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Tuberculosis Services in Douglas County Wisconsin Department of Health Services Division of Public Health P–00647 (10/2019) Tuberculosis Services In Douglas County A quick guide for health care providers Reporting Requirements Health Care Provider Support Where to Report Douglas County Health Department Phone: [PHONE REDACTED] Fax: [PHONE REDACTED] After Hours: [PHONE REDACTED] Prepared by the Douglas County Public Health ---PAGE BREAK--- Tuberculosis Services in Douglas County 2 Reporting Requirements By law, medical providers, infection control practitioners and laboratories must report ALL suspected or confirmed cases of tuberculosis within 24 hours of diagnosis. Routine follow-up visits must also be reported. ***Please do not wait for lab results to report a suspect TB case*** 1) Active TB, Suspect A clinical illness marked by and laboratory tests that may be indicative of tuberculosis, such as a prolonged cough, prolonged fever, hemoptysis, compatible radiographic findings or other appropriate medical imaging findings. A negative TB test does not rule out active TB disease and the diagnosis should be based upon the clinical picture, history, and risk factors. Active TB cannot be ruled out until culture results are finalized. WHEN: Report within 24 hours, place patient in airborne isolation to reduce potential spread of disease and begin sputum collection. HOW: By phone to Douglas County Public Health ([PHONE REDACTED]) In addition to the immediate report, report via the Wisconsin Electronic Disease Surveillance System or fax an Acute and Communicable Diseases Case Report 44151) to Douglas County Health Department 2) Active TB, Confirmed A clinical illness with a test result of Mycobacterium tuberculosis (M.TB) or M.TB complex from any body site. WHEN: Report within 24 hours, place patient in airborne isolation to reduce potential spread of disease and begin sputum collection if not already complete. HOW: By phone to Douglas County Public Health ([PHONE REDACTED]) In addition to the immediate report, report via the Wisconsin Electronic Disease Surveillance System or fax a Tuberculosis Suspect Case Date Report (F-42001) to Douglas County Health Department 3) Nontuberculosis mycobacteria (i.e. M. avium, M. gordonae) WHEN: Within 72 hours HOW: Report via the Wisconsin Electronic Disease Surveillance System or fax an Acute and Communicable Diseases Case Report (F-44151) to Douglas County Health Department Each suspected TB infected or confirmed Nontuberculosis mycobacterium case is monitored by a Public Health Nurse. Reporting to the local health department is required but no Public Health follow-up or intervention is necessary. 4) Individuals with a positive TB test WHEN: Local recommendation—report within 72 hours of positive TB skin test reading or positive IGRA blood test results HOW: By phone or fax to Douglas County Public Health Positive tuberculosis test (TST, IGRA test): all patients with positive tests should be fully evaluated for TB disease (chest x-ray: collect sputum if or abnormal CXR) before initiating treatment for tuberculosis infection. ---PAGE BREAK--- Tuberculosis Services in Douglas County 3 Health Care Provider Support TB Case Management Services Available Douglas County Public Health is responsible for ensuring that adequate, appropriate diagnostic and treatment services are available, as well as monitoring the results of therapy, by providing consultation, education, and case management for clients with suspect or active TB disease and TB infection. There is no fee for these services. In collaboration with the medical provider, the public health provides the following services for all clients with suspect or active TB disease and TB infection: Anti-tuberculosis medication for active or latent TB patients through the Wisconsin TB Dispensary if qualifications are met (contact Douglas County Public Health for more information) Facilitate coordination of TB patient evaluation, testing, and treatment. Case management, from diagnosis to cure. Contact identification and monitoring, including TB testing when necessary. Directly observed therapy (DOT) for all TB disease and TB infection cases on a case-by-case basis. Patient education Monitoring of medication side-effects and adherence. Management of non-adherent clients. Isolation orders. Assist with sputum collection for submission to the Wisconsin State Lab of Hygiene (WSLH) for analysis. Low-income individuals requiring medical care for TB may be eligible for specific funding for physician, laboratory, and x-ray services. Prior authorization from public health is required. TB consultation is available to all health care partners. See attached resource list for local, state and national partners. ---PAGE BREAK--- Tuberculosis Services in Douglas County 4 Targeted Testing for TB Disease and Infection Targeted testing for TB is done to identify persons at high risk for TB who would benefit from treatment for TB infection. It is recommended that clinicians offer targeted tuberculosis screening by TB skin test or IGRA test to high-risk persons as part of their routine evaluation. In general, high-risk groups that should be tested for infection include: Close contacts of a person known or suspected to have TB Foreign-born persons from areas where TB is common