Tuberculosis

Tuberculosis is a disease that is spread from person to person through the air. TB usually affects the lungs. The germs are put into the air when a person with TB of the lung coughs, sneezes, laughs, or sings. A person who breathes in the bacteria can become infected. Anyone can get TB, but some people are at higher risk. Those at higher risk include:

• People who share the same breathing space (such as family members, friends, co-workers) with someone who has active TB disease.
• Travelers to countries where TB is common.
• People who live in high-risk residential settings, such as nursing homes, homeless shelters, or correctional facilities.
• People with medical conditions that weaken the immune system, such as diabetes, certain types of cancers, being underweight, substance use through injections, treatment for rheumatoid arthritis or Crohn’s disease, organ transplants, severe kidney disease, head and neck cancer, or medical treatments such as corticosteroids.
• Children, especially those under age

Symptoms of TB can be different depending on the site of disease. The most common site for TB to develop is in the lungs, but TB can cause disease anywhere blood flows.

Symptoms of pulmonary TB (in the lungs or respiratory tract) include:

• A cough that lasts three weeks or longer
• Chest pain
• Coughing up blood or sputum (phlegm from deep inside the lungs)

Other generalized symptoms of TB:

• Weakness or fatigue
• Loss of appetite
• Unexpected weight loss
• Chills
• Fever
• Night sweats (usually drenching clothing or bed coverings)

While most people experience symptoms, a person can have TB disease without symptoms if TB disease is identified early. Early identification is critical to preventing the spread of TB in the community.

Other potential signs of active TB disease in persons with risk factors may include:

• Recurrent infections despite treatment with antibiotics that would normally cure the illness (e.g., pneumonia, infections in the bones or joints or any other body site).
• An abnormal chest x-ray with nodules, infiltrates, pleural effusions, or cavities.
• Difficulty getting pregnant, or frequent miscarriages in persons from areas of the world with higher incidences of TB.

Anyone can get TB, but your risk may be higher if you:

• Were born or frequently travel to countries where TB is common, including some countries in Asia, Africa, and Latin America.
• Live or used to live in large group settings where TB is more common, such as homeless shelters and correctional facilities.
• Recently spent time with someone who has active TB disease
• Have a weaker immune system because of certain medications or health conditions such as diabetes, cancer, and HIV.
• Work in places where TB is more likely to spread, such as hospitals, homeless shelters, correctional facilities, and nursing homes.

There are two types of tests for TB infection, a blood test, and a skin test. Blood tests are more accurate, especially for those that have received the TB vaccine.

You should get tested for TB if:

• You have spent time with a person known or thought to have infectious TB
• You frequently travel to countries where TB disease is
• You currently live, used to live, or are employed in a large group setting where TB is more common, such as a homeless shelter, prison, jail, or nursing
• You are a health care worker who cares for patients with TB
• You live in high-risk residential setting or use injectable

In addition, children, especially those under 5, have a higher risk of developing TB disease once infected. Therefore, testing for TB infection in children who may have been exposed to a person with TB disease is important.

Tuberculosis testing can be done by your health care provider or your local county health department.

TB germs can live in your body for years without causing symptoms. If you have inactive TB, treating it is the best way to protect yourself from getting sick with active TB disease.

If you have been diagnosed with active TB disease, you can be treated with medicine. You will need to take and finish all of your TB medicine as directed by your health care provider.

Whether you are an individual person looking to increase your knowledge about tuberculosis, or a health care professional, the Florida Department of Health has many resources available.

Centers of Excellence

• Southeastern National TB Center
• Global Tuberculosis Institute at Rutgers
• Curry International TB Center
• Mayo Clinic Center for Tuberculosis

Organizations/Associations

• American Lung Association
• International Union Against TB and Lung Disease

National Resources

• Tuberculosis Elimination
• Tuberculosis
• Tuberculosis Clinical Care and Treatment During Pregnancy
• Clinical Care for People with TB and HIV | Tuberculosis (TB)
• Tuberculosis Refugee Health
• National Prevention Information Network
• U.S. Occupational Safety and Health Administration
• National Institute of Allergy and Infectious Diseases
• U.S. National Library of Medicine and National Institutes of Health

International

• Stop TB Initiative
• Global TB Program

Yes. In 2023, 624 cases of active TB disease were identified in Florida (a rate of 2.8 per 100,000 persons).

