Tuberculosis Reporting, Waco-McLennan County Public Health District TB Control WMCPHD (254)-750-5496 Local health care providers, including physicians offices, labs and hospitals, are required by law to notify the Health District of certain conditions/illnesses (including TB) in the state of Texas. Health care providers, hospitals, laboratories, schools, and others are required to report patients who are suspected of having a notifiable condition (Chapter 97, Title 25, Texas Administrative Code). http://info.sos.state.tx.us/pls/pub/readtac$ext.viewtac?tac_view=4&ti=25 &pt=1&ch=97 Please report all suspects and the cases of Tuberculosis to TB Control at Waco- McLennan County Health Department. Disease reporting number is (254) 750-5496 Reports may also be faxed to (254) 750-5453 Please call TB Control WMCPHD (254)-750-5496 for additional information or questions. Attached Documents: TB Services at Waco McLennan County Public Health District. TB 400 A TB 400 B Tuberculosis Symptom Questionnaire
Tuberculosis (TB) TB Services at Waco McLennan County Public Health District. The Waco-McLennan County Public Health District (WMCPHD) has a team of specially trained staff that can assist in the medical management of clients diagnosed with Tuberculosis (TB). Coordination with the client s primary care physician is vital to ensure that all aspects of the client s health are addressed. WMCPHD staff is trained in contact investigation, direct observation therapy, proper medication management, and overall case management of the client with tuberculosis. TB Skin Testing Tuberculosis skin testing is provided to contacts to cases in the TB clinic and not typically administered on Thursdays since they must be read 48-72 hours after administration, which would fall on a weekend. Testing may be offered free of charge to persons who have had recent exposure to a person with confirmed, active tuberculosis and in other situations that place them at considerable risk for development of TB disease if infected. Receiving TB Services WMCPHD TB staff can assist with sputum collection, blood work, and ordering of medications and supplies. They also have an excellent rapport with Regional TB experts from Texas Center for Infectious Diseases and UT Tyler and can assist in getting medical consultations for client with drug resistance, adverse drug reactions, and pediatric cases. Persons diagnosed with TB are provided medications free of charge through WMCPHD and the Department of State Health Services (DSHS) Pharmacy. Sputum for detection of acid fast bacilli and culture are also provided free of charge through DSHS in coordination with WMCPHD TB Elimination office. Persons with positive TB skin tests, but no evidence of disease may be referred to WMCPHD clinics for the initiation of treatment for Latent TB infection (LTBI). Medications are offered based on a sliding scale income for the LTBI therapy through our offices; however, services are provided regardless of ability to pay. These medications are provided through the DSHS Pharmacy. Persons who are referred to WMCPHD for LTBI therapy without a physician s prescription will be evaluated for the risk vs. benefit of receiving therapy and the local Health Authority will determine the need for treatment. Additional Resources For more information about TB, LTBI, or drug treatment you can contact our offices at 254-5496 or visit the following websites: http://www.cdc.gov/tb/default.htm http://www.dshs.state.tx.us/idcu/disease/tb/ http://www.heartlandntbc.org/
Texas Department of Health Tuberculosis Elimination Division Report of Case and Patient Services Initial Report Hospital Admission Address Change Name Change (show new name and draw single line through old ) Other Change (please circle) SSN Medicaid # ID# DOB / / MM DD YY Name AKA (Last) (First) (Middle) Street Apt# City County Zip Code Patient s Tel.# Facility/Care Provider Name Initial Reporting Source Health Dept Private Physician Public Hospital VA Hospital Name of person completing this form Military Hospital TDCJ Other (Specify) Country of Birth Notice of Arrival of Reported at Death Reported Out of State or Country If foreign born, Alien with TB Class Yes No Yes Specify No Date of entry into U.S. / / A B1 If yes, Death Date / / ETHNICITY Unknown SEX Preferred Language B2 B3 Was TB cause of death Hispanic or Latino Male Yes No Unk Not Hispanic or Latino Female RACE (check all that apply) OCCUPATION (within past 2 years ) White Native Hawaiian Unemployed during last 2 yrs Unknown Other or Pacific Islander Employed (If