105 CMR 365.00 — Standards for management of tuberculosis outside hospitals

105 CMR: DEPARTMENT OF PUBLIC HEALTH

105 CMR 365.000: STANDARDS FOR MANAGEMENT OF TUBERCULOSIS OUTSIDE HOSPITALS Section 365.004: Definitions 365.100: Public Health Precautions 365.200: Case Management 365.300: Medical Care and Follow up 365.400: Tuberculosis Infection Management 365.600: Discharge of an Inpatient Tuberculosis Patient to Outpatient Treatment

105 CMR 365.00 Standards for management of tuberculosis outside hospitals

365.004 Definitions

365.004: Definitions Active Tuberculosis. Tuberculosis is a state of active disease in any organ or tissue, with active reproduction of Mycobacterium tuberculosis as determined by positive culture for M. tuberculosis or a diagnostic nucleic acid or other definitive laboratory test (in distinction to latent tuberculosis infection). The individual with active tuberculosis may or may not be infectious. Adherence. The extent to which a patient continues an agreed upon treatment plan for active or clinically suspected tuberculosis, including taking anti-tuberculosis medications and keeping health care appointments. Adherence Support. Any measures or interventions that assist an individual in achieving adherence with a regimen of treatment and care for tuberculosis. This may include, but is not limited to, assistance with food and shelter, incentives, enablers, and substance abuse and mental health treatment. Case Assessment. The investigation conducted by the local board of health nurse to determine the potential the patient has to transmit disease to others, based on level and duration of exposure, and the medical, environmental, economic and social factors which may influence adherence to the prescribed treatment plan. Clinically Suspected Tuberculosis. A condition in which the individual has laboratory evidence (smear or culture or other test) consistent with, but not confirmatory of, tuberculosis; or has chest X-ray findings interpreted as probable tuberculosis by a qualified medical authority. Communicable. The ability to transmit disease from one person or animal to another. Confirmed Case of Tuberculosis. An individual who meets the Centers for Disease Control and Prevention (CDC) criteria to verify a case as tuberculosis disease. Contact. An individual who has been exposed to a person with communicable infectious tuberculosis sufficient in both duration and proximity that there is increased risk for transmission of tuberculosis. Contact Investigation. The procedure of tracing, testing, evaluating, and treating persons who have been in contact with a person who potentially has infectious tuberculosis. Drug Resistant Tuberculosis. Tuberculosis caused by tubercle bacilli that are not susceptible to one or more anti-tuberculosis drugs. Enablers. A term used to describe those things that make it possible or easier for patients to receive treatment by overcoming barriers such as transportation difficulties. Incentives. Small rewards given to patients to encourage them to take their own medicines, keep their clinic appointments, or follow their directly observed therapy plan.

105 CMR: DEPARTMENT OF PUBLIC HEALTH

365.004 continued

365.004: continued Latent Tuberculosis Infection. Condition in which living Mycobacterium tuberculosis bacteria are present in an individual as evidenced by skin test or other test for determining the presence of tuberculosis infection. A person with latent tuberculosis infection does not have an illness and is not infectious until and unless they develop active tuberculosis. Nurse Case Manager. A registered nurse, designated by the local board of health, who has the overall responsibility of monitoring and coordinating the implementation of the patient's treatment plan until the completion of therapy. The nurse case manager also assists the patient in obtaining other community resources, such as social services, that will assist him or her with adherence to therapy. Tubercle Bacillus/Bacilli. A bacillus (bacteria) causing tuberculosis; usually refers to Mycobacterium tuberculosis. Tuberculosis Program. The program within the Department of Public Health that administers the provisions of 105 CMR 365.000. Tuberculosis Surveillance Nurse. A Public Health Nurse who works for the Tuberculosis Program.

365.100 Public Health Precautions

365.100: Public Health Precautions (A) The period of infectivity for tuberculosis is defined in 105 CMR 300.200: Isolation and Quarantine Regulations. 105 CMR 300.200 determines when health care providers may discontinue isolation precautions and when individuals with confirmed or clinically suspected tuberculosis may resume community activities and community living. This includes but is not limited to resuming employment, school attendance, shelter living or other residential living arrangements. (B) Outpatient facilities (including but not limited to, hospital outpatient departments, clinics and medical office buildings where active tuberculosis cases are seen for treatment) shall follow current national and local infection control guidelines for the isolation of individuals who are excreting tubercle bacilli into the room air and who may be infectious to others.

