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Title


Division of Community and Public Health Section: Appendices
Subsection: Table of Contents APPENDICES
Sample Forms (click on link in each title)
4.01
Missouri Department of Health and Senior Services
Tuberculosis Case Management Manual


Division of Community and Public Health Section: Appendices
Subsection: Table of Contents Missouri Department of Health and Senior Services
Tuberculosis Case Management Manual


Division of Community and Public Health Section: Appendices
Appendix: 1.01 Missouri Statutes and Regulations Concerning Missouri Statutes and Regulations Concerning Tuberculosis

Click on the link after the title of the statute to access the complete text from the Revised Statues
of the State of Missouri
on the Missouri General Assembly's internet site.
Contagious Diseases Excluded from School (RSMo 167.191)

Commitment and Hospitalization of Tuberculosis Patients - Rehabilitation-Head Injury-
TB Testing

Definitions (RSMo 199.170 – 199.350) Local health agency may institute proceedings for commitment (RSMo 199.180) Patients not to be committed when (RSMo 199.190) Procedure in circuit court--duties of local prosecuting officers--costs (RSMo 199.200) Rights of Patient, witnesses--order of course--transportation costs (RSMo 199.210) Order appealable (RSMo 199.220) Confinement on order, duration (RSMo 199.230) Consent required for medical or surgical treatment (RSMo 199.240) Facilities to provided--costs, how paid (RSMo 199.250) Apprehension and return of patient leaving rehabilitation center without discharge (RSMo 199.260) Proceedings for release of patient (RSMo 199.270) Tuberculosis Screening for Residents and Workers in Nursing Homes (RSMo 199.350) Missouri Department of Health and Senior Services
Tuberculosis Case Management Manual


Division of Community and Public Health Section: Appendices
Appendix: 1.02 Missouri Statutes and Regulations Concerning Tuberculosis Missouri Regulations Concerning Tuberculosis
The Code of State Regulations, or rules, is available on the Missouri Secretary of State's web site in PDF format. Regulations are organized by title, division, chapter, and section. For example, 19 CSR 20-20.020 refers to Title 19, Division 20, Chapter 20, Section 020. The links that follow take the user to the appropriate division and chapter of the regulations. Scroll to the specific section number. 19 CSR 20-20.010 Definitions Relating to Communicable, Environmental and Occupational 19 CSR 20-20.020 Communicable, Environmental and Occupational Diseases 19 CSR 20-20.030 Exclusion from School and Readmission 19 CSR 20-20.040 Measure for the control of Communicable, Environmental and Occupational 19 CSR 20.20.050 Quarantine or Isolation Practices and Closing of Schools and Places of Public and Private Assembly 19 CSR 20.20.070 Duties of Local Health Departments 19 CSR 20-20.080 Duties of Laboratories 19 CSR 20.20.090 Contact with Communicable Diseases by First Responders or Emergency Medical Persons and Mortuary Personnel 19 CSR 20.20.100 Tuberculosis Testing for Residents and Workers in Long-Term Care Facilities
and State Correctional Centers

Chapter 61--Licensing Rules for Family Day Care Homes
19 CSR 30-61.010 Definitions
19 CSR 30-61.125 Medical Examination Reports

Chapter 62--Licensing Rules for Group Day Care Homes and Child Day Care Centers
19 CSR 30-62.010 Definitions 19 CSR 30-62.122 Medical Examination Reports Missouri Department of Health and Senior Services
Tuberculosis Case Management Manual


Division of Community and Public Health Section: Appendices
Appendix: 1.02 Missouri Statutes and Regulations Concerning Tuberculosis Missouri Department of Health and Senior Services
Tuberculosis Case Management Manual


Division of Community and Public Health Section: Appendices
Subsection: 2.01 Educational Materials Educational Materials
Ordering Educational Materials A list of educational materials that may be ordered through the Section for Disease Prevention, Bureau of Communicable Disease Control and Prevention follows. To place an order, call the Bureau at (573) 751-6113. For more information on how to order literature from the Department of Health and Senior Services warehouse, glick on Applications and Forms, and then click on Literature Order Form. CDC Educational Material and Internet Resources
The CDC has prepared a useful list of education resources. You can access it at Missouri Department of Health and Senior Services
Tuberculosis Case Management Manual


Division of Community and Public Health Section: Appendices
Subsection: 2.02 Medication Fact Sheet – Isoniazid (INH) Educational Material
Medication Fact Sheet - Isoniazid (INH) It is important to take this medication for the full time of treatment. It is important that you do not miss any doses. If you do miss a dose, take it as soon as possible. However, if it is almost time for your next dose, skip the missed dose and go back to your regular schedule. DO NOT double dose. To store medication:  Keep out of the reach of children  Store away from heat and direct light.  Do not store in the bathroom, near the kitchen sink, or in damp places. Heat or moisture may cause the medicine to break down. How to take this medication:  Take on an empty stomach with a glass of water.  The tablet may be crushed in applesauce.  Do not drink alcohol of any type, including wine or beer.  Do not take antacids one hour before or after taking INH. Tell your doctor, nurse or pharmacist if you take ANY other medication; especially medication for seizures. Possible drug effects: Tiredness Change in color of urine or stool Tingling or numbness of fingers or toes Loss of appetite Yellow skin or eyes The information on the action and possible side effects of this medication prescribed by the doctor has been explained to me and I understand. I will call the doctor or nurse if I have any questions or symptoms. Name: _ Date: _ Witness: Missouri Department of Health and Senior Services
Tuberculosis Case Management Manual


