|
Form Approved
OMB No. 0920-xxxx
Expires xx/xx/xxxx
|
|
|
|
|
|
| TB Indicator Data |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| Name of Panel Site/Country: ______________________________ |
|
|
| Date of submission: ___/___/ 2016 Year data collected: January - December 2015 |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
How to enter repeat medical examinations: ►For an expired medical (e.g., person did not travel before expiraton date on DS form): - Record the information from BOTH the first and second examinations as individual and separate events ►For a repeat examination at the completion of TB treatment: - Record ONLY information from the initial examination where the applicant was assigned a Class A designation for TB |
|
|
|
|
TB Indicators for Each Calendar Month |
|
|
|
|
|
|
|
|
|
|
| Indicator |
Jan. |
Feb. |
Mar. |
Apr. |
May |
June |
July |
Aug. |
Sept. |
Oct. |
Nov. |
Dec. |
TOTAL |
HELPFUL TIPS |
| 1. Number of Applicants Screened |
|
|
|
|
|
|
|
|
|
|
|
|
|
ALL information for an applicant should only be entered into the column of the month in which the applicant was first examined. Example: an applicant is examined in April and must submit sputum; all the results of that sputum testing (including DST if performed) should STILL be entered in the APRIL column even though the final results will not be available until June. |
| 1a. Total number of applicants screened (ALL APPLICANTS OF ANY AGE) |
|
|
|
|
|
|
|
|
|
|
|
|
0 |
|
| 1b. Number of Applicants ≥ 15 years old screened |
|
|
|
|
|
|
|
|
|
|
|
|
0 |
|
| 1c. Number of applicants 2-14 years old screened |
|
|
|
|
|
|
|
|
|
|
|
|
0 |
|
| 1c. Number of applicants < 2 years old screened |
|
|
|
|
|
|
|
|
|
|
|
|
0 |
|
| 2. Number of TB Suspects |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| 2a. CXR Suggestive of TB |
|
|
|
|
|
|
|
|
|
|
|
|
0 |
|
| 2b. Signs & Sym. TB & Normal CXR (do NOT include TST or IGRA positive 2-14 year olds here) |
|
|
|
|
|
|
|
|
|
|
|
|
0 |
Do NOT include children 2-14 years old who have ONLY a positive TST or IGRA in row 2b. For TB Indicator reporting purposes, a positive TST or IGRA is NOT considered a "sign or symptom of TB." |
| 2c. HIV & Normal CXR & no Signs TB |
|
|
|
|
|
|
|
|
|
|
|
|
0 |
|
| 2d. TOTAL |
|
|
|
|
|
|
|
|
|
|
|
|
0 |
|
| 2e. TOTAL With Sputum Submitted (i.e., sputum samples have been provided by the applicant; final results may not be available yet) |
Should not be higher than value for 2d
|
|
|
|
|
|
|
|
|
|
|
|
0 |
Row 2e should be all applicants who have provided sputum specimens that have been submitted for processing (sputum culture results may still be pending at time of data submission). This number should not be higher than 2d. |
| 3. Non TB Mycobacteria |
|
|
|
|
|
|
|
|
|
|
|
|
|
Section 3: Non-tuberculous mycobacteria (NTM) means that NTM was the lab result; it does NOT mean that the culture was completely negative for any organism. ONLY applicants with lab results that read "NTM" should be entered here! An applicant who has lab culture results that are positive for BOTH NTM and MTB should be entered twice on the spreadsheet - once as an NTM-positive result (here in section 3) and once as an MTB pulmonary TB case (section 5). |
| 3a. Smear+ /NTM+ |
|
|
|
|
|
|
|
|
|
|
|
|
0 |
|
| 3b. Smear- /NTM+ |
|
|
|
|
|
|
|
|
|
|
|
|
0 |
|
| 3c. TOTAL |
|
|
|
|
|
|
|
|
|
|
|
|
0 |
If an applicant with cultures positive only for NTM (that is, the applicant does not have any cultures positive for MTB) requires treatment for the NTM for clinical reasons, please include that as a note at the bottom of the spreadsheet. |
