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Understanding the TB Cohort Review Process: Instruction Guide (2006)

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Appendix B: Sample Cohort Review Forms


New York City Department of Health and Mental Hygiene, Bureau of Tuberculosis Control (BTBC)


Cohort Presentation I: Pulmonary or Laryngeal TB Case

1.Name: _______________ CRS # _______________

Noncount [No further report necessary]
______ year-old ____{male/female}, born in ____________ {country}.

Special therapy ________ {+ or – /refused/unknown}__Protease inhibitor or NNRTI (name)1: _______

2a.Sputum Smear Positive,2Pulmonary,3 2b.Sputum Smear Negative, Sputum Culture Positive 2c.Other:(Pediatric; other respiratory culture positive; cavitary, culture negative) 4
  1. __ Pulmonary3 TB
    __ (Both) Pulmonary & Extrapulmonary {site}.
  2. Sputum smear positive: _____ plus5
  3. Culture _____ [+, –, or not done]
  4. If culture positive, Source: _____
  5. Date assigned: _______
  6. Date interviewed: __________
    If >3 days for interview – state reason6:
  1. __ Pulmonary3 TB
    __ (Both) Pulmonary & Extrapulmonary {site}.
  2. Sputum smear negative
  3. Sputum culture positive
  4. Date assigned: ______
  5. Date interviewed: _______________
    If >5 days for interview – state reason6:
  1. __ Pulmonary3 TB
    __ (Both) Pulmonary & Extrapulmonary {site}.
  2. Smear status: _______ [–, or not done]
  3. Culture ___ [+ or –] if +, source of + culture: _____
  4. Date assigned: ______
  5. Date interviewed: ____________
    If >5 days for interview – state reason6:

Drug Susceptibility Results:
__ Pansensitive __MDR__ Rifampin resistant__Other resistance _______

Chest Radiograph Results:
__Cavitary7 __(Abnormal)__ Non-Cavitary __Normal CXR

 

3a. Treatment outcome at time of cohort

__Completed therapy

__Taking TB medications8 If yes, has completed ______ months of tx.9

__ Likely to complete therapy by (date) _______________

__ Did not complete treatment and no longer in care (reason):
__Refused__Lost__Died__Reported at death__Moved10 Where_________
Date of Interstate referral: _________

 

3b. __ On DOT: ___ total number of months on DOT; __ months on DOT with ≥ 80% compliance
If NO DOT, why not: _______________ __ Pharmacy checks11 done

4. If case is a child 18 years old or under: Source identified?12 Name: _______ CRS#: ________

5a. __ Employed Type of Work ________________
__ECI associated with this case ECI site and results: _______________

5b. Contacts
___ Identified13

___ Inappropriate for TST (Died prior to end of window period)14
___ Appropriate for TST15

___ Evaluated16
___ Prior cases (adequately treated)
___ Prior positive
___ Infected with disease: Name: _________ CRS#: _____
___ Infected with suspected disease17: Name: _______ CRS#: ____
___ Infected (New TST+), no disease [confirmed by CXR]

___ Appropriate for treatment of latent TB infection (LTBI)18

___ Started treatment for LTBI19

___ Completed treatment for LTBI
___ Current to care
___ Discontinued treatment for LTBI due to:

___ Adverse reactions to medications
___ Died
___ Moved10
___ Refused to continue treatment for LTBI
___ Lost to follow-up

 

6. Discussion20
TB 307 (Rev. 11/04)

Notes, Definitions and Special Cases

  1. If patient is taking a protease inhibitor or non-nucleoside reverse transcriptase inhibitors (NNRTIs), specify the name of the medication.
  2. Report positive sputum smears regardless of the culture’s result. Suspicious smears are considered to be positive.
  3. A disease site in the respiratory system including the airways (sputum and specimens from tissue codes: 18-25, 27 & 28).
  4. Use this section to present the following cases that do not meet the 2A or 2B criteria: culture negative, cavitary, respiratory culture positive, no sputum smear done; and pediatric cases (cases under 18 years old at TB diagnosis). For culture negative cases without a positive sputum smear or cavitary CXR, use Cohort Presentation II: Clinically Confirmed or Extrapulmonary.
  5. Highest grade of smear, if known.
  6. Use this space to document reasons for delayed interview, for example, a change in patient’s priority level.
  7. CXRs are reported as cavitary, non-cavitary, or normal. Do not report CXR dates or the results of follow-up CXRs.
  8. Do not list medications. The Director has the printout of drug regimens. However, be prepared to discuss if case is MDR, rifampin resistant, taking a protease inhibitor/NNRTI, or if regimen is unusual.
  9. If adherence for any period has been below 80%, state so and be prepared to explain.
  10. A case can only be closed as moved if an interstate had been done.
  11. For patients on self-administered treatment, present a review of pharmacy records to assess treatment adherence.
  12. Be prepared to present the source case and associated contact investigation, including whether this child was listed as a contact in the contact investigation for the source case.
  13. “Contacts identified” include all true contacts with legitimate names and addresses.
  14. Contacts “inappropriate for evaluation” will be subtracted from the contacts identified to determine the number appropriate for evaluation.
  15. Contacts “appropriate for evaluation” include all legitimate contacts identified who were not counted as “died prior to testing.” “Evaluation” consists of tuberculin skin testing and chest radiograph unless there is a documented prior positive TST. A contact is given one or two TSTs (Post–window period testing is only required for contacts who initially test TST-negative).
  16. Report only the number evaluated. Do not report the number of contacts who were UTL, who moved more than 60 days after being identified and were not evaluated, or who refused. These explanations may come up in discussion, but are not part of the standard format.
  17. All suspects must be reclassified to either “infected with disease” or “infected without disease” within four months of the initiation of treatment.
  18. Contacts “appropriate for treatment of latent TB infection” include all TST+ contacts recommended for medical follow-up for whom treatment is medically indicated. Persons identified during a contact investigation who need treatment, but were TST negative or prior TST positive, will be excluded from this number. Be prepared to explain.
  19. Report the number who started treatment for LTBI. Do not report the number of people who did not start treatment for LTBI; however, be prepared to explain. Do not report people who received window prophylactic treatment and were found not to have had latent TB infection. Provide updated information on those contacts who started treatment for LTBI.
  20. It is important to be familiar with
    • Patient’s adherence history, latest DOT status, dates of regulatory requests/outcomes, and current regulatory status;
    • Patient’s occupation and residence settings, particularly if patient is homeless;
    • Where contact with others occurred and how often;
    • When contacts were evaluated in relation to patient’s last positive smear;
    • If source case investigation was conducted and results, including relationship of this to any other known cases;
    • Evaluations of sex/needle-sharing partners of HIV-infected patients; also, are there any HIV-positive contacts;
    • Status of treatment for LTBI when appropriate, including window prophylaxis;
    • If and when expanded contact testing occurred and results of investigation.

