Local policies regarding the security and confidentiality of such information, including HIV test results, should adhere to all applicable laws.
TB programs should collaborate with HIV programs and other relevant disease control programs in developing and implementing confidentiality policies. TB programs should store TB data securely in an electronic system that allows data to be transmitted to care providers, other health departments, and consultants, as needed. These data should include not only case notes and medication records but also digital radiographic films if feasible , interpretations, laboratory results, and information about drug resistance.
Ongoing and systematic program evaluation activities are an integral component of public health program success. As TB program resources have decreased during the past decade, the need for ongoing program evaluation has acquired additional importance because finite resources should be applied to the most effective program activities.
Measuring the impact and effectiveness of individual activities within TB programs serves to facilitate continuous improvement and to examine the need for new or ongoing program activities. When developing a TB program or activity, staff should consider identifying a baseline before implementing the activity, particularly when that program is expected to be ongoing. In addition to analysis of surveillance data for monitoring morbidity trends, programs can determine the demographic characteristics of their patient population, monitor drug-resistance rates, and determine treatment outcomes.
Additional analyses regarding effectiveness and outcomes of contact investigations and targeted testing for LTBI and treatment programs should be performed.
These analyses can be used to assess program performance and progress toward achieving locally and nationally established program objectives. Since , CDC has included program evaluation as a core requirement of its cooperative agreements with TB programs. NTIP facilitates use of existing data to help programs prioritize activities and focus program evaluation efforts. NTIP provides a standardized method for calculating indicators and tracking program progress across sites and temporally, thus enabling the ability of CDC and TB programs to assess the impact of TB control efforts.
TB programs are encouraged to share NTIP and other program evaluation reports with relevant public, private, and community groups. TB programs should engage transparently with these groups in developing evidence-based efficient and effective strategies for sustaining TB prevention and care efforts. The cohort review process is a systematic review of management of TB patients and their contacts. Cohort review identifies areas of success and those that need improvements in programmatic and clinical operations.
A cohort is a group of TB patients identified during a specific time, often 3 months, who have completed or are nearing the end of treatment. Programs should review TB cases among children and other sentinel events as separate cohorts. Programs also should conduct periodic reviews of case registry and other selected data records systems e. Such periodic reviews assist in identifying gaps and challenges in program operations.
As part of evaluation efforts, TB programs should also analyze each new TB case and each TB-related death to determine whether the case or death might have been prevented. On the basis of such assessments, the program can develop and implement new policies to reduce the number of preventable cases and deaths and prepare annual reports based on these assessments in collaboration with community-based organizations and professional societies. These reports should document the extent and nature of the TB incidence and treatment completion in the area, assess the adequacy of prevention and care measures in demonstrating program effectiveness, and provide recommendations for program improvements.
A TB program might determine that an outside review by experts from the state health department, CDC, local lung associations, or other TB experts could be helpful in determining methods for improving program performance and community TB control and for providing support for major changes e. All TB programs should collect, analyze, and use data to help guide decisions about the quality of TB services and patient outcomes.
A quality improvement QI approach focuses on systematically assessing and improving processes and outcomes for patient care, with the overall goal of ensuring positive outcomes for patients. QI uses data to assess the strengths and weaknesses in delivering care to patients and measuring clinical outcomes.
Assessment and implementation methods will vary across programs. Improving the quality of patient care, ensuring positive outcomes for patients, and increasing efficiency of the care delivery system are common goals. To be effective, QI should be an ongoing process that involves managers, staff, and patients. The primary purpose of conducting an evaluation is to influence decisions.
By using results of the evaluation, decision-makers might decide to continue, change, expand, or end a program or associated activity. Evaluation design is dynamic, changing as programs develop and real-world challenges emerge. Therefore, the first task for the evaluator or evaluation team is to define the intended audience and develop measurable evaluation questions. The intended audience will influence the type of evaluation questions to be addressed.
For example, a local health department official might be interested in the number of persons successfully treated for LTBI in an outpatient clinic setting, whereas an official responsible for program funding is probably more interested in cost and availability of anti-TB medications.
The objective of the evaluation team is to use the best approach available that yields the most accurate results with available resources for conducting the evaluation. The evaluator or evaluation team should then be able to communicate results accurately and clearly to diverse audiences who might lack a complete understanding of program complexities and their potential impacts.
TB program staff apply analytic methods in different ways to assess program performance. Potential designs are available that can be used to answer the evaluation questions, and no single correct method exists.
A systematic review of literature or contact with a CDC program consultant can identify additional information and tools useful for successfully answering evaluation questions of interest. Program staff should share lessons learned with other programs and consider publishing results for the larger public health community.
