - State of Alaska
Alaska Tuberculosis Program Manual - Epidemiology - State of Alaska Alaska Tuberculosis Program Manual - Epidemiology - State of Alaska
TB/LTBI Prescription and Medication Request – Guidelines (5 pages) TB/LTBI Medication Return Form and Guidelines (2 pages) TB/LTBI Stock TB Medication Ordering Form and Guidelines (2 pages) TB Medication Dose Monitoring, Regimen 1 TB Medication Dose Monitoring, Regimen 2 TB Medication Dose Monitoring, Regimen 3 TB Medication Dose Monitoring, Regimen 4 TB School Testing Report Tuberculosis Discharge Planning Checklist Tuberculosis Screening and Clearance Card Tuberculosis Screening Questionnaire / Chest X-ray Interpretation Request – standard form (2 pages) Tuberculosis Screening Questionnaire Guidelines Tuberculosis Treatment Contract (2 pages) ALASKA TUBERCULOSIS PROGRAM MANUAL FORMS 18.2 Revised July 2012
ALASKA STATE PUBLIC HEALTH LABORATORY TB PCR Testing Authorization form 5455 Dr. Martin Luther King Jr. Anchorage, AK 99507 Phone: 907-334-2139 (TB Dept) FAX: 907-334-2161 The Alaska State Public Health Laboratory (ASPHL) has developed a nucleic acid amplification assay by real-time polymerase chain reaction (PCR) for use on respiratory specimens for the diagnosis of tuberculosis (TB). This assay was developed and its performance characteristics were determined by ASPHL. This assay has not been cleared by the U.S. Food and Drug Administration. The CDC recommends this type of testing be performed on at least one AFB smear positive respiratory specimen from each patient with signs and symptoms of pulmonary TB for whom a diagnosis of TB is being considered but has not yet been established, and for whom the test result would alter case management or TB control activities, such as contact investigations. Patient Criteria: Patient must have signs and symptoms of pulmonary TB Patient must be reported to the Alaska Tuberculosis Control Program as a suspect TB case (907-269-8000) Patient must not have been diagnosed with TB or a non-tuberculous mycobacterial infection or received treatment within the last 12 months Patient Name AFB Smear Results: DOB: Collection Date: Please answer the following questions. Circle Response Yes No Unknown Does the patient have signs and symptoms of pulmonary TB? Yes No Unknown Has the patient been diagnosed with TB or a non-tuberculous mycobacterial infection within the last 12 months? Yes No Unknown Has the patient received anti-TB treatment within the last 12 months? Yes No Unknown Is the patient a contact of a positive TB case? Yes No Unknown Abnormal Chest X-Ray? Yes No Unknown Skin test Positive? Pos Neg Unknown Not Done Quantiferon TB Gold Test Result? I _____Authorize ASPHL to perform TB PCR testing. I _____DO NOT Authorize ASPHL to perform TB PCR testing. The cost for testing is $153 and fees for service will be billed to the facility submitting the specimen. Clinician Printed Name:_____________________________________ Date:______________________ Clinician Signature:_________________________________________ Please fax completed authorization to 907-334-2161 Attn: TB Department 2/2012
- Page 345 and 346: Introduction Purpose Use this secti
- Page 347 and 348: National Guidelines The following g
- Page 349 and 350: Transfer Notifications CONTENTS Int
- Page 351 and 352: For roles and responsibilities, ref
- Page 353 and 354: Follow-Up Type When to Initiate Not
- Page 355 and 356: Action Transfers Within Alaska Tran
- Page 357 and 358: Provide the patient with a. A copy
- Page 359 and 360: References 1 CDC. International not
- Page 361 and 362: Infection Control CONTENTS Introduc
- Page 363 and 364: of TB infection control principles
- Page 365 and 366: Administrative Activities 13 Key ac
- Page 367 and 368: Personal Respiratory Protection Alt
- Page 369 and 370: For regulations in your area, refer
- Page 371 and 372: Employee Health All employees, phys
- Page 373 and 374: Figure 1: TWO STEP TESTING AND FOLL
- Page 375 and 376: Isolation To reduce disease transmi
- Page 377 and 378: Table 4: CRITERIA FOR PATIENTS TO B
- Page 379 and 380: When to Initiate Airborne Infection
- Page 381 and 382: Confirmed Tuberculosis Disease A pa
- Page 383 and 384: Multidrug-Resistant Tuberculosis Di
- Page 385 and 386: Environmental Controls in the Patie
- Page 387 and 388: Return to Work, School, or Other So
- Page 389 and 390: Tuberculosis Infection Control in P
- Page 391 and 392: Transportation Vehicles To prevent
- Page 393 and 394: 7 CDC. Guidelines for preventing th
- Page 395: Forms: Alaska State Public Health L
- Page 399 and 400: Anchorage Alaska State Public Healt
- Page 401 and 402: INDEX CASE INFORMATION Name: DOB: /
- Page 403 and 404: CONTACT Name: Tuberculosis Contact
- Page 405 and 406: Directly Observed Therapy (DOT) Cal
- Page 407 and 408: B. Documents patient care activitie
- Page 409 and 410: Alaska TB Program Section of Epidem
- Page 411 and 412: Treatment Summary for Active TB Nam
- Page 413 and 414: Interjurisdictional Tuberculosis No
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- Page 421 and 422: Latent Tuberculosis Infection (LTBI
- Page 423 and 424: Alaska Tuberculosis Program 9210 Va
- Page 425 and 426: Instructions for Collecting Sputum
- Page 427 and 428: TB Case Management Information Requ
- Page 429 and 430: Table 1: First-line anti-tuberculos
- Page 431 and 432: Return the fax to the Drug Room (90
- Page 433 and 434: Stock Orders: A small supply of
- Page 435 and 436: TB/LTBI Medication Return Form Reas
- Page 437 and 438: TB/LTBI Stock Medication Request FA
- Page 439 and 440: TB Medication Dose Monitoring Regim
- Page 441 and 442: TB Medication Dose Monitoring Regim
- Page 443 and 444: ALASKA DEPARTMENT OF HEALTH AND SOC
- Page 445: Tuberculosis Discharge Planning Che
TB/LTBI Prescription and Medication Request – Guidelines (5 pages)<br />
TB/LTBI Medication Return Form and Guidelines (2 pages)<br />
TB/LTBI Stock TB Medication Ordering Form and Guidelines (2 pages)<br />
TB Medication Dose Monitoring, Regimen 1<br />
TB Medication Dose Monitoring, Regimen 2<br />
TB Medication Dose Monitoring, Regimen 3<br />
TB Medication Dose Monitoring, Regimen 4<br />
TB School Testing Report<br />
<strong>Tuberculosis</strong> Discharge Planning Checklist<br />
<strong>Tuberculosis</strong> Screening and Clearance Card<br />
<strong>Tuberculosis</strong> Screening Questionnaire / Chest X-ray Interpretation Request – standard form (2 pages)<br />
<strong>Tuberculosis</strong> Screening Questionnaire Guidelines<br />
<strong>Tuberculosis</strong> Treatment Contract (2 pages)<br />
ALASKA TUBERCULOSIS PROGRAM MANUAL FORMS 18.2<br />
Revised July 2012
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