Tuberculosis Detection and Treatment

Primary care physicians (PCPs) are instructed to notify the Health Net Medi-Cal Health Services Department of all suspected or active tuberculosis (TB) cases to ensure coordination of care, correct utilization and timely delivery of medical care. Health Net's Medi-Cal Health Services staff communicates with the Medi-Cal TB Control Program nurse manager and the PCP concerning these cases. When necessary, Health Net's public programs administrators obtain referral information from Health Net's Medi-Cal Health Services staff, affiliated health plans and local health departments to ensure accurate tracking of TB cases.

PCPs need to contact the Local Health Department (LHD) TB nurse manager and the Health Net Medi-Cal Health Services Department for care management services for members who are repeated no-shows for appointments. The Health Net Medi-Cal Health Services staff attempts to contact the member. If no contact is made, the Health Net Medi-Cal Health Services staff notifies the PCP and coordinates with the LHD. The Health Net Medi-Cal Health Services staff updates the LHD TB nurse manager when members change providers.

The local TB Control Program reports to the PCP when the member does not respond to treatment or when the member experiences an adverse reaction to medication.

The LHD TB nurse manager is responsible for providing follow-up information concerning contact investigations, verifying and collecting additional information, and communicating with PCPs and Health Net's care managers.

Direct observation therapy (DOT) services are offered by local health departments (LHDs) to monitor members with clinically active tuberculosis (TB) who have been identified by their primary care physician (PCP) as at risk for potential noncompliance with the treatment regimen. DOT is a measure to ensure adherence to tuberculosis treatment for members at risk for noncompliance in taking medications or who are unable to follow the treatment regimen and to protect the public health. DOT is a process by which a health care worker observes the patient swallowing anti-TB medications. The purpose of DOT is to assure that the entire course of medication is taken in the correct dose, at the correct time and for the complete period of therapy. 

DOT services are carved-out under the Health Net Medi-Cal managed care program, but the member remains enrolled with Health Net for the purpose of receiving primary care and services unrelated to DOT.

The responsibility for paying for DOT services for a member enrolled in managed care rests with the LHD rather than the health plan.

Refer to the CDHS/CTCA Joint Guidelines for the Treatment of Active Tuberculosis Disease (PDF) for appropriate dosage recommendations for the detection and treatment of tuberculosis. 

When a primary care physician (PCP) identifies a member with tuberculosis (TB) who is at risk for nonadherence with the treatment regimen, the PCP must fax a copy of the DOT referral form (PDF) to the local health department (LHD) TB control officer. A copy of the referral form must also be faxed to Health Net's public programs administrator and the participating physician group (PPG) case manager.

The LHD must be notified when the PCP has reasonable grounds to believe that a member has ceased treatment, failed to keep an appointment, has adverse drug reactions, or has relocated without transferring or discontinuing care. 

The following members must be referred for direct observation therapy (DOT) services:

• members having multiple drug resistance (defined as resistance to Isoniazid and Rifampin)
• members whose treatment has failed
• members who have relapsed after completing a prior regimen
• children
• adolescents
• noncompliant individuals

Members with the following conditions should be considered for referral:

• substance abuse
• major psychiatric, memory or cognitive disorders
• elderly
• homeless
• formerly incarcerated
• slow sputum conversion
• slow or questionable clinical adherence
• adverse reaction to TB medications
• poor understanding of their disease process and management
• language or cultural barriers 

Primary care physicians (PCPs) are required to coordinate with the local health department (LHD) tuberculosis (TB) control officer and provide follow-up care to all members receiving direct observation therapy (DOT) services. PCPs need to inform the LHD TB Control Program of any changes in the member's response to the treatment or drug therapy. 

PCPs receive a periodic report from the LHD TB Control Program to advise them of members' treatment status. On completion of the DOT services, the LHD TB Control Program faxes a copy of the member's medical record and final status report to the PCP.

The PCP then arranges an appointment to develop a follow-up treatment plan for the member. The PCP's staff calls or mails the appointment schedule slip to the member. If the member does not show up for the scheduled appointment, a follow-up telephone call or letter should be initiated. If there is no response, the PCP notifies the LHD TB Control Program. 

The Health Net Medi-Cal Health Services Department makes a referral to the Health Net Health Education Department when a member is identified with tuberculosis (TB). Members are then thoroughly educated regarding TB. Effective health education programs and materials are available to members in a variety of languages. These services are provided through participating physician groups (PPGs), providers, participating hospitals, the LHD TB Control program, and Health Net.

Health Net requires participating primary care physicians (PCPs) to obtain the LHD TB Control Program office's approval prior to hospital transfer or discharge of any member with known or suspected tuberculosis (TB). The LHD TB Control Program office reviews requests for hospital transfer or discharge within 24 hours of receipt. Coordination of the treatment plan and discharge planning include the acute care facility, the Health Net Medi-Cal Health Services Department and the LHD TB Control program. 