employed, check all that apply) Student Child Black or American Indian Migrant/Seasonal Worker Retiree Disabled African American or Alaskan Native Health Care Worker (Specify) Homemaker Asian Unknown Correctional Emp Other Occupation Institutionalized Resident of Correctional Facility at Time of Dx Yes No Unknown Incarceration Date / / _ If Yes Federal Prison State Prison County Jail City Jail Juvenile Correctional Facility ICE Other Resident of Long Term Care Facility at Time of Dx Yes No Unknown If Yes Nursing Home Hospital-Based Facility Residential Facility Mental Health Residential Facility Alcohol/Drug Treatment Facility Other Long Term Care Facility Testing activities to find latent TB infections Patient referred, TB infection Project targeted testing Individual targeted testing Administrative: Not at risk for TB POPULATION RISKS MEDICAL RISKS Low Income Diabetes mellitus Leukemia Chronic renal failure Inner-city resident Alcohol Abuse (within past year) Lymphoma Organ Transplant Foreign born Tobacco use Cancer of head Other Binational (US-Mexico) Silicosis Cancer of neck None of these medical *Within past 2 years Corticosteroids or other Drug abuse within past year: risks apply Correctional employee* immunosuppressive therapy Injecting Health care worker* Gastrectomy or jejunoileal bypass Non-injecting HIV TEST RESULTS Prison/Jail inmate* age < 5 years Unknown if injecting Date HIV Test / / _ Long-term facility for Recent exposure to TB HIV seropositive (check Positive Negative elderly/resident* (Contact to TB case) only if laboratory confirmed) Pending Refused Health care facility/resident* Contact to MDR-TB case Tuberculin skin test conversion Not Offered Shelter for homeless persons* Weight at least 10% less than within 2 years Migrant farm worker* ideal body weight Fibrotic lesions (on chest x-ray) Date CD4 Count / / _ None of the above risks apply Chronic malabsorption syndromes consistent with old, healed TB Results CD4 Count TUBERCULIN SKIN TEST Documented history of positive TST? Yes No PRIOR LTBI TREATMENT Yes No / / mm Positive Negative Not Read Start Date / / _ / / mm Positive Negative Not Read Stop Date / / _ FOR TREATMENT OF LTBI ONLY / / _ Date Normal Chest X-ray Weight Height DOPT: Yes, totally observed No, self-administered Both ATS Classification DOPT Site: Clinic or medical facility Field Both 0 No M. TB Exposure, Not TB Infected Frequency: Daily Twice Weekly Three X s Weekly 1 M. TB Exposure, No Evidence of TB Infection 2 M. TB Infection, No Disease / / _ Date Regimen Start / / _ Date Regimen Stop 4 M. TB, No Current Disease / / _ Date Restart / / _ Date Regimen Stop Isoniazid mgs Other (specify) mgs Date reported to / / _ health department region central office Rifampin mgs Other (specify) mgs B6 mgs Prescribed for: months Maximum refills authorized: Physician Signature Date CLOSURE: Date / / _ Completion adequate therapy # months on Rx # months recommended Lost to followup Patient chose to stop Deceased (Cause) Adverse Drug Reaction Moved out of state/country to: Provider decision: Pregnant Non-TB Other: TB-400A (11/03)
Status New Recurrent Reopen Prior Therapy Yes No Start Date / / _ Stop Date / / _ ATS Classification 0 No M. TB Exposure, Not TB Infected 1 M. TB Exposure, No Evidence of TB Infection 2 M. TB Infection, No Disease 3 M. TB Infection, Current Disease 4 M. TB, No Current Disease 5 M. TB Suspect, Diagnosis Pending Predominant Site: (Class 3, 4) Significant Sites other than Predominant 00 Pulmonary 30 Bone and/or Joint 10 Pleural 40 Genitourinary 20 Lymphatic 50 Miliary/Disseminated 21 Cervical 60 Meningeal 22 Intrathoracic 70 Peritoneal 23 Other 80 Other (Specify) Other Diagnosis Treatment for Active TB Disease Weight Height Regimen Start / / Regimen Stop / / Restart / / Stop / / Directly Observed Therapy (DOT) Doses: Yes No If no, specify reason DOT Site: Clinic or other medical facility Field Both Frequency: Daily Twice Weekly Three X s Weekly Isoniazid mgs Rifater mgs Rifampin mgs Levofloxacin mgs Rifamate mgs Gatifloxacin mgs Pyrazinamide mgs Moxifloxacin mgs Ethambutol mgs Rifapentine mgs Streptomycin mgs Clofazimine mgs Ethionamide mgs Cycloserine mgs Capreomycin mgs PAS mgs Amikacin mgs B6 mgs Ciprofloxacin mgs mgs Ofloxacin mgs mgs Rifabutin mgs mgs Prescribed for: months Maximum refills authorized: Closure: Date _ / / % doses taken by DOT # doses taken # doses recommended # months on Rx # months recommended Completion of adequate therapy Lost to followup Patient chose to stop Adverse drug reaction Deceased (Cause) Moved out of state/country to: Date