Clinicians, not the patient, are responsible for successful treatment of active tuberculosis (TB) disease. Nurse care management helps ensure adherence to the overall treatment plan. The Centers for Disease Control and Prevention (CDC) 2016 guidelines for treatment of drug susceptible tuberculosis recommend care management for all patients with active disease. This is to ensure successful treatment and safety of the patient and public. Care management for tuberculosis is complex. Nurse case managers connect patients with needed clinical and social services throughout treatment. TB care management includes:
- Providing ongoing patient education.
- Providing directly observed therapy (DOT).
- Creating a plan for treatment that takes into consideration a patient's values, needs, culture, and beliefs.
- Appropriately using available resources, including enablers and incentives, to help patients complete treatment.
- Determining the risk of infectiousness to others and evaluating those who are at risk for infection and disease.
Please see the Wisconsin TB Program (WTBP) Care Management for Active TB Disease, P-00647, guide for step-by-step instructions on case management activities.
Who performs nurse care management?
Public health nurses at local health departments usually perform the nurse case management role. They coordinate care between the treating physician, the health department, social service workers, infection control nurses, and other specialists involved in the care of the patient.
Is DOT necessary?
DOT is the standard of care for treatment of all forms of active TB disease. DOT increases the number of patients cured and completing treatment, as well as increasing the likelihood that the patient’s bacterial load, especially the number of live bacteria in the patient’s respiratory specimens, will decrease over time. Wisconsin statutes and Wis. Admin Code § DHS 145.10(6)(b) state that the local health officer or the health department may require a person to receive DOT.
WTBP recommends performing DOT seven days a week for two weeks at the initiation of treatment. After two weeks, DOT can be decreased to five days a week during the intensive phase (first two months of treatment). During the continuation phase (after first two months of treatment), DOT can be further decreased, if necessary and appropriate for the patient. See Table 2 in the 2016 CDC guidelines for more information.
Can patients perform DOT by video?
Electronic or video DOT (eDOT or vDOT) is the use of electronic technologies to remotely monitor TB patients ingesting their medication, either in real time or recorded. There are multiple technologies available to administer vDOT. Some patients will use their own personal device, as long as the technology is compatible with the health department’s technology and patient security and privacy are not compromised. Depending on the resources of the local health department (LHD) and patient, smartphones, tablets, or computers with webcams can be used.
On a case-by-case basis, vDOT will be authorized by the WTBP. Some reimbursement through the TB Dispensary is available for vDOT, see Attachment F TB Dispensary Policies and Procedures. Eligibility for vDOT will depend upon LHD legal approval, experience in TB case management, and overall nursing experience.
There are important criteria that patients should meet before considering medication administration by vDOT:
vDOT Inclusion Criteria:
Treatment history must include:
- Completed intensive phase (for active TB); vDOT may be started earlier if all inclusion criteria (below) are met an all exclusion criteria are ruled out.
- Demonstrated medication adherence while on in-person DOT (100% adherent).
Other Inclusion Criteria:
- Motivated to have vDOT.
- At least 18 years of age.
- Ability to effectively communicate with the patient without language barriers.
- Patient is able to identify each medication accurately and describe possible side effects.
- Patient is able to demonstrate proper use of technology used for vDOT.
- Privacy guaranteed (other people not able to see or hear) or waiver form signed.
- Reliable internet or telephone connection.
Patients meeting the criteria below should NOT be considered for a vDOT regimen:
- Regimen includes intermittent dosing for active TB disease (i.e., doses are given three or fewer times per week).
- Adherence issues with DOT or related issues (missing appointments, dishonesty, inappropriate use of technology)
- Less than 18 years old (minor)
- Language barrier
- Medical condition that puts patient at increased risk for adverse reaction (for example, AIDS, poorly controlled diabetes, cancer, dialysis)
- Substance abuse, incarceration, homelessness, unstable housing
- Memory impairment or psychiatric concerns
- Medication intolerance or adverse reaction
- Risk for hepatic complications (alcohol or liver disease)
- Disabled or unable to fully participate in vDOT, such as vision impairment or other physical challenges
- Court-ordered therapy
For more information on eDOT, please see the CDC eDOT Toolkit.
- Active Tuberculosis Disease Fact Sheet, P-42099 – A fact sheet with information on TB infection and TB disease, how TB spreads, signs and symptoms, prevention, and treatment.
- Latent Tuberculosis Infection Fact Sheet, P-42099b – A fact sheet with information on TB infection, medicine, testing, prevention, and treatment.