TB PEN focal points participate in bimonthly conference calls to share program evaluation successes and challenges to assist one another in improving the quality of their TB program activities.
TB PEN collaborates with TB ETN on a biennial conference that enables TB PEN focal points to learn from in-person educational sessions, scientific research lectures, poster presentations, and program evaluation updates at local, state, tribal, and federal levels and from networking with program evaluation colleagues. The TB PEN steering committee also maintains a website that contains program evaluation and quality improvement resources Numerous advances in TB prevention and control have occurred within laboratory science since this report was last published in Two types of immunologic-based test methods are available for detecting M.
New molecular diagnostic tests identify both M. Use of whole-genome sequencing can identify M. These modalities allow for earlier identification of M.
However, specimens should still be cultured for phenotypic drug susceptibility. TB programs should have access to the most updated tests, with results reported as they become available, for managing complex cases of disease, remove persons from isolation in a timely fashion, and identify linked cases.
Laboratories should report test results, including negative results, to the public health TB program in addition to the ordering clinician. LTBI is the presence of M.
Therefore, persons with LTBI do not experience clinical illness; they are asymptomatic, and their infection is not transmissible. LTBI treatment is important because it can substantially reduce the risk that persons infected with M. However, LTBI treatment can be associated with adverse events; therefore, the goal of preventive therapy is to treat those for whom prophylaxis for LTBI carries substantially more benefit than potential harm.
TB risk assessment is an essential TB prevention and control strategy that helps detect persons with LTBI who can benefit from treatment. Because TB risk assessment de-emphasizes testing of groups who are not at high risk for TB, it can help reduce wasted resources and prevent nonessential treatment.
Programs should pursue testing for LTBI only if diagnostic evaluation can be performed, a course of therapy can be prescribed, and therapy is likely to be completed. Guidelines provide recommendations for groups who should be screened, tested, and treated for LTBI 36 , A risk assessment based on local or state epidemiology of TB infection and disease should be prepared and made available to stakeholders and providers.
Considering these risk factors in two categories can be helpful: 1 risk factors for TB exposure or 2 risk factors for progression to active TB disease after becoming infected TB programs should retest a person who previously tested negative only if new risk factors occur after the previous assessment. Risk factors might include new close contact with a patient with infectious TB or new immunosuppression but also can include foreign residence or foreign travel in certain circumstances e.
Facilities should compile and analyze their epidemiologic and programmatic data and work with local and state health departments when making those decisions. Using both tests is not recommended unless the test that is initially used is negative. The criteria for tuberculin skin positivity, by reaction induration cutoff level and risk group, are provided Box 5. CDC recommends that the laboratory provide both quantitative and qualitative results TB disease should be ruled out after any positive TB test, with a thorough physical examination, history, chest radiography, and when indicated, bacteriologic studies.
If a patient has a positive test result and TB disease is ruled out, the patient should be considered for LTBI treatment. If the person accepts and is able to receive treatment for LTBI, the clinician should develop a plan of treatment with the patient to ensure adherence. However, if the patient refuses or is unable to receive treatment for LTBI, the clinician should educate the patient about the signs and symptoms of TB disease and about the need for rapid medical evaluation if TB signs or symptoms occur.
These studies present high quality of evidence, efficacy, effectiveness including better treatment completion rates and fewer side effects supporting the use of shorter regimens for LTBI 40 — Effective treatment of persons requires both a tailored medical management plan and a patient-focused case management plan.
After disease has been verified or is strongly suspected, both plans should be coordinated so that the most optimal care is provided to the patient, family, and community. TB control programs should ensure that the services needed for evaluating, treating, and monitoring TB patients are readily available in each community.
In certain areas, these services might be provided directly by the state TB program. The policies, procedures, and laws specified at the beginning of this report see Overall Planning and Policy Components provide guidance for managing care for persons with TB disease.
Although patients might undergo the majority of their evaluation and treatment in settings other than the health department, the major responsibility for monitoring and ensuring the quality of all TB-related activities in the community lies with the health department as part of its duties in protecting public health. The public health goals of TB patient management are to initiate treatment promptly and ensure completion of effective therapy to cure disease, reduce transmission, and prevent development of drug-resistant TB.
These goals are achieved through case management. The TB program should have protocols in place for TB case management and treatment 46 , TB programs should be familiar with and have access to new diagnostic tools e. Sputum and other specimens from suspected sites should be obtained as soon as possible for acid-fast bacillus smear and culture, rapid identification of M.
