Instructions for Form TB NDR "Notifiable Disease Report for Tuberculosis" - Hawaii

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Download Instructions for Form TB NDR "Notifiable Disease Report for Tuberculosis" - Hawaii

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Notifiable Disease Report for Tuberculosis: Definitions and Instructions
Hawaii State Department of Health
Tuberculosis Control Program
This document provides reporting requirements for suspected or confirmed tuberculosis (TB) as well as
definitions and instructions for completing the Notifiable Disease Report (NDR) for Tuberculosis (TB).
NDR QUESTION LIST
1. Name
2. Address
3. Homeless Within Past Year
4. Home Phone, Cellular, and Work
5. Next of Kin, Relationship, and Phone
6. Date of Birth
7. SSN (Social Security Number)
8. Sex at Birth
9. U.S. Citizen
10. Place of Birth
11. Foreign Born: Date Arrived in U.S.
12. Primary Occupation Within the Past Year
13. Race / Ethnicity
14. Reason Evaluated for TB
15. Date of Diagnosis
16. Status at Diagnosis of TB
17. Previous TB Disease
18. Site(s) of TB Disease
19. Bacteriology
20. Tuberculin Skin Test (TST) at Diagnosis
21. Interferon Gamma Release Assay (IGRA)
st
22. Date of 1
Chest Radiograph
nd
23. Date of 2
Chest Radiograph
st
24. Date of 1
Chest CT Scan or Other Chest Imaging
nd
25. Date of 2
Chest CT Scan or Other Chest Imaging
26. Date Therapy Started
27. Patient on Directly Observed Therapy (DOT)
28. Patient’s Weight at Diagnosis
29. Initial Drug Regimen and Frequency
30. HIV Status at Time of Diagnosis
31. HIV Antibody Test Date
32. Excess Alcohol Use Within Past Year
33. Injecting Drug Use Within Past Year
34. Non-Injecting Drug Use Within Past Year
35. Resident of Correctional Facility at Time of Diagnosis
36. Resident of Long-Term Care Facility at Time of Diagnosis
37. Additional TB Risk Factors
38. Date Reported (Reporting Section)
39. Hospital Admission Date
40. Hospital Discharge Date
41. Name of Primary Care Physician
42. Will the Patient be Referred to the Hawaii Department of Health for TB care?
43. Additional Notes/Remarks
44. DOH USE ONLY
TB NDR: Definitions and Instructions (Rev. 1/2009)
Page 1 of 21
Notifiable Disease Report for Tuberculosis: Definitions and Instructions
Hawaii State Department of Health
Tuberculosis Control Program
This document provides reporting requirements for suspected or confirmed tuberculosis (TB) as well as
definitions and instructions for completing the Notifiable Disease Report (NDR) for Tuberculosis (TB).
