Tuberculosis Case Management Manual

1.01 Missouri Statutes and Regulations Concerning Tuberculosis

Click on the link after the title of the statue to access the complete text from the Revised Statues of the State of Missouri on the Missouri General Assembly’s internet site.

Contagious Diseases Excluded from School (RSMo 167.191)

• http://www.moga.mo.gov/mostatutes/stathtml/16700001911.html

Commitment and Hospitalization of Tuberculosis Patients – Rehabilitation-Head Injury – TB Testing

• Definitions (RSMo 199.170 – 199.350)
• Local health agency may institute proceedings for commitment (RSMo 199.180)
• Patients not to be committed when (RSMo 199.190)
• Procedure in circuit court—duties of local prosecuting officers—costs (RSMo 199.210)
• Rights of Patient, witnesses—order of course—transportation costs (RSMo 199.210)
• Order appealable (RSMo 199.220)
• Confinement on order, duration (RSMo 199.230)
• Consent required for medical or surgical treatment (RSMo 199.240)
• Facilites to provided—costs, how paid (RSMo 199.250)
• Apprehension and return of patient leaving rehabilitation center without discharge (RSMo 199.260)
• Proceedings for release of patient (RSMo 199.270)
• Tuberculosis Screening for Residents and Workers in Nursing Homes (RSMo 199.350)

1.02 Missouri Statutes and Regulations Concerning Tuberculosis

The Code of State Regulations, or rules, is available on the Missouri Secretary of State’s web site in PDF format. Regulations are organized by title, division, chapter, and section. For example, 19 CSR 20-20.020 refers to Title 19, Division 20, Chapter 20, Section 020. The links that follow take the user to the appropriate division and chapter of the regulations. Scroll to the specific section number.

• 19 CSR 20-20.010 Definitions Relating to Communicable, Environmental and Occupational Diseases
• 19 CSR 20-20.020 Communicable, Environmental and Occupational Diseases
• 19 CSR 20-20.030 Exclusion from School and Readmission
• 19 CSR 20-20.040 Measure for the control of Communicable, Environmental and Occupational Diseases
• 19 CSR 20-20.050 Quarantine or Isolation Practices and Closing of Schools and Places of Public and Private Assembly
• 19 CSR 20-20.070 Duties of Local Health Departments
• 19 CSR 20-20.080 Duties of Laboratories
• 19 CSR 20.20.090 Contact with Communicable Diseases by First Responders or Emergency Medical Persons and Mortuary Personnel
• 19 CSR 20.20.100 Tuberculosis Testing for Residents and Workers in Long-Term Care Facilities and State Correctional Centers

http://www.sos.mo.gov/cmsimages/adrules/csr/current/19csr/19c20-20.pdf

Chapter 61--Licensing Rules for Family Day Care Homes

• 19 CSR 30-61.010 Definitions
• 19 CSR 30-61.125 Medical Examination Reports

http://s1.sos.mo.gov/cmsimages/adrules/csr/current/19csr/19c30-61.pdf

Chapter 62—Licensing Rules for Group Day Care Homes and Child Day Care Centers

• 19 CSR 30-62.010 Definitions
• 19 CSR 30-62.122 Medical Examination Reports

http://s1.sos.mo.gov/cmsimages/adrules/csr/current/19csr/19c30-61.pdf 

2.01 Educational Materials

Ordering Educational Materials

Educational materials may be ordered through the Section for Disease Prevention, Bureau of Communicable Disease Control and Prevention. To place an order, call the Bureau at (573) 526-5832.

To order literature from the Department of Health and Senior Services warehouse, go to the DHSS website.

CDC Educational Material and Internet Resources

The CDC has prepared a useful list of education resources. You can access it at the CDC website.

2.02 Medication Fact Sheet – Isoniazid (INH)

It is important to take this medication for the full time of treatment. It is important that you do not miss any doses. If you do miss a dose, take it as soon as possible. However, if it is almost time for your next dose, skip the missed dose and go back to your regular schedule. Do not double dose.