Each patient should receive a medical evaluation and chest radiography, with additional imaging of the affected area, if not the lungs. A medical regimen should be prescribed on the basis of patient clinical and epidemiologic characteristics Case management for TB disease includes patient-centered activities e. The case management team should work closely with those providing medical management to ensure optimal care for each patient.
Public health workers in TB programs play an integral role in helping patients complete TB treatment through the case management process.
Case management provides patient-centered care for treatment completion and ensures that all public health activities related to stopping TB transmission are completed. This includes ensuring that each patient is educated about TB and its treatment, the importance of treatment adherence, and that contacts should be elicited and evaluated. Within 3 working days after the case is reported, a health department worker should visit the patient in the hospital or at home to conduct an interview, initiate patient education, identify contacts, make referrals for medical evaluation, and detect possible problems related to adherence to therapy.
An initial treatment and monitoring plan should be developed and implemented within 1 week of diagnosis. This treatment plan should be reviewed regularly and modified as needed when additional relevant information becomes available e.
TB programs should fulfill their mandated responsibilities and also respect the relationship between the patient and the primary health care provider. Other resources describe case management for persons with TB disease 46 , In addition to the medical and case manager, team members might include clinic supervisors, outreach workers, health educators, nurses, nurse practitioners, physician assistants, pharmacists, physicians, and social workers.
The patient is always a member of the team; family members might assist as available or interested. Specific responsibilities might be assigned to other team members; however, the case manager is ultimately responsible for ensuring that needed activities are performed.
The specifics of this team, including size and number of members and function of each member, vary by jurisdiction and local needs.
Although certain patients might undergo their evaluation and treatment in settings other than the health department e. Thus, all TB patients should be assigned case managers, whether they receive TB care in health department clinics or from private providers. A specific clinician should be responsible for decisions regarding patient medications, testing, and assessment of progress throughout treatment.
That clinician should provide medical oversight of all patient care and thus should have an excellent understanding of TB disease and its treatment, the effect of comorbidities on TB treatment, and drug-to-drug interactions A specific health care worker i. Although one person is assigned primary responsibility, case management can involve a team of persons who collaborate to provide continuity of care.
The case manager is responsible for ensuring the following activities are completed for all TB patients to whom they are assigned:. Identifying contacts of a patient with infectious TB and providing testing and treatment as needed for all contacts;. Expanding the contact investigation as necessary when results from initial investigations become available; and. An assessment of these factors should be included in developing a case management plan 46 , TB programs should educate patients about the causes and effects of TB, dosing and possible adverse reactions of their medications, and the importance of taking their medications according to the care plan.
To facilitate adherence, the plan should use short-course treatment regimens and fixed-dose combinations, if such regimens and combinations are recommended and available. A welcoming and respectful atmosphere within the clinic setting is fundamental to maintaining adherence. The case manager should conduct an assessment of risk for nonadherence to treatment.
With DOT, a health care provider or other responsible person observes the patient swallowing each dose of anti-TB medication. In certain instances, DOT might be administered by the staff of correctional facilities or drug treatment programs, dialysis center staff, home health care personnel, staff of maternal and child health facilities, or responsible community members. New technologic methods e. Incentives and enablers should be available for enhancing adherence to therapy.
An incentive is an inducement or reward that serves as motivation for a desired action e. An enabler is an item or action that removes barriers for achieving a desired outcome e.
Health care professionals, including private practitioners, who become aware of a TB patient who has demonstrated an inability or unwillingness to adhere to a prescribed treatment regimen should immediately consult the health department.
The TB program can assist in evaluating the patient for the causes of nonadherence to therapy and provide assistance e. If the patient still does not adhere to treatment, the health department should take action based on local and state laws and regulations. This entails issuing a health officer order for DOT or seeking court-ordered DOT or detention for patients who are unwilling or unable to complete treatment and who have infectious TB or for those who are at risk for becoming infectious or experiencing drug-resistant TB.
A list of recommended legal resources for TB programs has been developed Additional services might be needed to facilitate continuity and completion of therapy. Social workers, interpreters, and referral sources should be available in the clinic or easily accessible to the patients. To ensure that patients receive treatment until they are cured, TB programs should make use of available legal authority and facilities available to isolate and treat patients who have infectious TB see Overall Planning and Policy Components.
When all less restrictive measures have failed, TB programs should be prepared to use any available legal authority to detain patients unwilling or unable to complete their treatment. This authority also might apply to nonadherent patients who no longer have infectious TB but whose disease might again become infectious or develop drug resistance.
