Understanding the TB Cohort Review Process: Instruction Guide (2006)
Appendix C: Sample Cohort Review Forms
Washington State Department of Health Tuberculosis
Cohort Presentation Form: Pulmonary and Extrapulmonary TB
|Initials______||County________||TIMS Case #________|
- If the case is a child less than 5 years of age
- If the case is HIV+
__ Yes, source identified1 __ Yes, source identified
- ______year-old [male / female] born in ________ (Country). Arrived in the US _______(year). Class A, B1, B2 ________[yes, no].
- Risk/social factors [medical conditions, substance abuse, homeless, employment, other _______________________]
- _________ (date) patient presented with symptoms of [cough, hemoptysis, night sweats, fever, weight loss, chest pain, enlarged lymph node, other _______] for _______ (days, weeks or months).
- PPD ____mm read on _______ (date).
- CXR shows [cavitary / abnormal non-cavitary / normal] taken on ________ (date).
- This is a case of pulmonary2 TB and/or extrapulmonary
__ culture confirmed __ clinically confirmed __ provider diagnosed
- Sputum3 was collected on ____ (date) and received at lab on _____ (date).
- MTD negative/positive on ____ (date). __ not done
- Sputum4 smear [ ___ plus positive / negative] on ____ (date). LHJ first notified_____________ (date) by lab of sputum smear positive result.
- Sputum culture [+ / – / not done] and reported on ____ (date). Sputum culture conversion [occurred / did not occur / not obtained] within 2 months of treatment.
- Other specimens: source________ collected on ____ (date).
Smear [ ______ plus positive / negative] on ____ (date).
Culture results [+, – , not done] and reported on ___ (date).
- Sensitivity testing [pansensitive, MDR, resistant to______]. LHJ first notified _____ (date) by lab of susceptibility results.
- HIV5 [positive / negative / refused / not offered] on ____(date).
- TB treatment
- Four-drug regimen or other regimen ____started on ___ (date).
- Treatment plan of ____ (months).
- On DOT? [yes / no] for a total of: __ 26 wks__ 9 mos__18 mos__other______
- If no DOT, reason: __lack of resources __patient refused__provider refused__other_______
- Pharmacy checks done6? [yes, no].
- Completed ___ weeks of TB treatment on ____(date) OR still on therapy and is due to complete _____ (date).
- Did not complete therapy because:
__died __TB related __non-TB related
__moved Date of interjurisdictional referral:__________
__reported at death
- Treatment interruptions7 __yes__no
Medical/adverse reactions __yes__no
Patient nonadherence __yes__no
Provider reasons __yes__no
- Follow-up of the case
- Completion of therapy CXR on ____(date) showed [improved / worsened / no change / not done]
- If treatment still ongoing, follow-up CXR on ___ (date) showed [improved / worsened / no change / not done]
- Contacts (indicate number in each box)
Started treatment for LTBI14
Date contacts identified9_______
Completed treatment for LTBI
Date contacts interviewed10_________
Currently on treatment
those with initial and F/U PPD;
Discontinued treatment for LTBI due to:
Date of evaluation12 ____________
Prior positive PPD
Infected (TST+) without disease [confirmed by CXR]
Diagnosed with TB disease
Eligible for treatment of latent TB infection13
Started window prophylaxis (i.e., for those < 5 yrs of age, immunocompromised)
- Items needing follow-up: _____________________________
Please fill out but do not present this information during cohort review
LHJ first notified_______ (date) by [health care provider, other_______]
DOH first notified by LHJ_______ (date) [includes DOH calling LHJ and start of report]
- 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
- A disease site in the respiratory system including the airways
(e.g., endobronchial, laryngeal).
- Report the first sputum collected. All lab questions refer
to local labs or state public health lab.
- Report initial sputum unless initial is smear negative. Then
report first sputum that is smear positive.
- HIV testing should be current and done within 6 months of diagnosis.
- A review of pharmacy records to determine whether a patient
filled their anti-tuberculosis medications.
- Report >2 weeks interruption during initial phase or >20%
during the continuation phase.
- Contacts identified include all true contacts with legitimate
names, addresses, and DOB.
- Report date when the first contact was identified (usually when
case was interviewed).
- Report date when the first contact was interviewed.
- 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.”
- Report date when the first contact was evaluated with an initial
- 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).
- 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.
- Complete an interjurisdictional referral form. Send the form to the county where contact is transferring and send copy to DOH TB Program.