Pepin County Health Department will require all persons with suspect or confirmed infectious or high-risk tuberculosis to exercise all reasonable precautions to prevent the spread of infection to others. If persons can be safely maintained in their home environment without posing a danger to the health of the public, and they agree to voluntarily adhere to the necessary health measures, the health department will facilitate and support this. When management in the home is not possible due to environmental or family risk issues, public health will facilitate the person’s voluntary placement to a setting that offers proper airborne precautions. Legal confinement is used as a last resort only.
When voluntary measures are not workable, the Pepin County Health Officer will order confinement for up to 72 hours, excluding weekends and holidays. If the home environment is suitable, this confinement can be at home or, if it is not, the confinement will be to a location or facility with a negative pressure isolation room that provides for adequate airborne precautions. Confinement for confirmed or suspect infectious or high-risk tuberculosis may be used if the Health Officer determines that the individual poses an imminent and substantial threat to him or herself or to the health of the public, or has refused to undergo a medical examination, or has refused to follow a prescribed treatment regimen. The Health Officer will petition the court to order confinement of any individual with suspect or confirmed tuberculosis for care longer than 72 hours, if the individual terminates the treatment plan against medical advice or is non-compliant with the treatment plan, or if the Health Officer decides that confinement is necessary to protect others from becoming infected [Wisconsin Statute 252.07(8); 252.07(9)].
Determine if 72-hour confinement is necessary.
Review circumstances with the Health Officer. All of the following conditions must be met and documented:
Medical diagnosis of infectious tuberculosis or suspect tuberculosis.
Refusal to follow prescribed treatment regimen or refusal to undergo a medical examination to confirm whether the individual has infectious tuberculosis.
Documented evidence that the individual poses an imminent and substantial threat to himself or herself or to the health of the general public and exactly why.
The Health Officer will promptly alert corporation counsel and discuss the situation and collaboratively facilitate legal documentation and preparations for court-ordered confinement.
Consult with the Wisconsin Tuberculosis Program regarding the need for isolation/confinement whenever necessary. There is a Communicable Disease Epidemiologist with the Division of Public Health available after-hours to receive emergency calls at (608) 258-0099.
Order and enforce the confinement. See appendix A, Health Officer Confinement Order.
Confinement may be to the person’s home if it is safe to do so. If confinement is not possible at home, order the confinement to a facility or other safely secured isolation location, without shared air.
The Health Officer then notifies the court in writing of the need for court-ordered confinement including the attachment of the following documented evidence:
A written statement from a physician that the individual has infectious tuberculosis or suspect tuberculosis.
In the case of an individual with suspect tuberculosis, documented refusal to undergo a medical examination to confirm whether the individual has infectious tuberculosis, OR
In the case of an individual with a confirmed diagnosis of infectious tuberculosis, the Health Officer provides a written determination that the individual poses an imminent threat to himself/herself or to the health of the general public.
Make necessary safe transportation arrangements and notify designated facility or location of the individual’s impending arrival and ensure the availability of a negative pressure/airborne precautions room.
Provide the necessary medical and clinical information for the facility to assure proper care of the person and to facilitate them obtaining admission physician’s orders. Physician to physician communication may expedite smooth transition, especially if a different physician will be caring for the person in the health care facility or location.
If necessary, a law enforcement officer, or other person authorized by the Health Officer, shall transport the individual to a facility.
Educate the person(s) about the necessary respiratory precautions so that appropriate respiratory precautions and infection control procedures can be followed in order to protect the health of the public, including during transport.
Determine whether the local Health Officer confinement is successfully in effect and if court-ordered confinement should be established. Take care to ensure that the individual is given due process and that you have documented their receipt of all of the appropriate information [Wisconsin Statute 252.07(9)].
Notify corporation counsel of the current status of the person and determine the next appropriate legal actions for court-ordered confinement.
Prepare court petition for confinement per Wisconsin Statute 252.07(9) with assistance from corporation counsel (see appendix B, Health Officer Petition for Court-Ordered Confinement).
Secure a hearing date and time. The petition should include all of the following information and copies of all documented evidence must be attached to the petition:
Documentation of the medical status of the individual named in the petition, for instance:
The individual has infectious tuberculosis; or
The individual has noninfectious tuberculosis but is at high risk of developing infectious tuberculosis; or
The individual’s tuberculosis is resistant to the medication prescribed; or
The individual is suspected of having infectious tuberculosis.
Documented evidence that the individual has failed to comply with the necessary isolation and/or medical regimen or is assessed to be at great risk of elopement or non-adherence to medical evaluation or treatment; or
Demonstration and documentation that all other reasonable means of achieving voluntary compliance have been exhausted and no less restrictive alternative exists; or that no other medication or treatment for the resistant disease is available, including:
Evidence of the provision to the client of an original isolation order signed by the Health Officer before proceeding with court action, including date, time and place of service.
