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Subject 511-2-3 TUBERCULOSIS CONTROL

Rule 511-2-3-.01 Purpose

(1) The purpose of this chapter is to prevent spread of tuberculosis and to prevent the development of new cases.
(2) The Georgia Department of Public Health or its designee (Department) has the responsibility of developing procedures to ensure that persons with suspected cases of tuberculosis receive prompt diagnostic tests and persons with confirmed cases are given written treatment plans and an adequate oral explanation thereof which, if observed, can prevent the disease from spreading and lead to the recovery of the patient.
(3) A person with pulmonary tuberculosis, and positive sputum, who refuses to take prescribed chemotherapy is a threat to the health of the community. Each time this individual coughs or sneezes, living virulent tubercle bacilli are dispersed on droplet nuclei into the area. By inhaling these virulent bacilli, any individual living or being in close contact with this diseased person over a period of time may become infected with the disease. Furthermore, any person with tuberculosis who refuses to take the full recommended course of therapy is a threat to the community due to the possibility of that person developing drug resistant tuberculosis.

Rule 511-2-3-.02 Reporting

(1) In-patient or out-patient treatment of a case of active tuberculosis and treatment of a suspected case with two or more anti-tuberculosis drugs shall be reported to the Epidemiology and Prevention Branch of the Department through the local county health department or its designee (LCHD). The report shall state whether the case is still under treatment, the address of the case, the clinical status, treatment of the disease, the dates and results of sputum examinations and x-rays, instances of patient noncompliance with the treatment plan and any other information required by the Department. Said reporting should be done either by the attending physician or by the designated person at a treating hospital or clinic, if any. Also laboratories shall report to the Epidemiology and Prevention Branch of the Department and the LCHD all confirmed cultures of mycobacterium tuberculosis.
(2) A physician who attends a case of active tuberculosis shall examine or cause to be examined all persons working or living in close proximity to the patient who have a significant risk of infection, and shall forward the results of said examinations to the Epidemiology and Prevention Branch of the Department and the LCHD. In the alternative, such physician may refer such persons to the LCHD for examination. An examination required by this section shall include such tests as may be necessary to diagnose the presence of tuberculosis.

Rule 511-2-3-.03 Duties and Responsibilities of the County Health Departments

(1) It is the general responsibility of the LCHD to see that proper and reasonable measures are put into effect to prevent the spread of tuberculosis from any person capable of spreading it. In order to fulfill its responsibility the LCHD shall:
(a) ensure that all available tuberculosis control services are accessible to all residents;
(b) secure the prompt reporting of all diagnosed or suspected cases of tuberculosis;
(c) ensure effective treatment and continuing medical supervision of suspected and diagnosed cases of tuberculosis;
(d) ensure that contacts are identified and brought to examination, diagnostic conclusion and appropriate treatment if needed;
(e) provide for the discharge from supervision of patients whose treatment has been successfully completed; and
(f) keep each referring physician or institution informed as to the treatment of each referred patient.
(2) The LCHD shall promptly interview all reported or known persons who have a confirmed or suspected case of contagious tuberculosis.
(3) If, upon information obtained by an agent, the LCHD has reasonable cause to conclude that a person has a suspected or confirmed case of tuberculosis which needs prompt medical evaluation, the LCHD shall issue to the person a written order directing him/her to appear at a specified time and place to comply with a written plan of evaluation. The LCHD shall attach to the order a statement containing its factual basis and shall inform the person of the right to respond in writing to allegations in the statement prior to the scheduled time of the evaluation.
(4) If the person fails to submit to the planned evaluation and has not presented to the LCHD satisfactory reasons why such an evaluation is unnecessary, the LCHD may, in its discretion, file either a petition for an order of compliance or commitment.
(5) If, upon information obtained by an agent of the LCHD, the LCHD has reasonable cause to conclude that a minor may have been exposed to tuberculosis, the LCHD shall issue an order to the parent, guardian or custodian of the minor directing him/her at a specified date and place either to allow tuberculosis screening of the minor by the LCHD or to provide evidence of such screening by a licensed physician. The LCHD shall attach to the order a statement setting forth its factual basis and shall inform the parent, guardian or custodian of his/her right to respond in writing to allegations in the statement prior to the specified date of the screening, or submission of evidence thereof.
(6) If on the specified time the parent, guardian or custodian fails to submit the minor for screening and has not presented medical evidence or other written evidence that such screening is unnecessary, the Department may at its discretion file a petition for the screening of a minor in superior court.
(7) After it has identified a confirmed or suspected case of tuberculosis, the LCHD shall seek to implement a written plan of treatment which shall be explained to the patient who will be given an opportunity to consent to it in writing.
(8) The written plan of treatment shall contain a detailed description of the required cooperation of the patient and the set time schedule of any directly observed intake of prescribed drugs.
(9) The LCHD shall also explain orally and in writing to the patient the value of treatment and why drugs must be taken for the patient's recovery, control of cough, the prevention of the possible emergence of drug resistant organisms, and to prevent the spread of the disease to others.
(10) If, upon information obtained by an agent of the LCHD, the LCHD has reasonable cause to conclude that a patient is failing to comply with a plan of treatment, the LCHD shall issue a written order to the patient directing him/her to present evidence of an intention to comply with the plan of treatment by a specified date. The LCHD shall attach to the order a statement setting forth its factual basis and shall inform the person of his/her right to respond in writing to the allegations in the statement prior to the specified date.
(11) If by the specified date, the patient fails to present to the LCHD evidence that he/she has complied or intends to comply with the plan of treatment, the LCHD may in its discretion issue a quarantine order against the patient or file a judicial petition for an order of compliance or commitment. No such action, however, shall be taken against a patient who voluntarily accepts inpatient treatment recommended by the LCHD.
(12) Notwithstanding the provisions of any other regulation in this chapter, if the LCHD is unable to locate the person to be named in the petition after a good faith effort to do so, or if an imminent danger to public health exists, the LCHD may in its discretion file for a petition for commitment or compliance or issue a quarantine order without first issuing an order to the person.
(13) If a person fails to comply with a quarantine order or a judicial order, the LCHD may institute contempt, injunction, or other judicial enforcement action against the person as is authorized by law.
(14) The LCHD must notify the Director of the State Tuberculosis Control Program or his designee of the intent to initiate commitment proceedings and obtain confirmation of the availability of a bed for such patient before instituting commitment proceedings.

