Free Indiana State Tuberculosis Outbreak Response Plan - Indiana

REPORT OF TREATMENT FOR LATENT TB INFECTION
State Form 49894 (R3/7-07)

Indiana State Department of Health

Information contained on this form is confidential under IC 16-41-8-1

INSTRUCTIONS: 1. Submit only for persons being treated for latent TB infection who are requesting drugs through ISDH. 2. Submit with prescriptions to local health department. 3. Do not use to report verified or suspected cases of TB disease.

1. Name (last/first):____________________________, ________________ 2. Address :____________________________________________________ City:____________________________________________________ County:____________________________ ZIP Code:____________ 3. Phone: ( )_____________________________ 5. Sex: Male 4. Date of birth: _________________________

Referred from: ____________________________ Clinic: ___________________________________ Submitted by: _____________________________ Phone: ___________________________________ Date submitted: ___________________________

Female Refugee: Yes No

6. Country of birth: __________________ If foreign-born, year entered the U.S. ________ 7. Race (check all that apply): 8. Ethnicity: White Black or African American Native Hawaiian or Other Pacific Islander Hispanic or Latino

Asian American Indian/Alaska Native Multi-Racial Not Hispanic or Latino Induration size _____ mm

9. Tuberculin skin test results: Date given _____________

Date read ______________

Note: Do not consider as a positive reaction or a candidate for treatment if induration is <15mm and there are no risk factors. 10. Based on risk factors for TB exposure or for progression to active disease, this patient belongs to which of the following groups? · · · Negative (<5mm) initial skin test, but is a high-risk, close contact of an infectious case of TB. Treatment is recommended until latent TB infection is ruled out (i.e., HIV+, child <4, other high-risk medical conditions) HIV-positive Recent contact to an infectious TB case 5mm of induration is positive for: Chest x-ray consistent with old healed TB Organ transplant recipient or other immunosuppressive therapy or disorder 10mm of induration is positive for: Born in a high-prevalence country Injection drug user Resident or employee of a high-risk congregate setting Persons with certain high-risk medical conditions Children < 4 years of age · Children & adolescents exposed to high-risk adults Mycobacteriology laboratory personnel Recent (within the last 2 years) conversion to TST + Substance abuse, including alcohol Lived in high-prevalence areas of the U.S. or other country

No known risk factors (15mm of induration is positive for this group) Positive Negative Tested, results pending Test offered but refused Test not offered

11. HIV status:

12. Name of active case this patient is a contact of, if known: _________________________________________________ 13. Chest x-ray date: ______________ Results: Normal Abnormal, with stable fibrotic lesions consistent with old, healed TB Abnormal, but with no evidence of active TB disease

14. Drug regimen (see other side):__________________________________________________ for ________________ months 15. Reason for TB screening if patient has no risk factors: _______________________________________________________ ONLY REGIMENS RECOMMENDED BY THE AMERICAN THORACIC SOCIETY WILL BE PROVIDED (SEE OTHER SIDE). FOR LOCAL HEALTH DEPARTMENT USE ONLY Send with ISDH Drug Request Form and prescription to: Date received _____________________________________ Indiana State Department of Health Received by ______________________________________ 2 North Meridian Street, Section 6-A Phone ___________________________________________ Indianapolis, IN 46204 Phone: (317) 233-7434 Fax: (317) 233-7747

RECOMMENDED TREATMENT REGIMENS FOR LATENT TB INFECTION Drug Interval Adult Dosage Criteria for Comments (max) and Completion Duration INH Daily for 9 5 mg/kg 270 doses within Preferred regimen for all persons regardless of (300 mg) months 12 months age or HIV status. For HIV-infected patients, PIs, NRTIs, and Twice 15 mg/kg 76 doses within NNRTIs may be safely co-administered with (900 mg) weekly for 12 months INH. 9 months DOT must be used with twice-weekly dosing. INH Daily for 6 5 mg/kg 180 doses within Offer only if preferred or alternate regimens are (300 mg) months 9 months not feasible. Twice 15 mg/kg 52 doses within 9 Not indicated for patients with HIV infection or fibrotic lesions on chest x-ray. (900 mg) weekly for months Not indicated for children. 6 months DOT must be used for twice-weekly dosing. RIF Daily for 4 10 mg/kg 120 doses within May use for contacts to INH-resistant, RIF (600 mg) 6 months susceptible TB months* For persons who cannot tolerate INH or PZA. Not recommended for twice-weekly dosing. *The American Academy of Pediatrics currently recommends that children receiving RIF should be treated for 6 months Standard adult dosages: INH = 300 mg daily; RIF = 600 mg daily Pediatric dosages: INH daily: 10-15 mg/kg, 300mg max; INH twice weekly: 20-30 mg/kg, 900 mg max. RIF (daily only): 10-20 mg/kg, 600 mg max. Abbreviations: INH = isoniazid, RIF = rifampin, PZA = pyrazinamide, NRTIs = nucleoside reverse transcriptase inhibitors, NNRTIs = non-nucleoside reverse transcriptase inhibitors, PIs = protease inhibitors; DOT = directly observed therapy Pregnancy: INH regimens are preferred for pregnant women. For HIV + pregnant women, consult an expert. MDR-TB: consultation with an expert is required if the patient was exposed to a confirmed case of multi-drug resistant TB (resistant to both INH and RIF). Pyridoxine (Vitamin B6) may be given with INH to prevent peripheral neuropathy in susceptible adult patients. Adult dose is 50 mg/day. It should be used for exclusively breast-fed babies, children with poor diets, or adolescents and any children who report symptoms of peripheral neuropathy. Liquid INH should be avoided due to cramping and diarrhea that can be caused by its high osmotic load. Try crushing the tablet and mixing it with food or liquid.