Documentation of violation of the isolation orders or other adherence issues.
Circumstances surrounding the violation or risk of violation of the isolation order.
Petition the court to order the individual confined.
The local Health Officer shall give the individual written notice of a hearing at least 48 hours before a scheduled hearing is held per Wisconsin Statute 252.07(9)(b). See appendix C, Written Notice of Hearing.
Notice of the hearing shall include:
The date, time, and place of the hearing.
The grounds, and underlying facts, upon which confinement of the individual is being sought.
An explanation of the individual’s rights to due process (i.e. the right to appear at the hearing, the right to present evidence and cross-examine witnesses, and the right to be represented by counsel).
The proposed actions to be taken and the reasons for each action.
Instruction in precautions the individual must take if appearing in person at the hearing. Facilitate the necessary precautions/equipment for them.
Prepare for the hearing.
Determine if the person will be present during the court hearing.
A hearing may be conducted by telephone or live audiovisual means, if available [Wisconsin Statute 252.07(9)(d)].
If the person attends the hearing, public health must provide instructions and facilitate proper infection control measures.
Work with corporation counsel to determine who will prepare a court order. The order should address the following:
Need for court-ordered care and treatment, which may include: medical examination, diagnostic tests, drug regimen, directly observed therapy, etc.
Need to place individual in least restrictive protective setting, which may include: home, hospital, nursing home, or other facility or location. A jail setting should be used only as a last resort or for individuals with convicted or pending criminal offenses.
* See appendix D, Court Confinement Order.
Notify designated facility of pending placement and inform them about the person so they can develop an initial care plan, provide care based on the person’s needs, and facilitate initial physician’s orders.
Ensure the transfer of the necessary medical information appropriately to those who need to provide care while following appropriate patient privacy and confidentiality measures.
Determine who needs to be available for testimony and contact them to ensure their availability and arrange for the necessary participants in the hearing as advised by corporation counsel.
Order is issued by the court and served by the Health Officer or her designee.
An order issued by the court may be appealed as a matter of right. An appeal shall be heard within 30 days after the appeal is filed. An appeal does not stay the order [Wisconsin Statute 252.07(9)(e)].
If the individual is confined for more than 6 months, the court shall review the confinement every 6 months [Wisconsin Statute 252.07(9)(c)].
Facilitate the necessary transportation arrangements and notify the waiting facility of the individual’s impending arrival. Ensure that they have prepared and are informed of precautions to be taken and are updated about the care needs of the person.
Monitor, evaluate and intervene as needed during continuing care.
The Health Officer or designee will work with the health care provider and the facility’s professional staff to assure that the individual’s care and treatment needs are being met.
A representative from public health will visit the individual as often as is necessary to ascertain that the confinement or isolation is being maintained and shall monitor all individuals with infectious tuberculosis until treatment is successfully completed. These visits must occur at a minimum of every seven days.
Determine when confinement is no longer necessary.
Determine whether treatment is complete, the person is no longer infectious or is now willing to participate in a medical evaluation, the current treatment, and/or isolation/airborne precautions.
To determine that the individual is no longer a substantial threat to himself or herself or to the health of the general public, all of the following conditions must be met (refer to HFS 145):
An adequate course of chemotherapy has been administered for a minimum of 2 weeks, and
There is evidence of clinical improvement, and
Recent sputum or bronchial secretion smears are free of acid-fast bacilli from three different specimens obtained on three different days, and
The person is considered by the Health Officer not to be a threat to the public health and is likely to comply with the remainder of the treatment regimen.
* See appendix E, Notification to Individual of Release from Confinement.
Consult with the health care provider and/or health care facility to ensure that a coordinated discharge plan will be implemented that includes post-confinement follow-up care and a phone call to alert public health of the person’s discharge.
Continue case management and follow-up care until prescribed therapy is completed and continue to work closely with the Wisconsin Tuberculosis Program for case reviews.
Assess costs associated with confinement and determine sources of payment per Wisconsin Statutes 252.06(10) and 252.07(10). If the person is placed in the jurisdiction of another health department, the original health department retains responsibility for services and costs.
Resolve potential third party payor issues early to foster acceptance of the affected person by medical and institutional providers.
If appropriate, make a referral to Social Services for Medicaid application.
If other staff will be providing direct services to an infectious client, provide infection control/airborne precautions education and personal protective equipment.
Include education and reassurance of the need for close, prolonged contact for transmission when the immune system is intact to ensure that they will deal with the client in a positive manner while still protecting themselves adequately.
Expenses for food, medical care, and other articles needed for the care of the infected person shall be charged against the person or whoever is liable for the person’s support.