Division of Community and Public Health Section: Appendices
Subsection: 2.02 Medication Fact Sheet – Isoniazid (INH) What Should I Avoid While Taking Isoniazid?
Avoid alcohol while taking isoniazid. Alcohol will increase the risk of damage to the liver during treatment with this medication. Use caution with the foods listed below. They can interact with isoniazid and cause a reaction that includes a severe headache, large pupils, neck stiffness, nausea, vomiting, diarrhea, flushing, sweating, itching, irregular heartbeats, and chest pain. A reaction will not necessarily occur, but eat these foods with caution until you know if you will react to them. Call your doctor immediately if you experience any of these symptoms. Eat the following foods with caution:  cheeses, including American, Blue, Boursault, Brick, Brie, Camembert, Cheddar, Emmenthaler, Gruyere, Mozzarella, Parmesan, Romano, Roquefort, Stilton, and Swiss;  sour cream and yogurt;  beef or chicken liver, fish, meats prepared with tenderizer, bologna, pepperoni, salami, summer sausage, game meat, meat extracts, caviar, dried fish, herring, shrimp paste, and tuna;  avocados, bananas, figs, raisins, and sauerkraut;  soy sauce, miso soup, bean curd, and fava beans;  yeast extracts;  caffeine (coffee, tea, cola, etc.); and  beer (alcoholic and nonalcoholic), red wine (especially Chianti), sherry, vermouth, and other distilled spirits. Missouri Department of Health and Senior Services
Tuberculosis Case Management Manual
Division of Community and Public Health Section: Appendices
Subsection: 2.03 Medication Fact Sheet – Rifampin (RIF) Medication Fact Sheet - Rifampin
It is important to take this medication for the full time of treatment, even if you begin to feel better after a few weeks. It is important that you do not miss any doses. If you do miss a dose, take it as soon as possible. However, if it is almost time for your next dose, skip the missed dose and go back to your regular schedule. DO NOT double dose. To store medication:  Keep out of the reach of children  Store away from heat and direct light.  Do not store in the bathroom, near the kitchen sink, or in damp places. Heat or moisture may cause the medicine to break down.
How to take this medication:
 Take on an empty stomach with a glass of water.
 If stomach irritation occurs, take with food.
This drug will turn your urine, stool, sputum, and tears orange and can stain contact lenses. Tell
your doctor, nurse, or pharmacist if you are taking ANY medications, even drugs you can buy
without a prescription. In particular tell them if you take birth control pills, Coumadin, warfarin,
theophylline, methadone, Dilantin, digoxin, or medicine for HIV infection, seizures or heart
problems.
Possible drug effects:
Tiredness
Yellow skin or eyes Bone or muscle pain Loss of appetite The information on the action and possible side effects of this medication prescribed by the doctor has been explained to me and I understand. I will call the doctor or nurse if I have any questions or symptoms. Missouri Department of Health and Senior Services
Tuberculosis Case Management Manual
Division of Community and Public Health Section: Appendices
Subsection: 2.04 Medication Fact Sheet – Pyrazinamide (PZA) Medication Fact Sheet - Pyrazinamide (PZA)
It is important to take this medication for the full time of treatment, even if you begin to feel better after a few weeks. It is important that you do not miss any doses. If you do miss a dose, take it as soon as possible. However, if it is almost time for your next dose, skip the missed dose and go back to your regular schedule. DO NOT double dose. To store medication:  Keep out of the reach of children  Store away from heat and direct light.  Do not store in the bathroom, near the kitchen sink, or in damp places. Heat or moisture may cause the medicine to break down. How to take this medication:  It is okay to take PZA with food. Tell your doctor, nurse, or pharmacist if you are taking ANY medications, even drugs you can buy without a prescription. If you are diabetic, check with your doctor before changing your diet or dose of medication for diabetes. PZA may cause false positive results with urine ketone test. Possible drug effects: Tiredness Yellow skin or eyes Change in color of urine or stool Loss of appetite Joint pains, especially in the big toe The information on the action and possible side effects of this medication prescribed by the doctor has been explained to me and I understand. I will call the doctor or nurse if I have any questions or symptoms. Missouri Department of Health and Senior Services
Tuberculosis Case Management Manual
Division of Community and Public Health Section: Appendices
Subsection: 2.05 Medication Fact Sheet – Ethambutol (Myambutol) Medication Fact Sheet - Ethambutol (Myambutol)
It is important to take this medication for the full time of treatment, even if you begin to feel better after a few weeks. It is important that you do not miss any doses. If you do miss a dose, take it as soon as possible. However, if it is almost time for your next dose, skip the missed dose and go back to your regular schedule. DO NOT double dose. To store medication:  Keep out of the reach of children  Store away from heat and direct light.  Do not store in the bathroom, near the kitchen sink, or in damp places. Heat or moisture may cause the medicine to break down. How to take this medication:  It is okay to take ethambutol with food. Tell your doctor, nurse or pharmacist if you take ANY other medication; especially medication for seizures. Possible drug effects: Weakness Yellow skin or eyes Change in color of urine or stool Light headedness Loss of appetite The information on the action and possible side effects of this medication prescribed by the doctor has been explained to me and I understand. I will call the doctor or nurse if I have any questions or symptoms. Missouri Department of Health and Senior Services
Tuberculosis Case Management Manual
Division of Community and Public Health Section: Appendices
Subsection: 2.06 Medication Fact Sheet – Pyriodoxine (B6) Medication Fact Sheet – Pyriodoxine (B6)