To store medication:

• Keep out of the reach of children
• Store away from heat and direct light
• Do not store in the bathroom, near the kitchen sink, or in damp places. Heat or moisture may cause the medicine to break down

How to take this medication:

• Take on an empty stomach with a glass of water.
• The tablet may be crushed in applesauce
• Do not drink alcohol of any type, including wine or beer.
• Do not take antacids one hour before or after taking INH

Tell your doctor, nurse or pharmacist if you take ANY other medication; especially medication for seizures.

Possible drug effects:

• Tiredness
• Change in color of urine or stool
• Weakness
• Sore muscles
• Fever
• Tingling or numbness of fingers or toes
• Loss of appetite
• Vision changes
• Nausea Rash
• Vomiting
• Weight loss
• Diarrhea
• Yellow skin or eyes

The information on the action and possible side effects of this medication prescribed by the doctor has been explained to me and I understand. I will call the doctor or nurse if I have any questions or symptoms. If you experience any adverse effects from this medication, stop taking the medication immediately and notify your physician and/or your medical provider. Seek emergency help if you have any signs of an allergic reaction: hives, difficulty breathing, and swelling of the face, lips, tongue, or throat.

Name:___________

Date:___________

Witness:___________

What Should I Avoid While Taking Isoniazid?

Avoid alcohol while taking isoniazid. Alcohol will increase the risk of damage to the liver during treatment with this medication.

Use caution with the foods listed below. They can interact with isoniazid and cause a reaction that includes a severe headache, large pupils, neck stiffness, nausea, vomiting, diarrhea, flushing, sweating, itching, irregular heartbeats, and chest pain. A reaction will not necessarily occur, but eat these foods with caution until you know if you will react to them. Call your doctor immediately if you experience any of these symptoms.

Eat the following foods with caution:

• Cheeses, including American, Blue, Boursault, Brick, Brie, Camembert, Cheddar, Emmenthaler, Gruyere, Mozzarella, Parmesan, Romano, Roquefort, Stilton, and Swiss;
• Sour cream and yogurt;
• Beef or chicken liver, fish, meats prepared with tenderizer, bologna, pepperoni, salami, summer sausage, game meat, meat extracts, caviar, dried fish, herring, shrimp paste, and tuna;
• Avocados, bananas, figs raisins, and sauerkraut;
• Soy sauce, miso soup, bean curd, and fava beans;
• Yeast extracts;
• Ginseng;
• Chocolate;
• Caffeine (coffee, tea, cola, etc.); and
• Beer (alcoholic and nonalcoholic), red wine (especially Chianti), sherry, vermouth, and other distilled spirits

2.03 Medication Fact Sheet – Rifampin (RIF)

It is important to take this medication for the full time of treatment, even if you begin to feel better after a few weeks. It is important you do not miss any doses. If you do miss a dose, take it as soon as possible. However, if it is almost time for your next dose, skip the missed dose and go back to your regular schedule. Do not double dose.

To store medication:

• Keep out of reach of children
• Store away from heat and direct light
• Do not store in the bathroom, near the kitchen sink, or in damp places. Heat or moisture may cause the medicine to break down.

How to take this medication:

• Take on an empty stomach with a glass of water
• If stomach irritation occurs, take with food

This drug will turn your urine, stool, sputum, and tears orange and can stain contact lenses. Tell your doctor, nurse, or pharmacist if you are taking ANY medications, even drugs you can buy without a prescription. In particular tell them if you take birth control pills, Coumadin, warfarin, theophylline, methadone, Dilantin, digoxin, or medicine for HIV infection, seizures or heart problems.

Possible drug effects:

• Tiredness
• Rash
• Itching
• Stomach pain
• Sore muscles
• Fever
• Vomiting
• Weight loss
• Diarrhea
• Yellow skin or eyes
• Chills
• Bone or muscle pain
• Loss of appetite
• Nausea

If you experience any adverse effects from this medication, stop taking the medication immediately and notify your physician and/or your medical provider. Seek emergency help if you have any signs of an allergic reaction: hives, difficulty breathing, and swelling of the face, lips, tongue, or throat. The possible side effects of this medication prescribed by the doctor, has been explained to me and I understand. I will call the doctor or nurse immediately if I have any questions or symptoms.

