Menu of Suggested Provisions For State Tuberculosis Prevention and Control Laws

D. Examination

1. Examination of TB Suspects

Descriptive Note: Examination enables public health officials to identify TB cases, facilitating immediate initiation of an appropriate treatment regimen for individuals who are found to have TB disease. The first two bullets below are examples of state statutory provisions that authorize public health officials to issue an order for examination (the second provision also specifically imposes a duty upon the individual suspected of having communicable TB to submit to examination), and the third bullet is an example of a state law that authorizes public health officials to petition the court directly for an order for examination. The final bullet is an example of a regulatory provision that contains detailed requirements for diagnostic evaluations.

• Whenever a health officer determines on reasonable grounds that an examination of any person is necessary for the preservation and protection of the public health, the health officer shall issue a written order directing medical examination, setting forth the name of the person to be examined, the time and place of the examination, and such other terms and conditions as the health officer may deem necessary. A copy of such order shall be served upon the person. Such an examination may be made by a licensed physician or advanced practice nurse of the person’s own choice under such terms and conditions as the health officer shall specify. Colo. Rev. Stat. Ann. § 25-4-506 (2009).
• When any health officer shall have reasonable grounds to believe that any person has tuberculosis in a communicable form and will not voluntarily seek a medical examination, it shall be the duty of such health officer to order such person, either orally or in writing, to undergo an examination by a physician qualified in chest diseases, or at some clinic or medical care facility qualified to make such examinations. It shall be the duty of such suspected person to present himself or herself for examination at such time and place as ordered by the health officer. The examination shall include an x-ray of the chest, examination of sputum, and such other forms and types of examinations as shall be approved by the [public health official]. Kan. Stat. Ann. § 65-116b (2009).
• Application to require examination or treatment for tuberculosis.
  • The department or a local board may apply for an order from the district court if a person is reasonably suspected to have or to have been exposed to tuberculosis, upon request of: a physician legally authorized to practice medicine in the state; the department; or a local health officer.
  • The application must request that the person be ordered to: submit to an examination for tuberculosis and, if the person is found to have tuberculosis, to complete an approved course of treatment; or enter or return to a treatment location to complete an approved course of treatment.
  • The application for an order [described above] must allege that the person: is suspected of having tuberculosis or has been exposed to tuberculosis and has refused to be examined for tuberculosis as required by rules adopted by the department; or has tuberculosis and has refused to be treated or to complete an approved course of treatment.
  • The application must state the names of witnesses by which facts alleged may be proved. At least one witness must be a physician. Mont. Code Ann. § 50-17-105 (2009).
• Diagnostic evaluations
  • 1) The designated public health nurse case manager for the health jurisdiction of residence shall monitor and facilitate timely diagnostic evaluation of all patients with suspected or confirmed infectious or potentially infectious TB disease, identified contacts to these patients and Class B1 or B2 referrals, regardless of the type of health care provider.
    • [NOTE: “Class B1 or B2 referrals” means referrals from the CDC’s Division of Global Migration and Quarantine, which informs the Department of persons who are refugees, parolees, asylees, or recent legal immigrants to the United States, and who were screened overseas and classified as either B1 meaning TB, clinically active, not infectious or B2 meaning TB, not clinically active, not infectious. These classifications are made within 12 months of immigration and these referrals require evaluation of their TB status within 30 days of arrival to prevent potential transmission. Source: N.J. Admin. Code § 8:57-5.3 (2010)].
  • 2) Where a health care provider, based on direct observation or other written clinical and/or laboratory findings, believes that a patient has suspected or confirmed infectious or potentially infectious TB disease, the health care provider shall schedule an appointment for a diagnostic evaluation in his or her office or by referral within five business days of such observation.
  • 3) The public health nurse case manager shall schedule a diagnostic evaluation in the public health clinic within 10 working days after notification of discharge of a [state] resident with suspected or confirmed infectious or potentially infectious TB disease from a hospital or correctional facility inside or outside [State], if the patient will be managed by a public health TB clinic.
  • 4) The public health nurse case manager shall schedule any contact or Class B1 or B2 referral identified or located during an investigation for a diagnostic evaluation in the public health clinic within 20 working days after identification or notification by the Department’s TB Program of his or her residence in the public health nurse case manager’s health jurisdiction.
  • 5) A diagnostic evaluation for a person with suspected or confirmed infectious or potentially infectious TB shall consist of at least a physical examination including visual acuity testing, a chest x-ray, sputum collection or induction and laboratory testing.
    • The health care provider may utilize the Department’s TB Standards of Care as a guideline for appropriate practice.
  • 6) A diagnostic evaluation of a contact or Class B1 or B2 referral shall consist of at least a Mantoux tuberculin skin test or an interferon gamma release assay, and a chest x-ray if the skin test is considered significant or the interferon gamma release assay is positive.
    • If active TB disease is suspected based on the results of the diagnostic evaluation, the health care provider shall complete the requirements at [5] above.
    • The health care provider may utilize the Department’s TB Standards of Care as a guideline for appropriate practice. N.J. Admin. Code § 8:57-5.8 (2010).