- Wisconsin TB cases by local public health regions and county, P-00438 (PDF) – A fact sheet with number of active TB disease cases by region and county.
- CDC Basic TB Facts – CDC TB basic facts page with links to information on how TB spreads, prevention, exposure, and more.
- Patient and General Public Materials – Fact sheets and posters from CDC with general TB information, available in English, Spanish, Tagalog, and Vietnamese.
- Key Messages for TB and Diabetes, Virginia Department of Health – A educational tool for patients and healthcare workers on TB and diabetes, available in English, Spanish, Arabic, Vietnamese, Tagalog, and Korean.
- Multilingual Educational Materials, NSW Multicultural Health Communication Services – A website providing basic fact sheets on TB disease, available in 15 languages.
- Tuberculosis, Germs, and Medicine, Public Health Madison & Dane County – An educational video on TB disease in Hmong with English subtitles.
Medications and Financial Support
- What You Need to Know About Your Medicine for Latent TB Infection - Isoniazid (PDF) – CDC information on the TB medication Isoniazid.
- What You Need to Know About Your Medicine for Latent TB Infection - Rifampin (PDF) – CDC information on the TB medication rifampin.
- What You Need to Know About Your Medicine for Latent TB Infection - Isoniazid and Rifapentine (PDF) – CDC information on the TB medications isoniazid and rifapentine.
- TB Disease Initial Request for Medication, F-44000 – Fill out this form to request medication for active TB disease from the Wisconsin TB Dispensary program.
- TB Infection Initial Request for Medication, F-00905 – Fill out this form to request medication for latent TB infection (LTBI) from the Wisconsin TB Dispensary program.
- Medication Refill Request, F-44126 – Fill out this form to request a refill on medication for active TB disease from the Wisconsin TB Dispensary program.
- Pre-authorization for Non-Routine Services Form, F-01459 – Fill out this form to request Wisconsin TB Dispensary coverage for nonroutine TB services.
- See the Financial Resources webpage for ways to support your patient during treatment.
- CDC 2005 Guidelines for Conducting Contact Investigations – Link to resources for planning contact investigations.
- Contact Investigation Toolkit, State of Washington TB Program – Includes contact investigation work sheets and samples of contact notification letters.
- Positive TST - What's next? P-02288 – A fact sheet outlining steps to take after a positive skin test result.
- Positive IGRA - What's next? P-01182 – A fact sheet outlining steps to take after a positive IGRA result.
- Skin Test Calipers and Rulers, Southeastern National TB Center – You can order tools for reading TB skin tests here.
Other Case Management Tools
- Wisconsin Case Management for Active TB Disease Treatment, P-00647 – A checklist document for case management activities, organized by treatment month from the Wisconsin Department of Health Services, Division of Public Health.
- Clinical Care Forms, Texas State TB Program – An assortment of case management tools, including template for patient assessment interview.
- TB Risk Assessment Questionnaire, F-02314 (In English and Spanish) – A worksheet to determine a person's risk for TB infection and disease.
- Home Sputum Collection: A Step by Step Guide, Public Health Madison & Dane County – An educational video for patients and caregivers on how to collect sputum, available in multiple languages.
- Sputum Collection: Spontaneously Produced, P-02380 (PDF) – A fact sheet for nursing staff on how to collect sputum specimens.
- Sputum Collection: Nebulized Induction, P-02381 (PDF) – A fact sheet for nursing staff on how to collect sputum specimens.
- Smoking Cessation Resources – CDC links to cessation best practices, quit lines, and more.
- Local Public Health in Wisconsin – A link to local public health departments in Wisconsin.
Clinical and Treatment Guidelines
- Treatment of Drug-Susceptible Tuberculosis, CDC/ATS 2016 – The most recent treatment guidelines for tuberculosis.
- Drug Resistant TB, CDC – An assortment of guidelines for the treatment of drug-resistant TB.
- Testing and Diagnosis of TB, CDC 2017 – The most recent guidelines for testing and diagnosis of TB.
- Clinical Algorithms and Short Clinical Guides, Heartland National TB Center – An assortment of clinical resources and references from a CDC-designated Center of Excellence for TB.
- Drug-Resistant TB, Curry International TB Center – An assortment of clinical resources and training for managing drug-resistant TB patients, from a CDC-designated Center of Excellence for TB.
- Southeastern National Tuberculosis Center – Wisconsin's CDC-designated Center of Excellence for TB, provides educational webinars and medical consultation support for the management of TB and LTBI.
Questions about TB? Contact us!
Phone: 608-261-6319 | Fax: 608-266-0049