Montgomery County TB Control Program Mission Statement

The mission of the TB Control Program is to protect the public health by assuring early identification and treatment of tuberculosis disease and to decrease the reservoir of possible TB infection by providing treatment for latent TB infection for those at risk of developing active tuberculosis disease.

What is tuberculosis (TB)?

Tuberculosis (TB) is a disease caused by bacteria called Mycobacterium tuberculosis that are spread from person to person through the air. TB usually affects the lungs, but it can also affect other parts of the body, such as the brain, the kidneys, or the spine. Not everyone infected with TB bacteria becomes sick. As a result, two TB-related conditions exist: latent TB infection and active TB disease.

Latent TB Infection

TB bacteria can live in your body without making you sick. This is called latent TB infection (LTBI). In most people who breathe in TB bacteria and become infected, the body is able to fight the bacteria to stop them from growing. People with latent TB infection do not feel sick and do not have any symptoms. The only sign of TB infection is a positive reaction to the tuberculin skin test or special TB blood test. People with latent TB infection are not infectious and cannot spread TB bacteria to others. However, if TB bacteria become active in the body and multiply, the person will get sick with TB disease.

TB DiseaseTB bacteria become active if the immune system can't stop them from growing. When TB bacteria are active (multiplying in your body), this is called TB disease. TB disease will make you sick. People with TB disease may spread the bacteria to people they spend time with every day. Many people who have latent TB infection never develop TB disease. Some people develop TB disease soon after becoming infected (within weeks) before their immune system can fight the TB bacteria.  Other people may get sick years later, when their immune system becomes weak for another reason.

For persons whose immune systems are weak, especially those with HIV infection, the risk of developing TB disease is much higher than for persons with normal immune systems

The Difference between Latent TB Infection and TB Disease

A Person with latent TB A Person with TB Disease Has no symptoms Has symptoms that may include:

A bad cough that last 3 weeks or longerPain in the chestCoughing up blood or sputumWeakness or fatigueWeight lossNo appetiteChillsFeverSweating at night

Does not feel sick Usually feels sick

Cannot spread TB bacteria to others May spread TB bacteria to others

Usually has a skin test or blood test result indicating TB infection

Usually has a skin test or blood test result indication TB infection

Has a normal chest x-ray and a negative sputum smear

May have an abnormal chest x-ray, or positive sputum smear or culture

Needs treatment for latent TB infection to prevent active TB disease

Needs treatment to treat active TB disease

Epidemiology of TB in the U.S.A.

Data and Statistics

Tuberculosis (TB) is one of the world’s deadliest diseases:

One third of the world’s population are infected with TB. Each year, over 9 million people around the world become sick with TB. Each year, there are almost 2 million TB-related deaths worldwide. TB is a leading killer of people who are HIV infected. In total, 12,904 TB cases (a rate of 4.2 cases per 100,000 persons)were reported in the United States in 2008. Both the number of TB cases reportedand the case rate decreased; this represents a 2.9% and 3.8% decline,respectively, compared to 2007.

MARYLAND

2007Cases Rate

2008Cases Rate

2009Cases Rate

270 4.5 278 4.9 219 3.8

MONTGOMERY COUNTY

2007Cases Rate

2008Cases Rate

2009Cases Rate

82 8.8 88 9.3 70 7.2

Treatment for Latent TB Infection (LTBI) DOPT

People with latent TB infection have TB germs in their bodies, but they are not sick because the germs are not active. However, they may develop TB disease in the future. They are often prescribed treatment to prevent them from developing TB disease. Usually, only one drug is needed to treat latent TB infection. The medicine usually taken for the treatment of latent TB infection is called Isoniazid (INH). INH for 9 months is the preferred regimen or Rifampin for 4 to 6 months. These drugs kill the TB bacteria that are in the body.

Treatment for TB Disease - DOTA person with active TB disease has a large amount of TB bacteria in the body. TB disease can be treated by taking several drugs for 6 to 12 months or longer. It is very important that people who have TB disease finish the medicine, and take the drugs exactly as prescribed. If they stop taking the drugs too soon, they can become sick again; if they do not take the drugs correctly, the germs that are still alive may become resistant to those drugs. TB that is resistant to drugs is harder and more expensive to treat.

CONTACT OF INVESTIGATION DEFINITION

A "Contact" is a person of any age who has been in close association with an active case of TB. An infected contact is a person who over a sufficient length of time has become infected with M. tuberculosis by breathing the contaminated air. The goal of a tuberculosis contact investigation is both to identify other active cases of tuberculosis and to identify and complete treat individuals with new latent TB infection.Tuberculosis contact investigation is required for all pulmonary TB cases in Maryland.

Annotated Code of Maryland, Health – General §§18-324

Examination – The Secretary or a health officer may have an individual examined, if the Secretary or the health officer knows or is notified in writing by a physician that the individual is suspected of having tuberculosis.