The county in which a person with a communicable disease resides is liable for the following costs accruing under this section, unless the costs are payable through third party liability or through any benefit system:
The expense of employing guards.
The expense of enforcing isolation in the confinement area.
The expense of conducting examinations under the direction of the Health Officer.
For inpatient care of isolated pulmonary tuberculosis clients and inpatient care exceeding 30 days for other pulmonary tuberculosis patients that is not covered by Medicare, Medical Assistance, or private insurance, reimbursement may be requested from the Department of Health and Family Services. Details must be worked out with the Wisconsin Tuberculosis Program.
Communicable disease staff will debrief with management team following each implementation of this policy and procedure to determine effectiveness and any changes desired.
American Thoracic Society. Diagnostic Standards and Classification of Tuberculosis in Adults and Children. April, 2000.
Centers for Disease Control and Prevention. Core Curriculum on Tuberculosis; 4th Edition. 2000.
National Tuberculosis Controllers Association. Tuberculosis Nursing: A Comprehensive Guide to Patient Care. 1997.
Wisconsin Department of Health and Family Services. Wisconsin Administrative Rule, Control of Communicable Diseases, Chapter 145.
Wisconsin Tuberculosis Program Confinement Preparedness and Implementation. 2001.
Wisconsin Statute Chapter 252.07(8) and 252.07(9)
POLICY TITLE:TB – Directly Observed Therapy
EFFECTIVE DATE: 9/19/03
DATE REVIEWED/REVISED: 7/16/12
AUTHORIZED BY: Heidi Stewart, BSN, Health Officer / Director PURPOSE STATEMENT:
To assure adherence to prescribed treatment regimens for persons with suspect or active tuberculosis disease or latent tuberculosis infection (LTBI).
To prevent transmission of TB.
Pepin County Health Department will assure that all clients are comprehensively assessed and evaluated and that they are considered for DOT. Supportive services and incentives/enablers that reduce barriers to adherence will be provided or arranged for by the health department to ensure completion of treatment and to protect the health of the public. The health department will assure that all clients for whom DOT is indicated by CDC protocols, standards of practice, or recommendations of the Wisconsin TB Program, will be provided with DOT.
Pepin County Health Department will prioritize the provision of all public health services for tuberculosis in Pepin County with emphasis on:
1) the care of persons with suspect and active disease;
2) persons who are close or high-risk contacts of persons with suspect or active
3) those with latent tuberculosis infection (LTBI).
Pepin County Health Department may choose to use unlicensed personnel or volunteers as determined by health department decision, as a valuable adjunct to assure medication adherence for persons affected by tuberculosis. If such persons are utilized, the health department and staff will adhere to statutes, rules, and standards of practice for the implementation of such services.
Pepin County Health Department will utilize legal measures for persons who fail to adhere to prescribed medications and present a risk to the health of the public. When persons with tuberculosis refuse to adhere to prescribed medications and/or at any time present a risk to the health of the public, the Health officer may issue an order requiring the person to receive DOT. Should it become necessary at any time, the Health officer or the Department of Health and Family Services (DHFS) will obtain an order from the court to provide DOT.
If the person fails to comply with court ordered DOT, the person may be subject to isolation or confinement pursuant to s. 252.07(8) and (9), Wis. Stats., or to other and additional sanctions as the Court may determine.
Assess client needs and environmental factors to guide development of individualized care and management, including DOT when indicated.
Evaluate all persons face-to-face to determine the need for DOT, both initially and on an ongoing basis.
Validate information from referral and other sources. Collect and evaluate relevant new information.
Consult Health officer according to health department policy/procedure/practice regarding assessment findings and decision-making regarding DOT and document decision.
Assess for the potential negative effect, for disease transmission/progression if treatment is incomplete, as well as for the risk of non-adherence by the client. (For example, is there a vulnerable population in the person’s environment, such as young children or those who are HIV +, that make it imperative to halt potential transmission?)
Assess and prioritize candidates for DOT based upon at least the factors listed below and on the comprehensive assessment findings (complete Appendix A).
Consider DOT imperative with the presence of any of these factors –
Prescription is for intermittent therapy
Suspicion or confirmation of drug resistance to one or more TB drugs
Infectiousness/potential for transmission (i.e. smear +, symptomatic, vulnerable contacts)
Recurrent TB disease
History of non-adherence to prescribed TB medications
Lack of sputum clearing or lack of clinical improvement despite treatment.