Other NAMES: Vitamin B6
It is important to take this medication for the full time of treatment, even if you begin to feel
better after a few weeks. It is important that you do not miss any doses. If you do miss a dose,
take it as soon as possible. However, if it is almost time for your next dose, skip the missed dose
and go back to your regular schedule. DO NOT double dose.
To store medication:
 Keep out of the reach of children  Store away from heat and direct light  Store stored in a cool (15-30°C) dry place in a tightly-closed container
How to take this medication:
 Take with a glass of water  The tablet may be crushed in applesauce  Some medicines or medical conditions may interact or decrease the effectiveness of some drugs with this medicine  Do not take large doses of vitamins (megadoses or megavitamin therapy) while taking  If stomach irritation occurs take with food.
Tell your doctor, nurse or pharmacist if you take ANY other medication; especially medication
for Parkinson's disease, seizures and or arthritis.
Possible side effects of medication:
Nausea
Tingling or numbness of the skin Trouble breathing If you experience any adverse effects from this medication, stop taking the medication immediately and notify your physician and/or your medical provider. Seek emergency help if you have any signs of an allergic reaction: hives, difficulty breathing, and swelling of the face, lips, tongue, or throat. The possible side effects of this medication prescribed by the doctor, has been explained to me and I understand. I will call the doctor or nurse immediately if I have any questions or symptoms. Name: _ Date: _ Witness: Missouri Department of Health and Senior Services
Tuberculosis Case Management Manual
Division of Community and Public Health Section: Appendices
Subsection: 2.07 Medication Fact Sheet – Rifapentine Medication Fact Sheet - Rifapentine
It is important to take this medication for the full time of treatment, even if you begin to feel better after a few weeks. It is important that you do not miss any doses. If you do miss a dose, take it as soon as possible. However, if it is almost time for your next dose, skip the missed dose and go back to your regular schedule. DO NOT double dose. To store medication:
 Keep out of the reach of children  Store away from heat and direct light  Do not store in the bathroom, near the kitchen sink, or in damp places. Heat or moisture may cause the medicine to break down.
How to take this medication:
 Take on an empty stomach with a glass of water  If stomach irritation occurs, take with food.
This drug will turn your urine, stool, sputum, and tears orange and can stain contact lenses and
dentures. Tell your doctor, nurse, or pharmacist if you are taking ANY medications, even drugs
you can buy without a prescription. In particular tell them if you take birth control pills,
Coumadin, Warfarin, Theophylline, Methadone, Dilantin, Digoxin, or medicine for HIV,
seizures, or heart conditions, and or arthritis. Before taking rifapentine, tell your doctor if you
have porphyria. (INH/Rifapentine 12-Dose Medication Authorization Form - see the TB Manual;
Appendices/Sample Forms located at:

Possible side effects of medication:
Tiredness
Yellow skin or eyes Bone or muscle pain Loss of appetite Easy Bleeding or Bruising The possible side effects of this medication prescribed by the doctor, has been explained to me and I understand. I will call the doctor or nurse immediately if I have any questions or symptoms. Missouri Department of Health and Senior Services
Tuberculosis Case Management Manual
Division of Community and Public Health Section: Appendices
Subsection: 2.08 Medication Fact Sheet – Levofloxacin Medication Fact Sheet - Levofloxacin

It is important to take this medication for the full time of treatment. It is important that you do
not miss any doses. If you do miss a dose, take it as soon as possible. However, if it is almost
time for your next dose, skip the missed dose and go back to your regular schedule. DO NOT
double dose.
To store medication:
 Keep out of the reach of children  Store at room temperature  Do not store in the bathroom, near the kitchen sink or in damp places. How to take this medication:  Do not take within two hours of indgestion of milk-based products, antacids, or taking iron, magnesium, calcium, zinc, vitamins, didanosine, sucralfate.  Avoid caffeinated foods and beverages.  May take with food.  Drink plenty of beverages.  May cause sun sensitivity; use sun screen Tell your doctor if you have any renal disease. Possible drug effects:  Pain, swelling, or tearing of the tendon (such as the back of your ankle, elbow), or muscle  Rashes or hives  Bruising or blistering  Trouble breathing or tightness in your chest  Diarrhea  Yellow skin or eyes  Anxiety, confusion, or dizziness The information on the action and possible side effects of this medication prescribed by the doctor has been explained to me and I understand. I will call the doctor or nurse if I have any questions or symptoms. Name: Missouri Department of Health and Senior Services
Tuberculosis Case Management Manual
Division of Community and Public Health Section: Appendices
Subsection: 2.09 Medication Fact Sheet –Streptomycin Medication Fact Sheet - Streptomycin
It is important to take this medication for the full time of treatment. If is important that you do not miss any doses. If you do miss a dose, take it as soon as possible. However, if it is almost time for your next dose, skin the missed dose and go back to your regular schedule. DO NOT double dose. To store medication:  Store in refrigerator Injection sites should be rotated for maximum absorption Possible drug effects  Problems with hearing, dizziness, or balance  Rash or swelling of your face  Trouble breathing  Decreased urination  Watery or bloody diarrhea  Increased swelling, pain, or redness at injection site  Muscle twitching or weakness The information on the action and possible side effects of this medication prescribed by the doctor has been explained to me and I understand. I will call the doctor or nurse if I have any questions or symptoms. Name: Missouri Department of Health and Senior Services
Tuberculosis Case Management Manual
Division of Community and Public Health Section: Appendices
Services
Subsection: 2.10 Tuberculosis Control Fact Sheet TUBERCULOSIS CONTROL FACT SHEET

Reporting
Ac tive tuberculosis disease or disease suspect – Report within 24 hours to your local public
health agency or to the Missouri Department of Health and Senior Services at (573) 751-6113 or
(866) 628-9891. Tuberculosis infection/Other mycobacterial diseases – Report within three days
to your local public health agency or the Missouri Department of Health and Senior Services at
(573) 751-6113 or (866-628-9891).

PROMPT REPORTING TRIGGERS THE FOLLOWING SERVICES AS NEEDED AT NO
COST TO THE PATIENT:

Medications
Routine anti-tuberculosis antibiotics including Isoniazid, Rifampin, Pyrazinamide, Ethambutol,
Streptomycin, Rifapentine, and Vitamin B6 are provided through the local public health agency
via contract with Preferred Pharmacy Services. Other second-line drugs may also be available.

Lab Services
The state tuberculosis laboratory is in Jefferson City, Missouri and is one of the best TB labs in
the country. Diagnostic and routine laboratory services may be available through the patient's
local public health agency, (e.g. liver enzymes, PPDs).