TB in the U.S. and Florida by the numbers:

• 8,331 reported TB cases in the U.S. in 2023 (a rate of 2.9 cases per 100,000 persons)
• 60 jurisdictions (e.g., states, cities, U.S. territories, and affiliated areas) that report TB data to CDC
• Up to 13 million estimated number of people in the U.S. living with latent TB infection

Source: Data and Statistics accessed 10/01/2024.

Factsheets

Florida Cases by County 2019-2023

• 2023 Summary Status Sheet
• 2022 Summary Status Sheet
• 2021 Summary Status Sheet
• 2020 Summary Status Sheet
• 2019 Summary Status Sheet

TB Control Section Employee Phone List

All county health departments (CHD) offer TB services, and eligibility requirements may vary depending on location and resources available. For each person reported with findings suggestive of or confirming active TB disease, and for human contacts to persons exposed to potentially infectious individuals, the CHD must assign a case manager for ongoing surveillance to assure timely diagnosis, treatment initiation, and completion of an effective medication regimen to cure.

Services available, but not limited to:

Medical Evaluation for TB Infection and Disease

The extent of medical evaluation depends on the reason for the testing, risk factors TB exposure and/or progression, TB test results, and other clinical findings.

Key points

• A negative TB test alone is not sufficient to rule out active TB disease in persons with symptoms or chest x-ray findings suggestive of TB disease.
• A positive TB skin test or blood test alone is not a reportable condition in Florida.
• TB testing activities should be done only when there is a plan for follow-up care to evaluate and treat all individuals diagnosed with latent TB infection or TB disease.
• Frequency of testing depends on a person’s risk factors. This could range from one-time only testing among persons at low risk for future TB exposure to annual testing among those at continued risk of exposure.

Any persons with signs or symptoms of TB disease or a positive result from a TB blood test or TB Skin Test should be thoroughly evaluated for TB disease. The five components of the TB medical evaluation include:

1. Medical history (TB symptoms, risk factors for exposure and progression, TB testing history, and history of treatment for active TB disease or latent TB infection)
2. TB blood test (preferred) or TB skin test (unless medical records are available to confirm a previous positive test result).
3. HIV testing (unless the individual opts out).
4. Chest radiograph (if TB test is positive, known HIV/AIDS positive or symptoms are reported)
5. Bacteriologic examination (sputum smear microscopy, nucleic acid amplification testing, culture and drug susceptibility must be completed if symptoms are reported, or if the chest x-ray is abnormal, and in HIV positive individuals with a CD4 count < 200).

State Tuberculosis Laboratory Service Guidance provides information about TB laboratory services provided by the Florida Department of Health’s Bureau of Public Health Laboratories in Jacksonville, Florida.

Individuals identified with signs or symptoms of active TB disease, including radiographic or laboratory findings suggestive of active disease must be reported to the local health department within one business day.

Latent Tuberculosis Infection (LTBI) diagnosis is inferred when a patient meets the following criteria:

Health care providers should encourage patients diagnosed with LTBI to complete treatment to cure the infection and prevent disease whenever possible. Short course regimens should be prescribed to treat LTBI whenever possible to increase the likelihood of patients completing a curative course of treatment.

Patients with LTBI who meet eligibility criteria may be referred to their local county health department for treatment assistance, if needed.

Referral documentation should include the reason the person was tested, a completed TB risk screening questionnaire, TB test results, recent chest x-ray results (and location where the chest x-ray was performed if the patient doesn’t have a CD with the imaging studies) and any other relevant medical history, including prescribed medications.

TB Disease

Presumptive TB Disease (evaluation or treatment in progress to rule out or confirm)

Findings suggestive of active TB disease (e.g., symptoms, radiographic imaging studies, or laboratory findings) should be reported to the health department and considered presumptive disease until the medical evaluation is complete (inclusive of finalized AFB cultures) to determine otherwise.