Homeless, or staying in a shelter or in a tenuous living situation; flight risk
Using IV drugs, using excess alcohol, other substance abuse
Young age of suspect/case with active disease (i.e., under age 18)
Close or high-risk contact (young child or HIV+) on window prophylaxis
History/presence of mental, physical, developmental, cognitive illness or disability, no caregiver
Too ill, elderly, frail, impaired or forgetful to self-manage, no caregiver
Give strong consideration to DOT with the presence of any of these factors which indicate a high risk for negative outcome or client non-adherence if DOT is not implemented –
Extrapulmonary TB with any medical or nonadherence risk factors
Children on LTBI therapy whose parents have any medical or nonadherence risk factors
Adherence questionable, vulnerable persons present (HIV +, young children)
History or presence of alcohol or other substance use
History or current adverse reactions or side effects attributed to TB drugs
History of poor adherence during any medical management
Consider that without DOT, the presence of any of these factors indicates a risk is evident for disease progression if treatment is incomplete –
History of incarceration; life rebuilding is taking priority (work, housing, etc.)
Lack of insight/understanding of the potential negative medical effects of non-adherence
Cultural risk factors – Language/communication/family issues, distrust of the health care system
Avoidance of government/authorities/institutions for fear of revealing immigration status
Past/current negative experience with social service, health care or third party payors
Subject to poverty, unemployment, underemployment, uninsured/underinsured
Preoccupation with other economic, family, social or substance abuse issues
Any other individual reasons that point to potential difficulty taking medications, such as difficulty swallowing pills, etc.
Document the assessment findings that are present or absent, the comprehensive assessment, and any consultation or decision-making with supervisory staff/Health officer for DOT prioritization.
Assess for and respect cultural, individual, and family differences that will contribute to development of strong, trusting relationships with the person and the family thus increasing the likelihood of adherence to therapy.
Determine the need for interpreters and/or translators and provide or arrange for services as needed taking into account at least the following considerations:
Avoid use of family members, especially children.
Use trained medical interpreters whenever possible to avoid lack of understanding of medical/health care terminology.
Keep in mind that there may be no equivalent word in the client’s language and the interpreter may interject their own interpretations or misunderstandings may occur.
Recognize that client and family may be reluctant to reveal information through a third party due to fear of lack of confidentiality, especially about sensitive information.
Assure confidentiality of information when using interpreters/translators and adhere to agency confidentiality policies and procedures. Reassure clients and families that measures are taken to ensure confidentiality.
Talk with the interpreter before the interviews and ensure that the interpreter uses the client’s own words for translations; keep words simple and concrete.
Address client directly (not interpreter) and maintain eye contact unless this is culturally offensive to the client or they have not adapted to this practice in American culture.
Watch clients and family members for cues and convey through your body language, expression and tone that you care, despite language barriers.
Use correct pronunciation of client’s names and some key phrases related to TB in the client’s language if possible.
Familiarize yourself with the history and culture of the racial or ethnic populations served.
Assess client and family’s knowledge about their condition and determine and implement appropriate education and the strategies needed to ensure completion of treatment.
Correct myths and misunderstandings early in treatment and provide clients and families with accurate facts about tuberculosis and what is needed for cure.
Individualize strategies to increase adherence and implement DOT.
Develop an individualized approach to each client’s care, including DOT when indicated. (See Appendix B entitled “Elements of a Treatment Plan for TB Clients” for a framework.)
Develop individualized treatment adherence strategies that encourage success for all clients, especially if DOT is not implemented, by doing at least the following:
Foster client and family participation at all levels including selecting the approaches for care, such as the time and place for visits (see Sample Voluntary Contract in Appendix C). Also consider partial DOT if appropriate.
Utilize the person’s interests and motivating factors, especially in selecting incentives and enablers for adherence, regardless of DOT status.
Utilize the client’s personal strengths, support systems and local resources to overcome barriers to adherence, capitalizing on their need to protect those who are important to them.
Remain open to the potential need to change and vary approaches, incentives and enablers as the treatment plan progresses and relationship with client evolves.
Revise approaches when indicated based upon ongoing assessment and evaluation, share changes with team members and document accordingly.
Document DOT method, if DOT is utilized.
If non-nursing personnel are being used for DOT, use Appendices D, E, and F. If a public health nurse is doing the DOT, complete Appendix G.
Document number of doses taken and/or number of doses missed.
Complete Appendix H bi-weekly throughout DOT.
Document comprehensive assessment of client’s medication adherence, any medical or adherence issues noted and what actions are taken in narrative notes as appropriate.
Protect the health of the public by issuing a Health officer order for DOT if deemed necessary or by obtaining a court order for DOT if client does not adhere to prescribed medication and presents a risk to the health of the public (see Appendix I).
Using Incentives and Enablers
The Tuberculosis Control Incentive Program administered by the American Lung Association of Wisconsin is designed to assist with the treatment of tuberculosis clients by providing funding to purchase incentives and enablers that will encourage clients to complete therapy.
The program is to be used primarily for clients who have active TB disease but can also be used for clients on treatment for Latent Tuberculosis Infection (LTBI) to encourage and reward them along the course of their treatment.