Contact Investigations and Case Management
Local public health agencies have community health nurses trained to conduct contact
investigations of communicable disease, including tuberculosis. A report of a suspect TB case
will trigger a contact investigation and 3-month follow-up.
Tuberculosis disease and infection cases may be managed through local public health agency.
Management includes monthly physical assessment, liver enzyme monitoring, sputum sampling,
directly observed therapy (the standard of care for all TB cases), and patient education.
Missouri Department of Health and Senior Services
Tuberculosis Case Management Manual
Division of Community and Public Health Section: Appendices
Subsection: 2.10 Tuberculosis Control Fact Sheet
Consultation

The Tuberculosis Control Program employs staff that oversees case management of all active
disease cases and suspects in Missouri. They are current on tuberculosis prevention, treatment
and control and are available for consultation as needed. Medical consultation by Dr. Dennis
Pyszczynski is also available on an as needed basis. Contact the Program at (573) 751-6113 to access consultation services.
Other Services
Diagnostic Services Program
pays for office visits and chest x-rays for those TB infection and
disease patients with no health insurance.
Incentive Program helps ensure compliance with low-income patients. Incentives include
expenses such as cab fare or bus tokens. Incentive funds are available through your local public
health agency.
Geo-Care – Geo-Care maintains a wing for state-of-the-art care and isolation of tuberculosis
patients. Geo-Care is located in Columbia, South Carolina. GEO-Care only receives those TB
patients that are most difficult to treat or non-compliant with their treatment.
Resources – The Tuberculosis Control Program houses a library with the latest treatment
information for tuberculosis and other mycobacterial diseases. CDC, ALA, American Thoracic
Society and other publications, videotapes and guidelines regarding the treatment of TB disease
and infection are available upon request.
We view TB control as a team approach. One person cannot do it alone, but one person can
make a difference. We need your help if we are to reach our goal of eliminating TB in Missouri.
TUBERCULOSIS C
ONTROL PROGRAM
PHONE: (573) 751-6113
FAX: (573) 526-0235
Missouri Department of Health and Senior Services
Tuberculosis Case Management Manual
Division of Community and Public Health Section: Appendices
Appendix: 3.01 Tuberculosis Forms and Documentation Tuberculosis Forms and Documentation

The following forms can be found in the Missouri Department of Health and Senior
Services Tuberculosis Case Management Manual Section
Appendices/ "Sample Forms"
The TB Case Management manual can be found at:


Required Forms:
LTBI:

 TBC-4 (TB Testing Record) preferably or CD-1 (Disease Case Report). If entered into WebSurv please do not fax. If not entered in WebSurv, please fax to David Oeser, 573-  TBC-2 Refusal of Tuberculosis Therapy (Only required if patient refuses to take treatment, please keep in patient record)  Isoniazid/Rifapentine (12-dose) Tuberculosis Medication Eligibility/Authorization Form (Only completed and faxed if requesting approval for the 12-dose regimen medication.) TB Disease:

 CD-1 (Disease Case Report)
 TBC-10 (TB History Form) please put patient's current weight on form.
 Tuberculosis Patient Responsibilities Notification
(located in the Court Force Handbook section of the TB Manual located at: It is highly recommended that this form be reviewed with the patient and signed at the beginning of treatment for all active tuberculosis cases and kept in the patient's record)  TBC-13 (Worksheet for Contacts) please fax at the beginning of the contact investigation and at completion, as well as when there are any new contacts added to the form.  Cohort Review Form (This form should be started as soon as you receive an active TB case. It will be requested from David Oeser when it is time for the case to be cohorted.) Please fax the above forms to David Oeser at 573-526-0235, unless otherwise indicated.
Required Documentation:

 CXR results (Cat Scan results if done)  Lab results (biopsy, sputum, etc.) Missouri Department of Health and Senior Services
Tuberculosis Case Management Manual
Division of Community and Public Health Section: Appendices
Appendix: 3.01 Tuberculosis Forms and Documentation  List of TB Meds (name of meds, doses, how often given, please resubmit if any changes  History and Physical (if patient is in the hospital)  Monthly DOT sheets (please fax on a monthly basis) Please fax the above documentation to Traci Hadley at 417-629-3477.

Additional Forms (keep in patient's record):

 TBC -8 (TB Medication Request Form) If patient has private insurance, Medicaid or Medicare, please complete the insurance portion on the form.  TBC-DSP: Only completed if patient has no insurance and no means to pay for services. Please complete and fax to Lisa Branson at 573-526-0234. Liver Function Tests (LFTs) are only approved for patients currently taking TB medications and having symptoms of possible hepatotoxicity. If patient has other medical issues and needs LFTs drawn, please call Traci Hadley at 417-629-3487 for approval.  TBC-15A (TB Case Register Card)  TBC-16 (Tuberculosis Medication Record)  Checklist for Active Tuberculosis (very helpful when following an active TB case)  Progress Notes  Tuberculosis Signs and Symptoms Checklist (All LTBI and TB Disease cases need to be assessed for signs and symptoms.) Helpful TB web addresses:

 Centers for Disease Control and Prevention/Tuberculosis  Centers for Disease Control and Prevention/5th edition of the Core Curriculum on Tuberculosis: What the Clinician Should Know  MMWR: Treatment of Tuberculosis, June 20, 2003/Vol. 52/No. RR-11 Missouri Department of Health and Senior Services
Tuberculosis Case Management Manual
Division of Community and Public Health Section: Appendices
Appendix: 3.02 Urine Chart URINE
COLOR
CHART