Residents and employees of high-risk congregate settings Health care workers who serve high-risk clients Medically underserved, low-income populations High-risk racial or ethnic minority populations Children exposed to adults in high-risk categories Persons who inject illicit drugs Persons with risk for infection and high-risk medical conditions such as, diabetes, chronic renal failure, silicosis, cancer of the head, neck and lung, leukemia, weight <10% of ideal body weight, gastrectomy, jejunoileal bypass, and those who will take TNF-alpha inhibitors and should be screened prior to treatment Applying, Reading and Documenting a Mantoux Tuberculin Skin Test Resources Mantoux TB Skin Test 1 CDC US Public Health Service (29:45) http://www2c.cdc.gov/podcasts/player.asp?f=3739 Mantoux TB Skin Test Facilitator Guide http://www.cdc.gov/tb/education/Mantoux/images/mantoux.pdf Mantoux TB Skin Test wall chart http://www.cdc.gov/tb/education/mantoux/wallchart.htm ---PAGE BREAK--- Tuberculosis Services in Douglas County 5 Suspect/Active TB Algorithm Suspect/ Active TB? Assess for Risk Factors Skin Test or IGRA Results Present? Medical Eval with Chest X-ray Chest X-ray Normal Consult with Public Health Chest X-Ray Evidence of TB Disease Collect 3 Consecutive Sputums and Isolate Patient 3 Smear Negative and 1 PCR Negative Consult with Public Health and Expert Provider Await Culture Results Positive Culture: Start Active TB Disease Treatment Negative Culture: Consult with Public Health / Consider LTBI Treatment Positive Smear and PCR Positive Start Active Disease Treatment Await Culture Results Positive Culture: Continue Active Disease Treatment Negative Culture: Consult with Public Health / Consider LTBI Treatment Medical Eval with Chest X-ray Chest X-ray Normal Consider LTBI Treatment Present? No Course of Action Medical Eval with Chest X-Ray Chest X-Ray Normal Consult with Public Health Chest X-Ray Evidence of TB Disease Collect 3 Consecutive Sputums and Isolate Patient 3 Smear Positive and 1 PCR Positive Start Active TB Disease Treatment Await Culture Results Consult with Public Health regarding Release from Isolation 3 Smear Positive and 1 PCR Negative Release from Isolation Await Culture Results Positive Culture: Start Active TB Disease Treatment Negative Culture: Consider LTBI Treatment YES ---PAGE BREAK--- Tuberculosis Services in Douglas County 6 TB Triage Risk Assessment Tool Instructions for use: Patients 12 years or older presenting with respiratory will be assessed by the ED or by admitting nurse (direct admit patient) for the possibility of TB disease. This tool is to be used to aid the physician and RN in determining the need for Airborne Isolation. This risk assessment is done using a point system. Any patient accumulating 8 or more points will be placed in Airborne Isolation until infectious TB has been ruled out or another diagnosis has been established. Exposure Risk Factors Exposure to active TB disease or history of positive TB skin test or Quantiferon TB Gold 4 points Foreign born (or child of) in high risk / endemic area including: Asia, Caribbean, Central and South America, Africa 4 points History of an extended stay 3 months) in high risk / endemic area for TB (including TB sanatorium) 2 points Currently homeless 1 point Resident or employee of correctional institution / long term care facility 1 point Total Medical History History of active TB 2 point History of active TB, actively coughing 8 points HIV positive or immunosuppressive condition, i.e., chemotherapy or corticosteroid use 3 points History of IV drug or alcohol abuse 1 point End stage renal disease / hemodialysis 1 point Total Signs and Bloody sputum or hemoptysis 3 points Unintentional recent weight loss 3 points Cough lasting more than three weeks 2 points Fever for greater than one week 1 point Pleuritic chest pain 1 point Loss of energy / fatigue 1 point Night sweats 1 point Total Diagnostic Tests Abnormal CXR 1 point CXR or CT scan with upper lobe infiltrate associated with mediastinal adenopathy (exclude patients with known atypical mycobacterium infection) 3 points Sputum for AFB x 3 ordered 8 points Sputum positive for AFB or MTD / PCR, or culture positive for Mycobacterium tuberculosis 8 points CXR or CT with cavitary disease or new granulomas (exclude patients with known cavitary neoplasm or atypical mycobacterium infection) 8 points Total Total points from all categories If the total points from all categories total 8 or more, the patient has the potential of having tuberculosis. ED physician or PCP (Direct admit patient) to contact the on-call ID physician with questions. Initiate Airborne Isolation by placing the patient in one of the designated negative pressure rooms. Notify Infection Preventionist SIGNATURE (caregiver completing triage): Date signed Time ---PAGE BREAK--- Tuberculosis Services in Douglas County 7 Resources Douglas County Public Health Website: www.douglascountywi.org Phone: [PHONE REDACTED] Fax: [PHONE REDACTED] After Hours: [PHONE REDACTED] Wisconsin TB Program Website: www.dhs.wisconsin.gov/tb Phone: [PHONE REDACTED] Fax: [PHONE REDACTED] Mayo Clinic Center for Tuberculosis - Mayo Clinic Website: www.mayo.edu.tuberculosis-center Phone: [PHONE REDACTED] State Lab of Hygiene Website: www.slh.wisc.edu Phone: [PHONE REDACTED] Centers for Disease Control (CDC) Website: www.cdc.gov/tb