R388.  Health, Disease Control and Prevention; HIV/AIDS, Tuberculosis Control/Refugee Health.
R388-804.  Special Measures for the Control of Tuberculosis.
R388-804-1.  Authority and Purpose.
	(1)  This rule establishes standards for the control and prevention of tuberculosis as required by Section 26-6-4, Section 26-6-6, Section 26-6-7, Section 26-6-8, and Section 26-6-9 of the Utah Communicable Disease Control Act and Title 26, Chapter 6b, Communicable Diseases-Treatment, Isolation and Quarantine Procedures.
	(2)  The purpose of this rule is to focus the efforts of tuberculosis control on disease elimination.  The standards outlined in this rule constitute the minimum expectations in the care and treatment of individuals diagnosed with, suspected to have, or exposed to tuberculosis.

R388-804-2.  Definitions.
	(1)  The definitions described in Section 26-6b apply to this rule, and in addition:
	(a)  Tuberculosis.  A disease caused by Mycobacterium tuberculosis complex, i.e., Mycobacterium tuberculosis, Mycobacterium bovis, or Mycobacterium africanum.
	(b)  Acid-fast bacilli (AFB).  Denotes bacteria that are not decolorized by acid-alcohol after having been stained with dyes such as basic fuschsin; e.g., the mycobacteria and nocardiae.
	(c)  Case of tuberculosis.  An episode of tuberculosis disease meeting the clinical or laboratory criteria for tuberculosis as defined in the National Notifiable Diseases Surveillance System (NNDSS).  The Department incorporates by reference the Tuberculosis 2009 Case Definition, CSTE (Council of State and Territorial Epidemiologists) Position Statement, 09-ID-65.
	(d)  Tuberculosis infection.  The presence of M. tuberculosis in the body but the absence of clinical or radiographic evidence of active disease as documented by a significant tuberculin skin test, or Interferon Gamma Release Assay (IGRA), e.g. Quantiferon or T-SPOT, a negative chest radiograph and the absence of clinical signs and symptoms.
	(e)  Tuberculosis disease.  A state of active tuberculosis, pulmonary or extra-pulmonary, as determined by a chest radiograph, the bacteriologic examination of body tissues or secretions, other diagnostic procedures or physician diagnosis.
	(f)  Directly observed therapy.  A method of treatment in which health-care providers or other designated individuals physically observe the individual ingesting anti-tuberculosis medications.
	(g)Drug resistant tuberculosis.  Tuberculosis bacteria which is resistant to one or more anti-tuberculosis drug.
	(h)  Multi-drug resistant tuberculosis.  Tuberculosis bacteria which is resistant to at least isoniazid and rifampin.
	(i)  Suspect case.  An individual who is suspected to have tuberculosis disease, e.g., a known contact to an active tuberculosis case or a person with signs and symptoms consistent with tuberculosis.
	(j)  Program.  Utah Department of Health:  Bureau of Epidemiology; Prevention, Treatment, and Care Program.
	(k)  Department.  Utah Department of Health.

R388-804-3.  Required Reporting.
	(1)  Tuberculosis is a reportable disease.  Individuals shall immediately notify the Department by telephone of all suspect and confirmed cases of pulmonary and extra-pulmonary tuberculosis as required by R386-702-2, R386-702-3.
	(2) The report may also be made to the local health department, who shall notify the Department of all suspect and confirmed cases within 72 hours of report.

R388-804-4.  Screening Priorities and Procedures.
	(1)  Private providers and local health departments shall screen individuals considered to be at high risk for tuberculosis disease and infection before screening is conducted in the general population.  Priorities shall be established based on those at greatest risk for disease and in consideration of the resources available.
	(2)  Individuals considered at high risk for tuberculosis include the following:
	(a)  Close contacts of those with infectious tuberculosis;
	(b)  Persons infected with human immunodeficiency virus;
	(c)  Individuals who inject illicit drugs;
	(d)  Inmates of adult and youth correctional facilities;
	(e)  Residents of nursing homes, mental institutions, other long term residential facilities and homeless shelters;
	(f)  Recently arrived foreign-born individuals, within five years, from countries that have a high tuberculosis incidence or prevalence;
	(g)  Low income or traditionally under-served groups with poor access to health care, e.g., migrant farm workers and homeless persons;
	(h)  Individuals who are substance abusers and members of traditionally under-served groups;
	(i)  Individuals with certain medical conditions that may predispose them to tuberculosis infection and disease, e.g., diabetes, cancer, silicosis, and immune-suppressive disorders;
	(j)  Individuals who have traveled for extended periods of time in countries that have a high tuberculosis incidence or prevalence;
	(k)  Other groups may be identified by order of the Department, as needed to protect public health.
	(3)  Employers who are required to follow Occupational Safety and Health Administration guidelines for the prevention of tuberculosis transmission disease shall develop and implement an employee screening program.
	(4)  Tuberculosis screening shall be completed using either the Mantoux tuberculin skin test method or an FDA approved in-vitro serologic test, e.g. IGRA.
	(a)  Screening for tuberculosis with chest radiographs or sputum smears to identify individuals with tuberculosis disease is acceptable in places where the risk of transmission is high and the time required to give the skin test makes the method impractical.
	(b)  If the skin test or serologic test yields results indicating tuberculosis exposure, the individual shall be referred for further medical evaluation.