All Medi-Cal members must receive an initial health appointment (IHA) (complete history and physical examination) within 120 days of the date of enrollment, unless the member's primary care physician (PCP) determines that the member's medical record contains complete and current information consistent with the assessment requirements within periodicity time requirements. Tuberculosis (TB) testing must be included if members are identified in specific targeted or at-risk groups. 

It is the responsibility of the local health department (LHD) to investigate tuberculosis (TB) contacts. When contacts with positive TB members are identified, the primary care physician (PCP) notifies the TB Control Program or the Health Net Medi-Cal Health Services Department of the actual or potential contact with a TB-diagnosed Health Net member. PCPs are required to provide examinations within seven days to their assigned members identified by TB Control Program as contacts. Examination results must also be reported in a timely manner back to the local TB Control Program office. 

Health Net uses laboratories that conform to legal and Centers for Disease Control and Prevention (CDC) guidelines. 

The Health Net Medi-Cal medical directors confer, as needed, with the local Tuberculosis (TB) Control Program nurse manager to ensure coordination of care and to correct identified deficiencies. Health Net's Medi-Cal medical directors, Health Services staff, public programs administrators, and the local TB Control Program collaborate in monitoring and evaluating care and services provided to potential and active TB cases. 

Primary care physicians (PCPs) are responsible for acting as the primary caregiver for the member and submitting the required tuberculosis (TB) reporting to the local TB Control Program office within one working day of identifying a TB case. Upon receipt by the local TB Control Program office, co-management of treatment is discussed. TB-diagnosed members are identified by PCPs during the normal course of practice and by specialists during consultation and treatment. The Health Net Medi-Cal Health Services Department is also notified for care management needs and tracking. 

Conflicts that arise between LHD TB Control Programs and Health Net or a participating provider are resolved by Health Net's public programs administrators. 

Primary care physicians (PCPs) who identify Class 3 and Class 5 TB cases refer them to the LHD TB Control Program for treatment.

The local health department (LHD) must be notified when the PCP has reasonable grounds to believe that a member has ceased treatment, failed to keep an appointment, had adverse medication reactions, relocated without transferring care, or discontinued care.

PCPs who elect not to refer the member identified with Class 3 or 5 TB to the LHD TB Control Program for treatment are bound by the requirements of California law in the identification, reporting, treatment, and coordination of care for these members. 

Screening is performed to identify infected people at high risk for disease who would benefit from treatment for latent tuberculosis infection (LTBI). It is also done to identify people with clinically active tuberculosis (TB) who need treatment. The following are at high risk for TB and need to be screened with a tuberculin skin test: 

• those with HIV infection
• those in close contact with someone having an infectious TB case
• those with medical conditions that increase the risk of TB
• foreign-born people from high TB-prevalence countries
• low-income people
• high-risk minorities
• alcoholics and intravenous drug users
• residents and employees of long-term care facilities (including prisons)
• populations identified locally as being at increased risk for TB (for example, health care workers in some areas)

Health Net collaborates with local refugee health programs to identify refugees who are possible candidates for local refugee health clinic services. Guidelines for this referral coordination may be found in the discussion of Refugee Health Programs.

TB testing, interpretation of testing and coordination of referral, treatment and follow-up for children through age 20, are to be provided in accordance with section 703 of Children's Medical Services Child Health and Disability Prevention (CHDP) program Health Assessment Guidelines. A TB exposure risk assessment is required at every CHDP program health assessment, and the tuberculin test must be performed at ages four to five and ages 13 to 16.

Classification of the tuberculin skin test reaction: 

Primary care physicians (PCPs) are responsible for reporting to the LHD TB Control Program all confirmed or suspected tuberculosis (TB) cases within one working day of diagnosis. Information reportable to the local health department (LHD) includes:

• member information (name, age, address, home phone number, date of birth, gender, ethnicity, and marital status)
• locating information (employer, work address and phone number)
• disease information (disease diagnosed, date of onset, symptoms, laboratory results, and prescribed medications)

Reports to the local TB Control Program must be made using the Tuberculosis Suspect Case Report form. 

In addition, suspected and confirmed cases of TB must also be reported as a communicable disease within one day of diagnosis to the Communicable Disease Report Division of the Local Health Department. This report must be made using the Confidential Morbidity Report form (PDF). Refer to Tuberculosis Reporting and Cases Management in the Communicable Disease Reporting discussion in Compliance and Regulations for specific information.

Documentation of the report to the LHD must be included in the member's medical record. Any necessary medical information must be provided to the LHD for members receiving direct observation therapy (DOT) services.

PCPs are required to collaborate with the local TB Control Program on treatment plans for members and promptly submit treatment plans to the local TB Control Program office with updates. Until treatment is completed, requests for updates may be monthly, unless otherwise determined by the local TB Control program office. The local TB Control Program office obtains monthly sputum smears and cultures and then reports the results to the PCP until the results become negative. Radiographs may be requested after several months of treatment.