365.200 Case Management

365.200: Case Management (A) Case management for tuberculosis is defined as the coordination of the medical, nursing, outreach, adherence support, and social service systems that will ensure that all persons with confirmed and clinically suspected tuberculosis are started on appropriate therapy, and that all persons with confirmed tuberculosis complete an appropriate and effective course of treatment. (B)(1) All persons with confirmed or clinically suspected tuberculosis shall have a nurse case manager designated by the local board of health who will work in consultation and cooperation with the Tuberculosis Program, as necessary. This case management is required regardless of the source of health care (public or private) and the ability to pay for the services or medications. The Tuberculosis Program shall assign Tuberculosis Surveillance Nurses and epidemiologists, as necessary, to work cooperatively and in consultation with local board of health authorities and the nurse case manager designated by the local board of health, to ensure that a case management system is in place for every confirmed or clinically suspected case of tuberculosis. (2) In consultation with the treating health care provider, the nurse case manager, designated by the local board of health, determines that a medical treatment plan is in place and is in accordance with the current American Thoracic Society (ATS), CDC, and the Infectious Disease Society of America (IDSA) treatment standards.

105 CMR: DEPARTMENT OF PUBLIC HEALTH

365.200 continued

365.200: continued (3) The initial case assessment and contact investigation by the local board of health shall begin within three working days of notification of a potential case of infectious tuberculosis. Contacts to the case shall be identified and categorized for their risk of tuberculosis infection as determined by their level of exposure and the person's potential for infectiousness. Contacts shall be investigated according to current ATS, CDC, and the IDSA standards and the policies of the Tuberculosis Program. Contact investigation reports shall be prepared and updated in accordance with the Tuberculosis Program policies and procedures. (4) An individualized nursing care plan shall be developed by the nurse case manager designated by the board of health to advance the individual needs of the person who has confirmed or clinically suspected tuberculosis. The nursing care plan content, and standards of care management, shall be consistent with standards established by the Tuberculosis Program.

365.300 Medical Care and Follow-up

365.300: Medical Care and Follow-up (A) All persons with confirmed or clinically suspected tuberculosis shall have an identified responsible physician, qualified and licensed to practice medicine, or a nurse practitioner licensed to practice in the expanded role under supervision, to provide medical supervision. Medical treatment for tuberculosis shall be according to the current standards set forth by the ATS, CDC, and the IDSA or other qualified medical authority, for chemotherapy and follow-up. The Tuberculosis Program shall make these standards available and provide consultation regarding appropriate therapy, when necessary. (B) Providers responsible for medical management of persons with confirmed or clinically suspected tuberculosis disease shall work in cooperation with the local board of health and the Tuberculosis Program for the purposes of case management as outlined in 105 CMR 365.200. (C) Providers must also notify the local board of health in the town where the patient resides and the Tuberculosis Program of any person with confirmed or clinically suspected tuberculosis, in a communicable form, who is unable or unwilling to receive proper medical care and, as such, poses a threat to the public health.

365.400 Tuberculosis Infection Management

365.400: Tuberculosis Infection Management Management and treatment of persons infected with tuberculosis, but without active disease, shall be provided in accordance with the current standards set forth by the ATS, CDC, and the ISDA or other qualified medical authority.

365.600 Discharge of an Inpatient Tuberculosis Patient to Outpatient Treatment

365.600: Discharge of an Inpatient Tuberculosis Patient to Outpatient Treatment Any acute or chronic care hospital or any other institution which provides health care to residents, including but not limited to: prisons; jails; residential treatment centers; nursing homes and rest homes, which plan to discharge a person with confirmed or clinically suspected tuberculosis into the community, shall do discharge planning in collaboration with the Tuberculosis Program. The Tuberculosis Program shall be notified of such persons with confirmed or clinically suspected tuberculosis, upon his or her admission to the hospital or institution, or upon recognition of their confirmed or suspected state, in order to begin the process of outpatient case management planning. A pre-discharge conference regarding case management shall be held and shall include the designated board of health case manager, the discharge planner and medical providers, and the Tuberculosis Surveillance Nurse from the Tuberculosis Program, as necessary. A plan for appropriate medical, nursing, and community agency follow-up shall be made prior to discharge into the community. REGULATORY AUTHORITY 105 CMR 365.000: M.G.L. c. 111, §§ 3, 5, 6, 7, 18, 81, 94H, 95; c. 111D, § 6.