Name:___________

Date:___________

Witness:___________

2.04 Medication Fact Sheet – Pyrazinamide (PZA)

It is important to take this medication for the full time of treatment, even if you begin to feel better after a few weeks. It is important that your do not miss any doses. If you do miss a dose, take it as soon as possible. However, if it is almost time for your next dose, skip the missed dose and go back to your regular schedule. Do not double dose.

To store medication:

• Keep out of the reach of children
• Store away from heat and direct light
• Do not store in the bathroom, near the kitchen sink, or in damp places. Heat or moisture may cause the medicine to break down.

How to take this medication:

• It is okay to take PZA with food

Tell your doctor, nurse, or pharmacist if you are taking ANY medication, even drugs you can buy without a prescription. If you are diabetic, check with your doctor before changing your diet or dose of medication for diabetes. PZA may cause false positive results with urine ketone test.

Possible drug effects:

• Tiredness
• Weakness
• Fever
• Nausea
• Vomiting
• Weight loss
• Yellow skin or eyes
• Change on color of urine or stool
• Loss of appetite
• Joint pains, especially in the big toe

If you experience any adverse effects from this medication, stop taking the medication immediately and notify your physician and/or your medical provider. Seek emergency help if you have any signs of an allergic reaction: hives, difficulty breathing, and swelling of the face, lips, tongue, or throat.

The possible side effects of this medication prescribed by the doctor, has been explained to me and I understand. I will call the doctor or nurse immediately if I have any questions or symptoms.

Name:__________

Date:__________

Witness:__________

2.05 Medication Fact Sheet – Ethambutol (EMB)

It is important to take this medication for the full time of treatment, even if you begin to feel better after a few weeks. It is important that your do not miss any doses. If you do miss a dose, take it as soon as possible. However, if it is almost time for your next dose, skip the missed dose and go back to your regular schedule. Do not double dose.

To store medication:

• Keep out of the reach of children
• Store away from heat and direct light
• Do not store in the bathroom, near the kitchen sink, or in damp places. Heat or moisture may cause the medicine to break down.

How to take this medication:

• It is okay to take Ethambutol with food

Tell your doctor, nurse, or pharmacist if you take ANY other medication; especially medication for seizures.

Possible drug effects:

• Weakness
• Stomach pain
• Vision changes
• Nausea
• Eye pain
• Vomiting
• Nervousness
• Yellow skin or eyes
• Dizziness
• Change in color of urine or stool
• Headache
• Light headedness
• Loss of appetite
• Joint pains
• Weight loss

If you experience any adverse effects from this medication, stop taking the medication immediately and notify your physician and/or your medical provider. Seek emergency help if you have any signs of an allergic reaction: hives, difficulty breathing, and swelling of the face, lips, tongue, or throat.

The possible side effects of this medication prescribed by the doctor, has been explained to me and I understand. I will call the doctor or nurse immediately if I have any questions or symptoms.

Name:__________

Date:__________

Witness:__________

2.06 Medication Fact Sheet – Pyridoxine (B6)

Other Names: Vitamin B6

It is important to take this medication for the full time of treatment, even if you begin to feel better after a few weeks. It is important that your do not miss any doses. If you do miss a dose, take it as soon as possible. However, if it is almost time for your next dose, skip the missed dose and go back to your regular schedule. Do not double dose.

To store medication:

• Keep out of reach of children
• Store away from heat and direct light
• Store in a cool (15 – 30°C) dry place in a tightly-closed container

How to take this medication:

• Take with a glass of water
• The tablet may be crushed in applesauce
• Some medicines or medical conditions may interact or decrease the effectiveness of some drugs with this medicine
• Do not take large doses of vitamins (mega doses or megavitamin therapy) while taking this medicine
• If stomach irritation occurs take with food

Tell your doctor, nurse or pharmacist if you take ANY other medication; especially medication for Parkinson’s disease, seizures and or arthritis.

Possible side effects of medication:

• Nausea
• Itching
• Stomach Upset
• Tingling or numbness of the skin
• Headache
• Swelling
• Drowsiness
• Dizziness
• Rash
• Trouble breathing

If you experience any adverse effects from this medication, stop taking the medication immediately and notify your physician and/or your medical provider. Seek emergency help if you have any signs of an allergic reaction: hives, difficulty breathing, and swelling of the face, lips, tongue, or throat.