| 4. Extrapulmonary TB Cases |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| 4a. Extrapulmonary TB Cases |
|
|
|
|
|
|
|
|
|
|
|
|
0 |
An applicant who has been diagnosed with both pulmonary and extrapulmonary tuberculosis should be entered twice - once here as an extrapulmonary TB case (Section 4) and once as a pulmonary TB case (section 5). |
| 5. Pulmonary TB Cases ( ***IMPORTANT*** these are ONLY the cases that are "Class A" for pulmonary mycobacterium tuberculosis (MTB), and therefore undergoing active treatment; do NOT include B1 TB cases with smear-negative and culture- negative results here). Positive cultures in this section mean they are positive for mycobacterium tuberculosis (MTB). |
|
|
|
|
|
|
|
|
|
|
|
|
|
B1s should NOT be entered in this section; only applicants with pulmonary MTB or those applicants for whom smear or culture results are still pending at the time of submission should be entered in this section. Applicants positive for only NTM should NOT be entered in Section 5 unless they are alsopositive for pulmonary MTB. |
| 5a. Smears Pending |
|
|
|
|
|
|
|
|
|
|
|
|
0 |
There should be zero or very few applicants in row 5a because smear results have rapid turnaround time and should NOT be pending at the time of data submission to CDC. If there is still any lab data (smears, cultures, or DST) pending at the time of your TB Indicator submission, please provide an explanation in the notes section at the bottom of the spreadsheet, along with the expected date of final lab results. |
| 5b. Smear+ /Culture+ |
|
|
|
|
|
|
|
|
|
|
|
|
0 |
|
| 5c. Smear+ /Culture- |
|
|
|
|
|
|
|
|
|
|
|
|
0 |
|
| 5d. Smear- /Culture+ |
|
|
|
|
|
|
|
|
|
|
|
|
0 |
|
| 5e. Smear- /Culture- (do NOT include B1s here) |
|
|
|
|
|
|
|
|
|
|
|
|
0 |
|
| 5f. Smear+ /Culture Pending |
|
|
|
|
|
|
|
|
|
|
|
|
0 |
|
| 5g. Smear- /Culture Pending |
|
|
|
|
|
|
|
|
|
|
|
|
0 |
|
| 5h. Smear+ /Culture Contamination |
|
|
|
|
|
|
|
|
|
|
|
|
0 |
|
| 5i. Smear- /Culture Contamination |
|
|
|
|
|
|
|
|
|
|
|
|
0 |
|
| 5j. TOTAL |
|
|
|
|
|
|
|
|
|
|
|
|
0 |
|
| 6. Drug Susceptibility Testing (DST) Results |
|
|
|
|
|
|
|
|
|
|
|
|
|
Remember to update DST results when available BEFORE TB Indicator submission |
| 6a. DST Pending |
|
|
|
|
|
|
|
|
|
|
|
|
0 |
|
| 6b. Pansusceotible |
|
|
|
|
|
|
|
|
|
|
|
|
0 |
|
| 6c. INH Monoresistance |
|
|
|
|
|
|
|
|
|
|
|
|
0 |
|
| 6d. RIF Monoresistance |
|
|
|
|
|
|
|
|
|
|
|
|
0 |
|
| 6e. MDR TB |
|
|
|
|
|
|
|
|
|
|
|
|
0 |
|
| 6f. XDR TB |
|
|
|
|
|
|
|
|
|
|
|
|
0 |
|
| 6g. Poly-resistance, not MDR or XDR TB |
|
|
|
|
|
|
|
|
|
|
|
|
0 |
|
| 6h. Monoresistant to drug other than INH/RIF |
|
|
|
|
|
|
|
|
|
|
|
|
0 |
|
| 6i. Unable to do DST (i.e., there was NTM overgrowth so that performing DST was not possible) |
|
|
|
|
|
|
|
|
|
|
|
|
0 |
This row is for the very few individuals whose cultures were contaminated with NTM such that performing DST on the MTB was not possible. Please provide details in the notes section at the bottom of the spreadsheet if you include anyone in this line. |
| 6j. TOTAL |
|
|
|
|
|
|
|
|
|
|
|
|
0 |
The total listed in row 6j should be the same as rows 5b + 5d |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| NOTES (please include any information here that you think may be helpful for CDC to have to interpret the information entered above or information about unique situations): |
|
| Public reporting burden of this collection of information is estimated to average 7.5 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-xxxx) |
|
|
|
|
|