Mantoux tuberculin skin testing is the standard method of identifying persons infected with M. tuberculosis. The Mantoux test must be administered and read by qualified staff. Steps of tuberculin skin testing are as follows: 

1. Inject intradermal Mantoux test (i.e., 0.1 ml of 5 TU purified protein derivative [PPD] tuberculin) into the volar or dorsal surface of the forearm.
2. Read the reaction to the test 48 to 72 hours after injection.
3. Measure the area of induration (palpable swelling) around the site of injection.
4. Record the diameter of the indurated area (measured across the forearm) in millimeters.

If the test is positive, a chest radiography must be done. If the chest radiography is negative, consider the person infected. As a positive tuberculosis (TB) test does not necessarily indicate the presence of active TB disease, an individual showing a positive TB test requires further screening with other diagnostic procedures.

Noncompliance is a major problem in tuberculosis (TB) control. A health care professional aware of a nonadherent TB member needs to contact the local TB Control Program office for intervention. The local TB Control Program official then meets with the member to determine why the member is nonadherent and takes necessary action.

Members not receiving direct observation therapy (DOT) should be asked about adherence at routine follow-up visits. Routine pill counts should be taken and urine tests should be used to check for the presence of drug metabolites. If the member's sputum remains positive after two months of treatment, DOT should be considered. 

Health Net's Medi-Cal medical directors confer, as needed, with the local Tuberculosis (TB) Control Program to provide coordination of care and to correct any identified deficiencies. They are available to care managers to assist with proper member management and member compliance problems.

When requested by the primary care physician (PCP) or the Health Net public programs administrator, the Health Net Medi-Cal Health Services Department is available to provide assistance with the coordination of the member's care. 

The following classes of people may be eligible for the treatment of latent tuberculosis infection (LTBI) if they have not received a prior course of antituberculosis (TB) treatment. Before starting treatment for LTBI, clinically active TB must first be excluded. It is essential to obtain a chest radiograph when evaluating a person for TB. Bacteriological studies need to be obtained for all persons with an abnormal chest radiograph.

• TB Class 3 (clinically active TB) - M. tuberculosis cultured (if done), or positive reaction to TB skin test, and clinical or radiographic evidence of current disease
• TB Class 5 (TB suspected) - Diagnosis pending

The definition of a positive tuberculin skin test is as follows:

• induration between 5 mm and 10 mm
  • people known or suspected to have HIV infection
  • contact with someone having an infectious case of TB
  • person with an abnormal chest radiograph, but no evidence of active TB (TB Class IV)
• induration between 10 mm and 15 mm
  • all except those listed above
• induration of 15 mm or more
  • in California, this cutoff is not recognized by public health departments. Tuberculin skin tests are not recommended for those at low risk for TB infection

  Tuberculin skin test conversion is defined as an increase of at least 10 mm of induration from less than 10 mm to 10 mm or more within 24 months from a documented negative to a positive tuberculin skin test.

People in the following categories are to be considered for treatment for LTBI if their tuberculin skin test is positive and they have not previously completed a course of anti-TB treatment:

• those known or suspected to have HIV infection, regardless of age
• those with an abnormal chest radiograph suggestive of TB and classified into ATS Class IV, regardless of age 
• close contact with a person having an infectious TB case, regardless of age
• all tuberculin skin test converters, regardless of age

People with the following conditions that have been associated with an increased risk of TB must be started on a treatment for LTBI, regardless of age:

• drug abuse (especially with injecting drug use)
• diabetes mellitus (especially insulin-dependent)
• silicosis
• prolonged corticosteroid therapy
• other immunosuppressive therapy
• cancer of the head and neck
• hematological and reticuloendothelial disease
• end-stage renal disease (ESRD)
• intestinal bypass or gastrectomy
• chronic malabsorption
• low body weight (10% or more under ideal body weight)
• malnutrition and clinical situations associated with rapid weight loss
• persons with positive tuberculin skin test

Close contacts with a tuberculin skin test under 5 mm should receive a chest radiograph and, once clinically active TB is excluded, should start the treatment for LTBI if:

• Circumstances suggest a high probability of infection.
• Evaluation of other contacts with a similar degree of exposure demonstrates a high prevalence of infection.
• The contact is a child (especially if under age four), is infected with HIV or is otherwise immunocompromised.
• For those who are started on a treatment for LTBI with a PPD less than 5 mm, a repeat tuberculin skin test should be performed 8 to 12 weeks after contact with the infectious person has been broken to determine if skin test conversion has occurred. A decision on continuing treatment for LTBI can be made once the result of the repeat skin test is available.

Health Net collaborates, communicates and contracts with local health departments (LHDs) in public health coordination, education, referrals, screening, treatment, direct observation therapy (DOT), care management, and related services.