DRAW
LFT'S

Missouri Department of Health and Senior Services
Tuberculosis Case Management Manual
Division of Community and Public Health Section: Appendices
Appendix: 3.03 Checklist for Latent TB Infection Cases Checklist for Latent TB Infection Cases
INITIAL WORKUP:
NOT APPLICABLE
Front side TBC-4 completed and entered in WebSurv Release of information signed Verbal/Written educational material given in client's primary language, if available Chest x-ray results obtained TB signs/symptoms checklist reviewed Liver function tests results obtained, if indicated Prescriptions obtained, faxed to the Contract Pharmacy and mail original Front side TBC-4 sent to DHSS TB Program and entered into WebSurv
DURING TREATMENT:

Checklist completed LFT if indicated Entered visit WebSurv Encounter page
COMPLETION OF TREATMENT:

Completion letter to client TBC- 4 sent to DHSS TB Program and entered in WebSurv Missouri Department of Health and Senior Services
Tuberculosis Case Management Manual
Division of Community and Public Health Section: Appendices
Appendix: 3.03 Checklist for Latent TB Infection Cases Missouri Department of Health and Senior Services
Tuberculosis Case Management Manual
Division of Community and Public Health Section: Appendices
Appendix: 3.04 Tuberculosis Signs/Symptoms Checklist
DSP Provider List
Last updated 11/13/15
Phone: (816) 232-6818 ANDREW COUNTY
Fax: (816) 232-6823 Savannah Medical Clinic Northwest Health Services, Inc. Social Welfare Board 803 Highway 71 West Robert R. Stuber, MD Savannah, MO 64485 904 S. 10th, Suite A Phone: (816) 324-3121 St. Joseph, MO 64503 Fax: (816) 324-3122 Phone: (816) 344-5201 Fax (816) 233-5296 BARRY COUNTY
(Contact Linda Judah at number above for
Cox Monett Hospital 801 N Lincoln Ave Monett, MO 65708 Heartland Adult Infectious Disease Phone: 417-235-3144 901 Heartland Road, Suite 4840 St. Joseph, MO 64506 BENTON COUNTY
Phone: (816) 271-1346 Warsaw Family Clinic Fax: (816) 271-1344 1320 Commercial, PO Box 908 (Sarah Vinzant Clinic Manager)
Warsaw, MO 65355 Phone (660) 438-5193 North End Health Center Fax (660) 438-3091 Northwest Health Services, Inc. 1515 St. Joseph Avenue BOLLINGER COUNTY
St. Joseph, MO 64505 Cross Trails Medical Center Phone: (816) 233-3338 (Affiliated w/Bollinger, Cape, & Perry Locations)
109 Highway 51 North, P.O. Box 349 South Side Health Center Marble Hill, MO 63764 Northwest Health Services, Inc. Phone: (573) 238-2725 5001 Lake Avenue FAX: (573) 238-3795 St. Joseph, MO 64504 BOONE COUNTY
Columbia/Boone County Health Dept BUTLER COUNTY
Columbia, MO 65205 1919 Big Bend Road Phone: (573) 874-7345 Poplar Bluff, MO 63901 FAX: (573) 499-0596 Phone: (573) 686-7223 FAX: (573) 686-7224 Advanced Radiology 311 Keene Street Columbia, MO 65201-6625 686 Lester Street, P.O. Box 220 Phone: (573) 442-1788 Poplar Bluff, MO 63902-0220 BUCHANAN COUNTY
Family Medicine Associates FAX: (573) 686-8452 Northwest Health Services, Inc. 2303 Village Drive Missouri Highlands Medical Clinic St. Joseph, MO 64506 Dr. Richard Hester; Lisa Hampton, FNP Missouri Department of Health and Senior Services
Tuberculosis Case Management Manual
Division of Community and Public Health Section: Appendices
Appendix: 3.04 Tuberculosis Signs/Symptoms Checklist Poplar Bluff Medical Park Condominium CARTER COUNTY
225 Physicians Park Dr., Suite 303 Big Springs Medical Clinic Poplar Bluff, MO 63901 Dr. Michael Moore; Michelle Burnham, FNP Phone: (573) 785-6536 Fax: (573) 785-0345 Van Buren, MO 63965 Phone: (573) 323-4253 CALLAWAY COUNTY
FAX: (573) 323-4465 Callaway Physicians 110 North Hospital Drive CEDAR COUNTY
Fulton, MO 65251 Cedar County Memorial Hospital Phone: (573) 642-5911 Medical Mall Clinic FAX: (573) 642-0358 1401 South Park Street (NO X-RAYS)
El Dorado Springs, MO 64744 Phone: (417) 876-2511 CALDWELL COUNTY
Hamilton Medical Clinic CLAY COUNTY
One Cross Street, PO Box 248 Samuel U Rodgers Health Center Hamilton, MO 64644 Phone: (816) 583-2713 or 816-583-2151 Liberty, MO 64068 Fax: (816) 583-2342 Phone: (816) 413-0662 (For appointments call: Jody Light with Clay
County Public Health Center – (816)-595-4255)
109 Main, PO Box 36 Braymer, MO 64624 COLE COUNTY
Phone: (660) 645-2218 Capital City Medical Associates: Fax: (660) 645-2820 Gracia Nabhane, MD 1505 Southwest Blvd. CAMDEN COUNTY
Jefferson City, MO 65109 Phone: (573) 634-2620 Lake Regional Clinic FAX: (573) 635-4787 1930 North State Hwy 5, Unit 1A Camdenton, MO 65020 Capital Region Physicians Phone: (573) 346-5624 1532 Southwest Boulevard FAX: (573) 346-1957 Jefferson City, MO 65109 (Camden County Patients Only)
Phone: (573) 632-5583 CAPE GIRARDEAU COUNTY
Lorenzo McKnelly, DO {2005-24}