The possible side effects of this medication prescribed by the doctor, has been explained to me and I understand. I will call the doctor or nurse immediately if I have any questions or symptoms.

Name:__________

Date:__________

Witness:__________

2.07 Medication Fact Sheet – Rifapentine (RPT)

It is important to take this medication for the full time of treatment, even if you begin to feel better after a few weeks. It is important that you do not miss any doses. If you do miss a dose, take it as soon as possible. However, if it is almost time for your next dose, skip the missed dose and go back to your regular schedule. DO NOT double dose.

To store medication:

• Keep out of the reach of children
• Store away from heat and direct light
• Do not store in the bathroom, near the kitchen sink, or in damp places. Heat or moisture may cause the medicine to break down

How to take this medication:

• Take on an empty stomach with a glass of water
• If stomach irritation occurs, take with food

This drug will turn your urine, stool, sputum, and tears orange and can stain contact lenses and dentures. Tell your doctor, nurse, or pharmacist if you are taking ANY medications, even drugs you can buy without a prescription. In particular, tell them if you take birth control pills, Coumadin, Warfarin, Theophylline, Methadone, Dilantin, Digoxin, or medicine for HIV, seizures, or heart conditions, and or arthritis. Before taking Rifapentine, tell your doctor if you have porphyria.

Possible side effects of medication:

• Tiredness
• Rash
• Itching
• Stomach pain
• Sore muscles
• Fever
• Vomiting
• Weight loss
• Diarrhea
• Yellow skin or eyes
• Chills
• Bone or muscle pain
• Loss of appetite
• Nausea
• Pale Skin
• Easy Bleeding or Bruising

If you experience any adverse effects from this medication, stop taking the medication immediately and notify your physician and/or your medical provider. Seek emergency help if you have any signs of an allergic reaction: hives, difficulty breathing, and swelling of the face, lips, tongue, or throat.

The possible side effects of this medication prescribed by the doctor, has been explained to me and I understand. I will call the doctor or nurse immediately if I have any questions or symptoms.

Name:__________

Date:__________

Witness:__________

2.08 Medication Fact Sheet – Levofloxacin (LFX)

It is important to take this medication for the full time of treatment. It is important that you do not miss any doses. If you do miss a dose, take it as soon as possible. However, if it is almost time for your next dose, skip the missed dose and go back to your regular schedule. Do not double dose.

To store medication:

• Keep out of the reach of children
• Store at room temperature
• Do not store in the bathroom, near the kitchen sink or in damp places

How to take this medication:

• Do not take milk-based products, antacids (especially aluminum containing), mineral supplements such as iron or magnesium, or multivitamins within 2 hours of this medication.
• Avoid caffeinated foods and beverages
• May take with food
• Drink plenty of beverages
• May cause sun sensitivity; use sun screen

Tell your doctor if you have any renal diseases.

Possible drug effects:

• Pain, swelling, or tearing of the tendon (such as the back of your ankle, elbow), muscle or joint pain
• Rashes or hives
• Bruising or blistering
• Trouble breathing or tightness in your chest
• Diarrhea
• Yellow skin or eyes
• Anxiety, confusion, or dizziness

If you experience any adverse effects from this medication, stop taking the medication immediately and notify your physician and/or your medical provider. Seek emergency help if you have any signs of an allergic reaction: hives, difficulty breathing, and swelling of the face, lips, tongue, or throat.

The possible side effects of this medication prescribed by the doctor, has been explained to me and I understand. I will call the doctor or nurse immediately if I have any questions or symptoms.

Name:__________

Date:__________

Witness:__________

2.09 Reference Complete List of TB Medication Fact Sheets

The Curry TB Center

For a complete list of TB Medication Fact Sheets, please visit The Curry TB Center.

2.10 Tuberculosis Elimination Fact Sheet

Reporting

Active tuberculosis disease or disease suspect – Report within 24 hours to your local public health agency or to the Missouri Department of Health and Senior Services at (573) 751-6113 or (866) 628-9891. Tuberculosis infection/non-tuberculous bacterium (NTMs) – Report within three days to your local public health agency or the Missouri Department of Health and Senior Services at (573) 751-6113 or (800) 392- 0272

List of Reportable Conditions

Prompt reporting triggers the following services as needed at no cost to the patient:

Medications

Anti-tuberculous medications including Isoniazid, Rifampin, Pyrazinamide, Ethambutol, Vitamin B6 and other antibiotics used to treat active TB disease, including second-line medications, may also be available as funding allows.

