Tuberculosis: Active Case Investigation

Policy

Category: Control of Infectious Diseases
Subject: Tuberculosis: Active Case Investigation
Division: N/A
Policy Number: CA.82.01.206
Effective Date: October 25, 2012

POLICY STATEMENT

It is the policy of Wellington-Dufferin-Guelph Public Health (WDGPH) to respond immediately (<12 hours) to the notification of a suspected or confirmed case of active tuberculosis.

SCOPE

This policy applies to all Control of Infectious Diseases (CID) team members and nursing students who may be required to respond to a suspected or confirmed case of active tuberculosis.

RESPONSIBILITES

Program Manager will:
  • Ensure employees adhere to this policy;
  • Ensure employees are trained to investigate active cases of tuberculosis;
  • Ensure employees are fit tested, equipped with N95 masks, and understand routine precautions when investigating clients suspected or confirmed with active TB disease;
  • Consult with the Medical Officer of Health for further direction as needed;
  • Direct the management of the investigation; and
  • Monitor policy compliance on a regular basis.
CID Team Member/Student will:
  • Adhere to this policy;
  • Will provide management of suspect or active cases throughout and until the completion of individual’s treatment for active disease; and
  • Use routine practices and appropriate PPE when meeting with clients suspected or known to have untreated active tuberculosis.

DEFINITIONS

Active tuberculosis (suspected, clinically diagnosed or confirmed) is defined as an individual:

  • With positive culture of Mycobacterium tuberculosis complex (M. tuberculosis, M. africanum, M. canetti, M. caprae, M. microti, M. pinnipedii or M. bovis excluding BCG strains) from sputum, body fluids or tissues;
    OR
  • Without bacteriological evidence  but with clinical signs or symptoms, radiological or pathological evidence of active pulmonary or non-pulmonary disease, preferably with:
  • A positive tuberculin skin test; AND/OR
  • Acid fast bacilli in smears from sputum or other body fluids or tissues; AND/OR
  • Response to anti-TB treatment.

REFERENCES AND RELATED FORMS, POLICIES AND PROCEDURES

Corresponding Procedure:  CA.82.02.206   Tuberculosis: Active Case Investigation
Health Protection and Promotion Act, 1990
Ontario Public Health Standards, 2008 (or as current)
Infectious Diseases Protocol, 2009 (or as current)
Tuberculosis Prevention and Control Protocol, 2008 (or as current)
Tuberculosis Prevention & Control Guidance Document, 2011
Canadian Tuberculosis Standards, 6th Edition 2007
Canadian immunization Guide, 7th Edition 2006

APPROVED BY

Rob Thompson 


Procedure

Category: Control of Infectious Diseases
Subject: Tuberculosis Active Case Investigation
Division: N/A
Procedure Number: CA.82.02.206
Effective Date: June 8,2011

PROCEDURE

  1. When notification is received of a suspected case of active tuberculosis (TB), the Public Health Nurse will start completing the Case Information form (HPDTB(F)1)  with all pertinent data and begin a file on the client.  The PHN will contact the physician and/or hospital ICP to obtain data and query regarding follow-up planned.  The PHN will advise physician about the process for referring to the TB Clinic if warranted and the availability of TB drugs through Wellington-Dufferin-Guelph Public Health.
  2. The PHN will contact the client to offer health teaching regarding transmission of tuberculosis and the disease process, medications, and compliance with treatment.  The PHN will give the client the Tuberculosis (HPDTB(FS)10) fact sheet.  There are also fact sheets available in other languages on Well-Net.
  3. For all clients with suspected or confirmed infectious TB, client will remain in airborne isolation in hospital or home isolation until three successive sputum samples are negative on smear or TB has been ruled out.  For clients with smear negative TB, isolation procedures can generally be discontinued after 2 weeks of appropriate multidrug therapy and clinical evidence of improvement in consultation with the treating physician and the Medical Officer of Health (MOH).  The PHN will explain home isolation to the client and may provide the Home Isolation for Tuberculosis fact sheet (HPDTB(FS)2).
  4. If the client is considered infectious, the PHN will complete a list of his/her close contacts (i.e. family, friends, co-workers, and other close contacts) and record on the Contact Tracing form (HPDTB(F)3).  Identified contacts and degree of contact will be reviewed with the Manager and Medical Officer of Health (MOH) to determine the circles of testing required.
  5. The PHN will contact the close contacts of the suspected case and advise them to have a tuberculosis test (TST) done either at their family physician’s office or Wellington-Dufferin-Guelph Public Health.  Record all TST results for contacts and follow-up done on the Contact Tracing form (HPDTB(F)3).
  6. Children under 6 years of age should be started on INH prophylaxis regardless of skin test results.  INH can be discontinued at 10 weeks after break in contact with active case if TST remains negative.* (Reference: Ministry of Health and Long-Term Care – Tuberculosis Protocol).        
  7. All contacts with a negative TST (less than 5 mm for contacts) should be advised to repeat TST at 8 weeks after break in contact with active case to assess for possible conversion due to exposure.
  8. All contacts with a positive TST (5 mm or greater for contacts) will be referred for further follow-up as outlined in the policy for CA.82.01.205 Follow-Up of Positive Tuberculin Skin Test.  The PHN will ensure that the client’s physician is aware that client is a contact of an active case of TB.
  9. The PHN will update client’s file with all new lab work as received, and record lab results (HPDTB(F)2) and chest x-rays on the Case Information form (HPDTB(F)1).
  10. The PHN will review sensitivity results and prescribed drug regimen to ensure its adequacy.
  11. The PHN will create the client as a confirmed or suspect case and submit required information via iPHIS to the Ministry of Health and Long-Term Care within 24 hours of receiving the initial report.
  12. The PHN will maintain contact with the client throughout the course of treatment either in the TB Clinic setting, or through telephone/home visit contact to monitor compliance with treatment.  The PHN will ensure that the prescribed course of chemotherapy is completed through the provision of DOT (Directly Observed Therapy), or using appropriate interventions according to Ministry of Health and Long-Term Care protocols.

REFERENCES AND RELATED FORMS, POLICIES AND PROCEDURES

Corresponding Policy:  CA.82.01.206   Tuberculosis: Active Case Investigation
CA.82.01.205 Follow-Up of Positive Tuberculin Skin Test.
Ministry of Health and Long-Term Care – Tuberculosis Protocol
HPDTB(F)1 Case Information form
HPDTB(FS)10 Tuberculosis
HPDTB(FS)2 Home Isolation for Tuberculosis fact sheet
HPDTB(F)3 Contact Tracing form

APPROVED BY

Rob Thompson