OSHA Guidelines

The Occupational Safety and Health Administration (OSHA) estimates that as many as 13 million adults in the United States are currently infected with TB and that 5 million workers are exposed. The purpose of the OSHA’s standard is to reduce these risks in health care and other work settings where active TB cases are likely to be encountered by employees. Homeless shelters have been defined as one of these facilities meeting the scope of occupational exposure to TB, along with hospitals, extended care facilities, and mycobacterium laboratories to name a few.Since the shelters in Montgomery County meet the above guidelines and inaddition had 0 -2 cases of TB diagnosed in the shelters over 12 years, the following recommendations are proposed to maintain appropriate TB control measures in the shelter environment.

Montgomery County Shelter Guidelines Administrative TB

Exposure Plan

The TB exposure determination and procedure for reporting an exposure is as follows:

A person with a cough lasting for more than three weeks in addition to at least two other symptoms such as fevers, night sweats and weight loss must be referred to Stella Akuchie, CHN, Homeless TB Nurse Coordinator by calling (240) 777 - 1832 or 1800 for advice.

All TB suspects or any individual with a cough must be instructed to cover his/her mouth

and nose with a tissue when coughing or cough in their sleeves and must be instructed in the proper disposal of tissues.

Procedure for transferring individuals with suspected TB: The individual with suspected TB may be transported to the nearest hospital by calling

911 services with prior notification of respiratory precautions to ambulance attendees. Procedure for informing employees of exposure if a client or staff member is diagnosed with TB: The TB Control Nurse Administrator will inform the Shelter Administrator of the possibility of any exposure,

work on a plan to inform affected individuals and provide TB screening. Remember the confidentiality of the active case must be maintained as well as the confidentiality of the exposed person.

Provide information and training to employees

Shelter Guidelines – cont. For clients with TB symptoms arrangement must be made to

referred to the TB control clinic immediately. If after hours referred to the Emergency room or to appropriate ventilated housing.

.Shelter staff can admit client with suspected or confirmed TB under the following circumstance: clients who are receiving appropriate anti - tb chemotherapy under Directly Observed Therapy, with laboratory confirmation of negative smears and cultures or with clinical improvement or chest x- ray improvement. In addition client must have appropriate documented clearance from the TB Control Medical Director

Attachment B

Dennis Avenue Health CenterTB Control Program2000 Dennis Ave.Silver Spring, MD 20902240-777-1800

TB Symptom Check List

Date: _______________________

Name of Client: _____________________ ______________________ _____________Last Name First Name Service Point

ID

Current cough for more than 3 weeks? Yes No Are you coughing up blood Yes No Fever or chills for more than 3 weeks? Yes No Do you have night sweats Yes No Unexplained weight loss of 10lbs. or more? Yes No Have you ever been told that you have TB? Yes No Have you ever been treated for TB? Yes No

Anyone with a cough lasting more than 3 more than weeks and answered yes to any of the remaining questions (#2-6) is to be referred to the TB Clinic at Dennis Avenue. Call Dennis Ave. TB Clinic 240-777-1800 for an appointment; complete the TB Control Program Referral Form with this form and provide copies for the client to take with them to their appointment at the Dennis Ave. TB Clinic.

Staff Person: _____________________________ _______________________________Completing First Name Last NameForm

Attachment CDennis Avenue Health CenterTB Control Program2000 Dennis Ave.Silver Spring, MD 20902240-777-1800

TB Screening Referral Form

Date: _________________________Name of Shelter: ____________________________Name of Client: _________________________ _____________________ ______________________

First Name Last Name Service Point IDTB Screening Appointment: _________________________________ ____________________

Date TimeThe above named client is seeking shelter and does not have a current TB clearance on file in ServicePoint. Please

screen this client for TB.

Information about the TB Clinic

Appointments: TB Screenings are by Appointment Only Call 240-777-1800 for an appointmentClinic Hours are Monday thru Friday 8A-12N, closed 12-1P for lunch, 1P-3P except on Wed. 2-3:30P

Location: 2000 Dennis Avenue Silver Spring, MD 20902

Directions: At Georgia Avenue and Dennis Avenue, the Health Clinic is located 2 blocks from the intersection, on Dennis Avenue on the right

Metro Bus lines Y7, Y8 and Q2 all stop at Georgia Avenue and Dennis AvenueTake this Referral Sheet to your appointmentTB Screenings must be completed within 4 days of admission to the shelter

Attachment A

HHS ContactsDennis Avenue Health Center (DAHC)2000 Dennis AvenueSilver Spring, MD 20902Yvonne Richards, RN, Manager, TB Outreach and Case Management 240-777-1798Cindy Edwards, RN, MHCA, Manager, Disease Control Program240-777-1024Health Care for Homeless (HCH)11 North Washington StRockville, MD 20850Ellen Brown, RN, LCSW-C, Manager, Health Care for the Homeless 240-777-3963 office 240-370-7717 cellVacant Position, Nurse Case Manager HCH240-777-XXXX officeSpecial Needs Housing HomelessServices - 1301 Piccard DriveRockville, MD 20851Kim Ball HHS Special Needs HousingAdministrator, Homeless Services 240-777-4125 office, 240-372-8451 cellTanya Jones LCSW-C, Shelter Coordinator for Single Adults240-777-4151