This is not a final diagnosis. The timeframe to complete the medical evaluation should not exceed 12 weeks from the time of reporting. Providers should collaborate with the health department on efforts to rule out or confirm TB, as well as patient education. Patients should only be informed that TB has been ruled out after receiving confirmation from the health department.

Once a communicable disease report has been sent, a TB case manager is assigned to assure timely evaluation and treatment, if appropriate.

Clinically Confirmed TB Disease (culture negative)

A case that meets all the following criteria:

Laboratory Confirmed TB Disease

• Isolation of M. tuberculosis from a clinical specimen,* OR
• Demonstration of M. tuberculosis complex from a clinical specimen by nucleic acid amplification test,** OR
• Demonstration of acid-fast bacilli in a clinical specimen when a culture has not been or cannot be obtained or is falsely negative or contaminated.

*Use of rapid identification techniques for M. tuberculosis (e.g., DNA probes and mycolic acid high-pressure liquid chromatography performed on a culture from a clinical specimen) are acceptable under this criterion.

** Nucleic acid amplification (NAA) tests must be accompanied by culture for mycobacteria species for clinical purposes. A culture isolate of M. tuberculosis complex is required for complete drug susceptibility testing and also genotyping. However, for surveillance purposes, CDC will accept results obtained from NAA tests approved by the U.S. Food and Drug Administration (FDA) and used according to the approved product labeling on the package insert, or a test produced and validated in accordance with applicable FDA and Clinical Laboratory Improvement Amendments (CLIA) regulations.

Provider Diagnosed TB Disease

• Negative TB skin test or blood test
• Other signs and symptoms compatible with tuberculosis (e.g., abnormal chest radiograph, abnormal chest computerized tomography scan or other chest imaging study, or clinical evidence of current disease)
• Treatment with two or more anti-TB medications and clinically responding to treatment
• Completed diagnostic evaluation and no other diagnosis explains the clinical syndrome

Reporting TB in Florida

Clinical and laboratory findings suggestive of or confirming active TB disease must be reported to the local county health department within one business day. If the report is made by telephone, the Practitioner Disease Reporting Form must be submitted within 72 hours of the report along with supporting documentation (e.g., TB risk assessment questionnaire, test results, micro lab results, radiographic imaging reports, medication records, and any other relevant medical records).

• Visit Disease Reporting and Surveillance for additional information, including reporting forms.

Complete form DH1173 Medical Report and Treatment Plan Form (Part 1 and 2) to the extent possible, within 72 hours of reporting, as required by Chapter 392.64, Florida Statutes.

Reportable Diseases and Conditions Investigation and Reporting

Individuals Refusing Examination or Treatment for Active TB

Inform the patient they may have active TB disease, which is a disease that poses a threat to the public health and that they need to remain in airborne infection isolation or on community respiratory isolation restrictions at home until the examination can be completed and isolation is discontinued by the local health department.

Thoroughly document all clinical findings and risk factors suggestive of disease, as well as any education and counseling provided to the patient about their condition.

If the patient continues to refuse, or plans to leave against medical advice, notify the medical director for the state’s Tuberculosis Control Program, Dr. David Ashkin, or his designee, at 561-266-6632 or 800-4TB-INFO to discuss the case and determine if legal intervention is necessary.

Inactive TB/LTBI

Infected individuals should complete preventative treatment whenever possible, to reduce or eliminate their risk of getting sick in the future.

There are several treatment options available to treat LTBI. Three, four, six, and nine-month options are available.

Health care providers should utilize the shortest and most cost-effective treatment option available for the patient.

• Treatment table: Latent Tuberculosis Infection Treatment Regimens
• Treating Inactive Tuberculosis

Active TB/Disease

Treatment to cure active TB disease (both pulmonary and extra-pulmonary) is required by law in Florida. Treatment plans are individualized to the patient and treatment must be reported to the county health department and require additional community supervision using traditional in-person or video directly observed therapy (DOT).

