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Understanding the TB Cohort Review Process: Instruction Guide
2006
Return Table of Contents
Appendix B: Sample Cohort Review Forms
New York City Department of Health and Mental Hygiene,
Bureau of Tuberculosis Control (BTBC)
Cohort Presentation I: Pulmonary or Laryngeal
TB Case
1. Name: _______________ CRS # _______________
Noncount [No further report necessary]
______ year-old ____{male/female}, born in ____________ {country}.
Special therapy ________ {+ or – /refused/unknown} __Protease
inhibitor or NNRTI (name)1: _______
2a. Sputum Smear Positive,2Pulmonary,3 |
2b. Sputum Smear Negative, Sputum Culture Positive |
2c.Other:(Pediatric; other respiratory culture positive; cavitary, culture negative) 4 |
- __ Pulmonary3 TB
__ (Both) Pulmonary & Extrapulmonary {site}.
- Sputum smear positive: _____ plus5
- Culture _____ [+, –, or not done]
- If culture positive, Source: _____
- Date assigned: _______
- Date interviewed: __________
If >3 days for interview – state reason6:
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- __ Pulmonary3 TB
__ (Both) Pulmonary & Extrapulmonary {site}.
- Sputum smear negative
- Sputum culture positive
- Date assigned: ______
- Date interviewed: _______________
If >5 days for interview – state reason6:
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- __ Pulmonary3 TB
__ (Both) Pulmonary & Extrapulmonary {site}.
- Smear status: _______ [–, or not done]
- Culture ___ [+ or –] if +, source of + culture: _____
- Date assigned: ______
- Date interviewed: ____________
If >5 days for interview – state reason6:
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Drug Susceptibility Results:
__ Pansensitive __ MDR __ Rifampin resistant __Other
resistance _______
Chest Radiograph Results:
__Cavitary7 __(Abnormal) __ Non-Cavitary __Normal
CXR |
3a. Treatment outcome at time of cohort
__Completed therapy |
__Taking TB medications8 If yes,
has completed ______ months of tx.9 |
__ Likely to complete therapy by (date) _______________ |
__ Did not complete treatment and no longer
in care (reason):
__Refused __Lost __Died __Reported at death __Moved10
Where_________
Date of Interstate referral: _________ |
3b. __ On DOT: ___ total number of months on DOT; __ months
on DOT with ≥ 80% compliance
If NO DOT, why not: _______________ __ Pharmacy checks11
done
4. If case is a child 18 years old or under: Source
identified?12 Name: _______ CRS#: ________
5a. __ Employed Type of Work ________________
__ECI associated with this case ECI site and results: _______________
5b. Contacts
___ Identified13
___ Inappropriate for TST (Died prior to end of window period)14
___ Appropriate for TST15
___ Evaluated16
___ Prior cases (adequately treated)
___ Prior positive
___ Infected with disease: Name: _________ CRS#: _____
___ Infected with suspected disease17: Name: _______
CRS#: ____
___ Infected (New TST+), no disease [confirmed by CXR]
___ Appropriate for treatment of latent TB infection (LTBI)18
___ Started treatment for LTBI19
___ Completed treatment for LTBI
___ Current to care
___ Discontinued treatment for LTBI due to:
___ Adverse reactions to medications
___ Died
___ Moved10
___ Refused to continue treatment for LTBI
___ Lost to follow-up
6. Discussion20
TB 307 (Rev. 11/04)
Notes, Definitions and Special Cases
- If patient is taking a protease inhibitor or non-nucleoside
reverse transcriptase inhibitors (NNRTIs), specify the name of
the medication.
- Report positive sputum smears regardless of the culture’s result.
Suspicious smears are considered to be positive.
- A disease site in the respiratory system including the airways
(sputum and specimens from tissue codes: 18-25, 27 & 28).
- Use this section to present the following cases that do not
meet the 2A or 2B criteria: culture negative, cavitary, respiratory
culture positive, no sputum smear done; and pediatric cases (cases
under 18 years old at TB diagnosis). For culture negative cases
without a positive sputum smear or cavitary CXR, use Cohort Presentation
II: Clinically Confirmed or Extrapulmonary.
- Highest grade of smear, if known.
- Use this space to document reasons for delayed interview, for
example, a change in patient’s priority level.
- CXRs are reported as cavitary, non-cavitary, or normal. Do
not report CXR dates or the results of follow-up CXRs.
- Do not list medications. The Director has the printout of drug
regimens. However, be prepared to discuss if case is MDR, rifampin
resistant, taking a protease inhibitor/NNRTI, or if regimen is
unusual.
- If adherence for any period has been below 80%, state so and
be prepared to explain.
- A case can only be closed as moved if an interstate had been
done.
- For patients on self-administered treatment, present a review
of pharmacy records to assess treatment adherence.
- Be prepared to present the source case and associated contact
investigation, including whether this child was listed as a contact
in the contact investigation for the source case.
- “Contacts identified” include all true contacts with legitimate
names and addresses.
- Contacts “inappropriate for evaluation” will be subtracted from
the contacts identified to determine the number appropriate for
evaluation.
- Contacts “appropriate for evaluation” include all legitimate
contacts identified who were not counted as “died prior to testing.”
“Evaluation” consists of tuberculin skin testing and chest radiograph
unless there is a documented prior positive TST. A contact is
given one or two TSTs (Post–window period testing is only required
for contacts who initially test TST-negative).
- Report only the number evaluated. Do not report the number
of contacts who were UTL, who moved more than 60 days after being
identified and were not evaluated, or who refused. These explanations
may come up in discussion, but are not part of the standard format.