NDR QUESTION LIST
1. Name
2. Address
3. Homeless Within Past Year
4. Home Phone, Cellular, and Work
5. Next of Kin, Relationship, and Phone
6. Date of Birth
7. SSN (Social Security Number)
8. Sex at Birth
9. U.S. Citizen
10. Place of Birth
11. Foreign Born: Date Arrived in U.S.
12. Primary Occupation Within the Past Year
13. Race / Ethnicity
14. Reason Evaluated for TB
15. Date of Diagnosis
16. Status at Diagnosis of TB
17. Previous TB Disease
18. Site(s) of TB Disease
19. Bacteriology
20. Tuberculin Skin Test (TST) at Diagnosis
21. Interferon Gamma Release Assay (IGRA)
st
22. Date of 1
Chest Radiograph
nd
23. Date of 2
Chest Radiograph
st
24. Date of 1
Chest CT Scan or Other Chest Imaging
nd
25. Date of 2
Chest CT Scan or Other Chest Imaging
26. Date Therapy Started
27. Patient on Directly Observed Therapy (DOT)
28. Patient’s Weight at Diagnosis
29. Initial Drug Regimen and Frequency
30. HIV Status at Time of Diagnosis
31. HIV Antibody Test Date
32. Excess Alcohol Use Within Past Year
33. Injecting Drug Use Within Past Year
34. Non-Injecting Drug Use Within Past Year
35. Resident of Correctional Facility at Time of Diagnosis
36. Resident of Long-Term Care Facility at Time of Diagnosis
37. Additional TB Risk Factors
38. Date Reported (Reporting Section)
39. Hospital Admission Date
40. Hospital Discharge Date
41. Name of Primary Care Physician
42. Will the Patient be Referred to the Hawaii Department of Health for TB care?
43. Additional Notes/Remarks
44. DOH USE ONLY
TB NDR: Definitions and Instructions (Rev. 1/2009)
Page 1 of 21
Reporting Requirements for Suspected or Confirmed Tuberculosis
Health care providers, laboratories, and infection control practitioners are required by Chapter 164 of Title 11,
Hawaii Administrative Rules, §11-164-3, to report any patient suspected of or confirmed with active TB disease
to the Hawaii State Department of Health, TB Control Program. The reports must be submitted to the TB Control
Program by facsimile or mail within 24 hours of a diagnosis of confirmed or suspected TB.
It is mandatory to report patients who have any of the following criteria:
Any laboratory specimen with smear positive results for acid fast bacilli (AFB) with suspicion of active
TB disease.
Any laboratory specimen with a positive result from a rapid diagnostic test, such as nucleic acid
®
amplification (NAA) test [e.g., Gen-Probe’s Amplified MTD
(Mycobacterium Tuberculosis Direct)].
Any laboratory specimen with a positive culture for M. tuberculosis complex.
Any other clinical specimen or pathology or autopsy findings consistent with active TB disease. For
example, this may include, but is not limited to, caseating granulomas in a biopsy of the lung, lymph
node, or other anatomic area.
Treatment with two or more anti-TB medications (e.g., isoniazid, rifampin, pyrazinamide, ethambutol) for
suspected or confirmed active TB disease.
Clinical suspicion of pulmonary or extrapulmonary TB such that the health care provider has initiated or
intends to initiate airborne isolation, or treatment for TB.
FOR HI DEPARTMENT OF HEALTH TB CLINICS ONLY: TB classification of 3, 4 or 5.
For infection control purposes, patients should be reported whenever TB is suspected, even if bacteriologic
evidence of disease is lacking, preliminary, or treatment has not yet been initiated. When a patient has an AFB-
positive smear or has been started on clinical treatment for TB, reporting should not be delayed pending
laboratory identification of M. tuberculosis with rapid diagnostic tests (e.g., NAA tests) or culture results.
TB NDR: Definitions and Instructions (Rev. 1/2009)
Page 2 of 21
Definitions and Instructions for Completing the NDR for TB
1. Name
Indicate the last name, first name, and middle initial for the TB patient. Also indicate any aliases or maiden
names.
2. Address
Indicate the street number, street names, city, state, and zip code of the TB patient's residence at the time of
diagnosis. To the extent possible, the address should represent the home address (whether permanent or
temporary) of the TB patient.
Follow these guidelines for special circumstances:
a. Patients who are residents of correctional facilities (e.g., local, state, federal, military) – the address of the
correctional facility should be entered in this field.
b. Patients who are residents of long term care facilities – the address of the long term care facility should be
entered in this field.
c. Homeless persons or others without any fixed residence – the address at which they are living at the time
of diagnosis (e.g., the locality of the shelter in which the patient was living) should be entered in this
field.
3. Homeless Within Past Year
Check “No” if the patient was not homeless during the 12 months prior to the time when the TB
diagnostic evaluation was performed.
Check “Yes” if the patient was homeless at any time during the 12 months prior to the time when the TB
diagnostic evaluation was performed.
Check “Unknown” if it is not known whether the patient was homeless during the 12 months prior to the
time when the TB diagnostic evaluation was performed.
A homeless person may be defined as:
1. An individual who lacks a fixed, regular, and adequate nighttime residence and who has a primary
nighttime residence that is:
a. A supervised publicly or privately operated shelter designed to provide temporary living
accommodations, including welfare hotels, congregate shelters, and transitional housing for the
mentally ill; or
b. A public or private place not designated for, or ordinarily used as, a regular sleeping
accommodation for human beings; or
c. An institution that provides a temporary residence for individuals intended to be institutionalized
2. An individual who has no home (e.g., is not paying rent, does not own a home, and is not steadily living
with relatives or friends).
TB NDR: Definitions and Instructions (Rev. 1/2009)
Page 3 of 21
3. An individual who lacks customary and regular access to a conventional dwelling or residence. Included
as homeless are persons who live on streets or in non-residential buildings.
4. Also included are residents of homeless shelters, shelters for battered women, welfare hotels, and single
room occupancy (SRO) hotels. In the rural setting, where there are usually few shelters, a homeless
person often will live on the street or with relatives in substandard housing.