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2. Examination of Contacts

Descriptive Note: The provisions in this section are examples of state laws addressing examination of contacts to individuals with active TB, ranging from general requirements to specific.

• The local health officer or the department may order an examination of a contact to detect tuberculosis. Contacts shall be reexamined at times and in a manner as the local health officer may require. Wis. Admin. Code [DHS] § 145.10 (2009).
• A physician who attends a case of active tuberculosis shall examine or cause all household contacts to be examined or shall refer them to the Department for examination. The physician shall promptly notify the Department of such referral. When required by the Department, non-household contacts and household contacts not examined by a physician shall submit to examination by the Department. An examination required by this section shall include such tests as may be necessary to diagnose the presence of tuberculosis, including but not limited to tuberculin tests, [blood] tests for tuberculosis infection, and where indicated, laboratory examinations, and x-rays. If any suspicious abnormality is found, steps satisfactory to the Department shall be taken to refer the person promptly to a physician or appropriate medical facility for further investigation and, if necessary, treatment. Contacts shall be re-examined at such times and in such manner as the Department may require. When requested by the Department, a physician shall report the results of any examination of a contact. New York, N.Y., 24RCNY Health Code § 11.21 (2009). [NOTE: the term “blood” in brackets replaced the term “serologic,” and the legal citation was retained].
• The health officer shall evaluate for tuberculosis infection any contact of a case having active tuberculosis. A tuberculosis screening test must be administered to a contact residing in the same household as the case or other similarly close contact. If the tuberculosis screening test is negative, the tuberculosis screening test must be repeated 8 to 10 weeks after the last date of exposure to the case having active tuberculosis. If the initial or second tuberculosis screening test is positive, the contact must be referred for a chest radiograph and medical evaluation for active tuberculosis. Any contact found to have active tuberculosis or tuberculosis infection must be advised to complete an effective course of treatment in accordance with the recommendations for the counseling of and effective treatment for a person having active tuberculosis or tuberculosis infection in accordance with the guidelines of the Centers for Disease Control and Prevention as adopted by reference.
  • A child or other high-risk contact whose initial tuberculosis screening test administered pursuant to [above] is negative must be advised to take preventive treatment, unless medically contraindicated. Preventive treatment may be discontinued if the second tuberculosis screening test administered pursuant to [above] is negative.
  • The health officer may issue an order for a medical examination to any contact who refuses to submit to a medical examination pursuant to [above], to determine if the contact has active tuberculosis or tuberculosis infection.
  • A contact of a case having tuberculosis or suspected case considered to have tuberculosis shall comply with all rules and regulations issued by the State Board of Health and shall submit to a medical evaluation to determine the presence of active tuberculosis or tuberculosis infection.
  • If the tuberculosis screening test administered pursuant to [above] is positive, or if there is radiological evidence of active tuberculosis in the lungs, the contact shall submit to further medical evaluation. An order to submit to a medical examination may be issued by the health officer if the contact fails to report for a medical evaluation when requested to do so by the health officer. Nev. Admin. Code § 441A.355 (2009); Nev. Admin. Code § 441A.365 (2009).

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