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

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Appendix C: Sample Cohort Review Forms

Washington State Department of Health Tuberculosis Program
Cohort Presentation Form: Pulmonary and Extrapulmonary TB

Initials______

County________

TIMS Case #________

1. If the case is a child less than 5 years of age
2. If the case is HIV+
   __ Yes, source identified¹ __ Yes, source identified

 

1.  
   1. ______year-old [male / female] born in ________ (Country). Arrived in the US _______(year). Class A, B1, B2 ________[yes, no].
   2. Risk/social factors [medical conditions, substance abuse, homeless, employment, other _______________________]
   3. _________ (date) patient presented with symptoms of [cough, hemoptysis, night sweats, fever, weight loss, chest pain, enlarged lymph node, other _______] for _______ (days, weeks or months).
   4. PPD ____mm read on _______ (date).
   5. CXR shows [cavitary / abnormal non-cavitary / normal] taken on ________ (date).

2.  
   1. This is a case of pulmonary² TB and/or extrapulmonary TB_________(site)
      __ culture confirmed  __ clinically confirmed  __ provider diagnosed
   2. Sputum³ was collected on ____ (date) and received at lab on _____ (date).
   3. MTD negative/positive on ____ (date). __ not done
   4. Sputum⁴ smear [ ___ plus positive / negative] on ____ (date). LHJ first notified_____________ (date) by lab of sputum smear positive result.
   5. Sputum culture [+ / – / not done] and reported on ____ (date). Sputum culture conversion [occurred / did not occur / not obtained] within 2 months of treatment.
   6. Other specimens: source________ collected on ____ (date).
      Smear [ ______ plus positive / negative] on ____ (date).
      Culture results [+, – , not done] and reported on ___ (date).
   7. Sensitivity testing [pansensitive, MDR, resistant to______]. LHJ first notified _____ (date) by lab of susceptibility results.
   8. HIV⁵ [positive / negative / refused / not offered] on ____(date).

3. TB treatment
   1. Four-drug regimen or other regimen ____started on ___ (date).
   2. Treatment plan of ____ (months).
   3. On DOT? [yes / no] for a total of: __ 26 wks__ 9 mos__18 mos__other______
   4. If no DOT, reason: __lack of resources __patient refused__provider refused__other_______
   5. Pharmacy checks done⁶? [yes, no].
   6. Completed ___ weeks of TB treatment on ____(date) OR still on therapy and is due to complete _____ (date).
   7. Did not complete therapy because:
      __refused treatment
      __lost
      __died __TB related __non-TB related
      __moved Date of interjurisdictional referral:__________
      __reported at death
   8. Treatment interruptions⁷ __yes__no
      Medical/adverse reactions  __yes__no
      Patient nonadherence  __yes__no
      Provider reasons  __yes__no

4. Follow-up of the case
   1. Completion of therapy CXR on ____(date) showed [improved / worsened / no change / not done]
   2. If treatment still ongoing, follow-up CXR on ___ (date) showed [improved / worsened / no change / not done]

5. Contacts (indicate number in each box)

	Identified8		Started treatment for LTBI14
	Date contacts identified9_______		Completed treatment for LTBI
	Date contacts interviewed10_________		Currently on treatment
	Evaluated11 [Include those with initial and F/U PPD; CXR if PPD positive]		Discontinued treatment for LTBI due to:
	Date of evaluation12 ____________		Adverse reactions to medications
	Prior positive PPD		Died
	Infected (TST+) without disease [confirmed by CXR]		Moved15
	Diagnosed with TB disease		Refused to continue treatment
	Eligible for treatment of latent TB infection13		Lost to follow-up
	Started window prophylaxis (i.e., for those < 5 yrs of age, immunocompromised)		Provider decision (e.g. unable to monitor pt care)

6. Items needing follow-up: _____________________________

_____________________________________

1. LHJ first notified_______ (date) by [health care provider, other_______]
2. DOH first notified by LHJ_______ (date) [includes DOH calling LHJ and start of report]

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1. Be prepared to present the source case and associated contact investigation, including whether this child or HIV-infected person was listed as a contact in the contact investigation for the source case.
    
2. A disease site in the respiratory system including the airways (e.g., endobronchial, laryngeal).
    
3. Report the first sputum collected. All lab questions refer to local labs or state public health lab.
    
4. Report initial sputum unless initial is smear negative. Then report first sputum that is smear positive.
    
5. HIV testing should be current and done within 6 months of diagnosis.
    
6. A review of pharmacy records to determine whether a patient filled their anti-tuberculosis medications.
    
7. Report >2 weeks interruption during initial phase or >20% during the continuation phase.
    
8. Contacts identified include all true contacts with legitimate names, addresses, and DOB.
    
9. Report date when the first contact was identified (usually when case was interviewed).
    
10. Report date when the first contact was interviewed.
     
11. Evaluation is defined as 1) TST positive, CXR completed, and sputum collected if indicated; 2) TST placed and read after the end of the window period; or 3) contacts with documentation of previous diagnosed disease or LTBI—even if no further tests and exams are done. If started on treatment for LTBI, do not include these contacts in the number of “eligible for treatment.”
     
12. Report date when the first contact was evaluated with an initial PPD.
     
13. Contacts “eligible for treatment of latent TB infection” include: i) all TST+ contacts recommended for medical follow-up for whom treatment is medically indicated; and ii) persons identified during a contact investigation who need treatment, whether or not they were TST tested (e.g., HIV).
     
14. 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.
     
15. Complete an interjurisdictional referral form. Send the form to the county where contact is transferring and send copy to DOH TB Program.