Rule 511-2-3-.04 Hospitalization of Committed Patients

(1) Upon commitment by court order of the superior court, individuals with tuberculosis are to be admitted to a facility approved by the Department for the treatment of tuberculosis patients (approved TB facility).
(2) At the approved TB facility, each patient shall receive the following:
(a) a complete medical and laboratory evaluation upon admission by a licensed physician;
(b) monthly x-rays as ordered;
(c) monthly observed sputum examinations with cultures and sensitivity studies as required;
(d) orders for prescribed drug regimens in the patient's chart and signed by a licensed physician;
(e) a medical evaluation at least once a month on the need for further commitment.
1. A copy of the monthly evaluation shall be forwarded to the committing LCHD.
(3) If a committed patient's behavior becomes unmanageable, he or she may be placed in the proper detention area for further treatment and counseling. If the approved TB facility's detention facilities prove inadequate, the patient may be transferred to more secure facilities designated for the care of tuberculosis by the State TB Control Program.
(4) Acutely ill patients may be transferred to an appropriate medical center for more intensive care.
(5) While these patients are in the hospital, no leaves of absence will normally be granted except for death or critical illness in the immediate family, medical reasons, or for other good cause approved by appropriate staff.
(6) Committed patients shall not be deprived of any social or recreational privilege granted other patients unless the patient is confined to a detention area. Patients confined to a detention area shall not be permitted off-unit privileges except as approved by medical staff.

Rule 511-2-3-.05 Discharge of Committed Patients

(1) The physical status of a patient shall be reviewed by the medical staff on no less than a monthly basis. If no review has taken place within the past month, the patient or his representative may request such a review. If, after such review, it is determined by the designated responsible physician at the approved TB facility or the Tuberculosis Control Program that a committed patient no longer has contagious tuberculosis or his/her discharge will not endanger the public health, he/she shall be discharged if consistent with the order of commitment.
(2) At least fifteen days prior to discharge, the LCHD or its designee must approve a suitable living environment in the community to which the patient is to be discharged.
(3) Upon discharge, the LCHD shall assume responsibility for directly observed therapy, certified sputum collections, chest x-rays and other clinical evaluations. If discharged patients are found to be noncompliant after discharge they are eligible for re-admission either as voluntary or recommitted patients.
(4) The discharging physician must notify and file notice of intent to discharge a committed person from the hospital fifteen days prior to granting a discharge with each of the following:
(a) Director of Tuberculosis Control Program, Department of Human Resources; and
(b) Responsible LCHD from which the individual was committed.

Rule 511-2-3-.06 Judicial Petitions

(1) The Department has concurrent authority with LCHD to file judicial petitions for commitment, orders of compliance, or contempt.
(2) When filing a petition for commitment which asks that the person be taken into custody by the sheriff or his/her deputies prior to the judicial hearing, the LCHD, the Department or their designees shall attach to the petition either an affidavit signed by an agent which alleges that person named in the petition may abscond or conceal himself/herself and the factual basis thereof or an affidavit signed by a physician which alleges that such person is an imminent danger to the public health and the factual basis thereof.