referral sent to Austin / / Provider decision: Pregnant Non-TB Other: Texas Department of Health Tuberculosis Elimination Division Report of Case and Patient Services Date reported to / / _ health department region central office Initial Report Drug Resistance Followup or Medical Review Hospital Admission or Discharge Name DOB / / (Last) (First) (Middle) MM DD YY SSN Street Apt# City County Zip Code Facility/Care Provider Name Facility responsible for patient care Public Health Clinic Private Physician Hospital Name of person completing this form Other (Specifiy) Signs/Symptoms at DX Chest X-Ray If Pediatric TB Case (<15 Years Old) Fever Y N Date / / _ Country of birth for primary guardians: Chills Y N Results: Normal Abnormal Not Done Unk Guardian 1) Cough Y N If Abnormal, check abnormality Status Guardian 2) Productive Cough Y N Cavitary Stable Patient lived outside US for > 3 months Hemoptysis Y N Non-cavitary, consistent with TB Worsening Yes No Unknown Night Sweats Y N Non-cavitary, not consistent with TB Improving If yes, Weight Loss (> 10%) Y N Comments: Unknown Country Other: AFB Smear Results Current / / _ Negative Positive Pending Not done Specimen type: sputum urine bronchial washing biopsy other If biopsy or other, list anatomic site of specimen: If other than sputa, type of exam Collection date of initial positive AFB smear: / / _ Collection date of first consistently negative AFB smear: / / _ Nucleic Acid Amplification Test Current / / _ Negative Positive Indeterminate Not done Culture Results Current / / _ Negative Positive for M. TB Positive for Non-M. TB Pending Not done Specimen type: sputum urine bronchial washing biopsy other If biopsy or other, list anatomic site of specimen: Collection date of initial positive MTB culture: / / _ Collection date of first consistently negative MTB culture: / / _ Sputum culture conversion documented? Yes No NA If no, then reason Susceptibility Results Date initial susceptibility culture was collected / / _ Initial culture was resistant to: Isoniazid Rifampin Ethambutol Date last positive culture was collected / / _ Last culture was resistant to: Isoniazid Rifampin Ethambutol Other quinolone(s) Other(s) Reason Therapy Extending > 12 months: Hospitalization Advised: Yes No Control Order / / Quarantine Advised: Yes No Court Action / / Return for chest x-ray: / / Compliant: Yes No Collect next sputum on: / / Other lab studies: / / Return to MD clinic on: / / Return to Nurse clinic on: / / Nurse Signature Date Physician Signature Date Authorize nurse to obtain informed consent General Comments: TB-400B (11/03)
Tuberculosis Symptom Questionnaire Name: DOB: Date: Previous PPD skin test results show you to be TB skin test positive. A positive skin test reaction means that sometime in the past you have come into contact with M. tuberculosis, the bacterium that causes tuberculosis (TB). An otherwise healthy person with a positive TB skin has about a 10% lifetime risk of developing active tuberculosis. The risk in the first two years after TB skin test conversion is about 5%. This means that of 100 people whose skin test converts and who do not receive adequate preventive therapy, 5 of them will develop TB during the first 2 years after TB skin test conversion. An immunocompromised person (HIV positive, receiving immunosuppressive or cancer chemotherapy) with a positive TB skin test has a risk that is approximately twice as high for developing active TB. Answer yes or no to the questions; if any answer is yes, give the approximate date the symptoms started and whether or not you still have them. Have you had any of the following symptoms in the past year? 1. Productive cough for 3 weeks or more No Yes Date Still Have? 2. Persistent weight loss without dieting. No Yes Date Still Have? 3. Persistent fever above 100 degrees F No Yes Date Still Have? 4. Night sweats No Yes Date Still Have? 5. Loss of appetite No Yes Date Still Have? 6. Swollen glands in neck or elsewhere No Yes Date Still Have? 7. Recurrent/persistent kidney/bladder infections No Yes Date Still Have? 8. Coughing up blood (hemoptysis) No Yes Date Still Have? 9. Shortness of breath No Yes Date Still Have? 10. Chest pains No Yes Date Still Have? 11. Fatigue or weakness of feeling ill No Yes Date Still Have? 12. Frequent of recurring chills No Yes Date Still Have? Persons with a positive PPD who are experiencing symptoms should receive a chest x-ray to assess for pulmonary tuberculosis. Physician Phone Please fax to Waco-McLennan County Public Health District, TB Control Department 254.750.5453.