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Menu of Suggested Provisions For State Tuberculosis Prevention and Control Laws

B. Investigation

1. Coordination of and Authority and Guidelines for Conducting Investigations

Descriptive Note:  Investigation is a fundamental component of TB prevention and control. This section contains examples of provisions that provide: 1) authority for conducting investigations, 2) guidance on how investigations should be carried out and what they should entail, and 3) instruction concerning coordination of investigations.

  • Each local health officer is hereby directed to use every available means to ascertain the existence of, and immediately investigate all reported or suspected cases of active tuberculosis disease in the jurisdiction, and to ascertain the sources of those infections. In carrying out the investigations, each local health officer shall follow applicable local rules and regulations and all general and special rules, regulations, and orders of the state department. Cal [Health & Safety] Code § 121365 (Deering 2009).
  • The department shall conduct or oversee the investigation, control, and monitoring of suspected or confirmed tuberculosis infection and disease within the state.  Local health departments shall investigate, control, and monitor suspected or confirmed tuberculosis infection and disease within their respective jurisdictions. Utah Code Ann. § 26-6-8 (LexisNexis 2009).
  • Reportable diseases
    • The authority or local public health administrator may investigate a case of a reportable disease, disease outbreak or epidemic. The investigation may include, but is not limited to:
      • Interviews of: 1) The subject of a reportable disease report; 2) Controls; 3) Health care providers; or 4) Employees of a health care facility.
      • Requiring a health care provider, any public or private entity, or an individual who has information necessary for the investigation to: 1) Permit inspection of the information by the authority or local public health administrator; and 2) Release the information to the authority or local public health administrator.
    • The authority shall establish by rule the manner in which information may be requested and obtained under [provisions directly above].
      • Information requested may include, but is not limited to, individually identifiable health information related to: 1) The case; 2) An individual who may be the potential source of exposure or infection; 3) An individual who has been or may have been exposed to or affected by the disease; 4) Policies, practices, systems or structures that may have affected the likelihood of disease transmission; and 5) Factors that may influence an individual's susceptibility to the disease or likelihood of being diagnosed with the disease. Or. Rev. Stat. Ann. § 433.004 (West 2009).
  • Upon receipt of a disease report pursuant to this article, the department may investigate the circumstances surrounding the occurrence of the reportable disease or condition to determine the authenticity of the report and to determine what public health measures have been given or should be provided. The department's investigation and actions may include the following:
    • Confer and coordinate with the physician, hospital, laboratory, institution, or person making the report;
    • Inspect premises pursuant to [state isolation statute];
    • Recommend the collection of laboratory specimens that may be necessary to confirm the diagnosis of the disease or to determine the source of the infection or epidemic;
    • Conduct an epidemiological investigation and record the findings on a case, [suspect], or epidemic;
    • Ascertain the source of the infectious agent, identify unreported cases, and evaluate contacts;
    • Recommend or implement public health measures;
    • Provide information concerning the reportable disease and its prevention to the case, [suspect], contact, or a responsible member of such a person's household or institution to prevent further spread of the disease; and
    • Forward a report regarding a person residing in another state to the respective state public health authority or to the national Centers for Disease Control and Prevention for the purpose of effective interstate communicable disease control. S.D. Admin. R. 44:20:02:07 (2009).
  • A local health officer who conducts an investigation pursuant to this article shall immediately notify the tuberculosis control officer of the existence and nature of the disease and of the measures taken to control tuberculosis. The local health officer shall keep the tuberculosis control officer informed of the prevalence of the disease as prescribed by the department. Ariz. Rev. Stat. § 36-723 (LexisNexis 2009).
  • A health care provider and a public, private, or hospital clinical laboratory shall assist in a disease investigation conducted by the department, a local board, or local department. A health care provider and a clinical laboratory shall provide the department, local board, or local department with all information necessary to conduct the investigation, including but not limited to medical records; exposure histories; medical histories; contact information; and test results necessary to the investigation, including positive, pending, and negative test results. Iowa Admin. Code r. 641-1.7(135,139A) (2009).

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2. Contact Investigations

Descriptive Note:  Public health officials investigate TB exposure and transmission and prevent future cases of TB through contact investigations. According to guidelines issued jointly by the National Tuberculosis Controllers Association (NTCA) and CDC, a contact investigation should be considered if the index patient has suspected or confirmed pulmonary, laryngeal, or pleural TB. The provisions in this section relate to contact investigations; the final bullet below is an Indiana regulatory provision that has reportedly been effective in focusing contact investigations. When choosing to incorporate specific documents by reference, such as the NTCA/CDC contact investigation guidelines, states may consider adding “as amended and supplemented” to include the most current version or supplement to the cited document.

  • The department and its authorized agents may counsel and interview, or cause to be counseled and interviewed, any person who has active tuberculosis, who is reasonably suspected of having active tuberculosis, or who is reasonably suspected of having been exposed to active tuberculosis, in order to investigate the source and spread of the disease and in order to require such person to submit to examination and treatment to cure as necessary.  All information gathered in the course of contact investigation is confidential, subject to the provisions of [tuberculosis confidentiality statute]. Such information is exempt from [inspection under the public records statute]. Fla. Stat. Ann. § 392.54 (LexisNexis 2009).
  • The initial case assessment and contact investigation by the local board of health shall begin within three working days of notification of a potential case of tuberculosis. Contacts to the case shall be identified and categorized for their risk of tuberculosis infection as determined by their level of exposure and the person's potential for generating air-borne tubercle bacilli (droplet nuclei). Contacts shall be investigated according to the ATS/CDC standards and the policies of the [state TB control program]. Contact investigation reports shall be prepared and given to the [regional TB nurse] for the region, according to the policies developed by the [state TB control program]. 105 Mass. Code Regs. 365.200 (2009).
  • For confirmed and suspected cases of pulmonary, laryngeal, or pleural tuberculosis, a contact investigation shall be performed, identifying both high and medium priority contacts. Prioritization of contacts is to be assigned in accordance with Guidelines for the Investigation of Contacts of Persons with Infectious Tuberculosis. Recommendations from the National Tuberculosis Controllers Association and CDC. MMWR; December 16, 2005; Vol. 54; No. RR-15. Priority is based on the likelihood of infection and the potential hazards to the individual contact infected.
    • Prioritization of contacts exposed to persons with acid-fast bacilli (AFB) sputum positive or cavitary tuberculosis (TB) cases is as follows:
      • High-priority contacts include the following: household contacts; Children less than five (5) years of age; persons with medical risk factors, including HIV; persons exposed during medical procedures; persons exposed in a congregate setting; persons that exceed duration of environment limits as determined on a case-by-case basis by the department TB control program.
      • Medium-priority contacts include the following: children five (5) to fifteen (15) years of age; persons that exceed duration of environment limits as determined on a case-by-case basis by the department TB control program.
    • Prioritization of contacts exposed to persons with AFB sputum negative TB cases with abnormal chest radiographs is as follows:
      • High-priority contacts include the following: children less than five (5) years of age; persons with medical risk factors, including HIV; persons exposed during medical procedures.
      • Medium-priority contacts include the following: household contacts; persons exposed in a congregate setting; persons that exceed duration of environment limits as determined on a case-by-case basis by the department TB control program. 410 Ind. Admin. Code 1-2.3-106 (2009).

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