5. Being homeless does not refer to a person who is imprisoned or in a correctional facility.
4. Home Phone, Cellular, and Work
Indicate the home, cellular, and work phone numbers that can be used to contact the TB patient.
5. Next of Kin, Relationship, and Phone
Indicate the next of kin of the TB patient, the relationship to the TB patient, and the phone number that can be
used to contact this person.
6. Date of Birth
Indicate the month, day, and year of birth for the TB patient. For example: 04/26/1968. A complete date of birth
is required. Partial dates are acceptable ONLY for patients where date of birth is truly unknown. For example,
certain societies or cultures throughout the world do not document the day, month, or sometimes, even the year of
birth. In such cases, enter “99” for either the day and/or month, and enter the year of birth. If the month, day, and
year of birth are all unknown, enter "99/99/9999" on the form.
7. SSN (Social Security Number)
Indicate the last 4 digits of the TB patient’s social security number.
8. Sex at Birth
Check the appropriate box for the biological sex of the TB patient at birth: “Male” or “Female”.
9. U.S. Citizen
Check the appropriate box for the U.S. citizenship of the TB patient: “No”, “Yes”, or “Unknown”. Persons born
abroad to a U.S. citizen parent are considered U.S. citizens. NOTE: People born in the Commonwealth of the
Northern Mariana Islands, Guam, Puerto Rico, and U.S. Virgin Islands are U.S. citizens. Those born in the
Federated States of Micronesia, Republic of Marshall Islands, and Palau are not considered U.S. citizens.
TB NDR: Definitions and Instructions (Rev. 1/2009)
Page 4 of 21
10. Place of Birth
Enter the country in which the patient was born. If the patient was born in one of the 50 United States, include the
specific state.
11. Foreign Born
“Date Arrived in U.S.” – For patients who were NOT born in one of the 50 United States, indicate the month,
day, and year that the TB patient arrived in the U.S., for example: 04/26/1968. A complete date of arrival in the
U.S. is required. Partial dates are acceptable ONLY for patients where date arrived in U.S. are truly unknown. In
such cases, enter “99” for either the day and/or month, and enter the year of arrival. If the month, day, and year of
arrival are not all known, enter "99/99/9999" on the form.
12. Primary Occupation Within the Past Year
Within the past 12 months from the diagnostic TB evaluation, select the primary occupation of the patient (select
one). If more than one occupation is applicable to the patient, choose the occupation which the patient performed
for the longest period of time within the past 12 months (i.e. the patient’s primary occupation). For example, if
the patient was a health care worker and a student (e.g. taking night classes), then the patient’s primary occupation
would be classified as “Health Care Worker”.
Check “Unemployed” if the patient was not employed during the past 12 months prior to the diagnostic
TB evaluation. This should not include persons who are not seeking employment such as infants,
children, students, homemakers, retirees, and persons receiving permanent disability benefits or persons
who were institutionalized. Such individuals should be included in the appropriate occupation option
such as “Retired” or “Not Seeking Employment”. “Unemployed” should be checked if the person was
unemployed for the majority of the prior 12 month period; shorter time frames, such as 1 week of
unemployment in the past 12 months such not be marked as “Unemployed”.
Check “Retired” if the patient was retired within the 12 months before the TB diagnostic evaluation was
performed.
Check “Health Care Worker” if the patient was an all-paid or unpaid person working in healthcare
settings with potential for exposure to M. tuberculosis. These may include but are not limited to
physicians, nurses, aides, dental workers, technicians, staff in laboratories and morgues, emergency
medical personnel, students, part-time staff, temporary and contract staff, and persons not involved
directly in patient care but potentially at risk for occupational exposure (e.g., volunteers, outreach
workers, dietary, housekeeping, maintenance, clerical, and janitorial staff). Also included are persons who
deliver health care in the community (e.g., public health nurse, visiting nurse, outreach worker).
Check “Migrant/Seasonal Worker” if the patient was required to be absent from a permanent place of
residence for the purpose of seeking employment or who may vary their employment for the purpose of
remaining employed while maintaining a permanent place of residence [e.g., migratory agricultural
worker, seasonal agricultural worker, migrant factory worker, migrant construction worker, migrant
service industry worker, migrant sporting worker (e.g., horse racing, dog racing)].
Check “Unknown” if the employment status during the 12 months prior to the diagnostic TB evaluation
of the patient was unknown.
TB NDR: Definitions and Instructions (Rev. 1/2009)
Page 5 of 21