Cape Girardeau County Public Health Mid MO Medical Consultants 1111 Madison Street Cape Girardeau, MO 63703 Jefferson City, MO 65101 Phone: (573) 335-7846 Phone: (573) 635-7651 FAX: (573) 335-5909 FAX: (573) 659-4515 Cross Trails Medical Center Com. Health Center of Central MO (Affiliated w/Bollinger, Cape, & Perry Locations)
(Main Office – Osage County Satellite Office)
408 S. Broadview 3400 W. Truman Blvd. Cape Girardeau, MO 63703 Jefferson City, MO 65109 Phone: (573) 332-0808 Phone: (573) 632-2777 Fax: (573) 632-2769 Missouri Department of Health and Senior Services
Tuberculosis Case Management Manual
Division of Community and Public Health Section: Appendices
Appendix: 3.04 Tuberculosis Signs/Symptoms Checklist
FRANKLIN COUNTY
514 State Street, PO Box 188 Mercy Clinic – Pulmonology/Sleep Medicine Mound City, MO 64470 Dr. Adeel Khan & Dr. Umer Siddigui Phone: (660) 442-5313 901 Patients First Drive Fax: (660) 442-5413 Washington, MO 63090 (NO X-RAYS)
Phone: (636-239-8832 FAX: (636) 239-8911 Mound City Medical Clinic Northwest Health Services GREENE COUNTY
502 State Street John R. Carlile, MD (Pediatric) Mound City, MO 64470 3443 South National Phone: (660) 442-5464 Springfield, MO 65807 Phone: (417) 269-4850 HOWARD COUNTY
FAX: (417) 269-4852 Fayette Medical Clinic 308 South Church GENTRY COUNTY
Fayette, MO 65248 King City Clinic Phone: (660) 248-2217 Northwest Health Services, Inc FAX: (660) 248-3450 605 Rhode Island, PO Box 278 King City, MO 64463 HOWELL COUNTY
Phone: (660) 535-4347 Burton Creek Rural Clinic Fax: (660) 535-6240 805 Kentucky Ave West Plains, MO 65775 HARRISON COUNTY
Phone: (417) 256-2111 Cainsville Medical Clinic 707 Victory Lane, PO Box 136 West Plains Imaging Cainsville, MO 64632 Phone: (660) 893-5750 West Plains, MO 65775 Fax: (660) 893-5751 Phone: (417) 257-7451 (NO X-RAYS)
IRON COUNTY
HENRY COUNTY
Viburnum Medical Clinic Golden Valley Medical Clinic Sharon Ann Payne, FNP 1602 North 2nd Street 18 Viburnum Center Rd. Clinton, MO 64735 Viburnum, MO 65566 Phone: (660) 890-8429 Phone: (573) 244-5406 (For Appointments Call: Quinten Harrison at
Fax: (573) 244-5590 number above)
Iron County Medical Clinic HOLT COUNTY
Mary Jarrells, FNP Northwest Health Services, Inc. Pilot Knob, MO 63663 401 East Nodaway, PO Box 169 Phone: (573) 546-0602 Oregon, MO 64473 Fax: (573) 546-0624 Phone: (660) 446-3307 Fax: (660) 446-3302 Annapolis Family Clinic Judith Medley, FNP Mound City Medical Clinic (Annex) 202 Allen St. Annapolis, MO 63620 Northwest Health Services Phone: (573) 598-4213 Missouri Department of Health and Senior Services
Tuberculosis Case Management Manual
Division of Community and Public Health Section: Appendices
Appendix: 3.04 Tuberculosis Signs/Symptoms Checklist Fax: (573) 598-4602 LAWRENCE COUNTY
Mt Vernon Clinic JACKSON COUNTY
Cheryl Williams, D.O. Truman Medical Center Lakewood 1011 S East Street 7900 Lee's Summit Road Mt.Vernon, MO 65712 Kansas City, MO 64139 Phone: (417) 466-7191 Phone: 816-404-7678 (no voice mail); Fax: 816-404-7721 LEWIS COUNTY
(For Appointments Call: Clare Powelson,
Lewistown Affiliates of Quincy Med Grp Scheduling Manager for the Disease Clinic and fax
105 Quincy, P.O. Box 98 DSP Diagnostic Form to Faye Orlovick at:
Lewistown, MO 63452 (816) 922-8952)
Phone: (573) 215-2715 FAX: (573) 497-2322 JASPER COUNTY
Sitaraman Subramanian, MD LINCOLN COUNTY
Troy Family Practice Carthage, MO 64836 900 East Cherry Street, P.O. Box 249 Phone: (417) 358-8900 FAX: (417) 358-8909 Phone: (636) 528-6755 FAX: (636) 528-6965 Jasper County Health Department Debra Royce, M.D. Troy Surgical Center & Family Care 105 Lincoln Street Carthage, MO 64836 Phone: (417) 358-3111 Phone: (636) 528-8585 FAX: (417) 358-0494 MACON COUNTY
JEFFERSON COUNTY
Jim L. DeLine, M.D. Jefferson County Health Department 307 McKay Street Chandra Babu Dommaraju, M.D. 405 Second Street, P.O. Box 437 Phone: (660) 385-3141 Hillsboro, MO 63050 FAX: (660) 385-5866 Phone: (636) 789-3372 FAX: (636) 797-4631 MADISON COUNTY
Madison Medical Center JOHNSON COUNTY
611 West Main Street Western Missouri Medical Center 403 Burkarth Road Fredericktown, MO 63645 Warrensburg, MO 64093 Phone: (573) 783-3341 Phone: (660) 747-2500 FAX: (660) 747-7006 MARION COUNTY
Central Family Medicine, Inc. 407 East Russell, Building C Warrensburg, MO 64093 Hannibal, MO 63401 Phone: (660) 747-5114 Phone; (573) 231-3149 FAX: (660) 747-5684 Missouri Department of Health and Senior Services
Tuberculosis Case Management Manual
Division of Community and Public Health Section: Appendices
Appendix: 3.04 Tuberculosis Signs/Symptoms Checklist Stephen Halpin, MD Phone: (573) 564-2101 FAX: (573) 564-2130 100 Medical Drive Associated Medical Arts Hannibal, MO 63401 504 North Sturgeon Street Phone: (573) 231-3120 Montgomery City, MO 63361 Phone: (573) 564-2990 MCDONALD COUNTY
FAX: (573) 564-2963 Anderson Rural Health Clinic Elk River Health Systems NEW MADRID COUNTY