Procedures and plans should be established to ensure that patients in isolation or detention have safeguards for due process e. A history of bladder cancer treatment in a patient with disseminated disease might lead the clinician to consider that the cause of the TB disease is Mycobacterium bovis BCG rather than M. As soon as patient specimens and bacteriology are obtained and TB disease is diagnosed or suspected, a clinician should start treatment and ensure the TB case is reported to the health department.
TB programs should send smear-positive respiratory specimens for TB identification and molecular diagnostic testing to test for genetic mutations that are surrogates for drug-resistant TB TB programs should start TB treatment either empirically or on the basis of laboratory findings such as molecular analysis or DST results.
Clinic services provided by TB programs, if available, should be accessible and acceptable to community members served by the clinic. Clinic hours should be convenient and ideally might include evening or weekend hours for persons who work or attend school. The clinic should be easily accessible by public transportation, or transportation should be provided, if possible. Intervals between the time of referral and the time of appointment and waiting times in the clinic should be kept to a minimum.
In busy TB clinics or multipurpose clinics, priority should be given to persons with TB disease or being evaluated for TB disease and to persons receiving TB medications. The clinic should have staff who speak the same language and have similar cultural and socioeconomic backgrounds as the community served by the clinic, or the clinic should employ persons trained to work in cross-cultural settings.
Language interpretation services should be available. Expert medical consultation should be available for management of all TB patients, including those who have drug-resistant TB. These consultative services should be available to the TB program and health care providers in the community. The consultation might be provided by a staff member of the TB program or by a local or regional consultant collaborating with the health department.
Treatment initiation decisions can be guided by results of molecular testing. Specimens might also be sent to National Jewish Health in Denver, Colorado, or to other laboratories, for a fee. Certain instruments can test for isoniazid resistance, as recommended by WHO. Newer drugs e. Drugs that are approved for other bacterial infections e. Although shorter treatment regimens for MDR TB are being investigated, describing those trials is beyond the scope of this report.
TB controllers should keep abreast of new developments related to drug-susceptible and drug-resistant TB. Medical consultation should be sought for any questions related to TB treatment and especially for decisions regarding MDR TB treatment regimens. A system should be in place to facilitate referral of TB patients for evaluation and treatment of other medical problems, including those conditions that can affect the course or outcome of TB treatment e.
If patients receive care in more than one setting, treatment should be coordinated with the other health care providers to ensure continuity and completion of therapy, minimize drug interactions, and avoid duplication of efforts. The TB program takes primary responsibility for ensuring TB treatment and monitoring for adherence. TB programs should refer patients with infectious TB with recommended respiratory precautions and notify the receiving health care provider or transport personnel that the patient has an aerosol-transmissible disease.
The TB program and all clinical settings should develop and implement protocols for ensuring rapid reporting of known or suspected TB cases to the health department having jurisdiction. The facility should have effective infection control measures in place to prevent transmission of TB infection within the hospital For example, the hospital should have provisions that allow patients with suspected or confirmed infectious TB disease to be separated from other patients.
Although ideally such patients should be placed in an airborne infection isolation room, if such a room is unavailable, a room with effective general ventilation should be used, with use of air cleaning technologies e.
Medical staff knowledgeable about the management of TB patients should be available to assist in patient care while the patient is hospitalized. In addition, medications should be available in the facility so that the patient can start or continue therapy in the hospital. Diagnostic services e. The patient should also be monitored for adverse events and for other existing or new medical conditions. Inpatient Care. Staff at inpatient settings might be unfamiliar with standards of TB treatment e.
Ingestion might not be documented, or the doses might not be counted in the overall dose count for treatment; therefore, the TB program and the patient are best served by the inpatient staff performing DOT and documenting actual ingestion of the medications. Discharge planning from the hospital begins as soon as the patient is admitted. Friday, June 29, - Childhood TB. Thursday, June 28, - Friday, September 14, - Tuesday, July 3, - Stop TB in my lifetime. Planning AOP. Strengthen local government ownership, coordination and partnership.
This will help the program in prioritizing augmentation in areas with high prevalence rate. Skip to Main Content Sitemap. Search form. NOTE: 6 days includes 2 days for detection and 4 days for specimen collection and delivery to lab. Skip directly to site content Skip directly to page options Skip directly to A-Z link.
Tuberculosis TB. Section Navigation. Facebook Twitter LinkedIn Syndicate. Minus Related Pages. Targets for incidence rates and objectives on case management and laboratory reporting are established on the basis of performance reported in NTIP using — data from the National TB surveillance system.
For Sputum Culture Conversion and Completion of Treatment, the latest year with data available is Targets are based on a statistical model that uses data to find trends from through or the latest year with data available.
TB programs with fewer than cases from — were excluded.
0コメント