Lab Services

The state tuberculosis laboratory is in Jefferson City, Missouri and is one of the best TB labs in the country. Diagnostic and routine laboratory services may be available through the patient’s local public health agency, (e.g. liver enzymes, PPDs).

Contact Investigations and Case Management

Local public health agencies have staff trained to conduct contact investigations of communicable disease, including tuberculosis. A report of a suspect TB case will trigger a contact investigation and 3-month follow-up.

Tuberculosis disease and infection cases are managed through local public health agencies. Management includes a monthly clinical evaluation, patient education, directly observed therapy (DOT is the standard of care for active disease), liver enzymes (LFT) and sputum sampling as recommended per CDC.

Consultation

The Tuberculosis Elimination Program employs staff that oversees case management of all active disease cases and suspects in Missouri. They are current on tuberculosis prevention, treatment and control and are available for consultation as needed. Medical consultation is available through the TB Elimination Program nurse.

Other Services

Diagnostic Services Program pays for office visits and chest x-rays for those TB infection and disease patients who have no health insurance or are underinsured.

Incentive Program helps ensure compliance with treatment orders and helps ensure treatment completion. Incentives include expenses such as cab fare or bus tokens. Incentive funds are available through your local public health agency.

Texas Center for Infectious Disease (TCID) – Texas Center for Infectious Disease maintains a state-of-the-art care and isolation of tuberculosis patients. Texas Center for Infectious Disease is located in San Antonio, Texas. This facility only receives those TB patients that are most difficult to treat or are noncompliant with their treatment. TCID accepts patients by a court order through a local public health agency (see 7.0 Court Force Handbook). TCID does not take patients on a voluntary basis. The state TB program must be notified immediately, if the LPHA is considering a court order for TCID.

Resources – the Tuberculosis Elimination Program houses a library with the latest treatment information for tuberculosis and other mycobacterial diseases. CDC, ALA, American Thoracic Society and other publications, videotapes and guidelines regarding the treatment of TB disease and infection are available upon request Material Available from the DHSS Warehouse | Health & Senior Services [NEEDS LINK]

We view TB Elimination as a team approach. One person cannot do it alone, but one person can make a difference. We need your help if we are to reach our goal of eliminating TB in Missouri.

3.01 Tuberculosis Forms and Documentation

The following forms can be found in the Missouri Department of Health and Senior Services Tuberculosis Case Management Manual Section Appendices/”Sample Forms”

The TB Case Management manual can be found at the DHSS Website.

Required Forms:

LTBI:

• Tuberculin Testing Record (TBC-4) preferably or Disease Case Report (CD-1). TB Infection is reportable to the TB Elimination Program, so this should be faxed to the State TB nurse, regardless where the patient is receiving their medications.
• TB Signs and Symptoms Checklist (Review with the patient). If the patient is having any signs or symptoms of tuberculosis collect sputum. (See the sputum collection instruction and algorithm in Section 4, TB Disease). Do not start patient on treatment for LTBI until all cultures (not smears) are negative.
• LTBI Medication Authorization (TBC-9). This completed form should be faxed to the State TB nurse for patients that qualify for obtaining medications thru the TB Elimination Program. A copy of the completed TBC-4, current CXR/CT chest report, and a copy of the prescriptions need to be faxed with the completed LTBI Medication Authorization form to the State TB nurse.
• INH/Rifapentine – 12 dose/3HP (TBC-7). This completed form should be faxed to the State TB nurse for patients that qualify for obtaining medications thru the TB Elimination Program. A copy of the completed TBC-4, current CXR/CT chest report, and a copy of the prescriptions need to be faxed with the completed LTBI Medication Authorization form to the State TB Nurse. This regimen must be given by Directly Observed Therapy (DOT). The LPHA nurse must fax a copy of the completed 3 HP Regimen Form (TBC-7) to the State TB Nurse weekly. If the patient declines treatment of LTBI, complete the Decline Treatment of LTBI document (TBC-2) and have the patient sign. Fax a copy of the TBC-2 and TBC-4 to the TB Elimination Program to be entered into WebSurv if the LPHA is not entering the information.