P.O. Box 750, 210 Main Dr. Theerawat Pattaropong Anderson, MO 64831 Phone: (417) 845-6984 FAX: (417) 845-6976 New Madrid, MO 63869 (NO X-RAYS)
Phone: (573) 748-2546 Goodman Family Clinic OREGON COUNTY
Elk River Health Systems Ozark Medical Center of Alton 125 East Main Street, PO Box 97 Goodman, MO 64843 Phone: (417) 364-8300 Phone: (417) 778-7225 FAX: (417) 364-7290 (NO X-RAYS)
OSAGE COUNTY
Com. Health Center of Central MO South West Community Clinic (Satellite Office – Cole County Main Office)
Elk River Health Systems P.O. Box 160, 109 N. Broadway 1016 E. Main St. South West, MO 64863 Phone: (417) 762-3287 Phone: 573-897-4946 FAX: (417) 762-3255 Fax: 573-897-4941 Pineville Medical PERRY COUNTY
Cross Trails Medical Center Elk River Health Systems (Affiliated w/Bollinger, Cape, & Perry Locations)
Pineville, MO 64856 1314 Brenda Avenue Phone: (417) 223-4290 Perryville, MO 63775 (NO X-RAYS)
Phone: (573)517-0405 Fax: (573) 517-0420 MILLER COUNTY
Benny Earl Thomas, DO PETTIS COUNTY
Highway 17 North, Box 207 Sedalia Internal Medicine Specialists Iberia, MO 65486 1712 South Lafayette Phone: (573) 793-2591 Sedalia, MO 65301 Phone: (660) 827-2526 MONTGOMERY COUNTY
FAX: (660) 827-5536 Montgomery City Medical Clinic I. Jeffrey Cramp, D.O. PHELPS COUNTY
240 North Pickering Rolla Family Clinic Montgomery City, MO 63361 1060 South Bishop Avenue Missouri Department of Health and Senior Services
Tuberculosis Case Management Manual
Division of Community and Public Health Section: Appendices
Appendix: 3.04 Tuberculosis Signs/Symptoms Checklist Rolla, MO 65401 Marsha Shively, FNP Phone: (573) 426-5900 220 E. Broad St. Fax: (573) 426-4466 Naylor, MO 63953 Phone: (573) 399-2311 PIKE COUNTY
Fax: (573) 399-2646 Eastern Missouri Health Services SALINE COUNTY
Louisiana, MO 63353 Saline County Health Department {2005-71}
Phone: (573) 754-4584 1825 S. Atchinson Ave. Marshall, MO 65340 POLK COUNTY
Phone: (660) 886-3434 Citizens Memorial Hospital 1500 North Oakland Grand River Medical Clinic Bolivar, Mo 65613 2305 S. 65 Highway Phone: (417) 326-6000 Marshall, MO 65340 Phone: (660) 668-7800 Polk County Health Department Wanita Lister, Family Nurse Practitioner SCOTT COUNTY
1317 West Broadway Missouri Delta Medical Center Bolivar, MO 65613 Phone: (417) 326-7250 Sikeston, MO 63801 Phone: (573) 471-1600 PULASKI COUNTY
Benny Earl Thomas, DO SHANNON COUNTY
108 Commercial, P.O. Box 516 Shannon County Family Clinic Crocker, MO 65452 Susan Norris, FNP Phone: (573) 736-2422 1003 S. Main St. Eminence, MO 65466 Benny Earl Thomas, DO Phone: (573) 226-5505 #1 Locust, Box O Fax: (573) 226-5584 Phone: (573) 759-7141 ST. CHARLES COUNTY
Midwest Chest Consultants Benny Earl Thomas, DO 330 First Capitol Drive, Suite 470 215 North Street, Box 4503 St. Charles, MO 63301 Waynesville, MO 65583 Phone: (636) 946-1650 Phone: (573) 774-6279 FAX: (636) 947-6621 FAX: (573) 774-5626 Catholic Community Services REYNOLDS COUNTY
Dr. Thomas J. Harrison, Jr. Ellington Family Clinic 6055 Mexico Road Dr. Joseph Camire St. Peters, MO 63376 Phone: 636-498-2273/936-0497 Ellington, MO 63638 (Refugee Pediatrics Only)
Phone: (573) 663-2525 Fax: (573) 663-7821 ST. FRANCOIS COUNTY
Parkland Health Center RIPLEY COUNTY
1101 W Liberty Street Naylor Medical Clinic Farmington, MO 63640 Missouri Department of Health and Senior Services
Tuberculosis Case Management Manual
Division of Community and Public Health Section: Appendices
Appendix: 3.04 Tuberculosis Signs/Symptoms Checklist Phone: (573) 760-8258 FAX: (660) 265-4627 Mineral Area Pain Center Thomas E. Williams, D.O. James N. Moore, DO Sullivan County Hospital Physician Clinic 608 Maple Valley Drive 630 West Third Street Farmington, MO 63640 Phone: (573) 756-3400 Phone: (660) 265-5204 ST. LOUIS COUNTY
TANEY COUNTY
Bridges Walk-In Clinic Robert Seelig, MD 774 N. New Ballas Road Forsyth, MO 65653 St. Louis, MO 63141 Phone: (417) 546-4200 Phone: (314) 567-1656 FAX: (417) 546-4505 (X-RAYS ONLY)
Tri Lakes Diagnostics Imaging Midwest Radiological Associates 523 State Highway 248, Suite 300 PO Box 38900-900 Branson, MO 65616 St. Louis, MO 63138 Phone: (417) 332-2152 Phone (314) 821-5600 Fax: (417) 332-0443 (X-RAYS INTERPRETATION ONLY)
(Make sure to fax approved DSP before
STE. GENEVIEVE COUNTY
Ste. Genevieve Co Memorial Hospital Cox Medical Center 800 Ste. Genevieve Drive 545 Landing Boulevard Ste. Genevieve, MO 63670 Branson, Missouri 65616 Phone: (573) 883-2751 Phone: (417) 335-7733 Fax to: (417) 335-7732 STODDARD COUNTY
(Contact Scheduling at (417) 335-7733 Option #1)
Cross Trails Medical Center (Affiliated w/Bollinger, Cape, & Perry Locations)
Lakes Region Imaging, LLC Advance, MO 63730 Branson, MO 65616 Phone: (573) 722-3034 Phone: (417) 335-7733 Fax to: (417) 335-7732 STONE COUNTY
(Contact Scheduling at (417) 335-7733 Option #1)