R388-804-5.  Diagnostic Criteria.
	In diagnosing tuberculosis, health care providers shall be expected to adhere to the standards listed in this document.
	(1)  The Department incorporates by reference the (IDSA/ATS/CDC) diagnostic and classification standards as described in the segment entitled "Clinical Practice Guidelines: Diagnosis of Tuberculosis in Adults and Children," Clinical Infectious Diseases (2016) doi: 10.1093/cid/ciw694 First published online: December 8, 2016.
	(2)  The Department incorporates by reference the CDC diagnostic and classification standards for use of Nucleic Acid Amplification test in the document entitled "Updated Guidelines for the Use of Nucleic Acid Amplification Tests in the Diagnosis of Tuberculosis," MMWR; 58 (01); 7-10, 2010.
	(3)  The Department incorporates by reference the CDC diagnostic and classification standards for use of Interferon Gamma Release Assays as described in the document entitled, "Updated Guidelines for Using Interferon Gamma Release Assays to Detect Mycobacterium tuberculosis Infection, United States, 2010" MMWR; 59 (no. RR-5); 1-25, 2010.

R388-804-6.  Treatment and Control.
	(1)  The Department incorporates by reference the IDSA/ATS/CDC treatment standards as described in the segment entitled "Infectious Diseases Society of America. Official ATS/CDC/IDSA Clinical Practice Guidelines:  Treatment of Drug-Susceptible Tuberculosis".  Clinical Infectious Diseases (2016) doi:  10.1093/cid/ciw376, August 10, 2016, "Centers for Disease Control and Prevention.  Treatment of Tuberculosis, American Thoracic Society, CDC, and Infectious Diseases Society of America."  MMWR 2003; 52 (No. RR-11), Centers for Disease Control and Prevention.  Controlling Tuberculosis in the United States:  Recommendations from the American Thoracic Society; CDC, and the Infectious Diseases Society of America. MMWR 2005; 54 (No. RR-12)" and "Centers for Disease Control and Prevention.  Targeted Tuberculin Testing and Treatment of Latent Tuberculosis Infection.  MMWR 2000; 49 (No. RR-6)."
	(2)  A health-care provider who treats an individual with tuberculosis disease shall use the IDSA/ATS/CDC treatment standards as a reference for the development of a comprehensive treatment and follow-up plan for each individual.  The plan shall be developed in cooperation with the individual and approved by the local health department or the Program.  Health-care providers shall routinely document an individual's adherence to prescribed therapy for tuberculosis infection and disease.  If isolation is indicated, the plan for isolation shall be approved by the local health department or the Program. Discharge from an inpatient facility shall not occur without the knowledge of, and in agreement with the local health department and/or the Program.
	(3)  A health-care provider who treats an individual with suspect or active tuberculosis disease shall provide for directly observed therapy.
	(4)  Individuals with infectious tuberculosis disease shall comply with the treatment plan as set forth by the provider and public health, including but not limited to isolation if necessary, wearing a mask approved by the local health department or the Program when outside the isolation area, abiding by a plan of directly observed therapy, providing laboratory samples, and attending all scheduled provider visits.
	(5)  Any individual who will not comply with public health shall be subject to involuntary isolation as establish in the Utah Communicable Disease Control Act.

R388-804-7.  Epidemiologic Investigations.
	(1)  The local health department shall conduct a contact investigation immediately upon report of an AFB smear positive suspected or confirmed case of laryngeal, respiratory, or pleural tuberculosis disease.
	(2)  The contact investigation shall include interviewing, counseling, educating, examining and obtaining comprehensive information about those who have been in contact with individuals who have infectious tuberculosis.
	(a)  The investigation shall begin within three days of notification of an AFB smear positive suspected or confirmed case and the initial evaluation shall be completed within fourteen days of notification.
	(b)  Investigations of contacts to persons with active TB disease shall include the evaluation of contacts and the treatment of infected contacts.
	(c)  The local health department shall submit demographic data to the Department at 30 days and at 120 days after initiation of the contact investigation, and following the completion of prophylactic treatment.

R388-804-8.  Payment for Isolation and Quarantine.
	(1)  Individuals who are isolated or quarantined at the expense of the Department shall provide the Department with information to determine if any other payment source for the costs associated with isolation or quarantine is available.

R388-804-9.  Penalty for Violation.
	(1)  Any person who violates any provision of this rule may be assessed a civil money penalty as provided in Section 26-23-6.

KEY:  tuberculosis, screening, communicable diseases
Date of Enactment or Last Substantive Amendment:  May 11, 2017
Notice of Continuation:  September 30, 2016
Authorizing, and Implemented or Interpreted Law:  26-6-4; 26-6-6; 26-6-7; 26-6-8; 26-6-9; 26-6b