TB Disease:

• CD-1. Notify the State TB nurse and fax a copy of the completed form as soon as you have been notified.
• TB Signs and Symptoms Checklist (Review with the patient).
• TB History (TBC-10),complete the PDF form including the patient’s current weight and fax the completed form to the State TB Nurse as soon as the patient interview has been completed (interview the patient within 3 business days).
• Tuberculosis (TB) Patient Responsibilities Notification (located in the TB Case Management Manual, 7.0 Court Force Handbook). The LPHA nurse should go over this form with the patient and the patient should sign and date it, along with the LPHA nurse witnessing the patient’s signature. Give a copy of the signed form to the patient and keep the original in the patient’s chart.
• TB Worksheet for Contacts of Newly Diagnosed Cases (TBC-13). Fax the completed form to the TB Elimination Program at the beginning of the contact investigation and at completion, as well as when there are new contacts added to the form.
• TB Medication Request Form (TBC-8). This must be faxed along with a copy of the prescriptions to the state contract pharmacy. (Verify with the State TB Nurse that the prescriptions are correct prior to faxing the medication request to the pharmacy).
• TB Medication Record (TBC-16). This must be faxed at the end of each completed month of medication to the State TB Nurse.
• Cohort Presentation (MO 580-2826) Save a copy of this PDF fillable form and begin filling it out as soon as you receive notification of a case. The form can be filled in as the case progresses through treatment to completion. The cohort is done bi-annually. You will receive a letter from the TB Elimination Program if you have a case to be cohorted. The completed form will need to be faxed to (573) 526-0234 upon notification that the case will be cohorted.

Required Documentation:

• CXR/CT scan report – fax to the State TB nurse
• Lab results – fax a copy of all labs, such as sputum smears/cultures, Liver function results (LFT), TST/IGRA (T Spot or Quantiferon Gold); biopsy report, etc. to the State TB Nurse
• Copy of Prescriptions (TB medications) must be faxed to the State TB Nurse. Resubmit if there are any medication changes.
• Copy of the History/Physical, emergency room note, Pulmonology or Infectious Disease Consult note, if patient was hospitalized or seen by a physician. Fax a copy to the State TB nurse.

The above documentation must be faxed to your State TB Elimination Program nurse.

Traci Hadley: (573) 526-0234 for regions A, D, E, G, H

Bev Myers: (573) 526-0234 for regions B, C, F, I

Additional Forms (keep in patient’s record):

• TBC-8 (TB Medication Request Form) - If patient has private insurance, Medicaid or Medicare, please complete the insurance portion on the form.
• TBC-DSP: Only completed if patient has no insurance or is underinsured. Please complete and fax to DSP Manager at (573) 526-0234. Liver Function Tests (LFTs) must be approved by your State TB elimination program nurse prior to testing. Please contact your State TB elimination program nurse for approval of LFTs for any other medical issues.
• Checklist for Active Tuberculosis (very helpful when following an active TB case) Progress Notes Tuberculosis Signs and Symptoms Checklist (All LTBI and TB Disease cases need to be assessed for signs and symptoms)

Helpful TB web addresses:

• Centers for Disease Control and Prevention/Tuberculosis
• Centers for Disease Control and Prevention/5th edition of the Core Curriculum on Tuberculosis: What the Clinician Should Know
• MMWR: Treatment of Tuberculosis, June 20, 2003/Vol. 52/No. RR-11

3.02 Urine Chart

3.06 Case Classification

Case/Contact Follow up and Control Measures:

• A person suspected of having TB disease (pulmonary or extra-pulmonary) should be isolated either in their home or in the hospital until they have met the following CDC criteria:
  • Compliant, on an adequate treatment regimen for two weeks or longer
  • Clinical symptoms are improved
  • and three consecutive negative AFB sputum smears

3.07 DSP Provider Listing

4.01 Annual Statement for Tuberculin Reactors