Lakes Area Medical Clinic T. Laurence Huffman, M.D. WASHINGTON COUNTY
11016 East Highway 76, PO Box 2576 Healthway Primary Care Branson West, MO 65737 200 Healthway Drive Phone: (417) 272-0400 Potosi, MO 63664 FAX: (417) 272-3900 Phone: (573) 438-2240 SULLIVAN COUNTY
WAYNE COUNTY
Milan Family Practice Clinic Wayne Medical Center Dale W. Essmyer, DO 212 East Second Street, P.O. Box 176 Piedmont, MO 63597 Phone: (660) 265-4456 Phone: (573) 223-4233 Missouri Department of Health and Senior Services
Tuberculosis Case Management Manual
Division of Community and Public Health Section: Appendices
Appendix: 3.04 Tuberculosis Signs/Symptoms Checklist WEBSTER COUNTY
WRIGHT COUNTY
Marshfield Family Clinic Mtn Grove Medical & Laser Center Dennis Robinson, MD 571 B Pom De Terre Road, PO Box 736 601 N. Bush Street Marshfield, MO 65706 Mountain Grove, MO 65711 Phone: (417) 859-7875 Phone: (417) 926-6643 FAX: (417) 468-7978 Tuberculosis Signs and Symptoms Checklist
Client Name: _ Date: _ Have you ever had a positive skin or blood test for TB? If yes, have you received treatment? Written Documentation? Missouri Department of Health and Senior Services
Tuberculosis Case Management Manual
Division of Community and Public Health Section: Appendices
Appendix: 3.04 Tuberculosis Signs/Symptoms Checklist Do you have a cough? Do you cough up anything? Do you cough up blood? Have you lost weight? Has your appetite decreased? Do you have fever or chills? Do you have night sweats? 10. Do you feel unusually tired or weak? 11. Do you have chest pains? 12. Have you been in close contact with someone who has TB? 13. Have you taken prednisone or steroids recently? 14. Are you taking any medications for arthritis? 15. Have you recently been treated for cancer? 16. Do you drink alcohol? 17. Are you pregnant? 18. Are you foreign born? If so, what country were you born in _ 19. How long have you lived in the United States? Nurse Signature: Date: _ Missouri Department of Health and Senior Services
Tuberculosis Case Management Manual
Division of Community and Public Health Section: Appendices
Appendix: 3.06 Case Classification Checklist for Active Disease Cases
INITIAL WORKUP
YES
NO
N/A
Conduct patient interview Complete TB History (TBC-10) Form CD-1&TB History Form faxed/ mailed to state TB nurse Isolate per the CDC recommendations (CDC Core Curriculum on Tuberculosis- Infection Control) Contact/source case investigation initiated using the Contact Worksheet (TBC-13) Patient education provided in client's primary language and documented, Isolation procedures as needed Admission note completed Sputum sent to the State Public Health Laboratory for culture & sensitivity Diagnostic services arranged, if needed HIV testing offered Baseline eye and color vision exam; LFT is applicable Prescriptions obtained and faxed to State Contract Pharmacy, along with the TB Medication Request (TBC-8) DOT initiated using the TB Medication Record (TBC-16) Contact Worksheet (TBC-13) faxed to state TB nurse DURING TREATMENT:
MONTH 1
MONTH 2
MONTH 3 MONTH 4
MONTH 5
MONTH 6
Assess & document on TBC-1 LFT, if indicated DOT (# of doses this month) Sputum submitted TB Medication Record (TBC-16) sent to state TB nurse monthly
COMPLETION OF TREATMENT:
YES
NO
Completion of therapy documented (including # of doses received) Completion letter to client State TB Nurse notified Division of Community and Public Health Section: Appendices
Appendix: 3.06 Case Classification Division of Community and Public Health Section: Appendices
Appendix: 3.06 Case Classification Description
No history of exposure. Negative reaction to TB skin test. History of exposure. No evidence of infection Negative reaction to TB skin test. Positive reaction to TB skin test. Negative bacteriological studies (if done). No clinical, bacteriological, or radiographic evidence of active TB. TB, clinically active M. tuberculosis cultured (if done). Clinical, bacteriological, or radiographic evidence of TB. History of episode(s) of TB OR Abnormal but stable radiographic findings. Positive reaction to TB skin test. Negative bacteriological studies (if done) AND No clinical radiographic evidence of current disease. Diagnosis pending. Comments:
CDC counts clinical cases of tuberculosis as a case if the criteria are met.
Tuberculosis disease is currently not reportable to CDC through MOHSIS.

Case/Contact Follow Up and Control Measures
 A person suspected of having tuberculosis of the throat or lungs should be isolated either in their home or in the hospital until they have met the following criteria: 2 weeks of treatment, 3 negative smears, and are clinically improving.

Source: http://www.casscountyhealth.com/wp-content/uploads/2016/02/TB-Manual.pdf

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