- All suspects must be reclassified to either “infected with disease”
or “infected without disease” within four months of the initiation
of treatment.
- Contacts “appropriate for treatment of latent TB infection”
include all TST+ contacts recommended for medical follow-up for
whom treatment is medically indicated. Persons identified during
a contact investigation who need treatment, but were TST negative
or prior TST positive, will be excluded from this number. Be
prepared to explain.
- 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.
- It is important to be familiar with
- Patient’s adherence history, latest DOT status, dates of
regulatory requests/outcomes, and current regulatory status;
- Patient’s occupation and residence settings, particularly
if patient is homeless;
- Where contact with others occurred and how often;
- When contacts were evaluated in relation to patient’s last
positive smear;
- If source case investigation was conducted and results,
including relationship of this to any other known cases;
- Evaluations of sex/needle-sharing partners of HIV-infected
patients; also, are there any HIV-positive contacts;
- Status of treatment for LTBI when appropriate, including
window prophylaxis;
- If and when expanded contact testing occurred and results
of investigation.
TB 307 (Rev. 11/04)
Cohort Presentation II: Clinically Confirmed or
Extrapulmonary TB Case
1. Name: ___________________ CRS # _____
Noncount [No further report necessary]
____ year-old ___ {male/female}, born in ________{country}.
Special therapy ___ {+ or – /refused/unknown} __ Protease inhibitor
or NNRTI (name)1: ____ Date Assigned: ______
Date Interviewed: ____ If > 5 days for interview – state reason:
_________
__ Clinically confirmed, pulmonary, smear negative,
culture negative, non-cavitary.2
__ Extrapulmonary only. [Site of disease: ________]
__Pansensitive __MDR __Rifampin resistant __ Other resistance
_______
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__ Completed therapy
__ Currently taking TB medications.3
Has completed __ months of treatment
__ Likely to complete therapy by (date) ____
__ Did not complete therapy and no longer in care
Reason patient did not complete: __Refused __Lost __Died
__Moved4 __Reported at death
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ON DOT: YES or NO (circle):
If YES: __ total number of months on DOT; __ months on
DOT with ≥ 80% compliance
If NO DOT, why not: ____________________
__ Pharmacy checks5 done
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Skip contacts.
If case is under 18 years old then use COHORT
PRESENTATION FORM I.
2. Discussion6
Notes:
If patient is taking a protease inhibitor or non-nucleoside reverse
transcriptase inhibitors (NNRTIs), specify the name of the medication.
If the patient has pulmonary disease and has either a positive
sputum AFB smear or a cavitary CXR then use Cohort Presentation
Form I: Pulmonary or Laryngeal TB.
Do not list medications. The Director has the printout of drug
regimens. However, be prepared to discuss if case is MDR or regimen
is unusual.
A case can only be closed as moved if an interstate has been done.
For patients on self-administered treatment, present a review of
pharmacy records to assess treatment adherence.
It is important to be familiar with:
- Adherence history;
- Patient’s occupation and residence settings, particularly if
patient is homeless;
- Results from any contact investigation that may have been conducted
before culture results were available, particularly if any HIV
positive contacts were identified.
TB 306 (Rev. 11/04)
Patient Review Calculation Form
Network: _________ ___ Quarter of ____ Date: ____
CASES:
A. Total counted cases |
G. Lost |
B. Cases started on drugs |
H. Died |
C. Cases completing recommended therapy |
I. Moved |
D. Cohort failures |
J. Cases reported at death |
E. Likely to complete |
K. Cases counted by other |
F. MDR |
L. Noncount |
Index of completion at the time of the patient review:
Index = |
C
B – (H+K+L) |
X 100 |
Index of completion at the time of the patient review, excluding
those who could not complete by the time of the review (MDRs):
Index = |
C
B – (H+F+K+L) |
X 100 |
Index of completion including those likely to complete by the end
of the cohort year (<365 days):
Index = |
C + E
B – (H+K+L) |
X 100 |
Index of completion including those likely to complete by the end
of the cohort year, excluding those could not complete treatment
within one year (MDRs):
Index = |
C + E __
B – (H+F+K+L) |
X 100 |
Death rate:
Index = |
__H + J__
A – (K+L) |
X 100 |
Default rate:
Index = |
G
A – (K+L) |
X 100 |
Total cohort failure rate:
Index = |
D + G
A – (K+L) |
X 100 |
Contacts:
Contact Index: |
all contacts identified
total cases appropriate for contact investigation |
Contacts inappropriate for evaluation X 100
All contacts identified |
Contacts appropriate for
evaluation
All contacts identified |
X 100 |
Contacts
evaluated
Contacts appropriate for evaluation |
X 100 |
Contacts appropriate
for treatment of LTBI |
X 100 |
Contacts infected w/o disease |
Contacts
that started LTBI |
X 100 |
Contacts appropriate for
treatment of LTBI |
Contacts
that did not start LTBI |
X 100 |
Contacts appropriate for
treatment of LTBI |
Contacts
completed LTBI |
X 100 |
Contacts started LTBI |
Contacts
still on LTBI |
X 100 |
Contacts started LTBI |
Categories of contacts that discontinued treatment
of LTBI:
Contacts
with adverse reaction |
X 100 |
Contacts started LTBI |
Contacts
died |
X 100 |
Contacts started LTBI |
Contacts
moved |
X 100 |
Contacts started LTBI |
Contacts
refused |
X 100 |
Contacts started LTBI |
Contacts
lost |
X 100 |
Contacts started LTBI |
Last Reviewed: 05/18/2008 Content Source: Division of Tuberculosis Elimination
National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention
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