The duration of treatment depends on the site of disease, drugs prescribed, drug susceptibility of the organism, clinical response to treatment, and patient adherence.

Treatment plans for active TB may range from 4 months (or 16 weeks) to treat clinically confirmed culture negative TB, or a minimum of 6 months (26 weeks), 9 months (39 weeks), or 12 months (52 weeks) for lab-confirmed TB disease.

The treatment plans in Florida usually require a combination of four medications that may include:

• Rifampin (RIF) (Rifabutin may be used as a substitute if clinically indicated)
• Isoniazid (INH)
• Pyrazinamide (PZA)
• Ethambutol (EMB)
• Levofloxacin or Moxifloxacin (Usually used when the site of disease involves bone, joint, brain, or if the organism is resistant to INH)

Supplemental vitamin B6 (Pyridoxine) is usually recommended for individuals taking INH.

A TB infection control plan is part of a general infection control program designed to ensure prompt detection of patients with infectious TB disease, airborne precautions, and treatment of people who have presumed or confirmed TB disease.

Guidelines‎

• Guidance on facility risk assessments and infection control practices
• Additional guidance for developing or maintaining a TB infection control plan

TB Screening and Testing for Health Care Workers

The Florida Department of Health supports implementation of the latest recommendations for tuberculosis screening, testing, and treatment of U.S. health care personnel.

Current Guidance and Recommendations:

• Baseline Screening and Testing for Health Care Personnel
• Frequency of Tuberculosis Screening and Testing for Health Care Personnel
• Tuberculosis Infection Control

Annual testing is not routinely recommended but may be considered for persons in positions or working in high-risk positions or settings.

Persons with documentation verifying a previous positive TB test result only require a single chest x-ray and symptom screening at hire to document baseline screening and testing for pulmonary TB. Repeat chest x-rays should only be ordered if there is a known exposure, or if the individual develops signs or symptoms of active TB disease.

Persons with untreated TB infection should be screened annually for TB symptoms, educated about risks, and encouraged to complete treatment for LTBI.

Health Care Facility Regulation

The TB Control Section does not regulate screening and testing practices in health care settings beyond the scope authorized by law pertaining to examination and treatment of persons reported with presumed or confirmed active TB disease and close contacts to persons with active TB disease.

For information about requirements for screening and testing in health care settings, please contact the Agency for Health Care Administration, 850-412-4402, for setting-specific regulations. If your facility is accredited, please contact the respective accrediting agency for information or interpretation of accreditation requirements.

Implementing a Respiratory Protection Program

The Occupational Safety and Health Administration requires the development, implementation, administration, and periodic reevaluation of a respiratory protection program in health care settings.

The most critical elements of a respiratory protection program include: assignment of responsibility, training, and fit testing.

Please contact your local health department for information about education and training opportunities offered in your area or DLTBNursingconsultants@FLhealth.gov for additional information.

Chapter 392, Florida Statutes

Chapter 64D-3, Florida Administrative Code

Laws and rules in Florida included, but are not limited to the following.

• 64D-3.029 Diseases or Conditions to be Reported
• 64D-3.036 Notifiable Disease Case Report Content is Confidential
• 64D-3.041 Epidemiological Investigations
• 64D-3.043 Tuberculosis Treatment and Follow-up
• 64D-3.045 Execution of Certificate for Involuntary Hold for Tuberculosis
• 64D-3.047 Enforcement and Penalties

The Florida Department of Health respects and adheres to all laws pertaining to patient confidentiality. The HIPAA Privacy Rule recognizes the legitimate need for public health authorities and others responsible for ensuring public health and safety to have access to protected health information to carry out their public health mission.

The rule permits covered entities to disclose protected health information without authorization for specified public health purposes, including activities conducted and information gathered for case reporting purposes as well as contact investigation and source case investigation.

_{Source: U.S. Department of Health and Human Services. Accessed 10/2/2024 at Disclosures for Public Health Activities}

• Health Care Provider Communication and Education Resources
• Health Care Provider Toolkit
• CDC Publications on Demand
• TB Partner Toolkit – Think.Test.Treat TB