TB 307 (Rev. 11/04)

Cohort Presentation II: Clinically Confirmed or Extrapulmonary TB Case

1.Name: ___________________ CRS # _____

Noncount [No further report necessary]
____ year-old ___ {male/female}, born in ________{country}.

Special therapy ___ {+ or – /refused/unknown}__ Protease inhibitor or NNRTI (name)1: ____ Date Assigned: ______
Date Interviewed: ____ If > 5 days for interview – state reason: _________

__ Clinically confirmed, pulmonary, smear negative, culture negative, non-cavitary.2
__ Extrapulmonary only. [Site of disease: ________]

__Pansensitive__MDR__Rifampin resistant__ Other resistance _______

__ Completed therapy
__ Currently taking TB medications.3

Has completed __ months of treatment

__ Likely to complete therapy by (date) ____
__ Did not complete therapy and no longer in care

Reason patient did not complete:__Refused__Lost__Died __Moved4__Reported at death

ON DOT: YES or NO (circle):

If YES: __ total number of months on DOT; __ months on DOT with ≥ 80% compliance
If NO DOT, why not: ____________________
__ Pharmacy checks5 done

Skip contacts.
If case is under 18 years old then use COHORT PRESENTATION FORM I.

 

2.Discussion6
Notes:
If patient is taking a protease inhibitor or non-nucleoside reverse transcriptase inhibitors (NNRTIs), specify the name of the medication.

If the patient has pulmonary disease and has either a positive sputum AFB smear or a cavitary CXR then use Cohort Presentation Form I: Pulmonary or Laryngeal TB.

Do not list medications. The Director has the printout of drug regimens. However, be prepared to discuss if case is MDR or regimen is unusual.

A case can only be closed as moved if an interstate has been done.

For patients on self-administered treatment, present a review of pharmacy records to assess treatment adherence.

It is important to be familiar with:

  • Adherence history;
  • Patient’s occupation and residence settings, particularly if patient is homeless;
  • Results from any contact investigation that may have been conducted before culture results were available, particularly if any HIV positive contacts were identified.

TB 306 (Rev. 11/04)

Patient Review Calculation Form

Network: _________ ___ Quarter of ____ Date: ____

CASES:

A. Total counted cases G.Lost
B. Cases started on drugs H.Died
C. Cases completing recommended therapy I.Moved
D. Cohort failures J.Cases reported at death
E. Likely to complete K.Cases counted by other
F. MDR L.Noncount

Index of completion at the time of the patient review:

Index = C
B – (H+K+L)
X100

 

Index of completion at the time of the patient review, excluding those who could not complete by the time of the review (MDRs):

Index = C
B – (H+F+K+L)
X100

 

Index of completion including those likely to complete by the end of the cohort year (<365 days):

Index = C + E
B – (H+K+L)
X100

 

Index of completion including those likely to complete by the end of the cohort year, excluding those could not complete treatment within one year (MDRs):

Index = C + E__
B – (H+F+K+L)
X100

 

Death rate:

Index = __H + J__
A – (K+L)
X100

 

Default rate:

Index = G
A – (K+L)
X100

 

Total cohort failure rate:

Index = D + G
A – (K+L)
X100

 

Contacts:

Contact Index:     all contacts identified     
total cases appropriate for contact investigation

 

Contacts inappropriate for evaluation X 100
     All contacts identified

 

Contacts appropriate for evaluation
   All contacts identified

X 100

 

        Contacts evaluated         
Contacts appropriate for evaluation

X 100

 

Contacts appropriate for treatment of LTBI X 100
Contacts infected w/o disease

 

    Contacts that started LTBI      X 100
Contacts appropriate for treatment of LTBI

 

    Contacts that did not start LTBI      X 100
Contacts appropriate for treatment of LTBI

 

    Contacts completed LTBI      X 100
Contacts started LTBI

 

    Contacts still on LTBI      X 100
Contacts started LTBI

 

Categories of contacts that discontinued treatment of LTBI:

    Contacts with adverse reaction      X 100
Contacts started LTBI

 

    Contacts died      X 100
Contacts started LTBI

 

    Contacts moved      X 100
Contacts started LTBI

 

    Contacts refused      X 100
Contacts started LTBI

 

    Contacts lost      X 100
Contacts started LTBI

 
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